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Vascular > Peripheral Vascular Disease > Flashcards

Peripheral Vascular Disease Flashcards

1
Q

Modifiable risks for atherosclerosis

A

Smoking
DM/Glycemic control
HT
HL
Renal disease
High homocysteine levels
Hypercoagulability

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2
Q

Non-modifiable risks for atherosclerosis

A

Age
Gender
Ethnicity

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3
Q

Definition of Peripheral arterial disease (PAD)

A

atherosclerosis leads to arterial stenosis and occlusion of major vessels supplying the lower extremities

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4
Q

Definition of Intermittent claudication (TASC II)

A

Reproducible ischemic muscle discomfort in lower limb by exercise, and relieved by rest within 10 minutes

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5
Q

Classifications for chronic lower limb ischemia

A
  • Anatomical
    • GLASS
    • TASC
    • Bolinger score
    • Graziani
  • Symptom
    • Rutherford
    • Fontaine
    • WIfI
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6
Q

Rutherford classification

A
  • Stage 0 – Asymptomatic
  • Stage 1 – Mild claudication
  • Stage 2 – Moderate claudication
  • Stage 3 – Severe claudication
  • Stage 4 – Rest pain
  • Stage 5 – Minor tissue loss with ischemic nonhealing ulcer or focal gangrene with diffuse pedal ischemia
  • Stage 6 – Major tissue loss – Extending above transmetatarsal level, functional foot no longer salvageable
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7
Q

Fontaine classification

A
    • Stage 1 – No symptoms
  • Stage 2 – Intermittent claudication subdivided into:
  • Stage 2a – Without pain on resting, but with claudication at a distance of greater than 200 meters
  • Stage 2b – Without pain on resting, but with a claudication distance of less than 200 meters
  • Stage 3 – Nocturnal and/or resting pain
  • Stage 4 – Necrosis (death of tissue) and/or gangrene in the limb
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8
Q

WIfI

A
  • Wound (Grade 0-3)
  • Severity of ischemia (Grade 0-3)
  • Foot infection (Grade 0-3)

Stratifies risk of amputation

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9
Q

Difference between intermittent and spinal claudication

A

Spinal claudication associated wtih nerological symptoms and relieved by spinal flexion

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10
Q

DDX for Intermittent claudication

A

Osteoarthrosis

Spinal stenosis

Nerve root compression

Venous claudication

Symptomatic baker cyst

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11
Q

Chronic limb threatening ischemia (CLTI) (TASC II)

A

Clinical syndrome defined by:

  • the presence of PAD in combination with
  • rest pain, gangrene, or a lower limb ulceration >2 weeks duration
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12
Q

Leriche syndrome

A

Buttock claudication

Gluteus muscle atrophy

Impotence

*internal iliac arterial occlusion

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13
Q

Ankle brachial index

A

Highest systolic ankle pressure in DP/PT

Highest systolic pressure over brancila artery

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14
Q

ABI

1) Normal
2) PAD
3) Intermittent claudication
4) Critical limb ischemia

A

1) >0.9
2) <0.9
3) 0.5-0.8
4) < 0.5

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15
Q

Duplex USG

A

1) Doppler: evaluates velocity and direction of flow
2) B mode: obtains image of vessel

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16
Q

IMEX

A
  • Cuffs of appropriate size are placed at above ankle, mid calf and mid thigh
  • Doppler placed at pedal artery
  • Sequential inflation and deflation of each cuff
  • pressure drop >20mmHg acorss segments = significant stenosis
17
Q

Describe normal Doppler waveform

A
18
Q

Management of PAD

A

Aims:

  • Decrease overall cardiovascular morbidity
  • Improve QOL
  • Avoid limb loss
  • Risk factor modification
    • ABCDE
    • Antiplatelet
    • BP control
    • Cholesterol reduction
    • DM control
    • Exercise /Smoking
  • Pharmacological treatment
  • Localize lesion
  • Revascularization
19
Q

Cilostazol (Pletaal)

A

Phosphodiesterase III inhibitor

increases intracellcular cyclic AMP -> vasodilation and antiplatelet activity

CI in HF

20
Q

Aspirin

A

irreversible COX inhibitor

Blocks prostaglandin synthesis from arachidonic acid

21
Q

Naftidrofuryl (Praxilene)

A

Peripheral vaso-dilator

Selective 5HT antagonist

Reduces RBC and plt aggregation

Used for intermittent claudication

22
Q

Management for suprainguinal

1) Type A
2) Type B
3) Type C
4) Type D

A

1) Endovascular
2) Endovascular
3) Surgery
4) Open surgical treatment

23
Q

Endovascular vs Surgical for infrainguinal disease

A

Open surgery if:

  • anatomy suitable,
  • good vein,
  • relatively young,
  • no other comorbidities likely survive > 2 years

Otherwise endovascular

24
Q

Vein vs Prosthetic graft

A

Vein has higher 5 year primary patency rate

25
Q

Miller cuff

A

Venous cuff interposing between synthetic graft and artery at distal anastomosis

  • reduces intimal hyperplasia at the toe and heel of anastomosis
  • higher patency rate
26
Q

Name some distal anastomosis-adjunctive procedures.

A
27
Q

Special signs for PVD

A
  • Buerger’s angle
  • Dependent rubor
  • Venous gutting
  • Sluggish vein refilling
28
Q

Explain the pathophysiology behind dependent rubor

A

Pre-capillary arteriole sphincter dilatation secondary to lactic acid production after anaerobic metabolism in ischemic state while elevating the leg

29
Q

What is supervised regular exercise?

A

Exercise for 30 minutes 3 times a week for 5 months

Meta-analysis (JAMA 1995) shows improves in walking distance

30
Q

Non-operative treatment of intermittent claudication

A
  • Risk factor modification
    • Smoking cessation
    • Treat DM/HT
    • Statin
  • Supervised regular exercise
  • Proper foot-care
  • Pharmacological treatment
    • Anti-platelet agent (reduces risk of MI, stroke)
    • Vasoactive agents
31
Q

Factors involved in deciding between endovascular and open surgery

A
  • Surgical risk
  • Life expectancy
  • Severity of ischemia
  • Anatomical pattern
  • Vein availability
32
Q

How to perform intra-arterial thrombolysis

A
  • Puncture of femoral artery (ipsilateral if palpable, contralateral if not palpable
  • Pass guidewire through clot
  • Introduce thrombolysis catheter
    *
33
Q

What is the antidote for intra-arterial thrombolysis?

A

Aprotinin (plasma inhibitor)

Whole blood, FFP

34
Q

How to perform upper limb embolectomy?

A
  • Drape whole upper arm
  • Lazy S incision (medial to distal bicep)
  • Control brachial artery, ulnar artery and radial artery
  • Transverse arteriotomy 1cm proximal to bifurcation
  • Fogarty ballon first pass through proximal limb (for clot retrieval and confirm flow)
  • Pass through distal limb (clot retrieval and confirm backflow)
  • Closure of arteriotomy with fine non-absorbable monofilament sutures

Vascular (6 decks)

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