Peripheral vascular disease Flashcards
Define peripheral vascular disease
Circulatory condition involving reduced blood flow to the limbs due to narrowed blood vessels
What is peripheral vascular disease also known as?
Chronic limb arterial insufficiency/ischemia
Give the etiology of peripheral vascular disease
Atherosclerosis HIV vasculopathy Popliteal aa entrapment Mucinous cystic degeneration Buerger's disease Abdominal aortic co-arctation Peripheral emboli Fibrodysplasia Pseudoxanthoma elasticum Persistent sciatic aa Iliac aa syndrome Primary arterial tumours Hypercoaguability
Name risk factors for atherosclerosis
Smoking DM Hypertension Hyperlipidemia Obesity Elevated homocystein/fibrinogen Male >55yo Family history
What is Leriche syndrome?
Clinical syndrome involving
- Buttock claudication
- Impotence
- Decr/absent femoral pulses
Name clinical features of peripheral vascular disease
Silent Intermittent claudication Absent pulses Trophic changes Rest pain Critical limb ischemia
Name the features of ischemic rest pain
> 2w duration
Worse at night
Relieved by leg dependency
Name causes of intermittent claudication
PVD
Venous claudication
Neurogenic claudication
Define intermittent claudication
- Pain, cramps or paresthesia distal to arterial occlusion
- Worsens upon exertion completely relieved by rest
- Reproducible
How do you differentiate between intermittent claudication, venous claudication and neurogenic claudication?
Quality of pain Onset Relieved by Location Legs affected
Give the characteristics of intermittent claudication
Cramping pain Gradual onset Relieved by rest Located at muscle groups Usually one leg affected
Give the characteristics of venous claudication
Aching, heavy pain Gradual/immediate onset Relieved by activity Whole leg Usually one leg affected
Give the characteristics of neurogenic claudication
Pins and needles Immediate onset Relieved by sitting down, flexion Poorly localized Often both legs affected
Differentiate between ischemic, venous and neuropathic ulcers
Pain
Location
Pulses
Appearance
Name the characteristics of ischemic ulcers
Painful
Distal foot
Absent foot pulses
Punch out w/ gangrenous base
Name the characteristics of venous ulcers
Mild pain unless septic
Medial malleolus
Pulses present
Shallow with granulation tissue at base
Name the characteristics of neuropathic ulcers
Painless
Located at pressure points
Pulses present
Granulation tissue
Define critical limb ischemia
- Persistent, recurring ischemic rest pain requiring opiate analgesia >2w
- Ulceration/gangrene of foot/toes
- Ankle systolic <50
- Toe systolic <30
What do absent femoral pulses indicate?
Aorto-iliac disease
What do absent popliteal pulses with present femoral pulses indicate?
Femoral-popliteal disease
What do absent foot pulses with palpable popliteal pulses indicate?
Tibio-peroneal disease
How can you asses severity of PVD using a measurement?
Ankle-to-brachial index
Discuss the grading of severity of PVD using ankle-to-brachial index
> 0.9 normal
0.8 - 0.9 mild
0.5 - 0.79 moderate
<0.5 severe
Name special investigations in PVD
Duplex ultrasound
Angiography
Convnitonal angiogram
What do duplex ultrasound findings indicate in PVD?
Triphasic flow - normal
Biphasic flow - proximal occlusion
Monophasic flow - proximal stenosis
Which classification is used to assess PVD severity?
Fontaine classification
Discuss the Fontaine classification of peripheral vascular disease
Stage 1 asymptomatic
Stage 2a intermittent claudication after >200m pain free walking
Stage 2b intermittent claudication after <200m pain free walking
Stage 3 ischemic rest pain
Stage 4 ischemic ulceration/gangrene
Name the objectives of management in peripheral vascular disease
Pain relief Ulcer healing Limb loss prevention Improve patient function and QOL Prolong survival
Discuss the management of peripheral vascular disease
Best medical therapy
- Pharmacology
- statins (dyslipidemia)
- ACE-Is (hypertension)
- metformin (diabetes)
- aspirin (all)
- PDE inhibitors - Lifestyle modification
- smoking cessation
- exercise
Surgery
Name indications for surgery in peripheral vascular disease
Disabling claudication
Critical limb ischemia
Name types of surgical intervention
Endovascular
- PTA and stenting
Open
- endartectomy
- surgical bypass
Name types of bypass grafts
Autogenous
- vein (long saphenous, short saphenous, superficial femoral)
- artery (internal mammary, radial)
Biological
- human umbilical vein
- bovine pericardial
- porcine
Synthetic
- ePTFE (goretex)
- dacron
Which trial compared open to endovascular surgery and what were the findings
BASIL trial
Endovascular = less invasive
Open = better long term patency
Name complications of surgical revascularisation
Early
- hemorrhage
- limb ischemia
- renal failure
- intestinal ischemia
Late
- graft occlusion
- infection
- aorto-enteric fistula
Which organism is most common in surgical revascularization infection?
Staph epidermidis
Discuss PDE inhibitors
Can be given after 3months graded exercise therapy in lifestyle-limiting intermittent claudication
Reduces platelet aggregation
Causes arterial vasodilation
