peripheral vascular disease Flashcards
what is peripheral arterial disease?
chronic insufficiency of the arterial blood supply due to stenosis or occlusion of the vessels
primary cause of peripheral arterial disease?
atherosclerosis
definition of critical limb ischemia
- rest pain > 2 weeks
- tissue loss (ulcers, gangrene, necrosis)
- ABI < 0.5
where is the occlusion in leriche syndrome?
bifurcation of the aorta
triad of symptoms in leriche sydnrome?
- buttock/thigh claudication
- absent/reduced femoral pulses
- erectile dysfunction
what is the name of the classification of peripheral arterial disease?
rutherford-fontaine classification
rutherford-fontaine classification GRADE I
asymptomatic
rutherford-fontaine classification GRADE II
intermittent claudication (IIA = > 200m, IIB = < 200m)
rutherford-fontaine classification GRADE III
rest pain
rutherford-fontaine classification GRADE IV
tissue loss - ulcers, gangrene, necrosis
normal ABPI ?
0.9-1.0
ABPI 0.9 - 0.5 =
intermittent claudication
ABPI <0.5 =
rest pain
ABPI < 0.3 =
tissue loss
ABPI > 1.1 =
calcified arteries (typically seen in diabetes) - false elevation
investigations for peripheral vascular disease
- ABPI
- duplex ultrasound
- CT angiogram/MR angiogram
- digital subtraction angiography (DSA)
conservative management of PVD
- smoking cessation
- physical exercise
- diet modification
medical management of PVD
- Antiplatelet therapy (aspirin, clopidegrel)
- Statins
- BP control
- Glycemic control
- Cilostazol
- Pentoxifylline
Endovascular management of PVD
Angioplasty +- stenting
Surgical management of PVD
- synthetic graft
- vein graft
- amputation
examples of grafts for PVD
-fem-pop bypass, fem-distal bypass, aorto-bifem bypass, axillo-bifem bypass, fem-fem cross-over
causes of ACUTE lower limb ischemia
- acute thrombus on preexisting atherosclerosis
- embolus
most common source of embolus?
cardiac
6 P’s
- pallor
- parasthesias
- perishingly cold
- pulselessness
- pain
- paralysis
Management of acute limb ischemia
- IV access and fluids
- O2
- Bloods - U&E, FBC, coag, troponin, glucose, group and save
- CXR
- ECG
- Analgesia
- unfractionated heparin
-depending on cause: embolectomy, amputation
Complications of reperfusion treatment
- reperfusion injury
- rhabdomyolysis
- compartment syndrome
AAA of 3cm - 4.4 cm managment?
annual surveillance USS
AAA 4.5 cm - 5.4 cm management?
3 month USS surveillance
> 5.5 cm AAA management?
surgery
The rate of expansion of an AAA is directly related to…
the size of the AAA
presentation of aneurysm expansion?
- abdominal/back/flank pain
- distal peripheral embolization or ischemia
- upper GI bleed from aortoenteric fistula
- syncope or shock with large pulsatile mass, echymosis or death
Benefits of US for AAA?
- best initial modality
- non invasive
- 98% accurary
Cons of US for AAA?
- does not determine extend of AAA
- inadequate for planning repair
imaging modalities for AAA?
- US
- CT with IV contrast
pros of CT for AAA?
- defines extent of aneurysm
- defines relationship of AAA to renal arteries
- can tell if AAA is leaking
- determines eligibility for AAA repair
what are the types of elective repair for an AAA?
- open surgical repair
- endovascular aneurysm repair
open surgical repair for AAA procedure
- long midline incision
- aorta clamped (below renal arteries to prevent ischemia)
- graft from iliac arteries
endovascular aneurysm repair of AAA procedure
- small groin incisions
- NO cross clamping of aorta
- insertion of stent with radiological guidance (high doses of neprhotoxic contrast)
EARLY complications of AAA repair
- death
- renal injury
- hemorhage
- MI
- bowel ischemia
- abdominal compartment syndrome
- limb ischemia
- wound infection
- atelectasis
LATE complications of AAA repair
- graft infection
- graft limb occlusion
- aortaenteric fistula
- endoleak
how many types of endoleak are there?
5
endoleak type I
leak at attachment sites of graft
endoleak type II
filling of aneurysmal sac by collaterol vessels
endoleak type III
leak through defect in graft
endoleak type IV
leak through fabric of graft due to porosity
endoleak type V
expansion of aneurysm sac without evidence of leaking
what are the three groups of veins in the legs
- superficial veins
- deep venous system
- perforators
Blood in the legs pass through superficial to deep systems via ____
perforators
where do most varicose veins come from?
long and short saphenous systems
risk factors for varicose veins
- age
- prolonged standing
- elevated BMI
- smoking
- female
- sedentary lifestyle
- high oestrogen states
- pregnancy
- pelvic masses
- previous DVT
- ligamentous laxity
- lower limb trauma
symptoms of varicose veins?
- pain
- itchiness
- dry skin
- heaviness
- oedema - worse in evening, hot weather
- tightness
complications of varicose veins?
- stasis dermatitis
- eczema
- phlebitis
- lipodermatosclerosis
- skin pigmentation
- ulceration
- bleeding
diagnosis and investigations for varicose veins
- clinical diagnosis
- examine abdomen for masses
- trendelenberg and perthes test
- ultrasound duplex of superficial and deep veins - to define anatomy
Conservative management of varicose veins
- leg elevation
- exercise
- weight loss
Medical management of varicose veins
- compression stockings
- sclerotherapy
- topical agents for skin changes
Surgical management of varicose veins
- radiofrequency ablation
- laser ablation
- local stab avulsions
What is virchows triad?
- stasis of blood flow
- endothelial injury
- hypercoagulabilty
Risk factors for DVT
- Trauma, travel
- Hormones (OCP, HRT)
- Road traffic accidents (fracture)
- Operations
- Malignancy
- Blood disordeers
- Obesity, old age
- Serious illness (prolonged hospital stay)
- Immobilization
- Smoking
what is homans sign?
calf pain on dorsiflexion of foot
investigations for DVT?
- d-dimer
- duplex scan
- CTPA
DVT prophylaxis
- low molecular weight hepain
- TEDS
- mobilization
- hydration
- smoking cessation
- stop OCP 4-6 weeks pre-op
what is the name of the scoring system for DVT?
wells score
criteria in wells score
- active malignancy (1)
- paralysis, paresthesis, recent immobilization (1)
- localized tenderness along deep venous system (1)
- entire leg swollen (1)
- calf swelling >3cm than other leg (1)
- pitting edema (1)
- collateral superficial veins (1)
- previously documented DVT (1)
- other diagnosis more likely (-2)
wells score 2 or more =
DVT likely
wells score 1 or less
DVT UNlikely
treatment of uncomplicated DVT
therapeutic LMWH then warfarin for 4-6 months
treatment of complicated DVT
- LMWH then warfarin
- thrombolysis/thrombectomy or IVC filter
risks of IVC filter
- air embolism
- arythmia
- hemothorax/pneumothorax
- IVC obstruction
- bleeding
indications for thrombolysis
- acute limb ischemia
- venous thrombosis
- acute graft thrombosis
- thromboses popliteal artery aneurysm
contraindications to thrombolysis
- bleeding disorders
- peptic ulcer current
- recent hemorhagic stroke
- recent major surgery
- evidence of muscle necrosis (may cause reperfusion injury)
complications of thrombolysis
- allergy
- bruising
- major bleed or stroke
- catheter leak, occlusion
what is a CVA?
rapidly developing neurological deficit lasting > 24 hrs
what is a TIA?
acute episode of focal neurological deficit <24 hrs
what is amaurosis fugax
transient monocular vision loss - curtain coming down
Diagnosis and investigations for CVA
- carotid duplex scan
- carotid MR angiography
- cranial CT/MR angiography
- cardiac echo/telemetry
Management of CVA
- antiplatelet agent - aspirin, clopidegrel
- anticoagulants
- smoking cessation
- BP control
- tight glucose control
- statin
indications for carotid endarterectomy
- 50-99% stenosis with recent CVA or TIA
- consider if asymptomatic with >70% in younger patients/low risk surgery patients
contraindications to carotid endarterectomy?
- severe neurological deficit
- occluded carotid artery
- severe comborbidities
