Peripheral Vascular Disease

Question 1

Chronic Peripheral Vascular Disease/ PAD

Presentation 4 (pain where suggests where)

Fontaine Classification 4

6Ps

Assessment

• History 3
• Exam 4
• Investigations
• Test? Formula? Results? Reasons for incorrect?(4)
• Imaging 2 and reasons for both

Cause 1
Rarer causes 4/6
Risk Factors 5

Management 
Non-surgical 
- 
- 
-
- 2 meds!

-
-

Answer 1

Presentation
- Claudication (cramp/pain on walking + relived by rest)
Calf suggests femoral disease, buttock suggest iliac
- Foot pain at rest (burning at night relieved by swinging feet out of bed
- Foot ulceration/ gangrene
- Impotence

Fontaine

1) Asymptomatic
2) Intermittent Claudication
3) Ischaemic rest pain (affects distal extremity)
4) Ulceration/ gangrene

6Ps

• Pulse-less
• Perishingly cold
• Parathesia
• Paralysis
• Pain
• Pallor

Assessment
- History SOCRATES, Claudication distance, Rest pain
- Examination Inspect (pale, pink, black, nicotine), Palpate (temp), Pulses, Blood pressure both arms, ABPI
- Investigation ABPI = Pleg/ Parm
0.9-1.2: 1 is normal
<0.9 is atherosclerosis/ PAD <0.5 critical ischaemia
>1.3 cant occlude vessel due to calcification or obese, upper limb ischaemia may confuse results, painful in ulcerated legs
Imaging:
Colour duplex/ Doppler US (flow rate and velocity) or MR/ CT angiography showing stenosis

Causes - Atherosclerotic plaque build up 
- Rarer causes ( Buerger's disease, Popliteal aneurysm, Pop entrapment, Cystic adventitial disease, Trauma, Aortic dissection) 
Risk Factors 
-Smoking
- Diabetes
- Age
- Hypertension
- Hypercholesterolaemia 

Management Non-Surgical

• Correct risk factors (STOP SMOKING, treat hypertension with ACEI + Bblocker)
• Encourage to keep walking/ supervised exercise programme
• vasodilators have little affect eg naftidrofuryl oxalate

1) Statins (Atorvastatin) SE- muscle cramp and deranged LFT
2) Anti-platelet (Clopidogril) to prevent CV event

Managment Surgical

• Angioplasty (Percutaneous transluminal angioplasty)
• Bypass surgery (Fem-pop bypass, fem-fem crossover, aorto-bifemoral bypass)
• Amputation (only 1-2%)

Question 2

Acute Ischaemia

Causes 4

They need… 2

Treatment for 3 causes

Answer 2

Classically Embolic event
Thrombotic (pre-existing disease)
Trauma
Dissection of vessel

Need urgent referral + assessment and revascularise within 6 hours (otherwise amputation or death!)

Treatment

• Embolus— embolectomy
• Thrombus —- Thrombolysis, angioplasty, bypass surgery
• Dissection —- surgical correction

Question 3

Ulcers 3 types, answer all for each

Pedial Pulse 
Pain
Location 
Depth 
Border
Skin

Answer 3

Arterial
Pedial Pulse- weak/absent
Pain- Severe (no pain if bad) improved leg over bed
Location - Between toes, Tibia, Lateral ankle
Depth- Deep
Border- well defined, hole punched, regular
Skin- cracked, cold, dry gangrene

Venous
Pedial Pulse- Strong (can be weaker with odeama)
Pain- Dull/achy, improved with elevating leg
Location- Distal medial calf/ ankle
Depth- Shallow
Border- Irregular
Skin- Weepy wound, varicose veins, scales

Diabetic
Pedial Pulse- Strong
Pain- Pins + needles/ loss of pain sensation
Location- Bottom of foot
Depth- Deep
Border- Round + Raised
Skin- Cracked/ blistered, RED, warm at early stages + gangrene later stages

Question 4

Aneurysms 
Definitions
Aneurysm 
True Aneurysm
False/ Pseudo-Aneurysm
AAA can be two types

Causes 5

Complications 4

Ruptured AAA presentation

Unruptured AAA:
Size considered AAA
Elective Surgery if > or ….

Risk factures for rupture 4

Surgery 2

Answer 4

Defintions
Aneurysm- artery dilation > 50% original diameter
True Aneurysm- all layers of arterial wall abnormally dilated
Pseudo-Aneurysm- only adventitia abnormally dilated after trauma to lumen
AAA can be sack-like (Berry Aneurysm) or fusiform (most)

Causes 
Atheroma 
Trauma 
Infection (mycotic Aneurysm in endocarditis) 
C.T disorder
Inlfam (Takayasu's arteritits) 

Presentation

• Intermittent or continuous abdo pain radiates to back, groin or iliac fossa
• Abdo mass thats expansile
• If in shock assume ruptured AAA

Unruptured AAA:
Size considered AAA > 3cm
Elective Surgery if > or equal 5.5cm or > 1cm/ year expansion
Cause- Degeneration of elastic lamellae and smooth muscle loss

Risk factors

• Smoker
• Inc BP
• Male
• +ve family history

Surgery

• Stenting (EVAR)- endovascular stent via femoral artery
• Elective surgery- open chest and replace weakend vessel portion with a graft tube