Peripheral Vascular Disease Flashcards
Define peripheral vascular disease
Circulatory condition in which narrowed blood vessels reduce blood flow to limbs. Also called chronic limb arterial insufficiency (ischaemia)
Name 13 causes peripheral vascular disease
• Atherosclerosis most common by far
• HIV vasculopathy
• popliteal artery entrapment by muscle due to congenital anatomical abnormality of gastrocnemius or strong sprinters.
• mucinous cystic degeneration
• Buerger’s disease (thrombangiitis obliteratans - progressive inflammatory segmental occlusion of small and medium sized vessel)
• abdominal aortic coarctation (narrowing)
• peripheral emboli
• fibrodysplasia (scarring)
• pseudoxanthoma elasticum (deposits calcium and other minerals in elastic fibres)
•Persistent sciatic artery
• iliac artery syndrome of cyclist
•Primary arterial tumours
• hypercoagulability (rare, affect veins more)
• radiation Vasculitis
• auto-immune Vasculitis eg takayasu arthritis
Name 7 risk factors for development of atherosclerosis
• Smoking
• obesity
• Diabetes, impaired glucose metabolism
• ht
• hyperlipidaemia
• elevated homocysteine and fibrinogen levels eg metabolic syndrome
• males
• > 55 age
Symptoms peripheral vascular disease? (3)
• Most asymptomatic due to good collateral until disease is advanced.
• intermittent claudication due to imbalance between demand and supply of oxygen and nutrients: muscle pain/cramps, usually calf muscle which occurs during exercise and relieved by rest (can also be caused by venous and neurogenic claudication)
• rest pain: ischaemic rest pain for at least 2 weeks, worse at night, relieved by leg dependency.
Examination findings peripheral vascular disease? (5)
• oedema due to hanging limbs to relieve pain
• erythema due to venous congestion
• cool limb
• ulceration or gangrene which doesn’t heal, is painful, distally on foot, absent foot pulses, punched out with gangrenous base.
• ankle to brachial index is less than 0,9
• hair loss, thin skin, nails yellow and brittle, muscle atrophy
Name 4 differences between ischaemic, venous and neuropathic ulcers
• Painful vs mild unless septic vs painless
• distally on foot vs medial malleolus vs pressure points
• absent foot pulses vs present
• punch out with gangrenous base vs shallow with gangrenous tissue at base vs punched out granulation tissue
Define critical limb ischaemia (4)
• Persistent, recurring ischaemic rest pain requiring opiates for at least 2 weeks ( <2 weeks = acute limb ischaemia until proven otherwise)
• ulceration or gangrene of foot or toes
• ankle systolic <50 (measure dorsalis pedis and tibialis post, take highest value)
• toe systolic <30 or absent pedal pulses in diabetic patients
Type of peripheral arterial disease if absent common femoral pulses?
Aorto-iliac disease
Type of peripheral vascular disease if absent popliteal pulse with present common femoral pulses?
Fem-pop disease
(Superficial femoral)
Type of peripheral vascular disease if absent foot pulses with palpable popliteal pulse?
Tibio-peroneal disease
Normal ankle-to- brachial index?
> 0,9 at rest and after exercise
ankle-to- brachial index in mild peripheral vascular disease at rest and after exercise?
0,8-0,9 at rest
0,5-0,9 after exercise
ankle-to- brachial index in moderate peripheral vascular disease at rest and after exercise?
At rest 0,5-0,79
After exercise 0,15-0,49
ankle-to- brachial index in severe peripheral vascular disease at rest and after exercise?
At rest <0,5
After exercise <0,15
Special investigations for peripheral vascular disease?
• Duplex ultrasound!
• angiography CT or Mr to plan intervention
• conventional angiogram invasive, only do for intervention
Classification disease severity of peripheral vascular disease based on Clinical presentation?
Fontaine classification
• stage 1: asymptomatic
• stage 2 a: intermittent claudication after >200 meters of pain free walking
• stage 2 b: intermittent claudication after <200 m walking
• stage 3: ischaemic rest pain
• stage 4 : ischaemic ulceration or gangrene
First line management peripheral vascular disease? (6)
Best medical therapy! Manage risk factors.
• stop smoking (buproprion helps)
• hyperlipidaemia: statins (simvastatin 40 mg) - even if patient doesn’t have high cholesterol.!
. Diabetic control: hba1c <7
• hypertension: ace-inhibitors.!
• antiplatelet agents: aspirin or clopidogrel if ASA contraindicated!
• exercise
Name 2 indications for surgery in peripheral vascular disease
. Disabling claudication
• critical limb ischaemia
Tibioperoneal disease
Name 3 surgical options to treat severe peripheral vascular disease
• Open endarterectomy
• open surgical bypass (inline or extra-anatomical) with graft (better long term patency)
• endovascular percutaneous transluminal angioplasty (PTA) with or without stent- preferred
Name 3 prerequisites for open surgical bypass in peripheral vascular disease
• Inflow. Open vessel above occlusion with high enough cardiac ejection fraction
• graft or conduit
. Distal run off
Name 3 types of vascular bypass grafts
Autogenous (lower rate infection and stenosis)
• vein: long saphenous best, short saphenous, arm, superficial femoral
• artery: internal mammary, radial
Biologic: arterial homografts- human umbilical vein, bovine pericardial patches, porcine patches
Synthetic
• ePTFE goretex
• Dacron polyester
Name 4 early complications of surgical revascularisation in peripheral vascular disease
• Haemorrhage
• limb ischaemia (acute thrombosis of reconstruction. Re-operate)
• renal failure (due to decreased cardiac output, hypotension)
• intestinal ischaemia uncommon (loss primary or collateral supply to bowel or athero-embolisation during manipulation )
Name 3 late complications of surgical revascularisation in peripheral vascular disease
• Graft occlusion
• infection
• aorto -enteric fistula (usually prox anastomosis of aorta-femoral bypass graft and 3rd or 4th part duodenum)
