Peripheral Vascular Disease

Question 1

Define peripheral vascular disease

Answer 1

Circulatory condition in which narrowed blood vessels reduce blood flow to limbs. Also called chronic limb arterial insufficiency (ischaemia)

Question 2

Name 13 causes peripheral vascular disease

Answer 2

• 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

Question 3

Name 7 risk factors for development of atherosclerosis

Answer 3

• Smoking
• obesity
• Diabetes, impaired glucose metabolism
• ht
• hyperlipidaemia
• elevated homocysteine and fibrinogen levels eg metabolic syndrome
• males
• > 55 age

Question 4

Symptoms peripheral vascular disease? (3)

Answer 4

• 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.

Question 5

Examination findings peripheral vascular disease? (5)

Answer 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

Question 6

Name 4 differences between ischaemic, venous and neuropathic ulcers

Answer 6

• 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

Question 7

Define critical limb ischaemia (4)

Answer 7

• 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

Question 8

Type of peripheral arterial disease if absent common femoral pulses?

Answer 8

Aorto-iliac disease

Question 9

Type of peripheral vascular disease if absent popliteal pulse with present common femoral pulses?

Answer 9

Fem-pop disease
(Superficial femoral)

Question 10

Type of peripheral vascular disease if absent foot pulses with palpable popliteal pulse?

Answer 10

Tibio-peroneal disease

Question 11

Normal ankle-to- brachial index?

Answer 11

> 0,9 at rest and after exercise

Question 12

ankle-to- brachial index in mild peripheral vascular disease at rest and after exercise?

Answer 12

0,8-0,9 at rest
0,5-0,9 after exercise

Question 13

ankle-to- brachial index in moderate peripheral vascular disease at rest and after exercise?

Answer 13

At rest 0,5-0,79
After exercise 0,15-0,49

Question 14

ankle-to- brachial index in severe peripheral vascular disease at rest and after exercise?

Answer 14

At rest <0,5
After exercise <0,15

Question 15

Special investigations for peripheral vascular disease?

Answer 15

• Duplex ultrasound!
• angiography CT or Mr to plan intervention
• conventional angiogram invasive, only do for intervention

Question 16

Classification disease severity of peripheral vascular disease based on Clinical presentation?

Answer 16

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

Question 17

First line management peripheral vascular disease? (6)

Answer 17

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

Question 18

Name 2 indications for surgery in peripheral vascular disease

Answer 18

. Disabling claudication
• critical limb ischaemia
Tibioperoneal disease

Question 19

Name 3 surgical options to treat severe peripheral vascular disease

Answer 19

• 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

Question 20

Name 3 prerequisites for open surgical bypass in peripheral vascular disease

Answer 20

• Inflow. Open vessel above occlusion with high enough cardiac ejection fraction
• graft or conduit
. Distal run off

Question 21

Name 3 types of vascular bypass grafts

Answer 21

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

Question 22

Name 4 early complications of surgical revascularisation in peripheral vascular disease

Answer 22

• 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 )

Question 23

Name 3 late complications of surgical revascularisation in peripheral vascular disease

Answer 23

• Graft occlusion
• infection
• aorto -enteric fistula (usually prox anastomosis of aorta-femoral bypass graft and 3rd or 4th part duodenum)