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SD2 > Peripheral Vascular Disease > Flashcards

Peripheral Vascular Disease Flashcards

1
Q

what is an aneurysm

A

dilatation of a vessel by more than 50% of its normal (AP) diameter

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2
Q

what is the normal aortic diamter

A

1-2 cm

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3
Q

describe a true aneurysm

A

all three layers of vessels are in tact, blood is contained (usually abdominal aortic)

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4
Q

describe a false aneurysm

A

when there is a breach in vessel wall and surrounding structures are acting as vessel- usually caused by trauma

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5
Q

name three morphology of aneurysms

A

saccular, fusiform, mycotic

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6
Q

describe what gives rise to mycotic aneurysms

A

secondary to and infectious process that weakens the artery wall, involves all three layers of the artery

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7
Q

which aneurysms have highest risk of rupturing

A

any can but saccular and mycotic more than fusiform

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8
Q

does atherosclerosis cause aortic aneurysms

A

no

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9
Q

what causes aortic aneurysms

A

medial degeneration

  • middle layer of vessel wall
  • imbalance between elastin and collagen in aortic wall
  • this leads to weakening of the wall
  • which leads to aneurysmal dilatation
  • increase in aortic wall stress
  • progressive dilatation

related to age, gender, smoking, hypertension

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10
Q

a quarter of AAA patients will have what

A

popliteal aneurysm

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11
Q

how do asymptomatic aneurysm present (vast majority)

A

no symptoms, identified om imaging/ surveillance

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12
Q

how do symptomatic aneurysm present

A
  • pain (renal colic)
  • trashing- thrombus in aneurysm due to turbulent blood flow breaks off and enters peripheral circulation, damaging distal arteries
  • rupture
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13
Q

how does a ruptured AAA present

A

sudden onset epigastric/ central pain
-may radiate through to back
-may mimic colic
collapse

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14
Q

what is found on examination of a ruptured AAA

A

may look well

hypo/hypertensive due to pain

pulsatile, expansile mass +/- tender

pulse transmitted from mass to flanks

hard to palpate due to obesity

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15
Q

describe the small amount of ruptured AAAs that make it to hospital

A

retroperitoneal usually, rupture contained by retroperitonium- tamponades itself

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16
Q

how severe are free intra-peritoneal rupture

A

rapidly fatal

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17
Q

when should intervention be taken for an AAA

A

balance fitness of patient and risk of rupture

if symptomatic or when asymptomatic and;
-size > 5.5cm AP diameter
or
-expanding >0.5cm/6 months or >1cm/ year

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18
Q

what does duplex ultrasound shows, its pros and cons

A

no radiation or contrast

only shows AP diameter and involvement of (iliac) arteries

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19
Q

describe a CT scan- aterial phase

A

IV contrast in aterial system shows aneurysm morphology, shape, size, iliac involvement. AND only one to show if ruptured

allows management planning

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20
Q

describe open repair of an aneurysm

A

laparotomoy to access it

clamp aorta and iliacs (for bloodless field)

dacron (polyester) graft (tube and bifurcated) anatstomosed onto artery

essential to close aneurysm sac over graft as bowl will stick to it

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21
Q

describe Endovascular Aneurysm Repair (EVAR)

A

exclude the aneurysm from within the vessel, graft inserted via peripheral artery, guided via x-ray. seal needed between tops of stent graft and vessel to prevent blood escaping into the sac

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22
Q

what is acute limb threat

A
  • acute limb ischaemia
  • acute on chronic limb ischaemia
  • diabetic foot sepsis
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23
Q

what is acute limb ischaemia

A

sudden loss of blood supply to a limb

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24
Q

what causes acute limb ischaemia

A

occlusion of native artery or bypass graft

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25
Q

what can cause a sudden occulsion of an artery

A 
Embolism
Atheroembolism- narrowing, bits break off 
Arterial dissection
Trauma e.g. dislocating knee	
Extrinsic compression- tumours
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26
Q

what are the clincal features of acute limb ischaemia

A 
6 P's 
Pain- excruciating  
Pallor 
Pulseless (arteries distal to blockage) 
Perishingly cold
Paraesthesia- nerve begins to die, what makes it so painful
Paralysis
27
Q

what are the aspects of acute limb ischaemia given in a history

A

No prior history of claudication- cramping

Known cause for embolism

Full complement of contra-lateral pulses (all pulses on other side)

28
Q

describe the pain of acute limb ischaemia

A

Severe, sudden onset, resistant to analgesia

Calf/muscle tenderness with tight (‘woody’) compartment indicates muscle necrosis

Often irreversible ischaemia

29
Q

why is pallor a symptom of acute limb ischaemia

A

Limb initially white with empty veins

30
Q

why does the limb appear mottled as the acute limb ischaemia progresses

A

capillaries fill with stagnated de-oxygenated blood giving a mottled appearance

31
Q

what does blanching mottling mean

A

salvageable if prompt revascularisation

32
Q

what does non blanching mottling suggest

A

irreversible ischaemia as artiers distal to the occlusion fill with propagated thrombus with rupture of capillaries

33
Q

why does ALI cause paralysis

A

as sensorimotor deficit indicative of muscle and nerve ischaemia

34
Q

what happens after 12 hours of ALI

A

fixed mottling, paralysis, non salvageable

35
Q

why do you never perfuse a non salvageable leg

A

as will release noxious chemical from dead muscle, killing the patient

36
Q

why are anticoagulants given in ALI

A

stops propagation of thrombus, may improve perfusion (careful as surgery may be needed)

37
Q

what tests are given on a patient presenting with an ALI

A

ABC, bloods, troponin, ECG (MI, dysrhythmia), CXR (underlying malignancy), arterial imaging (to plan appropriate management- CT angiogram/ catheter angiogram)

38
Q

what are the managements for ALI if the limb is salvageable

A

Embolectomy (balloon catherter) +/-fasciotomies +/- thrombolysis

39
Q

what are the managements for ALI if the limb is not salvageable

A

palliation or amputation

40
Q

what do diabetic foot problems include

A

diabetic neuropathy, peripheral vascular disease, infection

41
Q

what can combinations of diabetic foot problems lead to

A

tissue loss; ulceration, necrosis and gangrene = may result in amputation

42
Q

what is the source of sepsis

A

break in skin (don’t notice because of neuropathy), infection from nail plate or inter-digital space, neuro-ischaemic ulcer (secondary to neuropathy and repetitive trauma- increased pressure in feet)

43
Q

why is infection in the foot such a big problem

A

as muscles confined in rigid compartment which does not allow pus to escape, causing a build up of pressure which impairs capillary blood flow and further ischaemia and tissue damage. Can rapidly progress to sepsis and limb loss

44
Q

what are the systemic finding in diabetic foot sepsis

A 
Pyrexia
Tachycardic
Tachypnoeic
Confused
Kussmauls breathing (deep sighs- sepsis causes shock, hyper perfusion of distal organs and build up of lactic acid and CO2, trying to ventilate this acid out and raise pH)
45
Q

what are the local finding of diabetic foot sepsis

A

Swollen affected digit (‘sausage’ like)
Swollen forefoot (‘boggy’ feeling to swelling)
Tenderness
Ulcer with pus extruding
Erythema (redness of the skin), may track up the limb
Patches of rapidly developing necrosis
Crepitus in the soft tissues of the foot (Gas from gas forming organisms in soft tissues)

Pedal pulses may or may not be present

local findings may be tip of iceberg

46
Q

how is diabetic foot sepsis considered

A

vascular surgical emergency

47
Q

how is diabetic foot sepsis treated

A

antibiotics (got to cover gram +ve cocci, gram -ve bacilli and anaerobes)

rapid surgical debridement of infected tissue, wound open to encourage drainage

48
Q

when is a guillotine amputation done

A

to break cycle of infection, not neat stump, just clean above the ankle

49
Q

what forms plaques in atherosclerosis

A

activated platelets, LDL cholesterol, inflammatory cells (WBD->macrophages->foam cells)

50
Q

what is the role of collateral vessels in intermittent claudications

A

find way around blockage

51
Q

what are the non invasive investigations of lower limb ischaemia

A

measurement of ABPI, duplex ultrasound scanning

52
Q

what are the invasive investigations of lower limb ischaemia

A

magnetic resonance angiography, CT angiography, catheter angiography

53
Q

what is ABPI

A

ankle brachial pressure index (ankle pressure over brachial pressure)

54
Q

is it when ABPI is increased or decreased that there is a problem

A

drops

55
Q

how does narrowing of artery affect blood flow

A

turbulent flow

56
Q

how is progression of lower limb ischaemia slowed

A

stop smoking, lipid lowering, antiplatelets, hypertension Rx, diabetes Rx, life style issues

57
Q

how are claudication symptoms treated

A

exercise training, drugs, angioplasty/stenting, surgery

58
Q

what inflow surgery can treat lower limb ischaemia

A

endarterectomy, bypass,

59
Q

what outflow surgery can treat lower limb ischaemia

A

bypass

60
Q

describe the symptoms of critical limb ischaemia

A

rest pain- toe/foot ischaemia (when lying/sleeping)

ulcers/gangrene- severe ischaemia +damage (trauma + footwear)

worse at night

helped by sitting putting the leg in a dependent position and walking

61
Q

what are the clinical features of critical limb ischaemia

A 
cool to touch
absence of peripheral pulses 
colour change 
hair loss
thick nails 
shiny skin 
venous guttering 
ulcers
gangrene
62
Q

what are the risk factors for critical limb ischaemia

A

smokin, diabetes, hypertension, raised cholesterol

63
Q

how is critical lower limb ischaemia treated

A

analgesia, angioplasty/ stenting, surgery/ amputation (depends on function and patients chance of recovery)

SD2 (12 decks)

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