Peripheral Vascular Disease Flashcards
Ischemia is a condition in which blood flow (and thus oxygen) is restricted or reduced in a part of the body. Acute ischaemia is a sudden decrease in limb perfusion causing a potential threat to limb viability (and life). What is the definition of acute limb ischaemia?
1 - <1 week
2 - <2 weeks
3 - <4 weeks
4 - <12 weeks
2 - <2 weeks
acute = symptoms <14 days
chronic = symptoms >14 days
Ischemia is a condition in which blood flow (and thus oxygen) is restricted or reduced in a part of the body. What is the definition of chronic limb ischaemia?
1 - >1 week
2 - >2 weeks
3 - >4 weeks
4 - >12 weeks
2 - >2 weeks
What is the incidence of acute limb ischaemia?
1 - 14 / 100,000
2 - 140 / 100,000
3 - 1400 / 100,000
4 - 14,000 / 100,000
1 - 14 / 100,000
Results in:
- 30 day amputation rates 10-30%
- mortality = 30%
- thrombotic cause increases risk of limb loss
What is the incidence of chronic limb ischaemia (PVD) in 80 y/o?
1 - 1%
2 - 5%
3 - 20%
4 - 50%
3 - 20%
- BUT 50% are asymptomatic
- more common than HF
Which of the following is NOT a non-modifiable risk factor in PVD?
1 - Older age
2 - Family history
3 - Male
4 - Female
4 - Female
More common in men
Which of the following is NOT a modifiable risk factor in PVD?
1 - Smoking
2 - Alcohol consumption
3 - Poor diet (high in sugar and trans-fat and low in fruit, vegetables and omega 3s)
4 - Low exercise / sedentary lifestyle
5 - Anorexia
6 - Poor sleep
7 - Stress
5 - Anorexia
Obesity is a risk factor
Which of the following health conditions, DO NOT typically increase the risk of PVD?
1 - Diabetes
2 - Hypertension
3 - Chronic kidney disease
4 - Liver disease
5 - Inflammatory conditions (rheumatoid arthritis)
6 - Atypical antipsychotic medications
4 - Liver disease
Which of the following is NOT true about chronic limb ischaemia?
1 - 20-30% have diabetes
2 - black/African are higher risk
3 - 80-90% are asymptomatic
4 - 90% are caused by atherosclerosis
5 - 3-4% prevalence of amputation
2 - black/African are higher risk
The risk is greatest in the caucasians
Which of the following match the definition of gangrene?
1 - inadequate nutrients to tissues
2 - death of tissue.
3 - death of the tissue, specifically due to an inadequate blood supply.
3 - death of the tissue, specifically due to an inadequate blood supply.
- inadequate oxygen supply to the tissues due to reduced blood supply = ischaemia
- death of tissue = necrosis
Acute limb ischemia (ALI) is a medical emergency. It can present as absolute ischaemia, which is what?
1 - insufficient perfusion to continue normal cellular process (LIMB THREATENING)
2 - insufficient perfusion to permit full function, OK at rest (LIFESTYLE CHANGING
Symptoms depend on level of function, frail or immobile)
3 - insufficient perfusion and can cause pain at rest and gangrene
1 - insufficient perfusion to continue normal cellular process (LIMB THREATENING)
Acute limb ischemia (ALI) is a medical emergency. It can present as relative ischaemia, which is what?
1 - insufficient perfusion to continue normal cellular process (LIMB THREATENING)
2 - insufficient perfusion to permit full function, OK at rest (LIFESTYLE CHANGING
Symptoms depend on level of function, frail or immobile)
3 - insufficient perfusion and can cause pain at rest and gangrene
2 - insufficient perfusion to permit full function, OK at rest (LIFESTYLE CHANGING
Symptoms depend on level of function, frail or immobile)
Which of the following defines critical ischaemia?
1 - insufficient perfusion to continue normal cellular process (LIMB THREATENING)
2 - insufficient perfusion to permit full function, OK at rest (LIFESTYLE CHANGING
Symptoms depend on level of function, frail or immobile)
3 - insufficient perfusion and can cause pain at rest and gangrene
3 - insufficient perfusion and can cause pain at rest and gangrene
Gangrene = death of the tissue, specifically due to an inadequate blood supply.
Intermittent claudication (pain) is a symptom of PVD. Does this occur when an individual is active/exercising or when stationary?
- active/exercising
Pain will stop when they stop
Intermittent claudication (pain) is a symptom of PVD that is made worse by Intermittent claudication (pain) is a symptom of PVD being active/exercising. What is the most common location for this pain?
1 - hands
2 - bum
3 - thighs
4 - calves
4 - calves
Can also occur in bum and thighs as well
Which of the following is NOT one of the 6Ps that indicate acute ischaemia?
1 - Pallor (Pale)
2 - Painless
3 - Pulseless
4 - Perishingly cold
5 - Paraesthesia (sensations)
6 - Paralysis
2 - Painless
- ischaemia is very painful
The following are the 6Ps that indicate acute ischaemia. Of these which 2 are typically late presenting?
1 - Pale
2 - Pain
3 - Pulseless
4 - Perishingly cold
5 - Paraesthesia (sensations)
6 - Paralysis
5 - Paraesthesia (sensations)
6 - Paralysis
Pain caused by acute absolute limb ischaemia can feel like a burning sensation. Typically when is this pain worse?
1 - when walking
2 - when sleeping
3 - when running
4 - when sat on end of bed
2 - when sleeping
When legs are down, gravity helps blood flow and reduces symptoms
What is the most common cause of acute limb ischaemia?
1 - aneurysm
2 - aortic dissection
3 - popliteal entrapment
4 - thrombosis
4 - thrombosis
- long term atherosclerosis has caused an thrombosis
- thrombosis is essentially a blood clot obstructing flow
- IT IS NOT FLOATING AROUND
Is it straight froward to distinguish an embolus from a thrombosis?
- no
- very difficult
Does acute or chronic limb ischaemia allow for contralateral to form?
- chronic
Acute is so quick there is no time for contralateral to form
Neurosensory deficits can occur in acute ischaemia. 2 of the following would be suitable for revascularisation. Which 1 would NOT be suitable for revascularisation?
1 - no neurosensory deficit
2 - limb staining/mottling, significant tissue death
3 - neurosensory deficit
2 - limb staining/mottling, significant tissue death
- if unsalvageable then amputation is often required
Typically which medication is used to treat patients who present with acute ischaemia if considering intervention in the short term?
1 - heparin
2 - DAPTs
3 - DOACs
4 - LMWH
1 - heparin
- typically 1st line, but LMWH can also be used which are Dalteparin, Tinzaparin, Enoxaparin
Typically which imaging is 1st line in patients who present with acute ischaemia?
1 - duplex ultrasound
2 - angiogram
3 - MRI
4 - CTA
1 - duplex ultrasound
- CT angiogram is the gold standard though
all of the overs could also be used at some point
If an embolus is suspected a the cause for acute ischaemia, which of the following methods would be used?
1 - thrombolysis
2 - embolectomy
3 - DAPT
4 - angioplasty
2 - embolectomy
- followed by long term anti-coagulation, typically Warfarin
If a thrombotic cause is suspected as the cause for the acute limb ischaemia, which of the following methods would be used?
1 - thrombolysis
2 - embolectomy
3 - DAPT
4 - angioplasty
1 - thrombolysis
- followed up by angioplasty of the plaque
Patients with a blocked artery that may be caused by an embolus are typically treated with embolectomy if the tissue can be salvaged. Is it important to identify the source of the embolus?
- yes
- may cause anther one, AF is most common so treat this
In patients with chronic limb ischaemic and critical ischaemia, what is the most common cause?
1 - atherosclerosis
2 - aortic dissection
3 - popliteal entrapment
4 - thrombosis
1 - atherosclerosis
- common atherosclerotic risk factor
In patients with chronic limb ischaemic and critical ischaemia, which 2 of the following are the most common blood vessels involved?
1 - femoral and tibial
2 - abdominal aorta and femoral
3 - femoral and popliteal
4 - popliteal and tibial
3 - femoral and popliteal
- involved in 80-90% of patients
The pain that patients report in claudication is due to ischaemia and the local tissues then release what that is linked with the pain?
1 - histamine
2 - leukotrienes
3 - substance P
4 - adenosine
4 - adenosine
Which of the following is NOT typically a sign/symptom of chronic limb ischaemic and critical ischaemia?
1 - warm peripheries
2 - dry skin
3 - hair loss
4 - claudication
5 - pain at rest
1 - warm peripheries
- the peripheries will typically be cold
If a patient has chronic limb ischaemic and critical ischaemia, this can be classified based on the fontaine classification, stages 1-4. Which of the following is stage 3?
1 - Intermittent claudication
2 - Asymptomatic
3 - Ulceration or gangrene, or both
4 - Ischaemic rest pain
4 - Ischaemic rest pain
The ankle brachial index can be calculated to identify the severity of PVD. Which of the following indicates moderate PVD?
1 - 0.9-1.3
2 - 0.7-0.9
3 - 0.4-0.69
4 - <0.4
5 - >1.3
3 - 0.4-0.69
0.9-1.3 – Normal
0.7-0.9 – Mild obstruction
0.4-0.69 – Moderate obstruction
<0.4 – Severe obstruction
>1.3 – poorly compressible vessel (e.g. diabetes)
In a Bergers test, which can be used in PVD, what happens to the legs when they are raised?
1 - pallor
2 - rubor
3 - no change
4 - pain and rubor
1 - pallor
- ischaemia means no blood arrives at the ankles
Bergers
- elevate both patients legs at 45 degrees for 2 minutes
- patient sits up and lets the legs drop at the side of the bed
- positive = legs have pallor when raised and extreme rubor when dropped over side of bed
Typically which imaging is 1st line in patients who present with chronic limb ischaemic and critical ischaemia?
1 - duplex ultrasound
2 - contrast-enhanced MR angiography (MRA)
3 - CT angiography
1 - duplex ultrasound
- good at generating an anatomical map of the lower limbs
- others can be used by doppler is 1st line
Will pulses be present in patients with chronic limb ischaemic and critical ischaemia?
- can be present OR absent
Comparing arterial and venous ulcers provides:
arterial = caused by ischaemia secondary to an inadequate blood supply
venous = impaired drainage and pooling of blood in the legs
Which of these ulcers are larger?
- venous ulcers
Comparing arterial and venous ulcers provides:
arterial = caused by ischaemia secondary to an inadequate blood supply
venous = impaired drainage and pooling of blood in the legs
Which of these ulcers are typically deeper?
- arterial ulcers
Comparing arterial and venous ulcers provides:
arterial = caused by ischaemia secondary to an inadequate blood supply
venous = impaired drainage and pooling of blood in the legs
Which of these ulcers are typically causes by minor trauma?
- venous ulcers
Comparing arterial and venous ulcers provides:
arterial = caused by ischaemia secondary to an inadequate blood supply
venous = impaired drainage and pooling of blood in the legs
Which of these ulcers typically have irregular borders?
- venous ulcers
Comparing arterial and venous ulcers provides:
arterial = caused by ischaemia secondary to an inadequate blood supply
venous = impaired drainage and pooling of blood in the legs
Which of these ulcers typically have a punched out appearance?
- arterial ulcers
Comparing arterial and venous ulcers provides:
arterial = caused by ischaemia secondary to an inadequate blood supply
venous = impaired drainage and pooling of blood in the legs
Which of these ulcers are typically more painful?
- arterial
Comparing arterial and venous ulcers provides:
arterial = caused by ischaemia secondary to an inadequate blood supply
venous = impaired drainage and pooling of blood in the legs
Which of these ulcers typically occur in the gaiter area (mid calf to malleolus) and often referred to a upside down champagne bottle?
- venous ulcers
Arterial ulcers typically occur in peripheries such as the toes
If a patient presents with chronic limb ischaemic and critical ischaemia, should they be advised to stop walking if they experience pain?
- no
Need to push through the pain to develop collateral circulation
If a patient presents with chronic limb ischaemic and critical ischaemia, should they be advised to use TED stockings to help with blood flow?
- no
Can worsen PVD
Before prescribing compression stockings in venous insufficiency, it is important to check that patients ankle brachial pressure index (ABPI). What must the ABPI be between in order to use compression stockings?
1 - 0.9-1.3
2 - 0.7-0.9
3 - 0.4-0.69
4 - <0.4
5 - >1.3
1 - 0.9-1.3
This is the normal value for ABPI
Once a patients lifestyle factors have been addressed (Smoking, anti-platelet, statins, ACE inhibitor) have been initiated surgery can be implemented. What is the 1st line surgical approach?
1 - catheterisation via femoral or radial artery
2 - bypass
3 - anticoagulants
4 - any of the above
1 - catheterisation via femoral or radial artery
- drug elution
- covered stents
If a patient has a vein graft, which is the most common vein used?
1 - tibial vein
2 - iliac vein
3 - long saphenous vein
4 - humeral vein
3 - long saphenous vein
