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Vascular > Peripheral Vascular Disease > Flashcards

Peripheral Vascular Disease Flashcards

1
Q

What is peripheral vascular disease

A

A range of arterial syndromes caused by atherosclerotic obstruction of the lower-extremity arteries

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2
Q

How do you classify peripheral vascular disease

A

Rutherford classification

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3
Q

What are the different stages of the Rutherford classification

A

0 - Asymptomatic
1 - Mild claudication
2 - Moderate claudication
3 - Severe claudication
4 - Rest pain
5 - Ischaemic ulceration not exceeding ulcer of the digits of the foot
6 - Severe ischaemic ulcers or frank gangrene

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4
Q

What are some other (rarer) causes of claudication

A

Aortic coarctation
Arterial tumour
Arterial dissection

Even rarer causes:-
Takayasu’s arteritis
Thoracic outlet obstruction
Buerger’s disease

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5
Q

What is the definition of claudication

A

Inadequate blood flow during exercise, causing fatigue, discomfort or pain

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6
Q

What is the defintion of critical limb ischaemia

A

Patients with all of:

  1. Rest pain (constant, distal worse, worse at night or on raising feet) or tissue loss (ulceration or gangrene)
  2. ABPI less than 40mmHg
  3. At least 2 weeks of symptoms

Due to compromised blood flow to extremity

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7
Q

What is the definition of acute limb ischaemia

A

Sudden decrease in limb perfusion that threatens limb viability

Associated with the 6 Ps:-
Pain
Pulselessness
Pallor
Perishingly cold
Paralysis
Paraesthesis (last two- require immediate revascularisation)
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8
Q

Which artery causes calf claudication

A

Superficial femoral artery stenosis

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9
Q

Which artery causes thigh claudication

A

External iliac artery stenosis

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10
Q

Which artery causes buttock claudication

A

Stenosis of the lower aorta and common iliac artery

*May be associated with impotence

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11
Q

What are some differentials of claudication

A

Musculoskeletal - osteoarthritis
Neurological - spinal stenosis
Vascular - intermittent claudication, DVT

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12
Q

Why might a limb be red in peripheral vascular disease

A

Vasodilatation of the microcirculation due to tissue ischaemia

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13
Q

What is ankle brachial pressure index

A

Ankle pressure divided by brachial pressure
Normal index is 1
As the perfusion of the leg begins to decrease in a patient with peripheral vascular disease, the ratio begins to fall

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14
Q

What is the ABPI of a patient with intermittent claudication

A

0.5-0.8

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15
Q

What is the ABPI of a patient with rest pain

A

Less than 0.5

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16
Q

What are the features of rest pain

A

Felt in the least well perfused areas of the leg - over the toes and forefoot
Very severe, aching pain
Wakes the patient from sleep
Relieved by walking/hanging the foot over the edge of the bed

*Calf pain at night in the absence of foot pain is unlikely ischaemic

17
Q

What are the features of critical limb ischaemia used to define it

A

Presence of arterial ulcers or gangrene OR
Rest pain that lasts for 2 or more weeks and is only relieve by opiate analgesia AND
An absolute ankle pressure of less than 50mmHg

18
Q

Why do patients with rest pain get more severe pain at night

A

Decreased perfusion of the limb due to:-
Decreased cardiac output at night
Reduced effect of gravity (which normally increases blood supply to the legs)
Dilatation of the skin vessels due to the warmth of the bedclothes

19
Q

What is the non-surgical management of peripheral vascular disease

A

Management of CV risk factors
Exercise programmes- “walk through pain”
Analgesia

*Naftidrofuryl oxalate (vasodilator therapy) available for patients who do not want revascularization surgery

20
Q

What is the surgical management of peripheral vascular disease

A

Duplex ultrasound must be performed when revascularization is considered

Endovascular approach: Angioplasty, stunting or balloon
Surgical:
Endarterectomy- for localised lesions only
Anatomical bypass surgery- around lesion e.g. ileo-femoral bypass
Extra-anatomical bypass e.g. fem-fem cross over, ax-fem bypass
Amputation

21
Q

What is the pathophysiology of reactive hyperaemia

A

Due to the vasodilation of microcirculation, secondary to the build up of toxic metabolites due to a period of oxygen deprivation.

22
Q

What would patients with critical limb ischaemia die of without amputation?

A

Gangrene or sepsis

23
Q

What would be the symptoms of a patient with critical limb ischaemia without treatment?

A

Unremitting pain at rest requiring opiates
Ulceration without pain (especially in DM)
Limb loss if untreated

24
Q

What is acute-on-chronic limb ischaemia?

A

Acute ischaemia that occurs on a background of claudication

25
Q

What is the usual cause for acute-on-chronic limb ischaemia?

A

Thrombotic occlusion of atherosclerotic vessels

26
Q

What symptoms would you see with acute-on-chronic limb ischaemia?

A

Legs may be pale, cold and pulseless but no parasthesia or paralysis present

27
Q

Why are the symptoms of acute-on-chronic limb ischaemia not as severe as those of acute limb ischaemia?

A

As collaterals have developed due to the chronic nature of the disease so the degree of ischaemia is not as severe.

28
Q

What are the causes of acute limb ischaemia?

A
  1. Embolic (solid/liquid/gas travelling from one point of circulation to a point in the distal circulation where it causes obstruction). Look proximal for source: heart valves (IE), AF (thrombus), ventricle (post MI)
  2. Thrombotic
29
Q

How do you treat acute limb ischaemia due to embolic occlussion?

A

Embolectomy- cut in artery, place uninflated balloon down past embolus, inflate and pull up to take embolus with it.

Must be done within 6 hours to avoid irreversible tissue loss

30
Q

How to you manage acute-on-chronic ischaemia?

A

Longer time interval than acute:

  1. Thrombolysis
  2. Thrombolysis + angioplasty
  3. Bypass graft
31
Q

Why do you need to feel for pulses in a patient with varicose veins?

A

Certain percentage will also have arterial disease

32
Q

What is Aortoiliac Occlusive Disease (AKA Leriche syndrome)?

A

Atherosclerotic occlusion of abdominal aorta and iliacs

33
Q

What are the classic triad of symptoms of Aortoiliac Occlusive Disease (AKA Leriche syndrome)?

A

Buttock claudication and wasting
Erectile dysfunction
Absent femoral pulses

34
Q

What is a Duplex scan?

A

2 parts:

  1. B-mode USS
  2. Multidirectional Doppler: gives idea re flow. Monophasic wave form suggests significant stenosis in arterial system above.
35
Q

What differentiates intermittent claudication from spinal claudication?

A

Spinal- positional: better upstairs and on leaning forward. Ill defined pain

Arterial- set difference, reproducible, worse upstairs, eased by rest

36
Q

What is Buerger’s test?

A

Lift leg to 45 degrees and observe for pallor and venous guttering

Normal- raise leg to 90 degrees with no pallor

37
Q

What would a Buerger’s angle of 20 degrees be suggestive of?

A

Severe ischaemia

Vascular (18 decks)

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