Peripheral Vascular Disease Flashcards
causes of chronic limb ischema
- ATheroSCLeroSIS
other rare
1. FMD
2. radiation induced vascular injury
vasculides (Bueger disease and takayasu )
Rutherford (Fontaine ) system e
I - asymptomatic
II - I.C
a - claudication >200m
b - claudication <200 m
III - rest pain
IV - ulcers , gangrenedefinition of rest pain
SEVERE pain, typically in the sole of foot that is relieved at night and relieved by swinging the foot over the edge of the bed
critical limb ischemia
patient with rest pain >2 weeks and ulcers and gangrene
Leriche syndrome
occlusion at bifurcation of aorta causing TRAID
- buttock/ thigh claudication
- absent reduced femoral pulses
- erectile dysfunction
what is the most common spot for I.C
distal superficial femoral artery - upper calf
Locations of I.C
distal superficial femoral artery - upper calf popliteal artery - lower calf common femoral - thigh pain Aortoiliac - buttock and thigh pain Tibial / peroneal - foot pain
DDX of I.C
- Spinal stenosis
- Osteoarthritis
- Nerve root compression - sciatica
investigation of i.C
- ABI - < 0.8 in the affect limb
- Duplex US
- CT angio
- MRA
- Digital subtraction angiography - GOLD STANDARD - used only if surgery or endovascular intervention is considered
- AAA
what type of surgery can be used to unresponsive medical management of I.C or if they develop critical ischemia
Endarterectomy - isolated common femoral occlusion
Fem - fem bypass graft - unilateral femoral occlusion
Fem-pop bipass
Fem- distal bypass
Porto-bifem bypass
definition of acute lower limb schema
abrupt decrease in perfusion that threatens viability to the lower limb
Blue toe syndrome
Painful ischemic lesions of LL with intact pulses
Paradoxical emboli
from intracardiac shunts *PFO or AV malformation
Causes of acute limb ischema
- EMBOLI
- direct arterial damage
- Intra-arterial drug injection
- popliteal aneurysm
- iatrogenic
complication of reperfusion in acute lower limb ischemia
- Reperfusion injury
- Rhabdomyolysis
- Compartment syndrome
- Complicatiosn related to catheter
- AV fistula
- pseudoanneurysm
- arterial dissection
- arterial perforation
AAA
abnormal localized dilatation of aorta extending normal diameter by >50% or diameter > 3cm
screening for AAA
<5.5cm - US every 6 months
>5.5cm - Diameter repaired electively
AAA investigation
- US
- X-ray - calcification
- CT abdo
what are the findings you see on CT angio
- IV contrast with highly accurate in determining size and extent of aneurysm
- relation to renal artery
- presence of a leak
- if suitable for endovascular repair
Open surgery repair for AA
Dacron graft to repair the aneurysm
- midline laparotomy
- Aorta is clamped BELOW the renal artery to prevent renal ischema
- graph is placed
Complication of AAA early
EARLY - death, haemorrhage - MI , cardiac arythmies, cardiac failure - BOWL ischemia , abdominal compartment syndrome - Atelectasis , LRTI , ARDS - Endoleak - Renal dysfunction Limb ischemia, foot emboli Would infection Sexual impairment
Late complication of AAA
- Graft infection
- Graph occlusion
- graph migration
- Aortoembolic fistula
- Endoleak
Endoleak types
TYPE 1: leak at attachment site of graph
TYPE 2: filling / aneurysmal sac by collateral vessels
TYPE 3: leak through defect in graph
TYPE 4: leak through the fabric of graph due to porosity
Type 5: expansion of aneurysm sac w/o evidence of leak on imaging
how does a patient with thoraco-abdominal anneyrsm present
Chest pain , back pain ,acute aortic regard and acute cardiac failure
WIDEN mediastinum on CXR
how does a patient with femoral anneyrsm present
pulsate groin swelling ± lower limb ischemia
visceral anneursm
Splenic artery aneurysms
RIND
reversible ischaemic neurological deficit - last > 24 hours from which recovery is complete
contraindication to carotid endarterectomy
Severe neurological deficit after cerebral infraction
Occluded carotid artery
severe comorbidities
carotid endarterectomy
LA or GA
- incision along anterior boarder of SCM
- smooth plane in the media of the artery
- smooth tappering endpoint on internal carotid is obtained
- endarterectomy is closed primarily OR with a patch
- technical results is verified with angiography or duplex
Complication of surgical treatment
CVA OR MI - increase risk in stenting or endartectomy Death Would hematoma --> airway obstruction Recurrent stenosis CN 9,10,11 damage
cause of aterial ulcers
- ARTHEROSCLEROSIS
- ARTERIAL EMBOLIZATION
Rarer:
- vasospasm
- trauma
- prolonged exposure to cold
Leads to; schema and ulcerations of the skin
cause of venous ulcers
Valvular impotence + adequate muscle pump action –> venous HTN
- Venous stasis - capillaries distension and leakage of fibrin around surrounding vessels and prevents Oxygen and nutrients getting to the tissue
- Increase Venous pressure –> damage of endothelial –> release of free radicals and enzymes –> destroys the tissue
what is linked to venous ulcers
Popliteal vein compression and obesity
treatment of venous ulcers
multilayer compression dressings that control exudates and colonization
Antibiotics if cellulite present
graduated compression stocking (RULE OUT ARTERIAL )
Skin grafting
saphenofemoral ligation and varicose vein stripping
neuropathic ulcers cute
by trauma unnoticed by patient
features of neuropathic ulcer
- PAINLESS
- punched out appearance
- located over pressure points / calluses
surrounded by inflammatory process
Diabetic ABI
- false elevated b/c diabetic foot
Diabetic ulcer RF
- previous RF
- Peripheral Neuropathy (Stocking distribution or Charcots)
- Ass. PAD
- Callusus
- living aline
- Other diabetic related complications
before angiography what must you tell that patient with diabetes
STOP METFORMIN 48 hours before to prevent lactic acidosis
how to treat an infected diabetic ulcers
- BS antibiotics
- debridement of dead tissue
- amputation
- get x-ray to outrun osteomyltitis
venous system of let is comprised of three groups
- superficial veins - long and short system and tributaries
- deep venous system - running b/w muscular compartment of the leg
- perforators in the calf and thigh - connects superficial and deep system
definition of saphenous veins
- tortuous dilatation segments of veins > 3mm in size ass/ w/ venous HTN caused by incompetent valves
complication of varicose veins 7
- tortuous veins on exam
- statsis dermatitis // eczema
- phlebitis
- lipoermatosclerosis - fibrosi dermatitis of subcutaneous tissue
- skin pigmentation - due to heamosiderin deposition
- Ulceration
- Bleeding
saphena varix
thrill located at the SFJ
Perthes maneuver
test to dertmine potency of deep venous system
- normally when tourniquet is one - you get patient to walk / toe stands - which empty veins
- if deep vein obstruction exist - MORE CONGESTED
Trendelenburg test
used to distinguish patient with superficial venous reflux
- empty veins while supine
- close off varicose vein - just below SFJ
- ask patient to stand - slow filling - superficial vein problem
- if rapid filling = reflux pathway is involved
most accurate way to dx outpatient reflux of veins
Hand held doppler auscultation
Gold standard test for varicose beings
COLOR DUPLEX
surgical treatment for Varicose veins
- Local stab avulsion
- SF / SP ligation
- LSV stippling
- Endoscopic perforator ligation
- radio frequency ablation
- laser ablation
Complication post Varicose veins
- Hematoma
- Bleeding
- Damage to rural and saphenous vein
- recurrence
- damage to surrounding artery
- Infection
Homan’s sign
Calf pain on dorsiflexion of foot (unreliable and should NOT be performed
when do you give an IVC filter
inserted percutaneously via jugular / femoral vein to catch and prevent PE's Used in: recurrent PE despite treatment C/I anticoagulant - major surgery
risk of IVC filter
PAH BIA pneumothorax Air embolism Heamothorax Bleeding IVC obstruction Arrhythmia
When do you use thrombolysis in DvT
- ACUTE limb schema
- Venous thrombi
- Acute surgical graph occlusion
- thromboses popliteal artery aneurysm
how do you give thrombosis in a patient with DVT who qualifies and what is the complication
give via a low dose intra-arterial infusion - allergy cather leak and occlusion nursing major bleed and stroke
complication of venous gangrene
- PE
2. venous gangrene
