Peripheral Vascular Disease Flashcards by Alison Gourlay

What is an aneurysm?

Dilatation of a vessel by more than 50% of its normal diameter - (around 3cm)

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What is the normal aortic diameter?

1.2 – 2.0 cm

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What is a false aneurysm?

There is a breach in vessel wall (surrounding structures act as vessel wall)

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What is a true aneurysm?

The vessel wall is intact (i.e. all 3 layers)

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What is the pathenogenesis of an aneurysm?

Regulation of elastin/collagen in aortic wall
Aneurysmal dilatation
Increase in aortic wall stress
Progressive dilatation

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How do aneurysms present?

Asymptomatic (75% of AAA)
–Identified on imaging for other pathology
–Surveillance
Symptomatic
–Pain
May mimic renal colic
–“Trashing”
–Rupture

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How does an Abdominal Aortic Aneurysm rupture present?

Sudden onset epigastric/central pain
May radiate through to back
May mimic renal colic
Collapse

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When would you intervene in a AAA?

if it grows over 0.5cm in 6 months or >1cm in a year

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What is the only way to identify a ruptured AAA?

CT Scan

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What are the two types of AAA imaging?

CT scan and Duplex Ultrasound

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What are the two management options for an AAA?

Open Repair – open the body up
–Laparotomy
–Clamp aorta + iliacs

Endovascular Aneurysm Repair (EVAR) – requires a lot of follow up appointments
–Exclude AAA from ‘inside’ the vessel
–Inserted via peripheral artery
–X-ray guided

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What has a lower mortality? EVAR or Open Repair?

EVAR

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What can cause aneurysms?

Smoking
Hypertension
High Cholesterol
CVD
Diabetes

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What is acute limb ischaemia?

Sudden loss of blood supply to a limb due to occlusion of native artery or bypass graft

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What are the causes of Acute Limb Ischaemia?

Embolism
Atheroembolism – atherosclerosis plaque can break off and travel down the limb
Arterial dissection
Trauma
Extrinsic compression

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What are the 6 Ps of acute limb ischaemia? (clinical features)

Pain 
Pallor 
Pulseless
Perishingly cold
Paraesthesia
Paralysis

What does non blanching mottling mean?

Irrevesible ischaemia

Describe acute limb ischaemia pain?

Severe, sudden onset, resistant to analgesia

Calf/muscle tenderness with tight (‘woody’) compartment indicates muscle necrosis - Often irreversible ischaemia

Describe acute limb ischaemia pallor?

Limb initially white with empty veins

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

What is salvageable acute limb ischaemia?

0-4hrs

white foot
painful
sensorimotor deficit

What is partially reversible acute limb ischaemia?

4-12hrs

mottled
blanches on pressure

What is non salvageable acute limb ischaemia?

12+hrs

fixed mottling
non blanching
paralysis
compartments red

What is the management of acute limb ischaemia?

ABC – resuscitate and investigate
FBC, U/Es, CK, Coag +/- Troponin
ECG – MI, dysrhythmia 
CXR – underlying malignancy
Anticoagulate –Stops propagation of thrombus
Arterial Imaging
Urgent CT angiogram/ Catheter angiogram

What do diabetic foot problems encompass?

Diabetic neuropathy
Peripheral vascular disease
Infection

Where could diabetic foot sepsis come from?

simple puncture wound infection from the nail plate or inter-digital space from a neuro-ischaemic ulcer

What is the biggest risk factor for loss of a leg?

Diabetes

How does diabetic infection spread?

Within the foot the intrinsic muscles of the digits are confined within rigid compartments Infection tracks in the soft tissues into this rigid compartment. If the build up of pus cannot escape – the pressure builds up in this rigid compartment rapidly leading to impairment of capillary blood flow and further ischaemia and further tissue damage. –can rapidly progress to sepsis

What are the systemic clinical findings of diabetic foot sepsis?

``` Pyrexia Tachycardic Tachypnoeic Confused Kussmauls breathing ```

What are the local findings of diabetic foot sepsis?

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

What is the management of diabetic foot sepsis?

Vascular Surgical Emergency Appropriate antibiotics - Gram +ve cocci (S. aureus + Streptococcus sp.) Gram –ve bacilli (E. coli, Klebsiella sp, Enterobacter, Proteus sp and Pseuodomonas sp.) Anaerobes (Bacteroides)

How do you prevent diabetic foot sepsis?

adequate education foot assessment (diabetic foot clinic, podiatrist) pressure offloading footwear

What is intermittent claudication?

muscle ischaemia on exercise

What are the ranges for Ankle-Brachial Pressure?

Normal 0.9 - 1.2 Claudication 0.4 - 0.85 (– 1.0) Severe 0 - 4.5

What are the non invasive and invasive investigations of lower limb ischaemia?

``` Non invasive - Measurement of ABPI - Duplex ultrasound scanning Invasive - Magnetic resonance angiography (good cause no radiation, but need to lie for long) - CT angiography - quick - Catheter angiography ```

What is the treatment of lower limb ischaemia?

``` Slowing progression - Stop Smoking - Lipid Lowering - Antiplatelets - Hypertension Rx - Diabetes Rx - Life Style Issues Symptom improvement: - Angioplasty - Surgery - Exercise training ```

What is critical limb ischaemia?

Pain at rest = toe / foot ischaemia (nerve ending pain) | Ulcers/gangrene = severe ischaemia + damage

What are the amputation levels?

- transfemoral - hip disarticulation - through knee - transtibial