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Cardiovascular > Peripheral vascular disease > Flashcards

Peripheral vascular disease Flashcards

1
Q

What is an aneurysm?

A

Dilation of a vessel by more than 50% of its normal diameter

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2
Q

What is normal aortic diameter?

A

1.2-2cm anterior posterior therefore aorta >3cm is aneurismic

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3
Q

What is a true aneurysm?

A

The vessel wall is in tact- involves dilation of all 3 layers, intima, media and adventicia

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4
Q

What is a false aneurysm?

A

There is a breach in the vessel wall meaning surrounding structures act as a vessel wall

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5
Q

What are the 2 shapes of aneurysm?

A

Secular - most likely to rupture

Fusiform - most common

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6
Q

What are myotic aneurysms?

A

Secondary to infectious process and invole all 3 layers of the artery wall => weakness and rapid dilation

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7
Q

What is the pathogenesis of AAA?

A

Medial degeneration

1) Regulation of elastin/collagen in the artery wall
2) Aneurysmal dilation increasing aortic wall stress
3) Progressive dilation=> ruptue?

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8
Q

What are the risk factors for AAA?

A

Age, gender, smoking, hypertension and atherosclerosis

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9
Q

What is the prevalence of AAA?

A

8% in males over 65
Male: Female = 9:1
25% of people with AAA also have popliteal aneurysms which tend to clot leading to limb ischemia and amputations
Ruptured AAA is the 7th most common cause of death in males in the UK

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10
Q

How does AAA present?

A

75% assymptomatic and identified on imaging to other pathology (often renal failure) Surveillanc eprogramme for men over 65.
25% are symptomatic and present with:
1) Pain mimicing reanl cholic or MI
2) Trashing- forming a clot in the lumen which embolises and travels to distal arteries causing peripheral pain/ischemia
3) Rupture- sudden onset, central/epigastric pain. May radiate through to the back and mimic renal cholic, MI collapse

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11
Q

What would you find on examination of someone with a ruptured AAA?

A 
May look well
Hypo.hyper/normatensive
Pulsatile mass +/- tender 
Transmitted pulses possibly seen or felt in the back
Reduced or no peripheral pulses
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12
Q

What are the outcomes of ruptured AAA?

A

75% will not make it to hospital
Reteroperitoneal rupture- better survival as the peritoneum contains the rupture
Free intraperitoneal rupture into abdominal organs is rapidly fatal
Of the 25 % who make it to hospital, there is a 50% operative mortality

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13
Q

When should you intervene in a AAA?

A

1) Symptomatic, trashing, rupture
2) Assymptomatic = >5.5cm AP diameter. The risk of rupture begins to climb above 5.5cm
>0.5cm in 6 months expansion or >1cm in a year is worrying

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14
Q

How are AAA imaged?

A

U/S- assymptomatic screening or surveillance. Shows AP diamer and involvement of illiac arteries
CT andiogram- give conrast into the vein and time the contrast in the arteries. Give shape, size and illiac involvement. Allows for management and planning as some stents are unique t patients

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15
Q

What is the only way to identify a ruptured AAA?

A

CT scan

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16
Q

What are the surgical interventions for AAA?

A 
Open repair (traditional) 25%
Endovascular aneurysm repair (EVAR)
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17
Q

How is an AAA open repiar carried out?

A

1) Laparotomy and a clamp to aorta and illiacs. Open aneurysm sac.
2) Dacron graft used- can have a tube or bifurcated graft
3) The graft must not touch the bowel as the stitchig doesn’t dissolve and will irritate the bowel=> close aneurysm sac over the graft
4) Planned hospital stay ~7-10 days. Rupture ~1 month

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18
Q

How is an endovascular aneurysm repair carried out?

A

1) Much less invasive as you exclude AAA from the inside of the vessel. Grafts are inserted via a peripheral artery
2) X ray guided with modular components
3) Planned 3 days hospital stay. Rupture 7-10 days in hospital

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19
Q

What are the disadvantages of EVAR?

A

Require life long follow up and if the patient changes shape the graft may slip or not fit => leaks
15-20% of EVAR patients will need further intervention later in life

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20
Q

WHat is acute limb ischemia?

A

Sudden loss of blood supply to a limb. Occlusion of native artery r bypass graft => excruciating pain

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21
Q

Why is acute limb ischemia more common in the legs than arms?

A

The arms have a collateral blood supply

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22
Q

How do you determine between acute and acute on chronic limb ischemia?

A

A acurate history and examination.

Really important as the management and urgency are different.

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23
Q

What are the causes of a sudden artery occlusion?

A

Embolism- usually from heart (MI, AF or VF)
Atheroembolism at the site of occlusion
Arterial dissection (intima tears and this can block the artery)
Trauma- dislocation and fractures- especially knee
Extrinsic compression due to tumour/malignancy

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24
Q

WHat are the clinical features of lower limb ischemia? (6 Ps)

A 
Pain- excrutiating
Pallor- shet white initially
Pulseless- no peripheral pulses 
Perishingly COLD- no blood flow
Paraesthesia- numbness and tingling
Paralysis- poor prognosis
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25
Q

When is acute limb ischemia more likely?

A

No prior history of claudication
Known or likely cause of embolism (AF or arrythmia)
Full component of contralateral pulses

26
Q

Describe the pain with acute limb ishemia?

A

Severe, sudden onset, resistant to analgesia, calf/muscle tenderness with a tight compartments indicates muscle necrosis (usually irreversible ischemia)

27
Q

Describe the pallor with acute limb ischemia?

A

Initially white with empty veins. Later capillaries fill with stagnated and deoxygenated blood giving a mottled appearance (Blanching mottling- can be revascularised). Later arteries distal to occulsion will fill with thrombi and rupture capillaries (non blanching mottling- irreversible)

28
Q

Describe the paraethisia/paralysis with acute limb ischemia?

A

Sensor motor deficit are indicative of muscle and nerve ischemia- salvageable with prompt revascualisation

29
Q

What are the time frames for saving limbs?

A

0-4 hours = white painful and sensor motor deficit- salvageable
4-12 hours = mottled, blanches on pressure- partially reversible
>12 hours = Fixed mottling, non blaching, compartments tender, paralysis- non salvageable

30
Q

Why is you revascularise and reperfuse after 12 hours of acute limb ischemia are you likely to kill the patient?

A

Dead tissue and necrosis releases toxins which are poisonous to the heart and kidney

31
Q

What are the investigations important in acute limb ichemia?

A 
Bloods = FBC, U/Es, CK, Coagulation +/-troponin
ECG = MI or dysrhythmia
CXR = underlying malignancy- do not delay surgery for a CXR
32
Q

How is acute limb ischemia managed?

A

ABC- resuscitate and investigate
Anticoagulate- stops propagation of thrombus and can improve ischemia
CT angiogram of arteries to identify affected area

33
Q

If the limb is salvageable what next?

A

Embolectomy +/- Fasciotomies +/- thrombolysis

NB: Muscles will swell within fixed fascial compartment and compress arteries and veins so you must cut fascia.

34
Q

If the limb is not salvageable, what next?

A

Amputation or palliation (amputation is a huge surgery and life changing- will the person cope)

35
Q

What can cause diabetic foot sepsis?

A 
A puncture wound
Infection of a nail patate or interdigit space
Neuroischemic ulcer (occurs in area of increased pressure
36
Q

What problems can diabetis get with their feet?

A

Diabetic neuropathy- cannot feel trauma
PVD- stiffened arteries prone to atherosclerosis
Infections- highly prone to infections

ALL => Tissue ulceration, necrosis, gangrene and limb amputation

37
Q

What is the single strongest risk factor for limb loss?

A

Diabetes- 50% of diabetic amputees with undero a contralateral amputation within 5 years of the first amputation

38
Q

What happens if you get an infection in your foot?

A

1) Intrinsic muscles of digits are bound by ridgid compartments with plantar fascia, metatarsal bones and interosseous fascia
2) Infection tracts in the soft tissue into this redgid compartment
3) The build up of puss cannot escape
4) Increased pressure increases capillary blood flow => ischemia and tissue damage
5) Can rapidly progress to sepsis and limb loss

39
Q

Is diabetic foot sepsis a vascular surgical emergency?

A

YES

40
Q

What are the clinical findings of diabetic foot sepsis?

A

SYSTEMIC: pyrexia, tachycardia, tachypnoeic, confused, kussmauls breathing, acidotic
LOCAL: Swollen affected digit/forefoot, tenderness, ulcers, erythema up limb, patchy necrosis, crepitous in soft tissues +/- pedal pulses

41
Q

What is crepitous in soft tissues?

A

Bubble wrap under skin- gas from microorganisms

42
Q

What is Kussmauls breathing?

A

Deep and laboured breathing pattern

43
Q

What is the management of diabetic foot sepsis?

A

Appropriate antibiotic given at earliest opportunity

Surgery performed early to remove ALL infected tissue and leave wound open to encourage drainage

44
Q

What are the common microorganisms that cause diabetic foot sepsis?

A

Gram + = Staph aureus and Strep sp
Gram - = E coli, Klebsiella, Enterobacter and pseudomonas
Anaerobes = bacterioides

45
Q

How is diabetic foot sepsis prevented?

A

Adequate assessment, education and services (diabetic foot clinic/podiatrist) and pressure off loading footwear

46
Q

What is intermittent claudication?

A

Insufficient blood reaches exercising muscle => development of collateral arteries
Patient pain free at rest, develops pain in ischemic limb after variable periods of exercise which is relieved by rest.
Will progress if risk factors are not managed.

47
Q

What questions are good for a history of intermittent claudication?

A

How far on the flat can you walk pain free?
How far can you walk before you have to stop?
Does the distance change if you walk faster, uphill, heavier person?

48
Q

What is the Fontaine stage for claudication?

a) Stage 1
b) Stage 2a
c) Stage 2b
d) Stage 3
e) Stage 4

A

a) Stage 1 = Normal
b) Stage 2a = intermittent claudication >200m walking
c) Stage 2b = Intermittent claudication <200m walking
d) Stage 3 = Pain at rest
e) Stage 4 = Tissue lost

49
Q

What are the risk factors for intermittent claudication?

A

Male, Older, diabetes, smoking, hypertension, hypercholesterolaemia
Within 5 years of PVD, 7% have a CVA and 8% have MI

50
Q

What should you examine and investigate for intermittent claudication?

A

Examination = peripheral pulses
Investigations = Ankle brachial pressure index ABPI, duplex ultrasound scanning (non invasive)
Magnetic resonance angiography (MRA), catherter angiography (invasive)

51
Q

How do you carry out ABPI?

why must you be cautious with diabetics

A 
ABPI = ankle pressure /brachial pressure
Normal = 0.9-1.2
Claudication = 0.4-0.85
Severe = 0-0.45
Diabetics: can have calcified vessels which record falsely high ankle BPs
52
Q

What is duplex ultrasound useful for?

A

Assessing flow in both directions as it highlights in different colours. Helps you to see turbulence but needs a skilled opperator.

53
Q

What are the advantages and disadvantages for Magnetic resonance angiography?

A

+ No radiation, good images

- Contrast irritates kidney, tajes time, niosy, must be still, claustrophobic

54
Q

What are the advantages and disadvantages of CT angiography and Catheter angiography?

A

CT angiography
+ quick and accurate
- high dose radiation and contrast irritates kidney
Catheter angiography- takes 4 images without contrast and 4 with and then subtracts the images
+ Very accurate
- More invasive

55
Q

What is the medical management for chronic lower limb ischemia

A

Smoking, diet, exercise, statins, antiplatlets , hypertension Rx and diabetes Rx

56
Q

What will improve the symptoms of claudication symptoms?

A

Exercise training, drugs, angioplasty/stenting, maybe surgery.

57
Q

What are the problems with angioplasty/stenting for cludication?

A

Claudication can recur

Problems with stenosis and occlusion of stents

58
Q

What are the surgical options for claudication?

A 
Endartectomy
Bypass ( eg illiac crosspver graft, aortobifemoral graft or axillobifemoral grft). Can be anatomical or extraanatmical. Uses a prostetic or a vein (vein better as resists infection)
59
Q

What are the symptoms of critical limb ischemia?

A

Pain at rest effecting toes and forefoot
Worse at night, helped by sitting and putting leg is dependent position as gravity assits blood flow
Helped by getting up and walking about

60
Q

What are the risk factors for amputaion due to critical limb ischemia?

A

Smoking- major risk factor for peripheral artery disease
1 in 10 patients with intermittent claudication every 5 years if they continue to smoke.
Diabetes- incidence 2.5% of the population but 50% of all amputees are diabetic

61
Q

What are the levels of amputation?

A 
Hip disarticulation
Transfemoral
Through knee
Trans tibial 
Digit
62
Q

What must be considered when choosing a level of amputation?

A

The lower the amputation the less likely it is to heal
The higher the amputation the greater the loss of function
Independence is much more likely with a below knee amputation

Cardiovascular (24 decks)

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