Peripheral Vascular Disease Flashcards
In relation to the blockage where will pain be felt?
Distal
A patient comes into the GP with calf pain whilst playing golf, it is usually around the 5th hole but now nearer the 4th it is relieved when she stops. What is the diagnosis?
intermittent claudication
Describe intermittent claudication
muscle ischaemia on exercise, usually comes on at a steady distance & relieved at rest
Describe the progression of intermittent claudication
As symptoms worsen so does the blood supply until continuous pain at rest occurs leading to tissue loss
How can intermittent claudication be assessed?
Ankle brachial pressure index
What values indicate claudication from the ABPI?
Normal 0.9 -1.2
Claudication 0.4 - 0.85
Severe 0 - 0.4
What is a duplex ultrasound?
combination of doppler - looks at flow and ultrasound - sees a 3D image
Name three invasive tests for arterial disease
- Magnetic resonance angiography
- CT
- Catheter angiography
How can arterial disease be slowed down?
stop smoking lipid lowering anti platelet (aspirin & clopidogrel) hypertension treatment diabetes treatment lifestyle
What can be offered for intermittent claudication?
Supervised exercise programmes the more you walk the better it will be, however this only treats symptoms
What treatment is available for arterial disease?
- Angioplasty with batons & stents
- Bypass
Name three things required to complete bypass surgery
- inflow
- outflow
- graft
Why is it better to use a patients own vein as opposed to a prosthetic one?
Microorganisms love prosthetic veins whereas a patients own veins are resistant to infection
How can critical limb ischaemia be described?
Toe/foot pain usually at night when flat in bed, then progresses to all the time
What can critical limb ischaemia lead to?
Ulcers & gangrene as a result of minor trauma
State five clinical features of critical limb ischaemia
- cold
- absence of pulses
- poor tissue nutrition
- venous guttering
- ulcers/gangrene
What is venous guttering?
When you lift the leg up the vein will empty rapidly
If an artery cannot be treated what is required?
Amputation
What does amputation depend on?
Damage to leg & blood supply
Name the structure that connects the deep venous system to the superficial system
Perforators
What is required in order to get blood out of the legs?
- Vessel
- Valves (one-way system)
- Pump (muscles)
Define varicose vein
dilated, tortuous superficial elongated vein due to abnormal transmission of deep vein pressure
What are the two types of varicose vein?
Primary - occurs out of the blue
Secondary - due to DVT
Name risk factors for Varicose veins
- Age (old)
- Gender (female)
- Pregnancy
- Obesity
- Family history
State five clinical features of Varicose Veins
- bleeding
- thrombophlebitis
- venous hypertension
- lipodermatosclerosis
- ulceration
What do you do if a varicose vein starts bleeding?
Elevate and apply pressure
Define thrombophlebitis
inflammation of a vein caused by a clot
What does venous hypertension lead to?
Haemosiderin deposits
State the characteristics of lipodermatosclerosis
white cells, inflammation & fibrosis
Why must you be careful of ulceration?
There may be an underlying cause especially if it has rolled edges
What investigation is done for varicose veins?
Duplex scan to check if;
- occlusion or incompetence
- which vein/valve is affected
How can a varicose vein be managed?
Educate the patient, bandaging & graduated compression
When are compression stockings contraindicated?
Patients with a low ABPI
What procedures can be done on a patient with varicose veins?
Endogenous - foam or ablation - x-ray guided
Surgery - high tie distal from ablation (50% risk of wound infection)
What are the three types of ablation?
- mechanical
- laser (heat)
- radiofrequency (waves)
Define abdominal aortic aneurysm
dilatation of a vessel by more than 50% of its diameter
In terms of vessel wall what are the two types of aneurysm
true - vessel wall is intact
false - breach in the vessel wall
Name three types of aneurysm
- saccular
- fusiform
- mycotic - due to infection
Describe the pathogenesis of AAA
Medial degeneration leads to an imbalance between elastin/collagen. This causes aneurysmal dilatation and increase in vessel wall stress
Name four risk factors for AAA
- age
- gender
- smoking
- hypertension
What are the symptoms of an AAA?
75% asymptomatic
Symptoms ; pain, trashing, rupture
Define trashing
Parts of the thrombus break off & clot
How are asymptomatic patients diagnosed?
Imaging
How will an AAA rupture present?
Sudden onset epigastric pain, the patient may look well but will be hypo/hypertensive, pulsatile, have transmitted & peripheral pulses
What types of AA are treatable?
Contained retroperitoneal but 50% operative mortality
When are AAA dealt with?
If symptomatic, >5.5cm, grows >1cm/year
How are AAA detected?
Duplex ultrasound - allows you to see front - back diameter
Name the investigation used to assess the complexity of the aneurysm
CT scan using IV contrast, only method in detecting a ruptured AAA
What is the management for an AAA?
Open repair (laparotomy, clamp aorta & iliac, graft new aorta) Endovascular (EVAR, x-ray guided insertion of a stent with a seal)
Define acute leg ischaemia
sudden loss of blood supply to a limb
What are the causes of acute leg ischaemia?
- embolism
- atheroembolism
- arterial dissection
- trauma
- extrinsic compression (cancer & limb disease)
State the six P’s of acute leg ischaemia
Pain Pallor Pulseless Persistently cold Paraethesia Paralysis
After how many hours of no blood supply can a leg be saved?
0-4 hours salvageable
4-12 hours partly reversible
>12 irreversible (not blanching/ turning white from purple when pressed)
Describe the test for a patient with acute limb ischamia
ABC
FBC U/E, CK, Coag, Troponin
ECG
If the limb is salvageable what is done?
Embolectomy
Fasciotomies
Thrombolysis (rare)
If it is not salvageable what is done
Palliation or amputation
What does the ageing population mean?
Not just one emboli may be present
What is the triad for a diabetic foot sepsis?
- neuropathy
- PVD
- Infection
What does diabetic foot sepsis lead to?
Ulceration, necrosis & gangrene strongest risk factor for
State the causes for diabetic foot sepsis
- simple puncture wound
- infection from the nail plate/inter-digital space
- neuro-ischaemic ulcer
Build up of puss cannot escape, pressure builds up leading to rapid sepsis & necrosis
What are the features of diabetic foot sepsis?
- swollen affected digit/forefoot
- tenderness
- ulcer
- erythema
- patches of necrosis
Describe the management of diabetic foot sepsis
Polymicrobial needs broad spectrum antibiotics & rapid surgery of infected tissue - open wound to encourage drainage
How can diabetic foot problems be prevented?
Education &assessment
