Peripheral vascular disease Flashcards by Nader Raafat

Spectrum of severity of peripheral arterial disease (Fontaine classification)

I: Asymptomatic ischaemia

II: Limb claudication

III: Critical limb ischaemia (night/rest pain)

IV: Tissue loss + gangrene

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Features of asymptomatic ischaemia

ABPI <0.9

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ABPI >1

Calcified arteries –> inelastic

May falsely raise an ischaemic BP result

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Features of limb claudication in the Hx

Site: Muscle groups affected, location indicates where pathology is

Onset: Exertional, relatively constant distance (shorter if uphill, cold, after meal)

Character: Cramp-like, tight pain

Relieving factors: Rest (few minutes)

Severity: What is the claudication distance? Has it changed

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Where is the likely pathology in claudication affecting calves only

Popliteal or superficial femoral artery

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Where is the likely pathology when calves + thighs affected

SFA and profunda affected –> likely common femoral bifurcation

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Where is the likely pathology when claudication affects the buttocks?

Bifurcation of the common iliac affected

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What does a monophasic doppler sound indicate?

No elastic recoil of arteries –> indicates atherosclerotic disease

Quiter = more severe

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Triphasic doppler sound

Normal

Forward flow in systole

Reverse flow in late systole/early diastole

Elastic recoil in late diastole

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Biphasic doppler sound

Forward flow in systole

Reverse flow in diastole

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Claudication vs walking distance

Claudication: Distance before pain

Walking: Distance before they need to sit down

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Pathophysiology of night-time pain

Loss of beneficial effects of gravity + reduction of BP + CO during sleep –> woken in the middle of the night

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Features of night-time pain

S: Bottom of the foot

O: Wakes up in the middle of the night

E: Relieved by hanging legs off side of the bed, may choose to sleep on chair

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Definition of critical limb ischaemia

Rest pain persisting for >2w

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Differentiating diabetic neuopathy from critical limb ischaemia

Diabetic nephropathy features:

S: not always confined to foot

C: Burning, tingling, numbness

E: Exacerbated by touch

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Differential for lower limb pain

Peripheral arterial disease

Neurogenic (spinal stenosis/spinal root compression)

Venous outflow obstruction

Acute limb ischaemia

Compartment syndrome

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Features of neurogenic lower limb pain

S: Ill-defined, whole leg, often bilateral

O: Immediately upon standing/walking

C: May be associated with numbness/tingling

A: Nil

E: Relieved by bending forwards/rest/sitting

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Features of venous claudication

S: Nearly always unilateral, affects whole leg

O: Gradual from moment walking starts

C:‘Bursting’

A: Oedema, cyanosis, varicose veins, ?increased temperature

E: Relieved by leg elevation

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Features of acute limb ischaemia

6 Ps:

Paralysis

Paraesthesia

Pain (incl. muscle tenderness, indicates impending infarct)

Perishingly cold

Pallor

Pulseless

Features of embolic cause of acute limb ischaemia

Sudden onset

No previous Hx of claudication

Embolic source: E.g. AF

Normal pulses in contralateral leg

Pathophysiology of compartment syndrome

Increased pressure within muscle fascia compromising blood supply

Leading causes of compartment syndrome

Lower limb trauma (e.g. tibial fracture)

Reperfusion injury after Rx of acute limb ischaemia

Clinical features of compartment syndrome

Severe pain exacerbated by passive/active movement

Features of acute mesenteric ischaemia

Severe abdominal pain (out of proportion to nil signs)

Shock

Acidosis

Bloody diarrhoea

Definition of AAA

Focal dilatation of aorta \>150% of diameter, majority are infra-renal

Features of ruptured AAA

Abdominal pain radiating to back/fossae/groins (may be intermittent but *not* colic) Expansile abdominal mass Shock/syncope (may have raised BP early on) (often symptoms not clear/present, CT shoould be requested if suspicious)

Common sites for aneurysms

Abdominal Iliac Femoral Popliteal

Management of ruptured AAA

Catheterize bladder + gain large-bore IV access Keep BP \<100 to avoid rupturing contained leaks Prophylactic Abx

Features of Buerger's disease

Young heavy smokers (usually males 20-45) Thrombosis/inflammation of medium arteries/veins leading to ischaemia and thrombophlebitis Need to stop smoking

Investigation of peripheral arterial disease

Exclude DM, arteritis (CRP/ESR) FBC Lipids ECG ABPI Doppler USS (Duplex) Angiography

Risk factors for aneurysms

Hypertension Hypercholesterolaemia Diabetes Smoking FHx Trauma Connective tissue disorders (Marfan's, Ehlers-Danlos) Inflammatory arteritis (e.g. Takayasu's)

What is the ABPI

Ratio of highest pedal pulse (dorsalis pedis/PT) to highest brachial pulse (measure both arms)

Anatomical location of short saphenous vein

Behind the lateral malleolus Posterior calf Joins popliteal vein approx 2cm above the knee crease

Anatomical location of great/long saphenous vein

Medial malleolus Medial calf Join common femoral vein in groin

Etiology/risk factors of superficial venous insufficiency

Congenitally abnormal veins Direct trauma Superficial thrombophlebitis Prolonged standing/obesity Pregnancy/OCP Reduced calf muscle pump

Pathophysiology of post-thrombotic (i.e. post-DVT) syndrome

DVT damages venous valves Deep venous obstruction + valvular incompetence --\> pain, blue discoloration, ulceration Dilated superficial veins

Clinical features of superficial thrombophlebitis

Affects 10% of patients with varicose veins Red, tender cord

What do you suspect with recurrent superficial thrombophlebitis affecting non-seuqential/non-varicose veins

Underlying malignancy

Risk factors for DVT

**Lifestyle:** * Smoking * Obesity * Recent long-haul flight **Iatrogenic:** * Recent immobilisation/surgery * Central venous catheterisation * Oral contraceptive pill **Medical conditions:** * Recent trauma (think repetitive vigorous sport for upper limb) * Hereditary thrombophilia * FHx/PMHx of DVT * Pregnancy * Malignant disease

Primary investigation for varicose veins

Doppler ultrasound backflow (should be \<0.5s as calf muscle is released)

Causes of leg ulcers

**Venous** (70%) **Mixed arterial/venous** (15%) **Arterial** (2%) **Other:** Neuropathic (in DM), vasculitic, malignant, trauma (pressure sores)

Significant Hx questions for leg ulcers

**HPC:** Number, recent trauma, pain **PMHx:** DM/other neuropathy, DVT/VVs, peripheral arterial disease, vasculitis **DHx:** steroids

Pain characteristics in venous, arterial, neuropathic ulcers

**V:** Painless/pain improves on elevation **A:** Severe pain improves on dependency/worse on elevation **N:** Painless/neuropathic pain

Appearance of arterial, venous, neuropathic ulcers

**A:**'punched out', regular **V:** Irregular border, granulating base **N:** Soft/moist skin

Site of artierial, venous, neuropathic ulcers

**A:** Pressure points (heels, balls of feet, toes, malleoli) **V:** Medial calf (gaiter area, 80%), lateral gaiter area (20%) **N:** Pressure areas, soles of foot, tips of toes

Surrounding skin in venous, arterial, neuropathic ulcers

**V:** Warm, VVs, oedema, lipodermatosclerosis **A:** Cold, shiny, hairless, empty veins **N:** Dry, reduced sensation

What is lipodermatosclerosis?

Haemosiderin deposition from venous insufficiency --\> chronic inflammation + fat necrosis --\> hardening + discolouration of skin