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Orthopaedics > Peripheral Vascular Disease > Flashcards

Peripheral Vascular Disease Flashcards

1
Q

What is chronic limb ischaemia , RFs & how is it caused?

A

Peripheral arterial disease -> symptomatic reduced blood to limbs (commonly lower)

Causes: atherosclerosis, rarely vasculitis
RFs: smoking, DM, hypertension, hyperlipidemia, older, FH, obesity, physical inactivity

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2
Q

Stage 1-4 for chronic limb ischaemia

A 
Fontaine classification: 
1 - asymptomatic 
2 - intermittent claudication (cramping walking fixed distance, relieved few mins) 
3 - ischaemic rest pain 
4 - ulceration &/or gangrene
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3
Q

What is Buerger’s test & what is it used for?

A

Pt supine with raised legs -> pale (angle of this = Buerger’s angle*) -> lower legs until colour returns (May hyperaemic)

  • <20d = severe ischaemia

Chronic limb ischaemia

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4
Q

What is Leriche syndrome?

A

Peripheral arterial disease affecting aortic bifurcation - buttock/ thigh pain + erectile dysfunction

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5
Q

How can critical limb ischaemia be defined (3 ways)? What are some other signs?

A

Advanced form of chronic limb ischaemia
Chronic critical limb ischaemia - 3yr limb loss 40%

  • ischaemic rest pain >2weeks ✅opiates
  • ischaemic lesions or gangrene attributable arterial occlusive disease
  • ABPI <0.5

Other signs:
Limbs May pale/ cold, weak/ absent pulses
Limb hair loss, skin changes (atrophic/ ulceration/ gangrene)
Thickened nails

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6
Q

Differentials for limb ischaemia

A
  • spinal stenosis (neurogenic claudication)
    Pain back -> lateral leg (TfL) symptoms on initial movement/ relieved sitting
  • acute limb ischaemia - features <14days, presenting within hrs often
  • chronic limb ischaemia
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7
Q

Investigations for chronic limb ischaemia

A

Investigations:
~ Chronic limb ischaemia - clinical
~ Ankle-brachial pressure index - confirm diagnosis + quantify severity
>0.9 normal
0.5-0.8 moderate
(>1.2 calficiation/ hardening May cause falsely high)
~ duplex USS severity/ location
~ CT/ MR angiography ⭐️
~ CVS risk assessment (BP, glucose, lipid profile, ECG)
~ <50yrs without significant RFs thrombophilia screen + homocysteine levels

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8
Q

Management of chronic limb ischaemia

A

Conservative:
Smoking cessation, exercise, WL, diabetes control

Medical: statin (atorvastatin 80mg OD), anti-platelet (clopidogrel 75mg OD)

Surgical (risk factor modification discussed + supervised exercise failed improve, critical limb I = urgent, non healing infection/ necrosis/ rest pain ):

  • angioplasty +/- stenting
  • bypass grafting (diffuse/ younger)
  • combination
  • amputation (unsuitable revascularisation + incurable symptoms/ gangrene sepsis) 1-2% or 5% diabetes
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9
Q

What is acute limb ischaemia & 3 groups of causes

A

Sudden decrease limb perfusion threatens viability of limb
Occlusion arterial supply -> rapid ischaemia & poor functional outcomes hrs

3 main groups:

  • embolisation (AF, post-MI mural thrombus, AAA, prosthetic ❤️ valves)
  • thrombus in situ (atheroma plaque ruptures -> thrombus forms on cap acute-on-chronic)
  • trauma (less common, included compartment syndrome)
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10
Q

Clinical features of acute limb ischaemia

A

6 Ps

  • pain
  • pallor
  • pulselessness
  • paresthesia
  • perishing cold
  • paralysis

Sudden onset symptoms
Normal, pulsatile contralateral limb sign emboli occlusion

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11
Q

Rutherford Clinical categories of acute limb ischaemia

A

1 - viable - no sensory loss/ motor deficit, audible arterial/ venous Doppler - no immediate threat

2A - marginally threatened - minimal sensory loss + inaudible arterial Doppler

2B - immediately threatened - need immediate revascularisation - moderate sensory loss, rest pain, mild motor deficit, inaudible arterial Doppler

3 - irreversible - profound sensory loss, profound/ paralysis motor deficit, inaudible arterial/ V Doppler

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12
Q

Investigations acute limb ischaemia

A

Routine bloods - serum lactate, thrombillia screen <50yrs , G&S, ECG

Doppler USS
Consider CT angiography ⭐️

Limb salvageable -> CT arteriorgram - location occlusion

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13
Q

Management acute limb ischaemia

A

Surgical emergency

Complete arterial occlusion -> irreversible tissue damage within 6hrs

✅high flow O2, IV access, heparin

Rutherford 1/ 2a - prolonged heparin - regular APPT assessment

Surgery (2b mandatory)
Emboli cause - embolectomy, thrombolysis, bypass
Thrombotic disease - thrombolysis, angioplasty, bypass

Irreversible - amputation/ palliative

Long term:
Reduction CVS risks, anti-platelet (aspirin/ clopidogrel), maybe anticoagulation (warfarin/ DOAC), conditions treated
Amputation - OP, physio, rehabilitation plan

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14
Q

Complications of acute limb ischaemia

A

20% mortality
30 day post surgery 15%

Repercussion injury - sudden increase capillary permeability:

  • compartment syndrome (painful condition resulting from the expansion or overgrowth of enclosed tissue (as of a leg muscle) within its anatomical enclosure (as a muscular sheath) producing pressure that interferes with circulation and adversely affects the function and health of the tissue itself)
  • release K+, H+, myoglobin acidosis, AKI
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15
Q

Risk factors and clinical features of peripheral & visceral aneurysms

A

Aneurysm - persistent, abnormal dilation >1.5 X normal diameter

Aetiology unknown, possible causes: trauma, infection, Ct disease, inflammatory disease (Takayasu’s aortitis)

RFs: smoking, hypertension, hyperlipidemia, FH

Presentation:

  • asymptomatic
  • syntactic non-ruptured
  • ruptured stable/ unstable
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16
Q

Investigations & management peripheral & visceral aneurysms

A

CT angiography
MR angiography - reduced kidney damage risk, younger

US duplex - detection, follow up

Watchful waiting + medical (antiplatelet/ statin) + lifestyle
OR Surgery - endovascular/ open

17
Q

Where are the most common peripheral artery aneurysms & how do they present? Management?

A
  • popliteal 70-80% high risk embolisation/ occlusion, rare rupture
    Presentation: Acute limb ischaemia or intermittent claudication, incidentally (AAA repair, knee replacement), compression symptoms vein/ nerve

Investigations:
USS duplex (rule out bakers cysts, lymphadenopathy)
CT/ MR angiogram

Management: symptomatic / AS >2.5cm - treated
Thrombosis - thrombolysis/ embolectomy
Surgery - endovascular stent, ligation/ resection aneurysm + bypass graft

18
Q

Where is the second most common site for peripheral aneurysms? How do they present? Management?

A

Femoral artery typically pseudoaneurysms
Two major causes:
- percutaneous vascular interventions
- self injecting

Symptoms: thrombosis, rupture, embolisation, concurrent infection - varying acute limb ischaemia/ claudication - often just swelling in groin

  1. uS Doppler
  2. cT/ MR angiography

✅open surgical repair

19
Q

Where is the most common site for visceral artery aneurysms? How would it present & how would u manage?

A

Splenic artery 60%

Risk factors: female, multiple pregnancy, portal hypertension, pancreatitis, pancreatic pseudocyst formation

Symptomatic - vague epigastric or LUQ pain
Rupture - severe pain, haemodynamic compromise

CT / MR angiography
USS monitoring

✅endovascular repair

20
Q

What is the second most common location for visceral artery aneurysms? Presentation & management?

A

Hepatic artery 20%

Causes:
Percutaneous instrumentation 50% 
Trauma
Degenerative disease
Post liver transplant

Presentation:
Most asymptomatic
Stable symptomatic - vague RUQ/ epigastric pain, jaundice

CT / MR angiography

✅endovascular repair

21
Q

What type of aneurysms is often found incidentally but if it is sympathetic presents with haematuria, resistant hypertension or loin pain?

A

Renal artery aneurysms (3rd most common visceral aneurysms <20%)

CT / MR angiography

✅endovascular repair
(Kidney transplant)

22
Q

What is acute mesenteric ischaemia and how does it present? What are some differentials?

A

Sudden decrease blood supply to bowel -> ischaemia & eventually gangrene/ death

Presentation: generalised abdo pain out of proportion clinical findings, N&V 75%, unremarkable examination - May history CVS/ DVT/ PE/ hypercoaguable, late stage bowel perforation

Acute abdomen: Mesenteric ischaemia, peptic ulcer disease, bowel obstruction, AAA

23
Q

How can the causes of acute mesenteric ischaemia be classified?

A

Thrombus in situ (AMAT) - atherosclerosis - 25%

Embolism (AMAE) - cardiac/ abdo or thorac aneurysm - 50-%

Non-occlusive cause (NOME) - hypovolemic/ carcinogenic shock- 20%

Venous occlusion & congestion (MVT) - coagulopathy/ malignancy/ inflammatory disorders - <10%

Rarer: Takayasu’s arteritis, fibromuscular dysplasia, polyarteritis nodosa, thoracic aortic dissections

24
Q

How would you investigate acute bowel ischaemia?

A

Labs:
- ABG - acidosis, lactate
Routine bloods - FBC, U&Es, clotting, amylase, LFTs (coeliac trunk), G&S

Imaging:
CT + contrast (triple phase scan) (arterial BI - odematous -> loss bowel wall enhancement -> pneumatosis)
Perforation - erect CXR -> CT abdo + contrast

25
Q

What causes amylase to rise?

A 
3X - pancreatitis
Mesenteric ischaemia
Ectopic pregnancy
Bowel perforation 
Diabetic ketoacidosis
26
Q

Management of acute mesenteric ischaemia

A

Surgical emergency
✅resus - IV fluids, catheter, fluid balance chart
✅ confirmed - broad spec antibiotics
Acidosis, high risk multi organ failure - ITU input

Definitive:
Location/ timing/ severity

  • excision necrotic/ non-viable bowel (if can’t revascularise)
  • > potential relook laparotomy 24-48hrs - most covering loop/ end stoma + short gut syndrome
  • revascularisation of bowel (state patient/ bowel/ angiographic appearance vessels) angioplasty/ open embolectomy possible

Mortality 50-80%

27
Q

Define chronic mesenteric ischaemia and RFs

A

Reduced blood supply bowel gradually deteriorates - atherosclerosis CT/ SMA/ IMA

>60yrs
Females
Smoker
Hypertension
DM
Hypercholesterolaemia
28
Q

Clinical features of chronic mesenteric ischaemia

A

Typically asymptomatic due collateralisation (2 CT/SMA/IMA affected for symptoms) sometimes after eating/ haemorrhage exacerbate

Classic set symptoms:
Postprandial pain - 10mins-4hrs after eating
WL
Concurrent vascular co-morbidities e.g. MI, stroke, PVD

Also: change bowel habit, N&V, cachexia, abdo tenderness, abdo bruits

29
Q

Differentials for chronic non-specific abdo pain

A 
Chronic mesenteric ischaemia 
Chronic pancreatitis
Gallstone
Peptic ulcer disease
Upper GI malignancy
30
Q

Investigations for chronic mesenteric ischaemia

A

Blood tests - normal, electrolytes MG & Ca checked

Anaemia, CVS risk profile (lipids, glucose)

CT angiography⭐️

31
Q

Management of chronic mesenteric ischaemia and complications of the disease

A

Initial: modify RFs e.g. smoking, anti-platelet + statin

Surgery (severe disease, progressive, debilitating):

  • endovascular - mesenteric angioplasty + stenting
  • open procedures - endartectomy/ bypass

Complications:

  • bowed infarction
  • malabsorption
  • concurrent CVS disease
32
Q

State the most likely diagnosis for the following:
1. 30yr FM, BMI 31, RUQ pain 2hrs post eating especially fatty food

  1. 71yr M, MI/ Stroke, ex smoker, severe abdo pain 2hrs after eating
  2. 56yr M, asthma, severe central abdo pain after ETOH XS
  3. 82yr M, HTN, smoker, sudden abdo/ back pain
A
  1. Gallstone disease
  2. Chronic mesenteric ischaemia
  3. Acute pancreatitis
  4. AAA

Orthopaedics (14 decks)

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