Peripheral Vascular Disease Flashcards
What is chronic limb ischaemia , RFs & how is it caused?
Peripheral arterial disease -> symptomatic reduced blood to limbs (commonly lower)
Causes: atherosclerosis, rarely vasculitis
RFs: smoking, DM, hypertension, hyperlipidemia, older, FH, obesity, physical inactivity
Stage 1-4 for chronic limb ischaemia
Fontaine classification: 1 - asymptomatic 2 - intermittent claudication (cramping walking fixed distance, relieved few mins) 3 - ischaemic rest pain 4 - ulceration &/or gangrene
What is Buerger’s test & what is it used for?
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
What is Leriche syndrome?
Peripheral arterial disease affecting aortic bifurcation - buttock/ thigh pain + erectile dysfunction
How can critical limb ischaemia be defined (3 ways)? What are some other signs?
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
Differentials for limb ischaemia
- 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
Investigations for chronic limb ischaemia
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
Management of chronic limb ischaemia
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
What is acute limb ischaemia & 3 groups of causes
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)
Clinical features of acute limb ischaemia
6 Ps
- pain
- pallor
- pulselessness
- paresthesia
- perishing cold
- paralysis
Sudden onset symptoms
Normal, pulsatile contralateral limb sign emboli occlusion
Rutherford Clinical categories of acute limb ischaemia
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
Investigations acute limb ischaemia
Routine bloods - serum lactate, thrombillia screen <50yrs , G&S, ECG
Doppler USS
Consider CT angiography ⭐️
Limb salvageable -> CT arteriorgram - location occlusion
Management acute limb ischaemia
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
Complications of acute limb ischaemia
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
Risk factors and clinical features of peripheral & visceral aneurysms
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
Investigations & management peripheral & visceral aneurysms
CT angiography
MR angiography - reduced kidney damage risk, younger
US duplex - detection, follow up
Watchful waiting + medical (antiplatelet/ statin) + lifestyle
OR Surgery - endovascular/ open
Where are the most common peripheral artery aneurysms & how do they present? Management?
- 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
Where is the second most common site for peripheral aneurysms? How do they present? Management?
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
- uS Doppler
- cT/ MR angiography
✅open surgical repair
Where is the most common site for visceral artery aneurysms? How would it present & how would u manage?
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
What is the second most common location for visceral artery aneurysms? Presentation & management?
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
What type of aneurysms is often found incidentally but if it is sympathetic presents with haematuria, resistant hypertension or loin pain?
Renal artery aneurysms (3rd most common visceral aneurysms <20%)
CT / MR angiography
✅endovascular repair
(Kidney transplant)
What is acute mesenteric ischaemia and how does it present? What are some differentials?
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
How can the causes of acute mesenteric ischaemia be classified?
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
How would you investigate acute bowel ischaemia?
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
What causes amylase to rise?
3X - pancreatitis Mesenteric ischaemia Ectopic pregnancy Bowel perforation Diabetic ketoacidosis
Management of acute mesenteric ischaemia
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%
Define chronic mesenteric ischaemia and RFs
Reduced blood supply bowel gradually deteriorates - atherosclerosis CT/ SMA/ IMA
>60yrs Females Smoker Hypertension DM Hypercholesterolaemia
Clinical features of chronic mesenteric ischaemia
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
Differentials for chronic non-specific abdo pain
Chronic mesenteric ischaemia Chronic pancreatitis Gallstone Peptic ulcer disease Upper GI malignancy
Investigations for chronic mesenteric ischaemia
Blood tests - normal, electrolytes MG & Ca checked
Anaemia, CVS risk profile (lipids, glucose)
CT angiography⭐️
Management of chronic mesenteric ischaemia and complications of the disease
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
State the most likely diagnosis for the following:
1. 30yr FM, BMI 31, RUQ pain 2hrs post eating especially fatty food
- 71yr M, MI/ Stroke, ex smoker, severe abdo pain 2hrs after eating
- 56yr M, asthma, severe central abdo pain after ETOH XS
- 82yr M, HTN, smoker, sudden abdo/ back pain
- Gallstone disease
- Chronic mesenteric ischaemia
- Acute pancreatitis
- AAA
