Peripheral Vascular Disease Flashcards

1
Q

What causes peripheral vascular disease (PVD)?

Who does it affect?

A

PVD is caused by atherosclerosis causing stenosis commonly affecting the:
=> aorto-iliac arteries
=> infra-inguinal arteries

Commonly affects the middle aged ; men > women

Mortality is often assoc. with co-existing CVS or cerebrovascular disease, not PVD

PVD = umbrella term for many different conditions/manifestations

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2
Q

What are the clinical symptoms of chronic lower limb ishcaemia?

A

Fontaine classification:

Stage I: asymptomatic
Stage II: intermittent claudication
Stage III: Rest pain / nocturnal pain
Stage IV: necrosis / gangrene

=> intermittent claudication: patients complain of exertional discomfort/cramping pain in the calf, thigh, buttock. Relieved by rest.

Patients with aorto-iliac disease => pain in bum, hip, thigh ± erectile dysfunction

=> Rest pain: severe, burning, unremitting pain in foot - stops patient from sleeping. Relieved by dangling foot over the edge of the bed or standing on a cold floor = cardinal feature of critical ischaemia

=> Severe PVD / lower limb ischaemia = ulceration or necrosis of tissue (gangrene)

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3
Q

What are the signs of chronic lower limb ischaemia ?

A

Cold, white lower limbs with dry skin + lack of hair

Atrophic skin ; punched out ulcers (painful)

Pulses femoral, popliteal, foot absent

Ulceration ± dark discolouration of toes / gangrene

Capillary filling time >15s - severe ischaemia

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4
Q

What is the differential diagnosis for chronic lower limb ischaemia ?

A

Spinal canal claudication (all pulses present)

Osteoarthritis of the hip/knee (knee pain at rest)

Peripheral neuropathy

Popliteal artery entrapment

Venous claudication (bursting pain with walking with past hx of DVT)

Fibromuscular dysplasia

Buerger’s disease

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5
Q

What are the investigations for [acute & chronic] lower limb ischaemia?

A
  1. Ankle/Brachial pressure index (ABPI) - severity of chronic limb ischaemia
    => ABPI 0.5 - 0.9 = intermittent claudication
    => ABPI <0.5 = critical limb ischaemia
  2. Colour duplex ultrasound = first line investigation
  3. Contrast-enhanced MR angiography
  4. CT angiography
  5. Digital subtraction angiography
  6. Exclude diabetes, arteritis (ESR, CRP), FBC (anaemia, polycythaemia), U&E (renal disease), lipids (dyslipidaemia), ECG (cardiac ischaemia), thrombophililia screen
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6
Q

What is the medical management of chronic lower limb ischaemia?

A
  1. Risk factor management because PVD patients at increased risk of IHD and cerebrovascular disease. Diabetes managed + regular chiropodist review.
    Quit smoking.
  2. Supervised exercise programme to all with intermittent claudication
  3. Naftidrofuryl oxalate => vasodilator agent, inhibits vascular and platelet 5HT2 receptors => lowers lactic acid
    => Improves quality of life + increase walking distance
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7
Q

What is the surgical management of chronic lower limb ischaemia?

A

Percutaneous trans-luminal angioplasty = first line
=> carried out via a catheter inserted into femoral artery

Arterial stents may be used in recurrent iliac disease

Bypass procedures

Amputation in severe ischaemia with unreconstructable arterial disease

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8
Q

What are the symptoms of acute lower limb ischaemia?

A
5 P's
=> Pain
=> Pallor
=> Paraesthesia 
=> Paralysis 
=> Perishingly cold
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9
Q

What are the signs of acute lower limb ischaemia?

A

Cold skin with molting / marbling => irreversible

Pulses diminished/ absence

Sensation and movement of the leg reduced in severe ischaemia

Patients may deliver compartment syndrome with pain in the calf on compression

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10
Q

What is the underlying aetiology of acute lower limb ischaemia?

A

Acute limb ischaemia may occur due to an embolic or thrombotic disease.

Embolic disease:
=> commonly due to cardiac thrombus / arrhythmia i.e. AF

=> also due to 2nd to aneurysm thrombus or thrombus from an atherosclerotic plaque

Thrombotic disease:
=> more common than emboli

=> acute thrombus forms on a chronic atheroscleroctic stenosis in patients with symptoms of claudication

=> thrombus in normal vessels if hypercoagulable due to malignancy or thrombophilia

=> Prosthetic or venous graft can thrombose

=> Popliteal aneurysm can thrombose or embolise distally

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11
Q

What is the management for acute lower limb ischaemia?

A

Surgical emergency requiring revascularisation within 4-6h to save the limb !!

  1. Surgical management: urgent open surgery/angioplasty

=> Occluded grafts = graft thrombolysis

=> Underlying stenosis within a graft or vessel = angioplasty

=> Surgical removal (embolectomy)

=> Bypass graft after occlusion of popliteal aneurysm or acute-on-chronic lower limb arterial disease

=> Amputation for unreconstructable / severe ischaemia

  1. Medical management:
    => Patients improving can be managed on heparin + treatment of underlying cause

=> Emboli following MI or AF need long term warfarin

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12
Q

What are the complications of treating acute lower limb ischaemia?

A

Sudden improvement from ischaemic limb revascularisation => reperfusion syndrome => release of toxic metabolites into circulation

Oedema => compartment syndrome => requires fasciotomies

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13
Q

Acute aortic syndromes:

Acute aortic syndromes include
=> aortic dissection
=> intramural haematoma
=> penetrating aortic ulcers

A

INFO CARD

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14
Q

Acute aortic syndromes:

What is aortic dissection?

A

Aortic dissection starts with a tear in the intima. Blood penetrates the diseased medial layer, through the intimal layer => aortic dissection

Aortic dissection is classified according to the timing of diagnosis from the origin of symptoms:

i. Acute : <2 weeks
ii. Sub-acute : 2-8 weeks
iii. Chronic : >8 weeks

*mortality decreases with time

Aortic dissection can also be classified anatomically:
i. Type A : aortic arch and aortic valve proximal to left subclavian artery origin
=> this includes De Bakey type 1 (extends to abdominal aorta)
=> De Bakey type 2 (localised to ascending aorta)

ii. Type B : descending thoracic aorta distal to the left subclavian artery origin
=> this includes De Bakey type 3

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15
Q

What are the clinical features of acute aortic syndromes?

A

Symptoms:
=> sudden onset of severe, central chest pain
=> often radiates to the back and down the arm
=> mimics MI
=> pain = tearing in nature
=> pain may be migratory

Signs:
=> Shock
=> Neurological symptoms secondary to loss of blood supply to spinal cord 
=> Aortic regurgitation
=> Coronary ischaemia 
=> Cardiac tamponade

=> Acute kidney failure, acute lower limb ischaemia, visceral ischaemia in distal extension

=> peripheral pulses absent

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16
Q

What are the investigations for acute aortic syndromes?

A

Urgent CT scan

Transoesophgeal echocardiography or MRI will confirm the diagnosis

Mediastinum widened on X-ray

17
Q

How do you manage acute aortic syndromes?

A
  1. At least 50% of patients are hypertensive => urgent anti-hypertensive medications to reduce BP below 120mmHg => IV beta-blocker i.e. labetolol, metropolol and GTN vasodilator
  2. Type A dissections: surgery - arch replacement
  3. Type B dissections: better prognosis
    => medical management
    => Endovascular intevention with stents if rapidly growing dissection (>1cm/year) ; refractory pain ; malperfusion syndrome ; blunt chest trauma ; penetrating aortic ulcers or intramural haematoma
18
Q

What is intramural haematoma?

A

Intramural haematoma = precursor of dissection - rupture in the aortic media with aortic wall infarction

Intramural haematoma seen in descending thoracic aorta

19
Q

Deep penetrating aortic plaques => intramural haematoma, dissection or ulceration/perforation

Predisposition to aortic dissection in patient’s with autoimmune rheumatic disorders and Marfans & Ehlers-Danlos syndrome

A

INFO CARD

20
Q

What is Raynaud’s phenomenon or Raynaud’s disease?

A

Spasms of digital arteries precipitated by cold and relieved by heat. Bilateral ; fingers > toes

If there is no underlying cause => Raynaud’s disease

Affects 5% of population ; women > men

21
Q

What are the clinical features of Raynaud’s?

A

=> Vasoconstriction causes pallor => cyanosis

=> Redness due to hyperaemia

=> Duration of attack variable - can last upto hours

=> Numbness ; burning sensation ; severe pain as fingers warm up

=> Chronic severe disease => infarction and digital loss

22
Q

How do you diagnose Raynaud’s?

A

Primary Raynaud’s disease needs to be differentiated by secondary treatable causes leading to Raynaud’s phenomenon.

Secondary causes:
=> Rheumatic autoimmune disorders i.e. systemic sclerosis
=> Atherosclerosis
=> Occupations with vibrating tools
=> Ergot-containing drugs + beta blockers
=> Smoking

23
Q

How do you manage Raynaud’s?

A

Avoid cold provocations by wearing gloves + warm clothes

Stop smoking

Vasodilators but not recommended

24
Q

What is thromboangiitis obliterans (Buerger’s disease)?

A

Inflammtion of small vessels of the lower limbs in young men who smoke.

Clinical presentation:
=> Severe claudication + rest pain => gangrene
=> Thrombophlebitis
=> Treatment similar to other PVD
=> Stopping smoking = essential + critical

25
Q

Cardiovascular syphillis gives rise to:

=> uncomplicated aortitis
=> aortic aneurysm in ascending aorta
=> aortic valvulitis with regurgitation
=> stenosis of the coronary ostia

A

Diagnosis confirmed by serology

Treatment with penicillin

Aneurysm and valvular disease treated as needed

26
Q

What is superficial thrombophlebitis?

A

Commonly affects saphenous vein + assoc. with varicosities.

Local superficial inflammation in the vein wall with secondary thrombosis

Clinical presentation => painful, tender, cord-like structures assoc. with redness and swelling

Treatment: rest ; elevation of limb ; analgesics i.e. NSAIDs