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Cardiovascular > Peripheral Vascular Disease (PAD) > Flashcards

Peripheral Vascular Disease (PAD) Flashcards

1
Q

What is acute arterial insufficiency?

A

Acute occlusion/rupture of a peripheral artery.

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2
Q

Where does acute arterial insufficiency generally affect?

A

Lower > upper extremity

Femoropopliteal > aortoiliac

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3
Q

What is the aetiology of acute arterial insufficiency?

A

Embolus, thrombus, trauma, idiopathic.
Less common: pro-coagulant state, thrombosed aneurysm, dissection, fibromuscular hyperplasia, arteritis, entrapment, advential cysts.

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4
Q

What are the features supportive of cardiac embolus causing acute arterial insufficiency?

A

-History of MI

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5
Q

What are the clinical features of acute arterial insufficiency?

A
  • Pain: absent in 20%
  • Pallor
  • Paresthesia
  • Paralysis/power loss
  • Polar (cold)
  • Pulselessness (not reliable)
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6
Q

How should acute arterial insufficiency be investigated?

A

CXR, ECG, arteriography

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7
Q

Mx acute arterial insufficiency?

A
  • Immediate heparinization w/5000IU bolus (APTT >60s)
  • Absent power/sensation: immediate revascularisation
  • Present power/sensation: work up (inc angio)
  • Progress to embolectomy/ thrombectomy/ amputation
  • Commence warfarin d1 post op for 3/12
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8
Q

What are the complications of acute arterial insufficiency?

A
  • Compartment syndrome (prolonged ischaemia)

- Renal failure and multi organ system failure due to ischaemic muscle

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9
Q

What is the aetiology of chronic arterial insufficiency?

A

Predominately atherosclerosis; usually affects lower extremities.

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10
Q

What are the RFx for chronic arterial insufficiency?

A

Major: smoking, DM, hyperhomocysteinemia
Minor: HTN, hyperlipidemia, FHx, obesity, sedentery life, male gender

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11
Q

What are the clinical features of chronic arterial insufficiency?

A
  • Claudication
  • Pulses may be absent
  • Bruits may be present
  • Signs of poor perfusion
  • Other signs of atherosclerosis (IHD, impotence, splanchnic ischaemia)
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12
Q

What are the signs of poor arterial perfusion?

A
  • hair loss
  • hypertrophic nails
  • atrophic muscle
  • skin ulcerations and infections
  • poor capillary refill
  • prolonged pallor with elevation and rubor on dependency
  • venous troughing
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13
Q

Ddx of chronic arterial insufficiency?

A
  • OA: worse at night, varies day-day.
  • Neurogenic claudication (due to spinal stenosis/radiculopathy)
  • Varicose veins
  • Inflammatory (Buerger’s disease, Takayasu’s arteritis)
  • Other: popliteal entrapment, radiation injury, trauma
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14
Q

What are the non-invasive Ix of chronic arterial insufficiency?

A

-ABI:

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15
Q

What are the invasive Ix of chronic arterial insufficiency?

A

-Arteriography: superior resolution (to MR/CT), better for tibial arteries.

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16
Q

What are the indices for ABI?

A 
Ankle-Brachial Index:
>1.2: suspect wall calcification
>0.95: normal
0.85-0.94: Mild
0.5-0.84: Mod
0.26-0.49: Severe
17
Q

Conservative treatments of chronic arterial insufficiency?

A
  • RFx mod: smoking cessation, manage HTN/ hyperlipidemia / DM
  • Exercise: improves collaterals / O2 extraction by muscle
  • Foot care: esp in DM.
18
Q

Pharmacotherapy for Mx chronic arterial insufficiency?

A
  • Anti-platelets: e.g. clopidogrel
  • Cilostazol: cAMP phosphodiesterase inhibitor with anti-platelet and vasodilatory effects. Improves walking distance
  • Pain relief: opiate analgesia, NSAIDs
19
Q

Surgical Mx of chronic arterial insufficiency?

A
  • Endovascular (stenting/ angioplasty)
  • Endarterectomy: remove plaques with patch repair (usually distal aorta/ common femoral)
  • Bypass graft
  • Chemical sympathectomy (EtOH injected into nerve plexus; rarely effective)
  • Amputation
20
Q

What are the indications for surgical Mx of chronic arterial insufficiency?

A

Pain interferes with lifestyle, rest pain, night pain, pre-/gangrene.

21
Q

What are the sites of bypass grafts in chronic arterial insufficiency?

A
  • Aortofemoral
  • Axillofemoral
  • Femoropopliteal
  • Distal arterial
22
Q

Prognosis for Pts with claudication?

A

-Conservative Mx: 60-80% improve, 20-30% same, 5-10% deteriorate
If critical limb ischaemia = high risk of limb loss.

23
Q

What is claudication?

A

Ischaemic pain in exercising muscles: imbalance b/w demand of muscle and ability to maintain aerobic metabolism -> switch to anaerobic metabolism -> lactic acid build up -> aching discomfort.

24
Q

Clinical features of claudication?

A
  • Calf pain on exertion (+/- thigh or buttock)
  • Onset/severity related to workload
  • Relieved with rest
  • Reproducible
25
Q

What is implied by ischaemic rest pain?

A

Perfusion so poor that anaerobic metabolism present in skin and nerves of distal extremity even at rest

26
Q

Clinical features of ischaemic rest pain?

A
  • ?aided by gravity: hang foot over bed
  • pts awake w/ burning pain in extremity
  • worst case: all night sleeping in chair
27
Q

What are the patterns of lower limb occlusive disease?

A

-Aorto-iliac (inflow)
-Femoro-popliteal (outflow)
-Tibial/crural
Hx/Exam should be matched to a pattern/combo of patterns

28
Q

CFx aortoiliac arterioocclusive disease?

A
  • Claudication: calf, thigh, buttock
  • Pulses: reduced femoral and below
  • ?Bruit over aorta / iliac
29
Q

CFx femoro-popliteal arterio-occlusive disease?

A
  • Claudication: calf
  • Pulses: reasonable femoral, weak/absent popliteal + pedal pulses
  • Bruit: line of fem/pop arteries
30
Q

CFx tibial / crural arterio-occlusive disease?

A
  • Claudication: ?none
  • Pulses: pop present, pedal absent
  • Bruits: popliteal / upper tibial arteries
31
Q

What are the interventions available for claudication?

A
  • Angioplasty: +/- stenting (better for short segments, proximal arteries)
  • Endarterectomy: short segments
  • Bypass: longer blocks
32
Q

Pros/Cons of endovascular interventions for claudication?

A
  • Quick recovery
  • May have access vessel problems
  • Chance of thrombosis / embolisation
33
Q

Risks of open bypass claudication intervention?

A
  • Wound issues
  • Cardiac risks etc
  • Graft thrombosis
  • Long recovery (may be 2-3/12)

Cardiovascular (22 decks)

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