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Surgery > Peripheral Vascular Disease (PVD) > Flashcards

Peripheral Vascular Disease (PVD) Flashcards

1
Q

Define Peripheral Vascular Disease (PVD)

A

Obstruction of large arteries not within the coronary, aortic or brain vasculature.

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2
Q

What are the causes of PVD?

A
  • Atherosclerosis
  • Inflammation leading to stenosis
  • Thrombosis
  • Emboli
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3
Q

What are the risk factors for PVD?

A
  • Sex: male
  • Age : older
  • Diabetes mellitus
  • BP high
  • Elevated cholesterol (hyperlipidaemia)
  • Tobacco
  • Renal disease
  • Obesity
  • Homocysteinaemia
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4
Q

What are the stages of Atherosclerosis?

A
  1. Fatty Streak
  2. Fibrous Plaque
  3. Atherosclerotic Plaque
  4. Plaque rupture/ fissure & thrombosis
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5
Q

What symptoms may an atherosclerotic plaque produce?

A
  • Stable angina
  • Intermittent claudication
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6
Q

What symptoms may a ruptured plaque/ fissure & thrombosis produce?

A
  • Unstable angina
  • MI Stroke/ TIA
  • Critical leg ischaemia
  • Cardiovascular death
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7
Q

What are symptoms of PVD?

A
  • Intermittent claudication
  • Rest pain (burning distally)
  • Blueness or paleness
  • Coolness
  • Gangrene
  • Sores, wounds or ulcers (slowly or not healing)
  • Infection (between toes)
  • Diminished hair & nail growth where affected
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8
Q

What is Leriche’s syndrome? What does it indicate?

A
  1. Buttock intermittent claudication
  2. Sexual impotence
  3. Absent femoral pulse
  • Indicates bilateral aorto-iliac occlusion
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9
Q

Define gangrene

A

Tissue necrosis with putrefaction

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10
Q

Describe dry gangrene

A
  • Necrosed tissue mummified following infarction
  • Black (haemoglobin breakdown) and dry
  • Cellulitis spreads
  • Zone of demarcation
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11
Q

Describe wet gangrene

A
  • Superadded infection with the spore- and gas- forming anaerobe Clostridium perfringens
  • Severe pain, patient septic & unwell
  • Gas collection in subcutaneous tissue results in crepitus
  • Cellulitis does not spread
  • No zone of demarcation
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12
Q

What examinations would you perfume on suspected PVD?

A
  • Pulses in limbs (& evidence of AF)
  • BP
  • Temperature of both limbs
  • Palpate for abdo, femoral & popliteal aneurysm
  • Capillary refill of toes
  • Ankle-brachial pressure index (ABPI)
  • Doppler
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13
Q

What is Buerger’s angle/ sign?

A

The angle at which the foot becomes white when raised from lying flat

A normal leg should remain perfused at 90 degrees

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14
Q

What is an ABPI and what does it show?

A

Ankle-brachial pressure index

The difference between brachial and ankle

  • BP 0.9-1.2 = normal
  • 0.4-0.8 = moderate arterial disease, consistent with claudication
  • <0.4 = severe ischaemia, consistent with rest pain
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15
Q

What investigations would you perfume in suspected PVD?

A
  • Arterial ultrasound scan with duplex
  • Angiography
  • CT
  • Magnetic resonance angiography
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16
Q

Describe arterial ultrasound scan with duplex

A
  • Determines degree of blood flow (& extent of atherosclerosis)
  • Waveform
    • Triphasic = normal
    • Biphasic = moderate disease
    • Monophasic = significant disease
17
Q

Describe angiography

A
  • Goild standard anatomical definition of the arterial tree
  • Intra-arterial contrast, CT or magnetic resonance
  • Done when surgery of angioplasty/ stent considered
18
Q

What are the risks of angiography?

A
  • Bleeding
  • False aneurysm
  • Thrombosis
  • Distal embolization
  • Allergic reaction to contrast
  • Nephrotoxicity
19
Q

Describe Fontaine’s classification of PVD

A
  1. Stage 1 = Asymptomatic
  2. Stage 2 = Intermittent claudication
  3. Stage 3 = Rest pain
  4. Stage 4 = Ulceration and/or grangrene
20
Q

Define critical limb ischaemia

A

Chronic or acute-on-chronic ischaemia that endangers the whole or part of a leg

21
Q

What are signs of critical limb ischaemia?

A
  • Rest pain
  • Tissue loss
  • Ankle pressure <50mmHg
  • Toe pressure less than 30mmHg
22
Q

What are indications for intervention in lower limb ischaemia?

A
  • Critical limb ischaemia
  • Disabling claudication
23
Q

Detail risk factor modifications you would want to consider

A
  • Smoking cessation
  • Antiplatelet therapy
  • Treatment of hyperlipidaemia
  • Exercise programmes
  • Diabetes management
  • Hypertension management
24
Q

Describe the effectiveness of smoking cessation

A
  • Improvement in claudication in 3-6 months
  • Reduced risk of critical ishaemia, MI and mortality
25
Q

What are the aims of treating hyperlipidaemia?

A

LDL <5.0mmol/l

26
Q

Describe the methods and indications for use of different antiplatelet therapys

A
  • Aspirin
    • Lowers MI, stroke and death risk
    • Low dose as effective as high dose
  • Clopidogrel
    • Better than aspirin in lowering risks
    • Costly, use for;
      • Aspirin intolerance
      • Ineffectiveness of aspirin
      • High risk cases
27
Q

Outline the TASC guidelines

A
  • Type A - endovasc. treatment
    • Single stenosis <10cm
    • Single occlusion <5cm
  • Type B - endovasc. treatment
    • Single <15
    • Multiple, each <5
    • Heavily calcified <5
    • Popliteal stenosis
  • Type C - surgery
    • Recurrent after 2 endovasc. interventions
    • Mulitple totalling >15
  • Type D - surgery
    • Chronic >20
    • Popliteal & prox. trifurcation vessels
28
Q

What is the treatment for patients with stable claudication?

A
  • Risk factor reduction
  • Supervised exercise program
  • +/- Cilostazol - phosphodiesterase 3 inhibitor
    1. Antagonise platelet aggregation
    2. Increase heart contractility
    3. Enhance vascular smooth muscle relaxation
29
Q

What surgical options are available in the treatment of PVD?

A
  • Angioplasty
  • Plaque excision
  • Bypass grafting
30
Q

Describe angioplasty

A
  • Mechanically widen narrowed/ obstructed arteries using water-inflated balloon
  • Poor sustained benefits
31
Q

Describe bypass grafting

A
  • Needed to circumvent seriously stenosed areas
  • Saphenous vein > short SV > aim veins OR synthetic (ePTFE) graft
    • Synthetics & veins equal in larger arteries
    • Synthetics perform poorly in smaller arteries
32
Q

What is Buerger’s disease (thromboangiitis obliterans)?

Outline;

  • Aetiology
  • Presentation
  • Diagnostic criteria
A

Chronic segmental inflammation & thrombosis of small-medium sized arteries & veins of peipheral upper & lower limbs (especially hands & feet).

Aetiology

  • Young men
  • Smoking
  • Lower socio-economic groups

Presentation (mainly hands & feet)

  • Claudication to severe rest pain
  • Exactly the same but more aggressive than PVD
  • Reynaud’s phenomenom
  • Later: enlarged, red, tender cord-like veins

Diagnostic criteria

  • Shionoya
    • Smoking history
    • Onset <50yrs
    • Infrapopliteal arterial occlusions
    • Either arm involvement or phebitis migrans
    • Absence of atherosclerotic risk factors other than smoking
33
Q

What is Subclavian Steal Syndrome?

  • Definition
  • Causes
  • Presentation
A

Definition

  • Subclavian steal phenomenon: Stenosis/ occlusion of subclavian artery proximal to vertebral artery origin ⇒ ipsilateral backflow in that vertebral artery
  • Subclavian steal syndrome: Symptoms in upper limb, brain or heart.

Causes

  • Artherosclerosis
  • Surgical repair of coarctation or Fallot’s tetralogy
  • Asia 36% due to Takayasu’s arteritis (early presentation, females)

Presentation (2% symptomatic)

  • Arm claudication, pain, fatigue
  • On exercising the upper limb ⇒ Cerebellar signs
    • Vertigo
    • Visual loss
    • Ataxia, diplopia, dysphagia, dysarthria
    • Tingling/ numbness of the face
    • Sensory hemianaesthesia/ transient hemiparesis
    • Syncope
  • Signs
    • BP decreased in affected arm (/ difference of 10mmHg)
    • Collapsing pulse
34
Q

What is Takayasu’s arterisis?

A

Surgery (23 decks)

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