peripheral vascular system

Question 1

how is lower limb ischaemia defined

Answer 1

ABPI <0.9 at rest

Question 2

classification of lower limb ischaemia

Answer 2

I asymptomatic
II intermittent claudication
III night/rest pain
IV tissue loss

Question 3

what is intermittent claudication

Answer 3

pain felt in the legs on walking due to arterial insufficiency

Question 4

what is the claudication distance

Answer 4

how far patients say they can walk before the pain stops them from walking

Question 5

what is neurogenic claudication

Answer 5

due to neurological and musculoskeletal disorders of the lumbar spine

Question 6

what is venous claudication

Answer 6

due to venous outflow obstruction from the leg, following extensive DVT.
relieved by leg elevation

Question 7

why do patients get night/rest pain and what does it indicate?

Answer 7

poor perfusion resulting from the loss of the beneficial effects of gravity on lying down and the reduction in HR, BP and CO that occurs when sleeping.

indicates severe, multilevel lower limb PAD and is a red flag symptom as failure to revascularise the leg usually leads to the development of critical limb ischaemia with tissue loss (gangrene, ulceration) and amputation

Question 8

how can you differentiate between diabetic neuropathy and rest pain?

Answer 8

neuropathic pain is not usually confined to the foot and is associated with burning and tingling and is associated with dysaesthesia

Question 9

why do patients with severe lower limb PAD get gangrene and/or ulceration

Answer 9

even trivial injuries to the feet fail to heal allowing bacteria to enter.

Question 10

signs of lower limb PAD

Answer 10

• ischaemic signs: absence of hair, thin skin and brittle nails
• diminished/absent pulses

Question 11

signs of acute limb ischaemia

Answer 11

• pulseless
• pallor
• perishingly cold
• parasthesiae
• paralysis
• pain on squeezing muscle

Question 12

in acute limb ischaemia, what is the difference in onset and severity between embolus and thrombosis?

Answer 12

embolus: acute, ischaemia profound, no co-existing collaterals
thrombosis: insidious (hours or days), ischaemia less severe (pre-existing collaterals)

Question 13

commonest causes of acute limb ischaemia

Answer 13

• thromboembolism: usually from the left atrium in association with AF
• thrombosis in situ: thrombotic occlusion of an already narrowed atherosclerotic arterial segment

Question 14

What happens a few hours after an acute arterial occlusion?

Answer 14

the spasm relaxes and the skin microcirculation fills with deoxygenate blood, leading to light blue or purple mottling, which has a fine reticular pattern and blanches on pressure

Question 15

what happens in compartment syndrome?

Answer 15

occurs where there is increased pressure within the fascial compartments of the limb, most commonly the calf, which compromises perfusion and viability of muscles and nerves.

Question 16

Are ischaemic strokes or haemorrhagic strokes more common?

Answer 16

ischaemic

Question 17

What do strokes in the vertebrobasilar artery territory causes?

Answer 17

giddiness, collapse with or without loss of consciousness, transient occipital blinds or complete loss of vision in both eyes

Question 18

what do strokes in the carotid artery territory cause?

Answer 18

vary according to the cerebral area but can include motor deficit, visual field defect or difficulty with speech

Question 19

what are symptoms and signs of chronic mesenteric arterial insufficiency?

Answer 19

• severe central abdo pain developing after 10-15 mins after eating
• weight loss (pt scared of eating)
• diarrhoea
• profound metabolic acidosis

Question 20

main risk factors for an AAA

Answer 20

smoking
hypertension
familial/genetic element
three times more common in men

Question 21

the most common misdiagnosis for a ruptured AAA?

Answer 21

renal colic

Question 22

what is raynauds phenomenon?

Answer 22

Digital ischaemia induced by cold and emotion and has three phases

• pallor (spasm)
• cyanosis (deoxygenation of static venous blood)
• redness (reactive hyperaemia)

Question 23

what should you always ask about in men with buttock (gluteal) intermittent claudication?

Answer 23

may have erectile dysfunction

Question 24

what does purple discolouration of the fingertips indicate?

Answer 24

atheroembolism from a proximal subclavian aneurysm

Question 25

what does wasting of the small muscles of the hand indicate?

Answer 25

thoracic outlet syndrome

Question 26

what does corneal arcus and xanthelasma indicate?

Answer 26

hypercholesterolaemia

Question 27

what does Horners syndrome indicate

Answer 27

carotid artery dissection or aneurysm

Question 28

what does hoarseness of the voice and bovine cough indicate

Answer 28

recurrent laryngeal nerve palsy from a thoracic aortic aneurysm

Question 29

how do you perform Buerger’s test

Answer 29

• raise patients feet and legs to 45 degrees
• watch for pallow
• ask the patient to sit up and hang the legs over th
  bed
• watch for reactive hyperaemia

Question 30

what is the ABPI?

Answer 30

ratio of the highest pedal artery to the highest brachial artery pressure

Question 31

if the popliteal artery is easy to feel, what might you suspect?

Answer 31

an aneurysm

Question 32

ABPI in intermittent claudication and critical limb ischaemia?

Answer 32

<0.9 and <0.4 respectively

Question 33

what are the 4 ways that lower limb venous disease presents?

Answer 33

• varicose veins
• superficial thrombophlebitis
• DVT
• chronic venous insufficiency and ulceration

Question 34

what are varicose veins?

Answer 34

dilated, tortuous superficial veins causing aching, itching and swelling

Question 35

what does DVT cause?

Answer 35

-pain and tenderness in the affected part (calf)

Question 36

what does superficial thrombophlebitis cause?

Answer 36

red, painful area overlying the vein involved

Question 37

what is lipodermatosclerosis associated with?

Answer 37

chronic venous insufficiency.

Question 38

causes of leg ulcers?

Answer 38

probably venous disease
syphilis
Tb
sickle cell

Question 39

why do non-occlusive DVTs pose the greatest threat of PE?

Answer 39

clot lies within a flowing stream of venous blood and is more likely to propagate and has not yet induced an inflammatory response in the vein wall to anchor it in place

Question 40

what can oedema and a raised JVP suggest?

Answer 40

cardiac disease or pulmonary hypertension