Vascular Flashcards
What is peripheral arterial disease (PAD)?
Refers to narrowing of the arteries supplying the limbs and periphery, reducing the blood supply to these areas. It usually refers to the lower limbs, resulting in symptoms of claudication.
What is intermittent claudication?
Symptom of ischaemia in a limb, occurring during exertion and relieved by rest. It is typically a crampy, achy pain in the calf, thigh or buttock muscles associated with muscle fatigue when walking beyond a certain intensity?
What is critical limb ischaemia?
This is the end stage of peripheral arterial disease, where there is inadequate supply of blood to a limb to allow it to function normally at rest.
What is acute limb ischaemia?
Acute limb ischaemia refers to a rapid onset of ischaemia in a limb. Typically, this is due to a thrombus (clot) blocking the arterial supply of a distal limb, similar to a thrombus blocking a coronary artery in myocardial infarction.
Acute limb ischaemia refers to a rapid onset of ischaemia in a limb. Typically, this is due to a thrombus (clot) blocking the arterial supply of a distal limb, similar to a thrombus blocking a coronary artery in myocardial infarction.
What is atherosclerosis?
Atherosclerosis is a combination of atheromas (fatty deposits in the artery walls) and sclerosis (the process of hardening or stiffening of the blood vessel walls). Atherosclerosis affects the medium and large arteries. It is caused by chronic inflammation and activation of the immune system in the artery wall. Lipids are deposited in the artery wall, followed by the development of fibrous atheromatous plaques.
What are the non modifiable and modifiable risk factors of atherosclerosis?
Non modifiable- age, family history, male
Modifiable- smoking, alcohol consumption, poor diet (high in sugar and trans fat and low in fruit, vegetables an omega 3s)
Low exercise, sedentary lifestyle, obesity, poor sleep, stress
What are the end results of atherosclerosis?
Angina MI TIA Stroke Peripheral arterial disease Chronic mesenteric ischaemia
What is intermittent claudication?
A sign of peripheral arterial disease
Its crampy pain that occurs after walking a certain distance, after stopping and resting the pain will disappear.
The most common location is the calf muscles, but it can also affect the thighs and buttocks.
What is the presentation of critical limb ischaemia?
Pain at rest
Ulcers
Typically causes a burning pain, this is worse at night when the leg is raised as gravity no longer helps pull blood into the foot.
What is Leriche syndrome?
This occurs with occlusion of the distal aorta or proximal common iliac artery, there is a clinical triad of…
1) thigh/ buttock claudication
2) absent femoral pulses
3) male impotence
What are signs of arterial disease on inspection?
Skin pallor Cyanosis Dependent rubor (a deep red colour when the limb is lower than the rest of the body) Muscle wasting Hair loss Ulcers Poor wound healing Gangrene (breakdown of skin and a dark red/black change in colouration)
Reduced skin temperature
Reduce sensation
Prolonged capillary refill time (more than 2 seconds)
Changes during Buerger’s test
What is the buergers test?
This is used to assess for peripheral arterial disease in the leg, it involves two parts…
1) the first part involves the pt lying on their back (supine) and lifting the patients legs to an angle of 45 degrees at the hip. Hold the patient there for 1-2 minutes, looking for pallor. Pallor indicates peripheral arterial disease, as the arterial supply is not adequate enough to overcome the gravity.
The buergers angle refers to the angle at which the leg is pale due to inadequate blood supply. For example a buergers angle of 30 degrees means that the leg will go pale when lifted to 30 degrees.
The second part involves sitting the patient with their legs hanging over the side of the bed, blood will flow back into the legs assisted by gravity. In a healthy pt the legs will remain a normal pink colour, in a patient with peripheral arterial disease, they will go:
Blue initially as the ischaemic tissue deoxygenates the blood and dark red after a short time due to vasodilation in response to the waste products of anaerobic respiration.
What do arterial ulcers present like?
Smaller than venous ulcers Deeper than venous ulcers Have well defined borders Punched out appearance Occur peripherally (on toes) Have reduced bleeding Are painful
What do venous ulcers Present like?
Caused by impaired drainage and pooling of blood in the legs
Occurs after minor injury to legs
More superficial
Irregularly, gently sloping borders
Affects the gaiter area of the leg (from the mid calf down to the ankles)
Less painful than arterial ulcers
Occurs with other signs of chronic venous insufficiency- haemosiderin staining and venous eczema
What are the investigations done for venous ulcers?
ABPI
Duplex ultrasound
Angiography (CT or MRI)
What is the ABPI? How do you measure it?
Ratio of the systolic blood pressure in the ankle (around the lower calf) compared to the systolic blood pressure in the arm
The readings are taken manually using a doppler probe, for example: am ankle SBP of 80 and an arm SBP of 100 would be 80/100= 0.8
What would the following APBIs indicate
A) 0.9-1.3
B) 0.6-0.9
C) 0.3-0.6
D) <0.3
A) normal
B) mild PAD
C) moderate to severe PAD
D) <0.3 severe disease to critical ischaemia
In what type of patients can you not do ABPI for peripheral artery disease?
Diabetics
An ABPI above 1.3 can indicate calcification of the arteries, making them difficult to compress, this is more common in diabetic patients.
What are the managements of intermittent claudication?
Can use lifestyle modifications and exercise training
Medical treatments- atorvastatin, clopidogrel, NAFTIDROFURYL OXALATE (5HT2 receptor
antagonist that acts as a peripheral vasodilator)
Surgical options…
1) endovascular angioplasty and stenting
2) endarterectomy
3) bypass surgery
What is the management of critical limb ischaemia?
Patients with critical limb ischaemia require urgent referral to the vascular team. They require analgesia to manage the pain.
Urgent revascularisation can be achieved by:
Endovascular angioplasty and stenting
Endarterectomy
Bypass surgery
Amputation of the limb if it is not possible to restore the blood supply
What is the management of acute limb ischaemia?
Patients with acute limb ischaemia need an urgent referral to the on-call vascular team for assessment.
As an FY1 give IV heparin
Management options include:
Endovascular thrombolysis – inserting a catheter through the arterial system to apply thrombolysis directly into the clot
Endovascular thrombectomy – inserting a catheter through the arterial system and removing the thrombus by aspiration or mechanical devices
Surgical thrombectomy – cutting open the vessel and removing the thrombus
Endarterectomy
Bypass surgery
Amputation of the limb if it is not possible to restore the blood supply
What are varicose veins?
Distended superficial veins that are >3mm in diameter, they usually affect the legs
What is the pathophysiology behind varicose veins?
The deep and superficial veins are connected by vessels called the perforating veins (or perforators), which allow blood to flow from the superficial veins to the deep veins. When the valves are incompetent in these perforators, blood flows from the deep veins back into the superficial veins and overloads them. This leads to dilatation and engorgement of the superficial veins, forming varicose veins.
What happens in chronic venous insufficiency?
When blood pools in the distal veins, the pressure causes the veins to leak small amounts of blood into the nearby tissues. The haemoglobin in this leaked blood breaks down to haemosiderin, which is deposited around the shins in the legs. This gives a brown discolouration to the lower legs.
Pooling of blood in the distal tissues results in inflammation. The skin becomes dry and inflamed, referred to as venous eczema.
The skin and soft tissues become fibrotic and tight, causing the lower legs to become narrow and hard, referred to as lipodermatosclerosis.
What are the risk factors for varicose veins?
Increasing age Family history Female Pregnancy Obesity Prolonged standing- ie: occupations involving standing for a long time DVT
What is the presentation of varicose veins?
Varicose veins present with engorged and dilated superficial leg veins, they are asymptomatic or have symptoms of:
- heavy or dragging sensation in the legs
- aching
- itching
- burning
- oedema
- muscle cramps
- restless legs
