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Vascular Flashcards

1
Q

3 clinical criteria for Chronic Limb Threatening Ischemia?

A

Rest pain requiring regular opioid analgesia lasting >2 weeks
Gangrene or ulcers over toes/feet
Objective indication of poor vascular supply to LL.
(Ankle-brachial pressure index <0.5)
(Toe pressure index <0.3)
(TcPOr<30mmhg)

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2
Q

Where does ischemic rest pain usually occur?

A

Toes or foot. Severe disease affects more proximal areas

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3
Q

What time of day does ischemic rest pain worsen?
What positions causes pain for ischemic rest pain to worsen?

A

Typically at night due to lack of blood supply. Patient is supine and BP falls during sleep.
Otherwise, pain is worsened by lifting limb, relieved by dependency of limb.
Gets better after a short walk around the room.

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4
Q

What position do ischemic rest pain patients sleep in?

A

Sleep with leg hanging over side of the bed.

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5
Q

How common is deterioration for LEAD patients with IC?

A

Only 25% significantly deteriorate

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6
Q

Cause of symptomatic stabilization?

A

DEvelopment of collaterals
Metabolic adaptation of ischemic muscle
Patients alter gait to favour non-ischemic muscle groups

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7
Q

Modifiable Risk factors for PAD?

A

Smoking, HTN, Hyperlipidemia, DM, Obesity

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8
Q

Pathophysiology of PAD?

A

Atherosclerotic process with subintimal accumulation of lipid and fibrous material.
In LL arteries, atherosclerosis and associated thrombosis can lead to diffuse stenosis of peripheral arteries causing lower blood supply to LL.

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9
Q

Rarer causes of PAD?

A

Buerger’s disease
Vasculitis
Ergot toxicity
Vasospasm

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10
Q

Common sites of atherosclerotic narrowing in lower extremities?

A

Aortoiliac
Femoropopliteal
Tibial-peroneal

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11
Q

What is AIOD?

A

Occlusion of Abdominal aorta as it transits into common iliac arteries.

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12
Q

Symptoms of AIOD?

A

Claudication symptoms involving hip, proximal thigh muscle, buttocks, calf
Pelvic ischemic can present with ED.

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13
Q

Which pulse reduced in AIOD?

A

Reduced femoral pulses

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14
Q

What is Leriche’s syndrome?

A

Occlusion at bifurcation of terminal aorta.

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15
Q

Presentation of Leriche’s syndrome?

A

Buttock claudication, ED, reduced/absent femoral/distal pulses, aortoiliac bruits

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16
Q

Symptoms of Femoropopliteal Occlusive Disease?

A

Crampy calf pain with walking that occurs at reproducible distance and is relieved by rest.
Lower/absent popliteal, pos tibial and dorsalis pedis pulses

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17
Q

Which occlusive disease commonly seen in smokers?

A

Femoropopliteal occlusive disease

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18
Q

Common presentation of Tibioperoneal Arterial Occlusive Disease?

A

Chronic limb threatening ischemia. Due to absence of collateral flow to foot

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19
Q

Which occlusive disease commonly seen in DM and CKD?

A

Tibioperoneal Arterial Occlusive disease

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20
Q

What is vascular claudication?

A

Reproducible discomfort of defined group of muscles induced by exercise and relieved with rest.
Cramping, aching pain in muscle group on exertion

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21
Q

Neurogenic claudication definition?

A

Pain from compressed cord and spinal nerves in spinal stenosis.
Pain relieved when sitting and flexing spine.

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22
Q

How does colour of LL show ischemia/perfusion in PAD?

A

Red - vasodilation of microcirculation due to tissue ischemia
White - advanced ischemia
Purple/blue - excess deoxygenated blood in tissue

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23
Q

Common site of ulcer in PAD?

A

Venous ulcers in medial malleolus
Arterial ulcers more distal - lat part of foot and lat malleoli
Neuropathic ulcers at heel and metatarsal heads

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24
Q

How to do Buerger’s test?

A

Get patient to lie as close to side of bed as possible.
Hold heel, slowly lift LL
Stop when toes become pale.
Estimate angle that LL makes with bed - Buerger’s angle. <20 is chronic ischemia

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25
3 Ls of PAD?
Life Limb Lifestyle
26
Rutherford classification for PAD
Stage 0 = asymptomatic 1 = Mild claudication 2 = Moderate claudication 3 = Severe claudication 4 = Ischaemic rest pain 5 = Minor tissue loss 6 = ulceration or gangrene
27
Basic investigations for PAD?
ABI Arterial Duplex US (1st line imaging).
28
Interpretation of ABPI?
Normal ABI is >0.9 ABI 0.5 - 0.9 = occlusion, often a/w claudication ABI <0.5 = Critical Ischemia rest pain If >1.40, suggests non-compressible calcified vessel
29
Some principles for PAD Management?
Risk factor modification first!! Claudication medical therapy if limitation affects SOL If suspected proximal lesion, localize lesion and revascularize surgically/endovascularly.
30
Best Medical Therapy for management of asymptomatic PAD patients ?
Smoking Cessation Diet, exercise Lipid control - LDL HTN control DM control Single Antiplatelet Therapy (SAPT) - clopidogrel/aspirin Smoking cessation
31
Indications for management of chronic limb ischemia?
1. Limb salvage, critical limb ischemia 2. Infection 3. Prevention of further peripheral atheroembolization 4. Incapacitating claudication
32
Colour changes in Pallor in Acute limb ischemia?
Pink or pale is ok. In severe ischemia, can be marble-white, esp if got embolus. Others: Mottling/marbling = patches of blue on white. Means deoxygenation of stagnated blood, surrounding areas of pallor due to vasoconstriction Duskiness = due to deoxygenation of stagnated blood too, but if there is fixed staining then limb is non-viable.
33
What is endovascular approach for PAD?
LL angiography, angioplasty KIV stenting
34
What is open surgical intervention for PAD?
Bypass grafting when lesions cannot be treated by angioplasty
35
3 normal elements of vessel wall?
Intima Media Adventitia
36
Subtypes of acquired aneurysm?
Atheromatous Mycotic Dissecting False Charcot-Bouchard Arteriovenous
37
Complications of aneurysms?
Rupture Thrombosis with occlusion Distal emboli from mural thrombus Pressure on adjacent structures Fistula
38
Examples of aneurysms pressing on adjacent structures?
AAA eroding vertebral bodies Femoral aneurysm pressing femoral nerve
39
Which arteries commonly affected by atheromatous aneurysm?
Abdominal aorta, popliteal, femoral artery
40
Definition of aortic dissection?
Bloodflow through defect in intima into medial layer between intima and adventitia. Blood returns to true lumen distally or ruptures externally.
41
Risk factors for aortic dissection?
Age (6th-7th decade) HTN Smoking Males (4:1 ratio) Structural abnormalities of aortic wall Collagen Vascular condition Pregnancy
42
Stanford classification for aortic dissection?
Stanford A - dissection involving the ascending aorta Stanford B - dissection not involving ascending aorta
43
DeBakey Classification for aortic dissection?
Type 1 - start in ascending aorta with involvement of aortic arch and often descending aorta Type 2 - start in ascending aorta and confined within it Type 3 - Start in descending aorta, limited to thoracic aorta Type 4 - from descending aorta, extend below diaphragm to abdominal aorta
44
Clinical pain of aortic dissection?
Anterior chest pain or back pain. Sudden onset, tearing sensation, mimicks MI.
45
Outcomes of aortic dissection?
True lumen compressed by false lumen leading to ischemia/malperfusion. False lumen can become aneurysmal when subject to systemic pressure.
46
Differentials of Aortic Dissection?
MI Pulmonary embolism Pericarditis Aortic aneurysm without dissection MSK pain Cholecystitis, GERD, PUD, Perforating ulcer, acute pancreatitis.
47
Gold standard investigation for aortic dissection?
CT Aortogram
48
Definition of Abdominal aortic aneurysm?
Aortic diameter >50% larger than normal. Normal aorta is 2cm.
49
Which connective tissue disorders is a risk factor for AAA?
Marfans - fibrillin-1-defect Ehler-Danlos syndrome type 4
50
Risk factors for AAA?
Smoking!!! HTN/HLD Male gender Family Hx Connective tissue disorders COPD Hyperhomocysteinemia
51
Indications for AAA surgery?
Aneurysm of any size painful or tender Aneurysm of any size causing distal embolization.
52
AAA rupture front or back?
Anterior into peritoneal cavity 20% Posterolaterally into retroperitoneal space 80%
53
Medical management for asymptomatic AAA?
Smoking cessation and optimize BP/HLD control. Statins lower aneurysmal growth rates
54
Indications for asymptomatic AAA surgery?
Aneurysm > 5.5 cm in largest diameter ▪ Patient fit for surgery (expected mortality rate < 5%) ▪ Increase in diameter of more than 5 mm / 6months or 1 cm / year ▪ Saccular aneurysm (rather than fusiform anatomy, due to higher risk of rupture)
55
Clinical presentation of CVI?
Venous dilatation Pitting edema Skin changes Venous ulcer formation
56
Pathophysiology of CVI?
CVI comes when there is venous HTN, which can result from: 1. Obstruction e.g. DVT, pregnancy 2. Dysfunction of venous valves e.g. varicose veins 3. Failure of venous pump (dependent on muscle contraction + competent venous valves)
57
How does venous dilatation present in CVI?
Telangiectasias Reticular veins Varicosities Corona phlebectatica
58
How does pitting edema present in CVI?
Unilateral edema worsened by dependency and better with recumbency
59
How do skin changes present in CVI?
Hyperpigmentation of skin over medial lower third of leg Phlegmasia Alba Dolens Phlegmasia Cerulea Dolens Atrophie blanche Venous Stasis eczema Lipodermatosclerosis
60
How does venous ulcer form in CVI?
Typically over medial malleolus Shallow, flat ulcer with sloping edges. Base may be sloughy or granulating In long-standing ulcer SCC can develop.
61
Cause of venous ulcers?
Obstruction to venous flow - thrombosis Incompetent valves - varicose veins, deep vein reflux Muscle pump failure - stroke, neuromuscular disease
62
Investigations for venous ulcers?
Exclude infection of ulcer and other complications first! Blood test for inflammatory markers, wound swab for culture, **XR to exclude underlying gas, bone involvement** 2. Venous duplex 3. Check PAD 4. Refer to derm 5. Biopsy venous ulcer to exclude malignancy
63
Management of venous ulcers?
Non-surgical: 2/4 layer compression bandage - podiatry Analgesia Abx if infected Elevate leg and rest Once healed, compression stockings for life
64
Surgical management of venous ulcers?
Endovenous ablation. First, exclude malignancy or other causes of ulcer (biopsy) Split skin graft can be considered with excision of dead skin and graft attached to healthy granulation tissue
65
4 causes of Acute limb ischemia
Arterial embolism (main) Acute thrombosis (main) Arterial trauma Dissecting aortic aneurysm
66
Early signs of acute limb ischemia
Pain, numbness, muscle paralysis, skin changes.
67
How long can LL survive before irreversible injury?
6-8 hrs
68
6 Ps of acute limb ischemia?
Paraesthesia Pain Pallor Poikilothermia Pulselessness Paralysis ## Footnote In order of presentation. Poikilothermia = impaired body temp regulation
69
In acute limb ischemia, if able to feel one good pulse (PT or DP), what does it mean?
Limb is likely not ischemic
70
What is Carotid Disease?
Stenosis in ICA causing symptoms of amaurosis fugax, Transient Ischemic Attack and/or ipsilateral ischemic stroke
71
Varicose veins definition
Dilated tortuous subQ vein that is over 3mm in diameter in upright position.
72
Low ankle pressure?
40-60 mmHg
73
Where is femoral pulse palpated?
At mid-inguinal point. Midway between pubic symphysis and ASIS.
74
Time taken for IC to go away after rest in VASCULAR vs NEUROGENIC claudication?
5-10 mins in vascular 30 mins+, much longer in neurogenic
75
How do diabetic patients with neuropathy feel like when theyre walking?
Walking on cotton wool or pebbles
76
Pale vs Plum/blue coloured limb in ALI?
Pale means no blood, plum means no outflow. PALE a/w worse cuz u rather deoxy blood than no blood.
77
What can be seen in Buerger's positive patients?
Sunset foot - reddish blue. Means VERY severe ALI.
78
What can AVG cause?
Pseudoaneurysm
79
AVF often causes?
True aneurysms cuz of repeated cannulation - can be due to outflow blockage
80
MEdical treatment for PAD?
Give antiplatelets and statins. Main aim is to low CVS risk
81
Blue toe syndrome?
Acute onset of purple painful digits in absence of evident trauma, cold-associated injury or disorders that induce generalized cyanosis.
82
What is polycythemia?
rise in erythrocyte count. Can be primary or secondary to stuff like smoking/COPD
83
All ulcers start with simple trauma. Anyth with rolled up edges suggests?
Malignancy
84
5 Ps of compartment syndrome?
Pain, pallor, paraesthesia, pulselessness, paralysis
85
Which electrolyte abnormality caused by compartment syndrome?
Hyperkalemia
86
May Thurner syndrome?
Nearby artery compresses the left iliac vein
87
Management for DVT?
Enoxaparin s/c 1mg/kg twice a day
88
Is Critical Limb ischemia = Chronic limb ischemia?
Critical limb ischemia is an advanced version of chronic
89
Differentiate btw vascular and neurogenic claudication? (aside from flexing spine)
Claudication distance more variable in neurogenic claudication
90
Differentiate Phlegmasia Alba vs Cerulea based on looks?
Alba = Pale limb Cerulea = Blue
91
What causes collapsing pulse?
Widened pulse pressure
92
What affects pulse pressure?
Stroke volume and arterial compliance. Low PP is due to low stroke volume | e.g. CCF, shock, tamponade, aortic stenosis
93
What causes high Pulse pressure?
Usually due to high stroke volume or **stiff arteries** | aortic regurgitation
94
Triad of blood Hyperviscosity syndrome?
Mucosal bleeding Neurological symptoms Visual changes
95
Site of arterial vs venous ulcers?
Arterial = Heels, toe tips, between toes, anterior tibia, lateral malleolus Venous = Gaiter area, lower calf
96
Base of Arterial vs Venous ulcers?
Arterial = Pale, yellowish base. Black if necrotic Venous = Sloughy or granulomatous
96
Edge of Arterial vs Venous vs Neuropathic ulcers?
Arterial = Punched out, well-demarcated borders Venous = sloping, irregular borders Neuropathic = Punched out, regular borders
96
Depth of arterial vs venous ulcers?
Arterial = Bone may be exposed Venous = Superficial, rarely exposing tendon/bone
97
Pain of Arterial vs Venous vs Neuropathic ulcers?
Arterial = Moderate to severe pain, intermittent claudication, better with dependency Venous = Mild pain, increased with dependency Neuropathic = No pain, paraesthesia

GS Medbear (14 decks)

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