Vascular Flashcards
Arterial supply of the lower limb
1) common iliac -> external iliac -> common femoral
2a) common femoral -> profunda femoris -> perforating branches
2b) common femoral -> superficial femoral -> popliteal
3) popliteal -> anterior + posterior tibial
4) anterior tibial -> dorsalis pedis
5) posterior tibial -> peroneal -> medial & lateral plantar
Profunda femoris runs ___, supplies ___ and superficial femoral runs ___, supplies ___
posterolaterally, supplies muscles of thigh
anteromedially, exits femoral triangle into adductor canal, through adductor hiatus into popliteal fossa. Supplies adductor muscles
On angiogram at trifurcation of leg arteries, most lateral to medial ___, ___, ___
anterior tibial
peroneal
posterior tibial
Posterior tibial artery runs ___ and becomes plantar arteries
posterior to medial malleolus
Femoral artery landmark
Mid-inguinal point (b/w pubic symphysis and ASIS)
Popliteal artery landmark
Popliteal fossa, palpate against upper end of tibia
Peripheral artery disease includes disease of all the arteries except ___, ___
coronary arteries and aorta
Intermittent claudication means?
reproducible discomfort of a defined group of muscles that is induced by exercise and relieved by rest
Chronic limb threatening ischemia clinical diagnosis
1) Rest pain requiring opioid analgesia >2 weeks
AND/OR
2) gangrene/ulcers over foot
AND
3) objective indication of poor vascular supply to lower limbs (ABPI <0.5 , toe pressure, TcPO2)
Ischemic rest pain presentation
pain at night during sleep (BP drop, pts not in dependent position)
pain on lying down, relieved by getting up having a short walk
pain aggravated by lifting the limb
Ischaemic ulcers tend to occur on ___ of the foot, tend to be (characteristic)
venous ulcers occur over the ___, tend to be (characteristic)
Neuropathic ulcers occur over ___
lateral malleolus - dry, punctate, deep (punched out, well-circumscribed)
medial malleolus - moist, diffuse, superficial (sloping)
heel, metatarsal heads
Gangrene is ___ tissue that progresses to ___. Caused when ____.
cyanotic, necrosis
arterial pressure falls below minimum required for metabolic functions
Gangrene can be wet or dry
Patients with intermittent claudication tend to have symptomatic stabilisation due to
1) collateral development
2) patient alters gait to use non-ischemic muscles
3) metabolic adaptation of ischemic muscle
Risk factors of peripheral arterial disease
Diseases: diabetes, coronary artery disease, previous stroke
Non-modifiable: age, gender, ethnicity, FH
modifiable: smoking, HT, HLD, diabetes, obesity
Atherosclerosis tends to form at ___
branch points (points proximal to bifurcations), bends & tethered segments
*aortoiliac, femoropopliteal, tibial-peroneal segments
What is Buerger’s disease known as? Main treatment?
Thromboangiitis obliterans
- inflammatory vasculopathy, non-atherosclerotic
main treatment is smoking cessation
What is Leriche syndrome
Occlusion at bifurcation of terminal aorta into common iliac arteries
Pts present with buttock, hip claudication, erectile dysfunction (impotence) Reduced/absent femoral & distal pulses
Tibial-peroneal occlusive disease presents a higher risk of ____ than femoropoliteal occlusive disease due to ___
chronic limb threatening ischemia
lack of collateral blood flow to the foot
Tibial-peroneal occlusive disease patients have absent ___, lack of ___, and ___
dorsalis pedis & posterior tibial pulse
leg hair
shiny skin
Characteristic description of neurogenic vs vascular claudication
neurogenic - pain from “park bench to park bench” (sitting down relieves pain
vascular - pain from “shop window to shop window” (does not have to sit, not walking will relieve pain)
Risk factors for peripheral artery disease
Smoking/ex-smoker
Diabetes
HTN, HLD
Hyperhomocysteinemia
Family history of AAA
What is wet gangrene?
Infected gangrene - blistering, bacterial infection & putrefaction occurs.
Emergency surgical debridement or amputation required
What is diabetic dermopathy?
Atrophic hyperpigmented skin, usually on shin
What do you inspect for when examining PAD patient?
- colour of skin
- trophic changes (loss of hair, thickening of nails, skin dry)
- loss of digits/foot
- presence of ulcers
- presence of gangrene
- diabetic skin changes/joint deformities
Landmark of LL pulses
1) DP: 1/3 way down a line joining midpoint of two malleoli to 1st webspace
2) PT: 1/3 way between medial malleolus and heel
3) Popliteal: patient knee bent, press against superior part of tibia at popliteal fossa
How to perform Buerger’s test
1) Pt lie down. Lift leg straight up until toes turn white
2) Angle at which toes turned white is the Buerger’s angle. Less than 20deg = chronic ischemia
3) Drop patient leg over edge of bed. Should have reactive hyperemia (foot turns purple red)
What clinical classifications are used for Lower Extremity Arterial Disease?
Rutherford (Grade 0-6)
Fontaine (Stage I-IV)
Fontaine classification for LEAD
Stage I: asymptomatic
Stage IIa: mild claudication
Stage IIb: moderate to severe claudication (<200m walk)
Stage III: ischaemic rest pain
Stage IV: ulceration/gangrene
How to measure ABPI
Brachial pressure: higher arm systolic pressure (either left or right)
Ankle pressure: higher of ankle systolic pressure using DP or PT (only the leg you are trying to measure)
ABPI = AP/BP
Interpreting values of ABPI
Normal: >0.9
Claudication: 0.5-0.9
Critical ischemic rest pain: <0.5
>1.4 = non-compressible calcified vessel (perform toe pressure index instead)
Normal arterial waveforms on Arterial Duplex ultrasound are ___
triphasic
mono or biphasic waves are abnormal
What is acute limb ischemia?
Sudden decrease in limb perfusion that threatens limb viability
*ischemic ulcers, gangrene, ischemic rest pain
Risk factors for acute limb ischemia
- ***Arterial embolism - emboli from heart or DVT clots
- *Acute thrombosis - thrombosis of previously stenotic artery (less severe bc collaterals form). Pts tend to have had claudication history
- Arterial trauma
- Dissecting aortic aneurysm
Quickest to slowest tissues affected by ischemia
Nerves > muscle > skin > bone
so numbness comes first, then paralysis, then skin changes
Clinical presentation of ALI (6 Ps)
paresthesia
pain
pallor
poikilothermia (inability to regulate temperature)
pulselessness
paralysis
Acute limb ischemia can be classified using
Rutherford criteria (Stage I-III)
Stage I - viable: no immediate threat of tissue loss
Stage II - threatened: salvageable if properly revascularised
Stage III - non-viable: has to be amputated