Vascular Flashcards
Cause of Peripheral Vascular Disease
Obstruction of the large arteries in the peripheries
Obstruction can arrise as a result of :
- atherosclerosis
- thromboembolic disease
- inflammatory stenosis
NAME THAT ARTERY
…
Paraphernalia of peripheral vascular disease
Oxygen, GTN spray, Cigarettes, Walking aids, amputation, prothesis
Signs in the Hands of peripheral vascular Exam
- Skin Changes:
- Tar Staining
- Tendon Palmar Xanthoma (Hypercholestolaemia)
- Purple Discolouration on Fingertips (Atherothromboembolism)
- Muscle Wasting
- Small Muscles (Thoracic Outlet Syndrome)
- Temperature
Normal difference in blood pressure between arms
<15mmHg
VENOUS SCARS/ ARTERIAL SCARS
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Arterial Disease Skin Changes
- Discolouration
- Erythema
- Pallor
- Brown Haemosiderin Deposits
- Purple or Black from Haemostasis
- Venous Guttering
- Trophic Changes
- Absence of Hair
- Shiny Skin
- Gangrene
- Ulcers
Name of the test for peripheral artery disease
Buerger’s Test
What happens in positive Buergers Test
Reactive Hyperaemia!
In normal person the leg goes pink when hang feet off couch.
In PAD they turn a bluish color from deoxygenated blood and then red from reactive hyperaemia from post- hypoxic vasodilation.
This can take up to 2 minutes in severe PAD
Classification of PAD by Buergers angle
Some discrepency in exact definition but:
Severe Ischaemia: Buerger’s Angle <50o
Critical Ischaemia: Buerger’s Angle <20-25o
Anatomical Location of the Femoral Artery
MID-INGUINAL POINT
Halfway between ASIS and Pubic Symphisis
Anatomical Location of the Popliteal Artery
Lower margin of the Popliteal Fossa between the two heads of the gastrocnemius muscle
Anitomical location of the Dorsalis Pedis Pulse
Lateral to extensor hallucis longus tendon
Pulses to feel in peripheral Vascular Examination
- Radial
- Radial Radial Delay
- Radio-Femoral Delay
- Brachial
- Carotid
- Subclavian
- Abdominal Aorta
- Femoral
- Popliteal
- Posterior Tibial
- Dorsalis Pedis
What special tests do you do in the vascular Exam?
Buerger’s Test
Ankle Brachial Pressure Index (ABPI)-on both sides!
Describe the Ankle Brachial Pressure Index
ABPI examines for a fall in BP in the arteries supplying the legs which occurs as a result of occlusive arterial disease in the lower limbs.
ABPI= Pleg/ Parm
- Sphygmomanometer proximal to ankle joint.
- Place doppler proble on posterior tibial pulse and inflate the cuff until the noice from doppler disappears
- Deflate cuff until doppler signal reappears.
- Can repeat on dorsalis pedis
- Highest reading is used
- Repeat on both arms with brachial artery.
- Use the highest systolic reading
What would you do to investigate this PVD patient?
Simple bedside tests that I would like to do include:
- Checking the pt’s BM
- A 12 lead echocardiogram for evidence of coexisting heart disease as the patient is likely to be an arteriopath.
I would like to do some bloodtests including:
- FBC to check for anaemia or polycythaemia
- U&Es to check the patients renal function-this is particularly important if there is a view to doing contrast studies later, particularly if the patient is diabetic as you can get contrast induced nephopathy.
- Serum Cholesterol for hypercholesterolaemia to address risk factor modification.
- Clotting for the presence of a coagulopathy.
- G&S incase the patient undergoes operative management
- ESR to screen for vasculitides and a specialist antinuclear antibody screen for selective patients
Imaging that I would like to request would include:
- CXR to look for coexisting cardiorespiratory disease and do a preoperative assessment
- Specialist Imaging that I would use to assess the extent of disease and help plan operative management would include
- a duplex scan to look for the degree of stenosis and
- a spiral CT to reconstruct 3D images of vessels non invasively.
- In some patients I would do a digital subtraction angiogram (DSA) to demonstrate the level of blockage, runoff and the presence of a collateral blood supply.
What is DSA?
Digital Subtraction Angiography
Computer software subtracts bone and soft tissue from image.
Arterial supply is demonstrated in high resolution and it uses less contrast material
Can you estimate the extent of stenosis from a hand held doppler probe?
Yes, the doppler probe detects arterial pulsation as an audible signal.
Normal vesels: Triphasic waveform
Mild Stenosis: Biphasic waveform
Severe Stenosis: Monophasic waveform
What is the treatment for Lower limb occlusive arterial disease?
Requires MDT approach
In general management can be divided into conservative, medical or surgical.
Conservative and Medical management focus around modifying risk factors
Conservative
- Stop Smoking
- Treat obesity with Diet
- If Diabetes: Liase with diabetic nurse for diabetic control
- Referal to podiatrist for foot care
- Dedicated exercise program in those with intermittant claudication to encourage collateral supply build up
Medical
- Aspirin (75mg)
- Treat HTN
- Treat Hypercholestrolaemia
- Treat Diabetes
_Surgical _
- Endovascular techniques with stents and grafting
- Reconstructive Surgery resulting in a bypass of the occlusion: This can be
- Anatomical (e.g fem-pop)
- Extra-Anatomical (e.g axillo-femoral)
- Amputation
Other operative measurs such as endarterectomy, where the atheromatous plaque is cored out, is commonly used in surgery for carotid artery stenosis.
Sympathectomies can be useful in those with chronic, intractable pain.
What are the benefits of Below knee amputation above an above knee amputaiton
BKA is prefered as
- Pts typically demonstrate better mobility- less likely to be wheelchair bound–> increased chance of successful rehabiliation and better QOL
- Preserve Limb Length
- Reduced energy required to mobalise
- Studies have shown the life expectancy for those with AKA is poorer than BKA
- AKA are more likely to develop critical limb ischaemia in the other leg
Reasons for Amputation
- Dead (e.g PVD)
- Dangerous (e.g Infection)
- Debilitating (e.g Trauma)
What level does the aorta bifurcate?
L4
What is an aneurysm?
A Pathological, localised, permanant dilation of an artery, involving all 3 layers of its wall to 1.5 times its normal diameter.
