Vascular Flashcards
What is the most common cause of peripheral vascular disease?
Atherosclerosis
What are the symptoms and signs of chronic PAD/ischaemia?
SYMPTOMS
- Intermittent claudication (usually in calf - due to ischaemia of the superficial femoral artery)
- Erectile dysfunction
- Rest pain
- Ask about all CVS symptoms too
- Gangrene/necrosis
SIGNS
- Cold, dry skin, lack of hair, absent pulses, ulceration, loss of sensation
- Buergers angle <20 degrees and cap refill >15s in severe disease
How is chronic lower limb ischaemia classified?
Fontaine classification: Stage 1 - asymptomatic Stage 2 - intermittent claudication Stage 3 - rest pain/nocturnal pain (critical limb ischaemia) Stage 4 - gangrene/necrosis
What are the DDs for PAD?
- Spinal canal claudication (but all pulses present)
- Osteoarthritis (more specific to knee)
- Peripheral neuropathy (numbness, tingling)
- Popliteal artery entrapment (young patients, normal pulses)
- Venous claudication (bursting pain on walking, previous history of DVT)
- Fibromuscular dysplasia
- Buergers disease (young males, heavy smokers)
What investigations should be done for PAD and how is it managed?
Investigations:
BEDSIDE: BP, ABPI, ECG (cardiac ischaemia)
BLOODS: FBC (anaemia, polycythemia), glucose (exclude DM), ESR (exclude arteritis), lipid profile, thrombophilia screen if below 50yo
IMAGING: duplex US (1st line - to assess patency of individual vessels), MR angiography (if more info needed), CT angiography (if MR contraindicated)
Management:
- All pts should take atorvastatin 80mg and clopidogrel
- Supervised exercise programme
- Surgery or amputation if severe <0.4
- Naftidrofuyrl oxalate for those who are not suitable for surgery (vasodilator)
What is critical limb ischaemia?
Definede as rest/night pain, requiring opiate analgesia and/or tissue loss (ulceration/gangrene) present for more thatn 2 weeks, in the presence of an ankle BP < 50mmHg
This can be partly relieved by hanging leg out of bed
What is acute limb ischaemia?
6 Ps:
Pale, pulseless, painful, paralysed, paraesthetic, perishingly cold
This is a surgical emergency! It is like a DVT in an artery. Often caused by thrombotic (1st)/embolic (2nd) disease or graft occlusion (3rd)
What is Buergers test?
- Lift both legs to 45 degrees and allow a minute for legs to go pale
- If pallor, ask patient to sit up and swing lower legs around to the ground
- Positive test is change in colour from white to pink
- Flushed red (reactive hyperaemia) is indicative of severe disease
How do you take an ABPI?
Measure BP manually at both brachial arteries and take the highest reading.
Using doppler, measure BP of one ankle at both arteries, and take the highest reading.
ABPI = ankle BP/arm BP
Repeat for the other leg
What is a normal ABPI reading - or one for venous disease?
1-1.2
What would the ABPI reading be in calcified vessels?
> 1.2
This might be in diabetic or elderly patients or a false negative!
What ABPI indicates mild arterial disease?
0.8-0.9
What ABPI indicates moderate arterial disease?
0.5-0.8
What ABPI indicates severe arterial disease (critical ischaemia)
<0.5
How is chronic ischaemia managed?
CONSERVATIVE - risk reduction (smoking, diabetes, cholesterol, BP), compression stockings, supervised exercise programmes for claudication
MEDICAL - naftidrofuryl oxalate (vasodilator), risk reduction (statins, clopidogrel/aspirin, antihypertensives)
SURGICAL - percutaneous transluminal angioplasty, stents, bypass procedures
When should angioplasty be given for intermittent claudication?
Offer angioplasty for treating people with intermittent claudication only when (all 3):
- Advice on the benefits of modifying risk factors has been reinforced
- A supervised exercise programme has not led to a satisfactory improvement in symptoms
- Imaging has confirmed that angioplasty is suitable for the person
When should bypass surgery be given for intermittent claudication?
Offer bypass surgery for treating people with severe lifestyle‑limiting intermittent claudication only when (requires both):
- Angioplasty has been unsuccessful or is unsuitable
- Imaging has confirmed that bypass surgery is appropriate for the person.
How is critical limb ischaemia managed?
CONSERVATIVE - lifestyle measures, risk reduction
MEDICAL - analgesia and laxatives
SURGERY - angioplasty and stent, major amputation (last resort)
How is acute limb ischaemia managed?
This depends on the degree of ischaemia and cause. Surgical intervention required within 4-6 hours to save the limb!
- Do urgent thrombolysis, angioplasty, embolectomy, bypass graft.
- Given heparin after procedure and look for source of emboli.
- Be aware of reperfusion injury and compartment syndrome!
What is reperfusion injury?
A potential complication of revascularization in acute limb ischaemia.
- Release of toxic metabolites
- Oedema
- Compartment syndrome
What is an embolectomy?
Surgical removal of an embolus, by inserting a catheter with an inflatable balloon
What is angioplasty?
The use of a balloon tipped catheter to open up an occluded vessel. Limited to single arterial segment.
What is endartectomy?
Surgical removal of plaque from an artery that has become narrowed
What is a bypass graft?
Surgical creation of a new pathway for blood to flow, using a graft (from a vein or synthetic). Often used if extensive disease with good distal arteries??
What is Buergers disease?
- Inflammatory arterial dises, present in young male smokers.
- Present with claudication in FEET or rest pain in EXTREMITIES
- Superficial thrombophlebitis in the veins
What is an aneurysm?
Abnormal dilation of an endothelial lined vessel, which is greater than 1.5x its normal diameter
What is the difference between true and false aneurysms?
True - abnormal dilatation involving all layers of the arterial wall
False (pseudo) - collection of blood in outer layer (adventitia) which communicates iwth the lumen
What are the 3 main types of aneurysm?
- Fusiform - bulges out on all sides forming a dilated artery eg. AAA
- Sac-like - localised dilatation of a vessel in a small area eg. berry
- Dissecting - blood leaks between the layers of the vessel wall, often due to a tear eg. aortic dissection