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Year 2 C&M symposia > Vascular Disease in the Lower Limb > Flashcards

Vascular Disease in the Lower Limb Flashcards

1
Q

What is ischaemia?

A

Restriction of blood supply&raquo_space; decreased oxygen and glucose.

  • perfusion fails to meet demands
  • leads to tissue death
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2
Q

What is the most common cause of lower limb disease?

A

Atherosclerotic plaque.

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3
Q

What are other causes of lower leg ischaemia?

A
  • Emboli

- Trauma

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4
Q

What are the main classifications of lower limb ischaemia? (2)

A
  • Acute

- Chronic

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5
Q

What is acute ischaemia?

A

Sudden loss of perfusion.

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6
Q

What normally cause acute ischaemia? (3)

A
  • Thrombus (atherosclerosis)
  • Embolus
  • 2* to trauma
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7
Q

What is chronic ischaemia?

A

Gradual loss of perfusion.

-caused by atherosclerosis

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8
Q

What is the general process of atherosclerosis formation?

A

Endothelial damage&raquo_space; lipid plaques in artery walls.

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9
Q

What do adhesion molecules released by endothelial damage attract?

A
  • Monocytes

- Platelets

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10
Q

What happens to monocytes attracted to endothelial damage?

A

They infiltrate the endothelium and differentiated into macrophages.

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11
Q

What happens to platelets attracted to endothelial damage?

A

They adhere to endothelium and release pro-inflammatory mediators.

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12
Q

What happens to circulating LDL when endothelial damage occurs?

A

It is oxidised and scavenged by macrophages&raquo_space; foam cells.

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13
Q

What happens to plaque if inflammation resolves?

A

It remains stable.

-may occlude artery lumen

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14
Q

What happens to plaque if inflammation continues?

A

It becomes unstable.

-liable to rupture

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15
Q

What happens when a plaque ruptures?

A

Platelet aggregation and coagulation cascade&raquo_space; thrombus.

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16
Q

What are the main risk factors for atherosclerosis?

A
  • Smoking
  • Hypertension
  • Hyperlipidaemia
  • Diabetes
  • Genetics
  • Male
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17
Q

What sort of arteries do atheromas tend to form in?

A

Medium-large conduit arteries, especially at birfurcations (turbulence).

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18
Q

What are the main benefits of taking statins for atherosclerosis? (3)

A
  • Decreases lipids
  • Antiplatelet activity
  • Stabilises plaque
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19
Q

Describe the general path of arteries in the leg.

A

Abdominal aorta&raquo_space; common iliac&raquo_space; internal and external iliacs.

External iliac&raquo_space; femoral artery.

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20
Q

What is the Fontaine classfication?

A

Severity of peripheral vascular disease, based on symptoms.

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21
Q

What are the stages of the Fontaine classification? (4)

A

1 - Asymptomatic
2 - Intermittent claudication
3 - Ischaemic rest pain
4 - Ulceration / gangrene (CRITICAL)

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22
Q

Why is acute ischaemia a surgical emergency?

A

Must be re-vascularised within an hour to preserve limb.

-significant mortality

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23
Q

What is the most common cause of acute ischaemia?

A

Atherosclerotic plaque rupture&raquo_space; thrombus/embolus causing complete occlusion.

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24
Q

Why does acute ischaemia present so suddenly?

A

Perfusion suddenly decreases, and no time for collateral circulation to develop.
-unlike chronic ischaemia

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25
Q

Is acute ischaemia painful?

A

Yes, can be very painful.

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26
Q

How are the signs/symptoms of acute ischaemia remembered?

A

6P’s.

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27
Q

What are the 6 P’s?

A
  • Pain
  • Pulseless
  • Perishingly cold
  • Pallor
  • Paraesthesia
  • Paralysis
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28
Q

How does the leg normally appear in acute ischaemia?

A

Markedly abnormal looking and pale.

-NB may appear red if hanging down

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29
Q

When may the affected leg not look as abnormal in acute ischaemia?

A

If the patient already has vascular disease or chronic ischaemia.
-collateral circulation

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30
Q

How is acute ischaemia treated?

A
  • Urgent re-vascularisation

- Treat risk factors (e.g. diabetes)

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31
Q

What investigations are carried out in acute ischaemia?

A

Investigation of the cause.

-e.g. blood tests, ECG, echocardiogram

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32
Q

What is chronic ischaemia?

A

Gradual decreased perfusion, 2* to atherosclerotic disease.

-often bilateral

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33
Q

How does the limb remain perfused in chronic ischaemia?

A

Collateral circulation develops.

-limb poorly perfused

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34
Q

What happens to a chronic ischaemic limb eventually?

A

EITHER:

  • limb eventually becomes critically ischaemic
  • plaque suddenly ruptures&raquo_space; ACUTE ON CHRONIC ischaemia
35
Q

What is the general development of chronic ischaemia?

A

Atheroma plaque grows&raquo_space; increased obstruction.

  • initially only painful when active (INTERMITTENT CLAUDICATION)
  • eventually painful at rest (CRITICAL ISCHAEMIA; ulceration and gangrene)
36
Q

What is intermittent claudication?

A

Cramping pain in the leg induced by exercise.

-usually due to arterial occlusion

37
Q

What is critical ischaemia?

A

Severe artery obstruction progresses&raquo_space; pain, ulceration and gangrene.

38
Q

When does chronic gangrene present?

A

EITHER:

  • at intermittent claudication (pain when walking)
  • at critical ischaemia (resting pain, ulceration, gangrene)
39
Q

How is chronic ischaemia investigated?

A
  • Blood tests
  • ECG
  • Vascular imaging
  • Ankle brachial pressure index
40
Q

How is chronic ischaemia managed?

A
  • Smoking cessation
  • Exercise
  • Antiplatelet drugs (e.g. aspirin)
41
Q

What type of gangrene normally develops due to chronic ischaemia?

A

Dry gangrene.

  • tissue necrosis without infection
  • black, shrunken toes
42
Q

Why does dry gangrene normally develop instead of wet gangrene?

A

Decreased blood supply&raquo_space; decreased O2 and glucose to drive bacterial infection.

43
Q

What is usually the 1st sign of decreased blood flow to the leg?

A

Claudication.

-then resting pain

44
Q

What is a non-invasive procedure?

A

Doesn’t require incision into the body / removal of tissue.

45
Q

What are the main non-invasive techniques used to view lower limb vasculature? (3)

A
  • Duplex scanning
  • MR angiography
  • CT angiography
46
Q

What is the main invasive techniques used to view lower limb vasculature?

A

Catheter/contrast angiography.

47
Q

What is duplex scanning?

A

Vasculature ultrasound.

-no ionising radiation

48
Q

What effect is used in duplex scanning?

A

Doppler effect.

-change in wave frequency

49
Q

What measurements can be obtained from duplex scanning? (2)

A
  • Volume

- Velocity

50
Q

What does ‘operator dependent’ mean in terms of duplex scanning?

A

Only person doing the scan can interpret the results.

51
Q

What is CT angiography?

A

Combination of cross-sectional x-rays.

52
Q

What is CT angiography useful to assess? (3)

A
  • Aneurysms
  • Bleeding
  • Peripheral vessels
53
Q

What is MR angiography (MRA)?

A

Magnetic resonance.

-no ionisation

54
Q

When is MR angioplasty not suitable?

A
  • Pacemaker
  • Prostheses
  • Claustrophobia
55
Q

What effect does MR angiography have on stenosis?

A

Overestimates stenosis.

56
Q

Which non-invasive techniques have no ionisation? (2)

A
  • Duplex scanning

- MR angiography

57
Q

Which non-invasive technique has ionisation?

A

CT angiography.

58
Q

NB. what is angiography?

A

Imaging technique used to visualize the inside / lumen, of blood vessels and organs.

59
Q

What is the main invasive techniques used to view lower limb vasculature?

A

Catheter/contrast angiography.

60
Q

What type of procedure is catheter angiography; invasive or non-invasive?

A

Invasive.

-contrast is injected

61
Q

What is the access point for catheter angiography in the leg?

A

Femoral artery over the femoral head.

-superficial and compressible

62
Q

What is the access point for catheter angiography for the heart or kidneys?

A

Radial artery.

63
Q

What are the 2 main types of contrast used?

A
  • Iodine (iodinated)

- CO2

64
Q

What is interventional radiology?

A

Use of imaging to affect treatment, rather than just diagnosis.
-e.g. x-ray, CT, ultrasound

65
Q

What are the main advantages of interventional radiology?

A
  • Minimally invasive alternative to surgery (imaging guide treatment)
  • Allows novel treatment (thermal tumour ablation, chemoembolisation)
  • Can be live-saving
66
Q

What is the 1st line procedure for haemoptysis (coughing up blood)?

A

Endoscopy (camera), then embolisation.

67
Q

What are the main uses of non-haemorrhagic embolisation? (3)

A
  • Chemo-embolisation (tumour)
  • Selective internal radiotherapy (SIRT)
  • Uterine artery embolisation (fibroids)
68
Q

What is therapeutic embolisation?

A

Therapeutic introduction of a substance into a vessel.

-prevents haemorrhage / breaks down tumour / decreases blood flow

69
Q

What are the main uses of interventional radiology? (2)

A
  • Vascular radiology (close/open arteries)

- Oncology (chemoembolisation, thermal ablation)

70
Q

What are the main vascular diseases in the legs? (2)

A
  • Peripheral vascular disease (» ischaemia)

- Aneurysmal disease

71
Q

What are the main causes of ischaemia? (3)

A
  • Thrombus
  • Embolus
  • Other (e.g. intrinsic clotting abnormality, surgery)
72
Q

What are the main signs of acute ischaemia?

A

Initially pale leg
» mottled (patchy) leg; 6-12 hours
» irreversible (fixed blue) ischaemia

73
Q

What are the main stages of ischaemia?

A

I - viable
IIa - marginally threatened
IIb - immediately threatened
III - irreversible injury

74
Q

If someone presents with suspected stage I-IIa ischaemia, how is it dealt with?

A

Imaging.

75
Q

If someone presents with suspected stage IIb-III ischaemia, how is it dealt with?

A

Immediate treatment.

76
Q

What is CT angiography good for?

A

Aneurysm and dissection.

-rapid scan times

77
Q

What are the key treatment principles of ischaemia?

A
  • Clear clot
  • Treat underlying lesions
  • Revascularise
78
Q

What are the main endovascular treatment options? (3)

A
  • Thombolysis
  • Aspiration
  • Stent
79
Q

What are the main surgical treatment options? (2)

A
  • Thrombectomy

- Bypass

80
Q

What is thrombolysis?

A

Breakdown of blood clots by pharmacological means.

-infusion of tissue plasminogen activator (tPA) to activate plasminogen to plasmin

81
Q

What is aneurysmal disease?

A

> 50% expansion of an artery.

82
Q

Who is screened for aneurysmal disease?

A

Males, >60 years.

83
Q

What size aneurysm needs treatment?

A

> 5.5 cm.

  • surgery/endovascular
  • emergency for rupture

Year 2 C&M symposia (11 decks)

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