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CP3 SURGERY > Vascular - Peripheral Arterial Disease > Flashcards

Vascular - Peripheral Arterial Disease Flashcards

1
Q

What is the Fontaine classification

A

Outlines the progression of chronic lower limb peripheral aa disease

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2
Q

What are the 4 stages of Fontaine classification

A 
1 = Asymp 
2= Int claudication 
3 = ischaemic rest pain 
4 = ulceration/gangrene
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3
Q

ABPI

A

Ankle-branchial pressure index

Used to assess aa disease

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4
Q

ABPI <0.8

A

aa diseasae present

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5
Q

ABPI - norm value

A

0.8-1.2

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6
Q

ABPI <0.4

A

Critical limb ischaemia

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7
Q

What can an ABPI >1.2 mean?

A

False _ve due to calcification

> in diabetics

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8
Q

Causes of chronic peripheral aa disease (3)

A

atherosclerosis ++
Fibromuscular dysplasia
Buerger’s disease

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9
Q

What is fibromuscular dysplasia

A

Non-inflammatory artery wall thickening

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10
Q

What is Buerger’s disease

A

Acute inflammation + thrombsis of lower limb aa/vv

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11
Q

Who gets Buerger’s disease

A

Young heavy smokers

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12
Q

Buerger’s +ve:

A

Supine Position
Legs held to 45’
Pallor observed + tissue ischaemia
Then ask pt to sit up at 90’ - perfusion will gradually return

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13
Q

Intermittent claudication - Sx

A

Ischaemic cramping mm pain on walking, R by rest

Mostly on calf

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14
Q

If intermittent claudication felt on thigh/buttock, which aa are affected

A

Internal iliac aa

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15
Q

If intermittent claudication felt on calves, which aa = affected

A

Femoral/popliteal aa

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16
Q

If buttock intermittent claudication, what else must you ask about + why

A

Penile function

b/c Leriche syndrome

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17
Q

Signs intermittent claudication (5)

A 
Absent pulses 
Cold, pale legs
Atrophic, hairless + shiny legs 
Beurgers ankle <20' 
Aa ulcers
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18
Q

What does ischaemic rest pain indicate

A

Critical lower limb ischaemia

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19
Q

Classical PS ischaemic rest pain (4)

A

At night on forefoot
Pt wakes from sleep + swings leg off bed
Hx int claudication
Signs aa insifficiency

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20
Q

Ix peripheral aa disease (4)

A

Bloods incl FBC, HbA1C, lipids
ABPI
USS duplex
CT angiogram

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21
Q

Mx peripheral aa disease if ABPI >0.6 (5)

A 
Lifstyle - stop smoking, exercise, W loss 
Raise heel of shoes 
Footcare
Optimisation of BP/DM
Start clopidogrel + atorvastatin
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22
Q

Mx peripheral aa disease If ABPI <0.6, highly Sx or Conservative measures have failed (3)

A

PTA
Surgical reconstruction
Or amputation

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23
Q

What is PTA

A

Percutaneous transluminal angioplasty

Balloon in narrow segment

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24
Q

Why can diabetics present differently w/ peripheral aa neuropathy?

A

Due to presence of peripheral neuropathy

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25
Q

What are the 3 main effects of peripheral neuropathy in diabetic aa disease

A

Sensory neuropathy
Autonomic neuropathy
Motor neuropathy

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26
Q

Consequences of Sensory neuropathy in DM peripheral aa disease

A

Reduces protective reactions to minor injury

Reduces awareness of Sx infection/ischaemia

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27
Q

Consequences of Autonomic neuropathy in DM peripheral aa diseasse

A

Lack of sweating –> dry, fissured skin –> entry of bacteria

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28
Q

Consequences of motor neuropathy in DM peripheral aa disease

A

wasting of small mm of foot –> loss of arches + development of abnormal P areas in feet

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29
Q

Sx of peripheral neuropathy UNACCOMPANIED by aa disease

A

Stabbing pain in feet
Red + warm w/ strong pulses
Unlikely to be relieved by swinging foot over bed
+/- hyperalgesia + allodynia

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30
Q

What is DM w/ critical limb ischaemic likely to present with?

A

Ulceration

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31
Q

What can Ulcers in DM + critical limb ischaemia rapidly progress to?

A

Gangrene

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32
Q

What is Gangrene?

A

Dead tissue, normally colonised by bacteria

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33
Q

Wet gangrene

A

Infected w/ proliferating organisms

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34
Q

Dry gangrene

A

Colonized but organisms aren’t proliferating

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35
Q

Why does int claudication occur `

A

At rest O2 requirement of mm is met by collateral system of profunda femoris
Exercise prdouces a demand that can’t be met + mm becomes ischaemic

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36
Q

DDx intermittent claudication (5)

A 
Spinal stenosis 
Venous claudication 
MSK (OA/RA)
Peripheral neuropathy 
Popliteal aa entrapment
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37
Q

How is spinal stenosis different to intermittent claudication? (3)

A

Pain = relieved by sitting down or flexing spine rather than standing still
+ Assoc w/ numbness+ tingling
Pulses = present

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38
Q

How is venous claudication different to intermittent claudication (4)

A 
Starts as soon as walking starts
Affects whole leg
Bursting in nature 
elevate to relieve pain 
\+ signs vv disease + Hx DVT
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39
Q

What % of leg ulcers are venous?

A

85%

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40
Q

Vv ulcer - Hx of

A

DVT
Varicosities
Obesity

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41
Q

Do you get pain in vv ulcers?

A

Rarely

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42
Q

Site of vv ulcers

A

Medial malleolus + gaiter area

43
Q

Ulcer appearance vv ulcer

A

Shallow w/ flat margin

+ signs vv insufficiency, red + warm

44
Q

Mx of ulcers - if ABPI >0.8 + signs vv disease

A

4 layer compression bandaging
Leg elevation
Once healed –> LT stockings

45
Q

Mx ulcers if ABPI <0.8

A

Rx to GP for CV risk mod
Rx to vascular
Tx w/ surgery if necess

46
Q

Sx - chronic small bowel ischaemia (4)

A

Severe post-prandial colic
PR bleeding
W loss
Malabsorption

47
Q

Ix chronic small bowel ischaemia

A

Angiography

48
Q

Mx chronic small bowel ischaemia

A

Angioplasty

49
Q

PS large bowel ischaemia (5)

A 
L sided abdo pain 
Bloody diarrhoea 
Pyrexia 
Tachycardia 
Leukocytosis
50
Q

What can large bowel ischaemia progress into?

A

Gangrenous colitis, peritonitis + shock

51
Q

Ix large bowel ischaemia

A

AXR/ Ba enema - thumb printing

MR angiography = diagnostic

52
Q

Mx large bowel ischaemia

A

Fl + Abx

PTA + stenting if severe

53
Q

What is the majority of renal aa stenosis due to?

A

Atherosclerosis

54
Q

PS RAS (4)

A

Resistant HTN
Worsening RF after ACEi
Sudden onset pulm oedema
Renal bruits

55
Q

Ix RAS (3)

A

Renal USS
CT/MRI angiography
Renal angiography = GOLD STANDARD

56
Q

What is seen on USS in RAS

A

Small kidney

57
Q

Medical Tx RAS (3)

A

ACEi
Statins
Antiplatelets

58
Q

Surgical Mx RAS (2)

A

Angioplasty + stenting

59
Q

Conservative Mx of aa occlusive disease (3)

A

RF Mx
Low dose aspirin
Supervised exercise programmes

60
Q

Causes of acute aa occlusion (4)

A

Embolus
Thrombus
Trauma
Failure of interventions e.g. stent

61
Q

What is thrombosis predisposed to by?

A

Virchow’s triad

62
Q

Virchow’s triad

A

Endothelial dysfunction
Changes in blood flow
Changes in blood coagulability

63
Q

What is an embolic occlusion?

A

Occlusion of vessel by a mass of material transported in bloodstream

64
Q

Where do thromboemboli arise from? (4)

A

LA in AF
LV post MI
Heart valves in endocarditis
Or mural thrombi in AAA

65
Q

Classic Sx acutely ischaemic limb

A 
6Ps 
Pulseless 
Painlful
Pallor 
Perishingly cold 
Paralysis 
Paraesthesia
66
Q

What indicates a non-viable limb?

A

Fixed staining of leg

Rigid mm

67
Q

What is the max amount of time a Dr has to re-establish flow in an acutely ischaemic limb

A

6hrs

68
Q

Mx acutely ischaemic limb

A 
WITHIN 6hrs 
A-E + Resus 
IV heparin ASAP
If no blood supply --> surgery 
Urgent CT angiogram
69
Q

Mx acutely ischaemic limb - embolus Mx

A

Open embolectomy + Fogarty catheter

70
Q

Mx acutely ischaemic limb - thrombosis Mx

A

Thrombolysis

Interval angioplasty to Tx underlying disease

71
Q

What must be observed post op after Mx of acutely ischaemic limb

A

Reperfusion injury

72
Q

What is a reperfusion injury?

A

Inflammation + oxidative damage when blood flow is restored to tissue after a long period of anoxia

73
Q

What can reperfusion injury to lead to?

A

Compartment syndrome

74
Q

Embolus occlusion - onset

A

V sudden, v severe b/c lack of collaterals

75
Q

Thrombosis occlusion - onset

A

Insidious onset, < severe Sx as advanced collaterals

76
Q

Embolus occlusion - pulses

A

Prev normal

Normal collateral pulses

77
Q

Thrombus occlusion - pulses

A

Long standing decreased pulses bilaterally

78
Q

Mx of transection

A

Apply P

If signif ischaemia –> grafting

79
Q

When Mx transection, do you reapir the aa or vv first and why

A

VV

BEcause need to allow vv drainage

80
Q

What is an A-V fistula?

A

Acquired communication between aa and vv

81
Q

Causes AV fistula (3)

A

Penetrating trauma
Erosion of aneurysm into vv
Haemodialysis

82
Q

What happens to peripheral vv pressure in AV fistula

A

Increases

83
Q

Consequence change to peripheral vv pressure in AV fistula (3)

A

Swelling
Varicosities
Leg ulceration

84
Q

What happens to peripheral aa pressure in AV fistula

A

Decreases

85
Q

Consequence of change to peripheral aa P in AV fistula

A

Decrease in stroke volume

–> LV dilation + failure

86
Q

Sx non-iatrogenic AV fistulae (5)

A 
Limb heaviness 
Relieved on elevation 
Pain 
Oedema + prominent vv 
Audible murmur /thrill
87
Q

Ix AV fistula (2)

A

Duplex USS

Contrast CT

88
Q

Reynaud’s phenomenon

A

Episodic digital vasospasm in the absence of an identifiable assoc disorder

89
Q

Reynaud’s syndrome

A

Reynauds occuring 2’ to another condition

90
Q

2’ conditions causing Reynaud’s syndrome (6)

A 
CT: systemic sclerosis, mixed CT disease, SLE, Sjogren's, polyarteritis nodosa 
Macrovascular disease 
Occupational trauma 
Dx 
Malignancy 
AF
91
Q

Drugs causing Reynaud’s syndrome (2)

A

B-blockers

Cytotoxic Dx

92
Q

Triggers Reynaud’s (2)

A

COld exposure

Emotional stress

93
Q

What are the 3 phases of Reynaud’s

A

Pallor (b/c digital aa spasm)
Cyanosis (b/c accum deoxy blood)
Rubor (erythema b/c reactive hyperaemia)

94
Q

How long do Reynaud’s attacks last

A

Usually <45mins

95
Q

Features of Reynaud’s suggesting a 2’ cause (4)

A

Dilated nail fold capillary loops
If PS early childhood or >30
Asymmetrical
Male

96
Q

Ix Reynaud’s (6)

A 
FBC
U+E
Coag 
Glucose 
TFT
ANA/RF/APA
97
Q

Mx Reynauds (4)

A

Keep warm
Stop smoking + exacc Dx
Nifedipine
Sympathectomy (severe)

98
Q

What is the thoracic outet

A

Space between the 1st rib + clavicle

99
Q

What structures pass through the thoracic outlet? (3)

A

SCA
SCV
Brachial plexus

100
Q

What is thoracic outlet syndrome

A

Narrowing of thoracic outlet

101
Q

Causes thoracic outlet syndrome (3)

A

Cervical rib
healed clavicular #
XS mm development

102
Q

PS thoracic outlet syndrome

A

T1 - wasting mm hand, paraesthesia inner forearm + hand

Aa Sx - upper limb claudication, post-stenotic dilatation –> thrombosis

103
Q

O/E thoracic outlet syndrome

A

BP is lower in affected arm

104
Q

Ix thoracic outlet sydrome (2)

A

Ateriography

XR

CP3 SURGERY (19 decks)

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