Vascular - Peripheral Arterial Disease Flashcards
What is the Fontaine classification
Outlines the progression of chronic lower limb peripheral aa disease
What are the 4 stages of Fontaine classification
1 = Asymp 2= Int claudication 3 = ischaemic rest pain 4 = ulceration/gangrene
ABPI
Ankle-branchial pressure index
Used to assess aa disease
ABPI <0.8
aa diseasae present
ABPI - norm value
0.8-1.2
ABPI <0.4
Critical limb ischaemia
What can an ABPI >1.2 mean?
False _ve due to calcification
> in diabetics
Causes of chronic peripheral aa disease (3)
atherosclerosis ++
Fibromuscular dysplasia
Buerger’s disease
What is fibromuscular dysplasia
Non-inflammatory artery wall thickening
What is Buerger’s disease
Acute inflammation + thrombsis of lower limb aa/vv
Who gets Buerger’s disease
Young heavy smokers
Buerger’s +ve:
Supine Position
Legs held to 45’
Pallor observed + tissue ischaemia
Then ask pt to sit up at 90’ - perfusion will gradually return
Intermittent claudication - Sx
Ischaemic cramping mm pain on walking, R by rest
Mostly on calf
If intermittent claudication felt on thigh/buttock, which aa are affected
Internal iliac aa
If intermittent claudication felt on calves, which aa = affected
Femoral/popliteal aa
If buttock intermittent claudication, what else must you ask about + why
Penile function
b/c Leriche syndrome
Signs intermittent claudication (5)
Absent pulses Cold, pale legs Atrophic, hairless + shiny legs Beurgers ankle <20' Aa ulcers
What does ischaemic rest pain indicate
Critical lower limb ischaemia
Classical PS ischaemic rest pain (4)
At night on forefoot
Pt wakes from sleep + swings leg off bed
Hx int claudication
Signs aa insifficiency
Ix peripheral aa disease (4)
Bloods incl FBC, HbA1C, lipids
ABPI
USS duplex
CT angiogram
Mx peripheral aa disease if ABPI >0.6 (5)
Lifstyle - stop smoking, exercise, W loss Raise heel of shoes Footcare Optimisation of BP/DM Start clopidogrel + atorvastatin
Mx peripheral aa disease If ABPI <0.6, highly Sx or Conservative measures have failed (3)
PTA
Surgical reconstruction
Or amputation
What is PTA
Percutaneous transluminal angioplasty
Balloon in narrow segment
Why can diabetics present differently w/ peripheral aa neuropathy?
Due to presence of peripheral neuropathy
What are the 3 main effects of peripheral neuropathy in diabetic aa disease
Sensory neuropathy
Autonomic neuropathy
Motor neuropathy
Consequences of Sensory neuropathy in DM peripheral aa disease
Reduces protective reactions to minor injury
Reduces awareness of Sx infection/ischaemia
Consequences of Autonomic neuropathy in DM peripheral aa diseasse
Lack of sweating –> dry, fissured skin –> entry of bacteria
Consequences of motor neuropathy in DM peripheral aa disease
wasting of small mm of foot –> loss of arches + development of abnormal P areas in feet
Sx of peripheral neuropathy UNACCOMPANIED by aa disease
Stabbing pain in feet
Red + warm w/ strong pulses
Unlikely to be relieved by swinging foot over bed
+/- hyperalgesia + allodynia
What is DM w/ critical limb ischaemic likely to present with?
Ulceration
What can Ulcers in DM + critical limb ischaemia rapidly progress to?
Gangrene
What is Gangrene?
Dead tissue, normally colonised by bacteria
Wet gangrene
Infected w/ proliferating organisms
Dry gangrene
Colonized but organisms aren’t proliferating
Why does int claudication occur `
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
DDx intermittent claudication (5)
Spinal stenosis Venous claudication MSK (OA/RA) Peripheral neuropathy Popliteal aa entrapment
How is spinal stenosis different to intermittent claudication? (3)
Pain = relieved by sitting down or flexing spine rather than standing still
+ Assoc w/ numbness+ tingling
Pulses = present
How is venous claudication different to intermittent claudication (4)
Starts as soon as walking starts Affects whole leg Bursting in nature elevate to relieve pain \+ signs vv disease + Hx DVT
What % of leg ulcers are venous?
85%
Vv ulcer - Hx of
DVT
Varicosities
Obesity
Do you get pain in vv ulcers?
Rarely
Site of vv ulcers
Medial malleolus + gaiter area
Ulcer appearance vv ulcer
Shallow w/ flat margin
+ signs vv insufficiency, red + warm
Mx of ulcers - if ABPI >0.8 + signs vv disease
4 layer compression bandaging
Leg elevation
Once healed –> LT stockings
Mx ulcers if ABPI <0.8
Rx to GP for CV risk mod
Rx to vascular
Tx w/ surgery if necess
Sx - chronic small bowel ischaemia (4)
Severe post-prandial colic
PR bleeding
W loss
Malabsorption
Ix chronic small bowel ischaemia
Angiography
Mx chronic small bowel ischaemia
Angioplasty
PS large bowel ischaemia (5)
L sided abdo pain Bloody diarrhoea Pyrexia Tachycardia Leukocytosis
What can large bowel ischaemia progress into?
Gangrenous colitis, peritonitis + shock
Ix large bowel ischaemia
AXR/ Ba enema - thumb printing
MR angiography = diagnostic
Mx large bowel ischaemia
Fl + Abx
PTA + stenting if severe
What is the majority of renal aa stenosis due to?
Atherosclerosis
PS RAS (4)
Resistant HTN
Worsening RF after ACEi
Sudden onset pulm oedema
Renal bruits
Ix RAS (3)
Renal USS
CT/MRI angiography
Renal angiography = GOLD STANDARD
What is seen on USS in RAS
Small kidney
Medical Tx RAS (3)
ACEi
Statins
Antiplatelets
Surgical Mx RAS (2)
Angioplasty + stenting
Conservative Mx of aa occlusive disease (3)
RF Mx
Low dose aspirin
Supervised exercise programmes
Causes of acute aa occlusion (4)
Embolus
Thrombus
Trauma
Failure of interventions e.g. stent
What is thrombosis predisposed to by?
Virchow’s triad
Virchow’s triad
Endothelial dysfunction
Changes in blood flow
Changes in blood coagulability
What is an embolic occlusion?
Occlusion of vessel by a mass of material transported in bloodstream
Where do thromboemboli arise from? (4)
LA in AF
LV post MI
Heart valves in endocarditis
Or mural thrombi in AAA
Classic Sx acutely ischaemic limb
6Ps Pulseless Painlful Pallor Perishingly cold Paralysis Paraesthesia
What indicates a non-viable limb?
Fixed staining of leg
Rigid mm
What is the max amount of time a Dr has to re-establish flow in an acutely ischaemic limb
6hrs
Mx acutely ischaemic limb
WITHIN 6hrs A-E + Resus IV heparin ASAP If no blood supply --> surgery Urgent CT angiogram
Mx acutely ischaemic limb - embolus Mx
Open embolectomy + Fogarty catheter
Mx acutely ischaemic limb - thrombosis Mx
Thrombolysis
Interval angioplasty to Tx underlying disease
What must be observed post op after Mx of acutely ischaemic limb
Reperfusion injury
What is a reperfusion injury?
Inflammation + oxidative damage when blood flow is restored to tissue after a long period of anoxia
What can reperfusion injury to lead to?
Compartment syndrome
Embolus occlusion - onset
V sudden, v severe b/c lack of collaterals
Thrombosis occlusion - onset
Insidious onset, < severe Sx as advanced collaterals
Embolus occlusion - pulses
Prev normal
Normal collateral pulses
Thrombus occlusion - pulses
Long standing decreased pulses bilaterally
Mx of transection
Apply P
If signif ischaemia –> grafting
When Mx transection, do you reapir the aa or vv first and why
VV
BEcause need to allow vv drainage
What is an A-V fistula?
Acquired communication between aa and vv
Causes AV fistula (3)
Penetrating trauma
Erosion of aneurysm into vv
Haemodialysis
What happens to peripheral vv pressure in AV fistula
Increases
Consequence change to peripheral vv pressure in AV fistula (3)
Swelling
Varicosities
Leg ulceration
What happens to peripheral aa pressure in AV fistula
Decreases
Consequence of change to peripheral aa P in AV fistula
Decrease in stroke volume
–> LV dilation + failure
Sx non-iatrogenic AV fistulae (5)
Limb heaviness Relieved on elevation Pain Oedema + prominent vv Audible murmur /thrill
Ix AV fistula (2)
Duplex USS
Contrast CT
Reynaud’s phenomenon
Episodic digital vasospasm in the absence of an identifiable assoc disorder
Reynaud’s syndrome
Reynauds occuring 2’ to another condition
2’ conditions causing Reynaud’s syndrome (6)
CT: systemic sclerosis, mixed CT disease, SLE, Sjogren's, polyarteritis nodosa Macrovascular disease Occupational trauma Dx Malignancy AF
Drugs causing Reynaud’s syndrome (2)
B-blockers
Cytotoxic Dx
Triggers Reynaud’s (2)
COld exposure
Emotional stress
What are the 3 phases of Reynaud’s
Pallor (b/c digital aa spasm)
Cyanosis (b/c accum deoxy blood)
Rubor (erythema b/c reactive hyperaemia)
How long do Reynaud’s attacks last
Usually <45mins
Features of Reynaud’s suggesting a 2’ cause (4)
Dilated nail fold capillary loops
If PS early childhood or >30
Asymmetrical
Male
Ix Reynaud’s (6)
FBC U+E Coag Glucose TFT ANA/RF/APA
Mx Reynauds (4)
Keep warm
Stop smoking + exacc Dx
Nifedipine
Sympathectomy (severe)
What is the thoracic outet
Space between the 1st rib + clavicle
What structures pass through the thoracic outlet? (3)
SCA
SCV
Brachial plexus
What is thoracic outlet syndrome
Narrowing of thoracic outlet
Causes thoracic outlet syndrome (3)
Cervical rib
healed clavicular #
XS mm development
PS thoracic outlet syndrome
T1 - wasting mm hand, paraesthesia inner forearm + hand
Aa Sx - upper limb claudication, post-stenotic dilatation –> thrombosis
O/E thoracic outlet syndrome
BP is lower in affected arm
Ix thoracic outlet sydrome (2)
Ateriography
XR
