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my podiatry notes > Circulatory disorders > Flashcards

Circulatory disorders Flashcards

1
Q

What is Chronic Venous Disease

A
  • It is a term used to describe chronic conditions which are caused by veins becoming incompetent
  • Chronic Venous Disease in the lower limb can be manifested as varocose veins, Venous Exczema and Venous Ulceration
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2
Q

Detail the main characteristics of the Venous system

A
  • Veins return deoxygenated blood from your organs back to your heart
  • The blood in the lower leg must travel against gravity in order to return back to the heart
  • Veins in the lower leg are divided into two categories
  • Deep Veins - are located underneath the deep fascia layer next to the arteries
  • Superficial Veins - are found in the subcutaneous tissue
  • Perfotrator veins are used perforate the deep fascia and transfer blood from the superficial to the deep venous system
    *
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3
Q

Detail the main charecteristics of the Venous system part 2

A
  • Venous system is designed to be a low pressure system in contrast to the arterial (high pressure)
  • Both superficial and deep veins are separated by a number of non return bicuspid valves approx every 10cm
  • Competent valves allow blood to drain from superficial veins to perforaters into the deep veins and back flow is prevented
  • Valves work in unison with lower limb muscle pumps in order to move the blood in an upward direction
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4
Q

Describe the Pathophysiology of Chronic Venous Disease

How does CVD develop

A
  • CVD develops when Venous pressure is increased (venous hypertension) and the return of blood to the heart is impaired
  • Incompetence of Bicuspid valves is the main contributer to poor venous drainage resulting in reflux/ retrograde flow (blood flow backwards)
  • Valves can be ineffective due to phlebetis (vein inflamattion) direct injury, pre exsiting weakness, DVT damage
  • Dusfunction of the calf pump can also cause venus hypertensionas blood will not effectively be drained form the lower limb
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5
Q

Describe how you would manage a patient with Chronic Venous Disease

A
  • The two principal management options for CVD are surgical intervention to correct underlying pathophsyiology or compression therapy.
  • Surgical intervention: All patients with symptomatic varacose veins, lower limb skin changes superficial vein thrombosis or healed venous ulcers should be referred to a vascular consultant to asses whether Venous surgery is an option
  • Compression therapy: Works in a number of different ways
  1. Provides structural support to the venous leg pump
  2. Prevents Venous dialation during walkin
  3. Increases the velocity of venous blood flow reducing inflamattion
  4. increases tissue pressure encouraging reabsorption of excess fluid into Venous and lympthaitic systems
  5. Improves Valvular efficiency
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6
Q

Describe what PAD is

A
  • Peripheral Arterial Disease can be described as the partial or complete obstruction of one or more of the arteries which perfuse (supply blood) the lower limbs causing a reduction in arterial blood supply.
  • PAD is a systematic disease (affects the entire body) so patients with PAD have similar risk of death from myocardial infarction, stroke and other vascular causes
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7
Q

What is Atherosclerosis

A

Atherosclerosis is the thickening in the wall of the arteries caused by fibro fatty plaques. This leads to Stenosis (narrowing of artery) or obstruction (occlusion) resulting in reduced blood flow

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8
Q

What is Claudication

A
  • Claudication refers to the occurrence of muscle cramping or tightness when an exercising muscle requires more oxygen/nutrients than the circulatory system is capable of providing
  • The cramp pain is usually experienced Distal to the disease in the arterial tree
  • Calf cramp usually means claudication in the Superficial femeral artery deep artery within the thigh
  • thigh cramp usually means the disease is present in the profunda artery (branch of superficial femoral artery)
  • Buttock claudication usually means disease is in the aorta/iliac system (arteries within abdomen and pelvis)
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9
Q

What are the symptoms of PAD Peripheral Arterial Disease

3

A
  • The primary symptom of PAD is Intermittent Claudication.
  • IC can be described as severe cramp or tightness in the calf, thigh or buttock area present after a short period of excursion, after which symptoms settle with rest but return with muscle exercise.
  • It never occurs when a patient is at rest sitting or lying down.
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10
Q

What are the risk factors for Peripheral Arterial Disease

A
  • Smoking
  • Hypertension (High blood Pressure) 140/90mmHG or higher
  • High Cholesterol
  • Diabetes
  • History of Cardiovascular Disease
    *
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11
Q

What is Ischemia

A

Refers to the restriction of blood flow (oxygen) to a certain part of the body

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12
Q

What is ischemic Rest Pain

A
  • It occurs with servere or critical limb ischemia
  • Blood supply to distal tissues and nerves has deteriorated so much that the supply of oxygenated blood does not meet local metabolic demand even at rest
  • It is described as extremely painful with a constant burning sensation felt in the toes, thought to be worse in bed due to the feet being elevated (reducing the hydrostatic pressure to the distal small arteries in the feet)
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13
Q

What is used to clinically diagnose PAD Peripheral Arterial Disease

A
  • Palpation of peripheral pulses can help to identify and locate the site of stenosis occlusion and the level of abnormality
  • ABPI is a more valid reliable marker for PAD offering an objective measure of the severity of symptomatic PAD
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14
Q

What is the ABPI Ankle Bronchial Pressure index test

A

It is basically a comparison between the blood pressure measured in the arm (Brachial) and the pressure measured in the ankle (Dorsalis Pedis or Posterior tibial arteries) which indicates the severity of the Peripheral Arterial Disease present.

The lower the ankle pressure is compared to the brachial pressure, the more significant the disease is

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15
Q

Detail how the ABPI test is performed

A
  • ABPI uses both Brachial readings and ankle readings
  • Ensure patient is lying in a supine position and is relaxed
  • Locate the brachial pulse, and apply the blood pressure cuff to the patients arm ensuring you can still access the brachial artery
  • Apply gel and use the Doppler to locate an audible signal in the artery.
  • The blood pressure cuff is then inflated until the artery is occluded and the sound is no longer audible through the doppler
  • The cuff is then slowly released and the pressure at which the sound is audible again is recorded
  • This process should be repeated in both arms and legs
  • The ABPI Ratio is calculated by dividing the highest ankle pressure by the highest systolic pressure in the arm
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16
Q

What is the Toe Brachiacl Index and why can it be useful when diagnosing PAD

A
  • Toe Brachial Index is a measure arterial perfusion in the toe.
  • It can be useful when dertermining the presence of any coexisitng occlusive PAD
  • Often the digital arteries escape significant calcification which may be present in other areas and give falsely elevated readings from the blood pressure cuff
17
Q

How to perfom the Toe Brachial Index test

A
  • Ensure patient is placed in the supine position and rested for 10min prior to the test
  • Place the PPG Probe Glass side down on to the Distal pulp of the hallux ensuring no light is able to penetrate (flat against the tip of the bottom of the toe securing in place)
  • Place the toe cuff firmly around the base of the hallux proximal to where the PPG probe will sit
  • Inflate the cuff until the PPG signal flatlines
  • Slowly release the pressure watching for the first upstroke on the digital monitor, this is the point at which the pressure should be read
  • Repeat on both arms and toes and divide the toe pressure by the brachial pressure
18
Q

What other forms of diagnostic imaging may be useful to confirm PAD if ABPI or TBPI results are inconclusive.

A
  • Duplex Ultrasound - Allows for the identification of the location of the disease as well as quantifying degrees of stenosis via comparison of waveform and peak systolic velocities
  • MRA (Magnetic Resource Aniogram) and CTA (Computer Tomography Aniogram) are also useful as they allow for imaging of the whole Arterial Tree from reneal system to the foot arch. Both require contrast die injection which is not recommended for patients with renal faliure
19
Q

What are the aims of PAD management

A
  • Reduce the risk of secondary cardiovascular events from occurring
  • Improve lower limb symptoms and the associated quality of life
  • Avoid all vascular associated premature deaths and amputations
20
Q

How can PAD be managed, describe how patient education can impact this

A
  • Patient Education - Patient needs to understand what the disease is, the risks associated with the disease and the suggested lifestyle changes to be implemented. It is important that the patient expectations of any suggested interventions (medical,surgical) are realistic with possible end results explained thoroughly
21
Q

PAD management, describe Cardiovascular Risk reduction

A

Cardivascular Risk Reduction:

  • Due to the strong association PAD has with Cardivascular disease the initial treatment for IC is to prevent secondary cardivascular disease.
  • Patients Require best medical therapy i.e prescribing of statins, antiplatlet agents, risk factor modification e.g. quit smoking, diet managment, management of diabetes and hypertension
22
Q

PAD Management, describe Antiplatelet Therapy role

A
  • AnitPlatelet Therapy Inhibits thrombus formation and reduce platelet aggregation improving arterial circulation by making your platelets less sticky
  • It will not improve IC symptoms but will reduce the risk of secondary disease cardiovascular events.
  • Anti platelet drugs include - Clomidogrel, aspirin and dipyridamole
23
Q

PAD Management, describe Lipid Therapy

A
  • Lipid therapy lowers harmful cholesturals levels in the body
  • Lipid modificatin can help reduce Cardivascular disease/events in patients with PAD using statins
  • Statins reduce LDL cholestural by inhibting the enzyme HMG- Coa which is important for cholestural production
24
Q

PAD management explain how excercise can be effective

A
  • Exercise improves IC Symptoms by increasing the rate of Aniogenesis (Formation of new blood vessels)
  • This increased rate of new blood vessel production leads to the formation of collateral blood supply which bypasses the areas of stenosis and occlusion consequentially improving blood supply to the limb.
  • Excersice has also been shown to improve cardiac effeciencey and function
25
Q

PAD management, explain the role of Revascularisation

A
  • Revascularization is a procedure used to restore blood flow in blocked arteries or veins and may be needed if PAD is severe, deteriorating or there is a problem with associated wound healing in the leg or foot.
26
Q

PAD management explain the use of Endovascular treatments

A
  • Endovascular meaning (inside the blood vessel)
  • Precutaneus Transluminal Angioplasty is a procedure that involves increasing the internal diameter of the arterial lumen by dilating and recanalising the stenosed or occluded artery
  • Stents can also be used and are metal mesh tubes which provide support inside the artery
  • Both stents and ballons bay be drug eluting (coated with slow release medication to prevent clotting
  • This leads to an increased arterial blood flow capability and immediate relief from associated symptoms
27
Q

What is Critical Limb Ischemia

A

Is a manifestation of severe or deteriorating PAD and describes people with Chronic ischemic rest pain (severe pain in toes and feet for more than 2 weeks) or patients with ischemic skin lesions static or deteriorating ulcers or gangrene

28
Q

What are the presenting patient history and features usually seen with Critical Limb Ischemia

A
  • Several historic cardiovascular risk factors e.g. smoking, hypertension, diabetes
  • Non palpable Monophasic pulse (single beat muffled and dull)
  • Ankle systolic pressure of less than 50mmHg (less than 70mmHg, if ulcers present)
  • Toe systolic pressure less than 30mmHg
  • Prior known diagnosis of PAD
29
Q

What Management steps should be taken for critical limb ischemia

A
  • Urgent referral to Vascular team detailing all features e.g. whether there is rest pain, wounds, gangrene, local or spreading infection
  • People with stable wounds or rest pain may be suatible for outpatient assesment within 7 days
  • Any signs of spreading infection, wet gangrene must be seen immidiatley admitted under the vascular team
    *
30
Q

What are the 6 p’s of acute ischemia

A

Sudden onset of all or most of the P’s in the foot/leg

  • Pallor/Colour - Useful in comparison to the opposite limb, also useful to check venous filling. Acute ischemic limb usually white rather than blue
  • Pain - In the foot or leg, usually occurs at rest, worse in the most distal part of the limb
  • Pulseless - Non palpable or non audible foot and or leg pulses
  • Paraesthesia - Reduced sensation, Burning pins and needles sensation in foot and or leg
  • Paralysis - Major loss of sensory or motor function in foot/leg (indicative of advanced Ischemia)
  • Poikilothermia - Skin is extremely cold, can be compared to opposite normal leg
31
Q

How should you asses a patient with Chronic Venous Disease

A
  • Detailed medical history description of presenting complaints as well as a physical examination of the lower leg and vein function should be completed
  • CEAP Classification system can be used to aid clinical assesment

my podiatry notes (8 decks)

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