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1st year systems ADAM > Arterial Disease of the Limbs - Presentation, Investigation & Therapy > Flashcards

Arterial Disease of the Limbs - Presentation, Investigation & Therapy Flashcards

1
Q

Name the arteries

A
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2
Q

How do you examine for the aortic pulse?

A

——Above the umbilicus. Use two hands to feel for pulsation vs expansion

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3
Q

How do you feel for the common femoral artery?

A

—Mid-inguinal point, ½ way between the Anterior Superior Iliac Spine and the pubic symphysis

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4
Q

How do you feel for the popliteal artery?

A

—Use both hands to feel deep in the popliteal fossa – leg relaxed into your hands

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5
Q

How do you find the posterior tibial pulse?

A

—: ½ way between the medial malleolus and the achilles tendon

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6
Q

How do you find the dorsalis pedis pulse?

A

Lateral to the extensor hallucis longus tendon

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7
Q

What is the cause of CLI (critical limb ischaemia)?

A

—Atherosclerotic disease of the arteries supplying the lower limb

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8
Q

What are the risk factors for CLI?

A

—Male

—Age

—Smoking

—Hypercholesterolaemia

—Hypertension

—Diabetes

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9
Q

What is stage 1 CLA according to the Fontaine classification?

A

—Stage I: Asymptomatic, incomplete blood vessel obstruction

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10
Q

What is stage 2 CLA according to the Fontaine classification?

A

—Mild claudication pain in limb

—Stage IIA: Claudication when walking a distance of greater than 200 meters

—Stage IIB: Claudication when walking a distance of less than 200 meters

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11
Q

What is stage 3 CLA according to the Fontaine classification?

A

—Stage III: Rest pain, mostly in the feet

Critical limb ischaemia

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12
Q

What is stage 4 CLA according to the Fontaine classification?

A

—Stage IV: Necrosis and/or gangrene of the limb

Critical limb ischaemia

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13
Q

Which leg does claudication usually impact?

A

Bilateral

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14
Q

What is typical past medical history for CLI?

A

—Other signs of atherosclerosis (MI, Stroke?)

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15
Q

What drug might a CLI patient be taking?

A

control of diabetes, aspirin?

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16
Q

What is the significance of a CLA patient occupation?

A

Determines the type of treatment

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17
Q

What are the signs of chronic ischaemia on examination?

A

Ulceration

Pallor

Hair loss

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18
Q

What should you feel during examination of CLA?

A

Capillary refill times

Temperature

Pulses

Peripheral sensation (particularly in diabetics)

STARTING AT TOES AND ALWAYS COMPARING SIDES

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19
Q

How do you auscultate for CLA?

A

Hand held doppler (ultrasound machine)

Listening to the dorsalis pedis and the posterior ribial pulses

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20
Q

What are the special examination tests for CLI

A

Ankle brachial pressure Index
Measures Ankle pressure + Brachial pressure

Buerger’s test

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21
Q

What is the buerger’s test?

A

Elevate legs - pallor
Buergers angle below a 20 degree angle indicates severe ischaemia

Hang feet over the edge of the bed - slow to regain colour, should progress
Dark red colour (hyperaemic sunset foot).

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22
Q

Why does hanging feet over the edge of a bed cause CLI patients’ feet to become hyperaemic?

A

Normally only 1/3 of the capillaries are open. In CLI all capillaries are open and autoregulation is lost

23
Q

What is peripheral vascular disease treated the same way as?

A

Should be managed the same way as those with established CHD

24
Q

What is best medical therapy?

A

Combination of antiplatelets and statins

—BP control: Target <140/85

—Smoking cessation

—Exercise: 150% improvement in walking time – body will develop own collaterals with neo-angiogenesis

—Diabetic control: 10% of PAD patients are undiagnosed diabetics. Tight glycaemic control prevents microvascular disease

25
Q

What type of therapy is best for

  1. Moderate symptoms
  2. Severe symptoms
  3. Critical symptoms
A

Moderate - BMT only

Severe - BMT, angioplasty/stent, surgical bypass

Critical - BMT, angioplasty / stent / endovascular reconstruction / surgical bypass

26
Q

What are the possible imaging investigations for CLI?

A

Duplex (ultrasonography where structure or architecture of the body part is captured and flow or movement of a structure is visualized)

CT/MRA

Digital subtraction angiogram (angiography)

27
Q

What are the advantages and disadvantages of Duplex?

A

Advantages:

—Dynamic – assess flow as well as anatomy

—No radiation/contrast

Disadvantages:

—Not good in the abdomen (iliacs)

—Operator dependent, time consuming

28
Q

What are the benefits of CT/MRA

A

Advantages:

—Detailed – allows treatment planning

—First line according to NICE

Disadvantages:

Uses Contrast and Radiation

—Can overestimate calcification, difficulty in low flow states (difficult if there is terrible heart failure and the contrast can’t really reach the feet)

29
Q

What are the possible conduits for surgical bypass?

A

Reversed saphenous vein

30
Q

What does surgical bypass require?

A

Inflow

A conduit

Outflow

31
Q

Why is an autologous conduit better than a synthetic one?

A

Risk of infection is worse

32
Q

What are the general risks / complications of surgical bypass?

A

Bleeding, wound infection, pain, scar, DVT, PE, MI, stroke, death (2%)

33
Q

What are the technical risks / complications of surgical bypass?

A

Damage to nearby vein, artery, nerve, distal emboli, graft failure (stenosis, occlusion)

34
Q

What is reintervention rate for surgical bypass?

A

18.3 – 38.8% (higher if smoking)

35
Q

What are 5 year patency rates of surgical bypass?

A

45-73%

36
Q

What are the different ways an embolus can arise?

A

MI, AF, proximal atherosclerosis (not DVT/PE these are linked to venous disease)

Trauma

Dissection

Acute aneurysm thrombosis

37
Q

What is the point in finding out the onset/duration of symptoms?

A

Lets you know the likely prognosis

38
Q

What are the 6 P’s of presentation?

A

—Pain

—Pallor

—Perishingly cold

—Paraesthesia

—Paralysis

—Pulseless

—Compare to contralateral limb

39
Q

What are the 6Ps of ALI

A

Pain
Pallor
Pulse Deficit
Paraesthesia
Paresis/Paralysis
Poikilothermia (cold)

40
Q

What is the pathophysiology of acute kimb ischaemia

A

Arterial embolus: MI, AF, proximal atherosclerosis (NOT DVT/PE)
Thrombosis: Usually thrombosis of a previously diseased artery.
Trauma
Dissection
Acute aneurysm thrombosis i.e. popliteal

41
Q

What is management of acute limb ischaemia?

A

ECG, bloods, nil by mouth

Analgesia

Anticoagulate (heparin - allows chance of blood getting through occlusion)

42
Q

What is management of a salvagable limb in ALI management?

A

If embolus - embolectomy

If thrombus - Endovascular :mechanincal thrombectomy/thrombolysis or open embolectomy +/- bypass

43
Q

What type of anaesthetic is used for embolectomy?

A

General or local

44
Q

What is the likely cause for ALI?

A

—30% embolic, 60% thrombosis in situ

45
Q

When does irreversible muscle ischaemia occur?

A

In 6-8 hours

46
Q

What is the pathophysiology of diabetic foot disease?

A

Microvascular peripheral artery disease

—Peripheral neuropathy – they lose sensation of their foot – more likely chance of trauma

—Mechanical imbalance – lose proprioception and walk differently – pressure points different and now damaged

—Susceptibility to infection

47
Q

How do you ensure footcare of a diabetic?

A

Always wear shoes

Check fit of footwear

Check pressure points of foot regularly

Prompt and regular woundcare

48
Q

What is diabetic foot management?

A

—Prevention

—Good wound care

—Tracking infection (lymphangitis or cellulitis)– consider systemic antibiotics

—Investigate for osteomyelitis, gas gangrene, necrotising fasciitis

—Revascularisation

—Disease is very distal – attempt distal crural angioplasty / stent

—Distal bypass

Amputation

49
Q

What is compartment syndrome

A

Muscle ischaemia
(irreversable after 6-8 hours)
Inflammation, oedema, venous obstruction
Tense, tender calf
Rise in creatie kinase
Risk of renal failure

50
Q

What are the different types of amputations

A
51
Q

What are the mobility % in amputations

A

Inside: 80% BKA, 40% AKA
Outside: 65% BKA, 43% AKA

52
Q

Which type of amputation requires more energy?

BKA or AKA (above or below the knee amputation)

A

—63% higher in BKA

—117% higher in AKA

53
Q

Look

A

1st year systems ADAM (52 decks)

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