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6. Cardiovascular System > 15. Peripheral Vascular Disease (PVD) > Flashcards

15. Peripheral Vascular Disease (PVD) Flashcards

1
Q

Outline the arteries in the legs.

A
  • Anatomy of arteries:
  • Aorta
  • Common Iliac
  • External Iliac
  • Internal Iliac
  • Common femoral
  • Superficial femoral
  • Popliteal
  • Anterior tibial
  • Posterior tibial
  • Peroneal
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2
Q

Define ischaemia.

A

Ischaemia refers to an inadequate oxygen supply to the tissues due to reduced blood supply and impaired vascular perfusion, leading to reversible tissue damage.

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3
Q

Define infarction.

A

Irreversible tissue death due to ischaemia.

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4
Q

Define necrosis.

A

Refers to the death of the tissue.

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5
Q

What is peripheral vascular disease (PVD)?

A

Essentially, it’s the partial blockage of leg or peripheral vessels by an atherosclerotic plaque and or resulting thrombus, resulting in insufficient perfusion of the lower limb, resulting in LOWER LIMB ISCHAEMIA.

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6
Q

What causes PVD?

A

Atherosclerosis causing stenosis of arteries

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7
Q

What is PVD? Explain the pathophysiology.

A

Narrowing of the arteries in the peripheral, non-coronary arterial circulation.
- Vessels of the lower extremities are most commonly affected

So, embolus forms -> narrowed arteries -> decreases blood flow -> less gas + nutrient exchange -> acute limb ischaemia -> tissue loss -> forms ulcers -> poor healing of ulcers -> ischaemic cells release adenosine -> adenosine signals nerves -> sensation of pain -> claudication.

Claudication = pain caused by poor circulation
- Happens when O2 demand > O2 supply

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8
Q

Give 5 risk factors for peripheral vascular disease.

A
  1. Hypertension.
  2. Hyperlipidaemia / Hypercholesterolaemia
  3. Diabetes.
  4. Smoking.
  5. Obesity.
  6. Physical inactivity.
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9
Q

Give 3 signs of PVD.

A
  1. Absent femoral, popliteal or foot pulses.
  2. Cold, white leg(s)
  3. Atrophic skin
  4. Punched out ulcers
  5. Postural colour change
  6. Capillary refill prolonged
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10
Q

What is a consequence of peripheral arterial occlusion?

A

Gangrene.

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11
Q

Name the classification system for peripheral vascular disease (PVD).

A

Fontaine classification.

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12
Q

What are the 4 stages in the Fontaine classification of PVD?

A
  1. Asymptomatic
  2. Intermittent claudication
  3. Ichaemic rest pain
  4. Ulceration/gangrene (critical ischaemia)
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13
Q

Give 2 diseases that result from stress induced ischaemia.

A
  1. Exercise induced angina.
  2. Intermittent claudication.
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14
Q

What is intermittent claudication?

A

A symptom describing muscle pain that is caused by moderate ischaemia.
Intermittent claudication occurs when exercising (stress induced) and is relieved with rest.

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15
Q

Name 2 diseases that are due to moderate ischaemia.

A
  1. Angina.
  2. Intermittent claudication.
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16
Q

Describe the clinical features of intermittent claudication.

A

Muscle cramping pain in calf/thigh/buttock after walking a given distance (shorter=more severe) - relieved by rest

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17
Q

Intermittent claudication: is O2 supply normal or low at rest and when you begin exercise?

A

Normal. Intermittent claudication is stress induced so at rest and when you begin exercise O2 supply is able to meet demand.

18
Q

Intermittent claudication: is O2 supply normal or low when you do moderate/hard exercise?

A

Low. O2 supply is unable to meet demand -> anaerobic respiration -> lactic acid.

19
Q

Intermittent claudication: is O2 supply normal or low after a short rest?

A

Low. It takes longer to recover as you’re getting rid of the lactic acid. After a long rest however it is normal.

20
Q

PVD most commonly causes pain in the calf.
What artery is the claudication therefore in?

A

If the pain is in the upper 2/3: superficial femoral

If the pain is in the lower 1/3: popliteal

21
Q

What can intermittent claudication lead on to if left untreated?

A

Critical ischaemia.

22
Q

How would intermittent claudication be managed, beyond conservative risk reduction treatments?

A

Revascularisation - percutaneous transluminal angioplasty (PTA) or surgical reconstruction/arterial bypass graft.

23
Q

Name a disease that is due to severe ischaemia.

A

Critical limb ischaemia.

24
Q

Give 2 diseases that result from ischaemia due to structural/functional breakdown.

A
  1. Critical limb ischaemia.
  2. Vascular dementia.
25
Q

What is critical limb ischaemia?

A

The end-stage of PVD, where there is an inadequate supply of blood to a limb to allow it to function normally at rest.

AKA - Blood supply is barely adequate for life.
- There is no reserve for an increase in demand.
- Very severe, cells are dying.
- O2 supply is ALWAYS low, even at rest!

26
Q

Give 4 signs of critical limb ischaemia.

A
  1. Rest pain.
  2. Classically nocturnal.
    - Burning foot pain at night relieved by hanging legs over the side of the bed.
  3. Ulceration.
  4. Gangrene.
27
Q

Diagnosis of peripheral vascular disease - critical limb ischaemia

A
  1. Ankle/brachial pressure index (ABPI)
    - The ratio of systolic blood pressure (SBP) in the ankle (around the lower calf) compared with the systolic blood pressure in the arm
    - Indicates the severity of disease
  2. Colour duplex ultrasound with cross sectional CT
    - First-line
  3. MR/CT angiography
    - To assess extent and location of stenoses and quality of distal vessels - if considering intervention
  4. Bloods
    * ESR/CRP:
    Exclude arteritis by looking at ESR/CRP - they would be raised in arteritis
    * FBC:
    - Looking particularly at haemoglobin to exclude anaemia or
    polycthaemia (increased red blood cells)
28
Q

Management of critical limb ischaemia.

A

Patients with critical limb ischaemia require urgent referral to the vascular team.
They require analgesia to manage the pain.

Urgent revascularisation can be achieved by:
1. Endovascular angioplasty and stenting
2. Endarterectomy
3. Bypass surgery
4. Amputation of the limb if it is not possible to restore the blood supply

29
Q

What is acute lower limb ischaemia?

A

Acute limb ischaemia refers to a rapid onset of ischaemia in a limb.

30
Q

What can cause acute ischaemia?

A
  1. Embolism
  2. Thrombosis
31
Q

Give 6 symptoms of acute ischaemia.

A

The 6 P’s:
1. Pain.
2. Pale.
3. Paralysis.
4. Paraesthesia.
5. Perishing cold.
6. Pulseless.

The more P’s present, the more sudden and the more complete
your ischaemia

32
Q

Acute ischaemia is not a surgical emergency. True or False?

A

False!

  • SURGICAL EMERGENCY requiring REVASCULARISATION WITHIN 4-6 HOURS TO SAVE THE LIMB!!
  • This is an EMERGENCY and requires urgent surgery and angioplasty (widening of arteries with balloon)
33
Q

Management of acute limb ischaemia.

A

Patients with acute limb ischaemia need an urgent referral to the on-call vascular team for assessment.

Management options include:

  1. Endovascular thrombolysis
    – Inserting a catheter through the arterial system to apply thrombolysis directly into the clot
  2. Endovascular thrombectomy
    – Inserting a catheter through the arterial system and removing the thrombus by aspiration or mechanical devices
  3. Surgical thrombectomy
    – Cutting open the vessel and removing the thrombus
  4. Endarterectomy
  5. Bypass surgery
  6. Amputation of the limb
    - If it is not possible to restore the blood supply
34
Q

Describe conservative treatment of limb ischaemia.

A
  1. Risk factor modificaition
    - Exercise + lose weight
    - Quit smoking
    - Treat hypertension, hyperlipidaemia and diabetes
    - Clopidogrel (anti-platelet) to prevent progression and reduce risk.
35
Q

Give 4 treatments for peripheral vascular disease.

A
  1. Risk factor modification.
  2. Vein bypass for critical leg ischaemia.
  3. Balloon angioplasty.
  4. Stenting of occlusion.
  5. Amuptation.
36
Q

Vasodilator drug commonly used in PVD if supervised exercise has not led to satisfactory improvement + patient doesn’t want to do surgery?

A

Naftidofuryl oxalate

37
Q

Describe the differences in the pain felt for intermittent claudication + critical leg ischaemia.

A

Intermittent claudication:
1. Tissue is NOT DYING just SUFFERING
2. When doing mild/moderate exercise, you have an oxygen debt, resulting in a build up of lactic acid resulting in pain.
3. NO resting pain

Critical leg ischaemia;
1. Tissue is DYING and SUFFERING AT REST
2. Blood supply is inadequate to allow basal metabolism; there is no reserve available for the increased demand.
3. Resting pain - typically nocturnal

38
Q

What is a non-healing painful ulcer on big toe with no trauma a symptom of?

A

Critical leg ischaemia

39
Q

What is ‘severe nocturnal pain in all toes of the left foot only relieved by hanging foot over the edge of bed (using gravity to perfuse)’ a symptom of?

A

Critical leg ischaemia

40
Q

What type of ischaemia is an acute MI an indicator of?

A

Acute ischaemia

41
Q

What is ‘a loss of the use of right side of body and fast irregular pulse’ a symptom of?

A

Acute ischaemia

6. Cardiovascular System (24 decks)

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