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Cardiology > Peripheral vascular disease > Flashcards

Peripheral vascular disease Flashcards

1
Q

What causes intermittant claudication? what are the clinical features?

A

This occurs when insufficient blood reaches exercising muscle.

The patient is pain-free at rest, but after variable periods of exercise develops ischaemic pain in the affected limb, which is relieved by further rest.

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2
Q

How is peripheral vascular disease staged?

A 
Fontaine stage:
I: normal
IIa: intermittant claud. >200m
IIb: intermittant claud. <200m
III: rest pain
IV: tissue loss
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3
Q

what are the main risk factors for peripheral vascular disease? (6)

A 
Male
Age
Diabetes
Smoking
HTN
Hypercholesterolaemia
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4
Q

What are the pulses that you feel for in the leg?

A
  • Femoral
  • Popliteal
  • Posterior tibial
  • Dorsalis pedis
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5
Q

What are the 2 non-invasive investigations for lower limb ischaemia?

A

Measurement of ABPI:
Ankle pressure/Brachial pressure (this is usually the same but as get worse, ankle pressure becomes alot lower than brachial)
-Duplex USS

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6
Q

What is a normal/claudication/severe ABPI?

A

Normal: 0.8-1.2
Claudication: 0.4-0.85
Severe: 0-0.45

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7
Q

What are the 3 invasive investigations for lower limb ischaemia?

A

Magnetic resonance angiography
CT angiography
Catheter angiography

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8
Q

What are the important lifestyle factors to discuss with a patient who has lower limb ischaemia?

A

stop smoking (smoking is a risk factor for amputation)

importance of walking to develop collateral circulation and success of supervised exercise programmes

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9
Q

What pharmacological management is involved in the treatment of lower limb ischaemia?

A

lipid lowering
antiplatelets
hypertension Rx
diabetes Rx (diabetes is a risk factor for amputation)

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10
Q

What is the surgical management of lower limb ischaemia?

A

angioplasty
stent
bypass

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11
Q

What are the 5 clinical features of critical limb ischaemia? What are these helped by?

A 
Rest pain (lying/sleeping) = 
toe / foot ischaemia (nerve ending pain)

Ulcers/gangrene (trauma/footwear) = severe ischaemia and damage

Toes and forefoot

Requires strong analgesia

Worse at night

Helped by:

  • sitting and putting the leg in a dependent position
  • getting up and walking about
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12
Q

What is the main management of intermittant claudication and critical limb ischaemia?

A

RISK REDUCTION

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13
Q

What is acute limb ischaemia?

A

sudden loss blood supply to a limb:

-occlusion native artery or bypass graft

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14
Q

what are 5 causes of sudden occlusion?

A
  • Embolism
  • Atheroembolism
  • Arterial dissection
  • Trauma
  • Extrinsic compression
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15
Q

What are the 6 P’s of acute limb ischaemia?

A 
Pain 
Pallor 
Pulseless
Perishingly cold
Paraesthesia
Paralysis
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16
Q

in acute limb ischaemia:

  • describe pain
  • what does a tight ‘woody’ compartment indicate?
A

Severe, sudden onset, resistant to analgesia

Calf/muscle tenderness with tight (‘woody’) compartment indicates muscle necrosis
Often irreversible ischaemia

17
Q

Describe the colour changes in the skin in acute limb ischaemia?

A

Limb initially white with empty veins

Later, capillaries fill with stagnated de-oxygenated blood giving a mottled appearance:
-Blanching mottling = salvageable if prompt revascularisation

Arteries distal to occlusion fill with propagated thrombus with rupture of capillaries
=Non blanching mottling = irreversible ischaemia

18
Q

Describe the clinical features seen:
0-4 hrs
4-12 hrs
>12 hrs

A 
0-4hrs:
-white foot
-painful
-sensorimotor deficit
SALVAGEABLE

4-12hrs:
-mottled
-blanches on pressure
PARTLY REVERSABLE

>12hrs:
-fixed mottling
-non-blanching
-compartments red and tender
-paralysis
NON-SALVAGEABLE
19
Q

What is the management for acute limb ischaemia?

  • bloods?
  • Investigations?
  • initial pharmacological mgt?
A

ABC – resuscitate and investigate

FBC, U/Es, CK, Coag +/- Troponin

ECG – MI, dysrhythmia

CXR – underlying malignancy

Anticoagulate:

  • Stops propagation of thrombus
  • May improve perfusion
  • Regional vs General Anaesthesia
20
Q

When would you consider arterial imaging for acute limb ischaemia?

A
  • No prior history of claudication
  • Cause for embolism known
  • Full complement of contra-lateral pulses

If doubts as to history: urgent CT angio/Catheter angio

21
Q

If limb is salvageable, what is the surgical management for acute limb ischaemia?

A

-Embolectomy
+/-
-fasciotomies
-thrombolysis

22
Q

If limb is not salvageable what is the management for acute limb ischaemia?

A

Palliation or amputation

23
Q

why is important to distinguish between acute vs acute on chronic acute limb ischaemia?

A

Different urgency and management

Importance of accurate history and exam

24
Q

What do diabetic foot problems encompass? what does this lead to?

A

Diabetic neuropathy
Peripheral vascular disease
Infection

Leads to tissue ulceration/necrosis/gangrene

May result in amputation

25
Q

What are the 3 different sources of diabetic foot sepsis?

A

simple puncture wound

infection from the nail plate or inter-digital space

from a neuro-ischaemic ulcer (occurs on areas of increased pressure, ie under the metatarsal heads).

26
Q

Why does the anatomy of the foot mean diabetic foot sepsis is a vascular surgical emergency?

A

Within the foot the intrinsic muscles of the digits are confined within rigid compartments bounded by plantar fascia, metatarsal bones and interosseous fascia.

Infection tracks in the soft tissues into this rigid compartment

if the build up of pus can’t escape = pressure builds up in the compartments = ischaemia/further tissue damage

=can rapidly progress to sepsis and ultimately limb loss

(more of a pressure problem rather than an ischaemic problem)

27
Q

What are the clinical systemic signs 5 seen in diabetic foot sepsis?

A 
Pyrexia
Tachycardic
Tachypnoeic
Confused
Kussmauls breathing
28
Q

What are the local signs seen in diabetic foot sepsis? 7

A

Swollen affected digit (‘sausage’ like)

Swollen forefoot (‘boggy’ feeling to swelling)

Tenderness

Ulcer with pus extruding

Erythema, may track up the limb

Patches of rapidly developing necrosis

Crepitus in the soft tissues of the foot (Gas from gas forming organisms)

(may or may not feel pedal pulses)

29
Q

what organisms can cause diabetic foot infection?

A

Gram +ve cocci (S. aureus + Streptococcus sp.)

Gram –ve bacilli (E. coli, Klebsiella sp, Enterobacter, Proteus sp and Pseuodomonas sp.)

Anaerobes (Bacteroides)

30
Q

What is the management of diabetic foot sepsis?

A

Abiotics

Rapid surgical debridement of infected tissue

If performed at early stages the foot and limb may be salvaged

Remove all infected tissue

Wound open to encourage drainage

Cardiology (17 decks)

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