Vascular SAQs 5 Flashcards
A 79-year-old man presents to the Accident and Emergency Department with a four-hour history of sudden onset of severe pain and numbness in his left leg extending up to his mid- thigh.
a) State your working diagnosis and the predisposing vascular diseases (3)
Acute limb ischemia due to left femoral arterial occlusion
Predisposing vascular diseases = atrial fibrillation leading to embolism, aortic dissection, pre-existing thrombosis in the artery, aortic aneurysm leading to embolism
Predisposing condition—DM, hyperlipidaemia, smoking, atrial fibrillation, vasculitis, fibromuscular dysplasia, aortic dissection, hypertension
Acute limb ischemia
a) List the clinical findings in the limb supporting your diagnosis
A 79-year-old man presents to the Accident and Emergency Department with a four-hour history of sudden onset of severe pain and numbness in his left leg extending up to his mid- thigh.
Pallor Cold Pulselessness Pain Paraesthesia Paralysis
a) What investigations would you perform? (3)
Acute limb ischemia
A 79-year-old man presents to the Accident and Emergency Department with a four-hour history of sudden onset of severe pain and numbness in his left leg extending up to his mid- thigh.
Urgent ABPI measurement
Urgent duplex ultrasound of femoral artery
Blood test—FBC, ESR, CRP, glucose, lipid profile
ECG to look for original source of emboli
a) What treatments would go give?
Acute limb ischemia
A 79-year-old man presents to the Accident and Emergency Department with a four-hour history of sudden onset of severe pain and numbness in his left leg extending up to his mid- thigh.
Analgesia
Anticoagulate e.g., heparin IV
Percutaneous intraluminal angioplasty with stent
Embolectomy with a Fogarty catheter,
Local thrombolysis with intra-arterial tPA or streptokinase
Open surgical reconstruction
A 68yo man complains of gradual onset of right calf claudication radiating up to his thigh on walking distances exceeding 75 yards
a) State your likely diagnosis and the anatomic site of his lesion (2)
Chronic limb ischemia due to peripheral vascular disease causing stenosis of right lower limb artery, producing intermittent claudication
Anatomical Site - right femoral artery
a) Write a short note on the disease process causing his symptoms. (3)
Atherosclerosis
Atherosclerosis—intimal injury and resulting inflammation. Circulating monocytes infiltrate the intima, taking up LDL cholesterol and forming foam cells – fatty streak
Fibro-lipid plaque and fibrous plaque – progressive accumulation of lipid and the migration and proliferation of smooth muscle cells that produce collagens, which form a fibrous plaque.
Rupture or ulceration of the fibrous plaque exposes thrombogenic contents of the core of the plaque, leading to thrombosis, which can partially and completely occlude the blood vessel. Thrombus can break off and embolize to cause distal vessel occlusion
a) Four common risk factors in this disease. (4)
Atherosclerosis
Diabetes mellitus Hypertension Smoking Hyperlipidaemia Family history
a) What measures would you advise him to adopt to alleviate his symptoms, to stop progression of the disease and improve his walking distance? (4)
Atherosclerosis
Stop smoking Weight loss Keep doing exercise, Treat DM, hypertension and hyperlipidaemia, Low cholesterol diet, Aspirin
A 59yo woman complains of rest pain in her left foot keeping her awake a night. She also had difficulty in walking.
a) List the clinical findings that would lead to a working diagnosis
Skin changes such as atrophic skin, punched out ulcer, postural/dependent skin colour changes
Pale and cold leg. Weak or absent femoral, popliteal, posterior tibial or dorsalis pedis pulses. Increased capillary refill time
Neurological changes: numbness/paraesthesia, muscle weakness, muscle atrophy
Reduced ankle-brachial pressure index e.g. <5
A 59yo woman complains of rest pain in her left foot keeping her awake a night. She also had difficulty in walking.
a) Name one radiological investigation you would request to demonstrate the lesion
Contrast arteriography, digital subtraction arteriography, colour duplex ultrasound
A 59yo woman complains of rest pain in her left foot keeping her awake a night. She also had difficulty in walking.
a) Write a short note on how radiological procedures may be used to treat her symptoms (2)
Percutaneous transluminal angioplasty – balloon dilatation and stent insertion
Intra-arterial infusion of thrombolytic agent (e.g. tPA) through radiologically positioned arterial line.
A 59yo woman complains of rest pain in her left foot keeping her awake a night. She also had difficulty in walking.
a) Discuss briefly the surgical options available to relieve her symptoms (3)
Removal of arterial occlusion by endarterectomy
Surgical arterial reconstruction by a bypass graft if distal run off is good (provided distal arteries filled by collateral vessels)
If distal disease unresponsive to angioplasty or surgery, lumbar sympathectomy may relieve and improve skin perfusion.
