Arterial Disease and Aneurysms Flashcards Preview

MD2 Vascular > Arterial Disease and Aneurysms > Flashcards

Flashcards in Arterial Disease and Aneurysms Deck (42):
1

List some causes of arterial occlusion

Atherosclerosis
Embolism (cardiac, arterial to arterial)
Pro-coagulant state
Low flow state
Thrombosed aneurysm
Dissection
Fibro-muscular hyperplasia
Arteritis
Entrapment
Adventitial cysts

2

Define claudication

Ischaemic pain in exercising muscles due to imbalance between workload of muscles and ability to maintain aerobic metabolism (angina of the legs)

3

Describe the pathophysiology of claudication

Posterior calf muscles dominate with walking
When flow of oxygenated blood is inadequate, muscles switch to anaerobic metabolism to meet energy demands
Lactic acid builds up and produces aching discomfort
Eases with rest

4

What are the clinical criteria for claudication?

Calf pain on exertion (+/- thigh, +/- buttock)
Onset and severity related to workload
Relieved with rest
Reproducible

5

Where does ischaemic rest pain occur?

Most distal part of the limb

6

Describe the pathophysiology of ischaemic rest pain

Inadequate perfusion resulting in anaerobic metabolism in skin and nerves (cf muscles) of the extremity

7

How is ischaemic rest pain defined clinically?

Burning pain in extremity at rest (often wakes patient in the night)
Usually relieved with gravity

8

What are the features of critical limb ischaemia (CLI)?

Ischaemic rest pain
Ulcers
Gangrene

9

At what ankle and toe pressure does rest pain occur?

Ankle pressure

10

At what ankle and toe pressure do ulcers/gangrene occur?

Ankle pressure

11

What is the trans-cutaneous O2 pressure in CLI?

12

What are some possible patterns of lower limb occlusive disease?

Aorto-iliac (inflow)
Femoro-popliteal (outflow)
Tibial/crural

13

What are the features of aorto-iliac occlusive disease?

Calf, thigh and buttock claudication
Reduced pulses femoral and below
May be bruits over aorta/iliac

14

What are the features of femoro-popliteal occlusive disease?

Calf claudication
Reasonable femoral pulse but weak or absent popliteal and pedal pulses
Bruit along line of femoral or popliteal arteries

15

What are the features of tibial/crural occlusive disease?

May be no claudication
Reasonable popliteal pulses but absent pedal pulses
Bruits over popliteal or upper tibial arteries

16

Describe the epidemiology of peripheral arterial disease

12% of adult population and 20% of population >70 years
Associated with 6-fold increase in CV mortality (patients at high risk need aggressive risk-factor modification and antiplatelet drugs)

17

Management options for claudication

Angioplasty +/- stenting
Endarterectomy
Bypass

18

When are angioplasty, endarterectomy and bypass indicated?

Angioplasty: best for short segments, better in proximal arteries
Endarterectomy: short segments
Bypass: longer blocks

19

What are the risks with endovascular interventions?

Chance of access vessel problems
Chance of thrombosis or embolisation

20

What are the risks with open bypass?

Wound issues
Cardiac risks
Graft thrombosis

21

Describe the recovery from endovascular procedures vs open bypass

Endovascular procedures: quick recovery
Open bypass: 2-3 months or longer before back to normal comfort, mobility, etc

22

What is the typical cause of sudden/severe ischaemia?

Embolus

23

What are the clinical features of sudden/severe ischaemia?

Pain (especially on using muscles; later pain in extremities lessens as nerve function decreases)
Paralysis of muscles (especially weakness of anterior compartment muscles)
Parasthesia
Pallor/mottled extremity
Perishingly cold
Pulseless

24

What is an aneurysm?

Degenerative focal arterial dilatation 1.25-1.5x greater in diameter than adjacent normal artery

25

Describe the pathogenesis and natural history of aneurysms

Weakness in elastin and collagen in adventia and media results in local inflammation with matric proteins and metallo-proteinases, leading to focal arterial dilatation
Abnormal wall becomes lined with thrombus
Natural history is continued expansion leading to eventual rupture

26

List common sites for aneurysm

Abdominal aorta (infra-renal)
Common iliac
Popliteal
Femoral
Thoracic aorta

27

Describe the risk of aneurysm rupture as related to diameter

Uncommon 6cm annual risk is 9%
>8cm annual risk is 25%

28

What is the 5-year survival of patients with aneurysm >5cm who are not operated on?

20%

29

Describe primary prevention for aneurysm

Smoking cessation
HTN control

30

Describe secondary prevention for aneurysm rupture

Screening and treatment of aneurysms >5-5.5cm

31

What is the average increase in the size of small aneurysms annually?

2.6 mm/year

32

What is the margin of error for U/S measurement of aneurysms?

Minimum +/- 2mm
Commonly +/- 4mm

33

How does ruptured AAA present clinically?

Sudden onset abdominal and/or back pain
Collapse

34

What is the typical demographic affected by ruptured AAA?

Male
>60 years

35

What are the clinical signs of ruptured AAA?

Pulsatile mass in lower abdomen (usually to one side and into iliac fossa)
Features of progressive hypovolaemia

36

What are the management options for ruptured AAA?

Prompt repair (open or endoluminal)
No intervention

37

When should "no intervention" be considered for a ruptured AAA?

Already unconscious/intubated on arrival (especially >80 years)
Demented/nursing home
Already turned down for elective repair in view of co-morbidities

38

Maximum time of surveillance before EVAR indicated?

3.0-3.9cm: 24 months
4.0-4.6cm: 12 months
4.7-5.0cm: 6 months
5.1-5.5cm: 3 months

39

What is the 5-year prognosis for patients with local vs systemic claudication?

Local: 5% require intervention, 2% amputation
Systemic: 30% die, 5-10% suffer non-fatal CV events

40

What is the management philosophy underlying claudication?

Reasonable distance claudication is benign (limb not in jeopardy)
Any intervention on an artery is a "controlled injury"; it may or may not work, there may be complications, and it may not be durable

41

When is an intervention for claudication reasonable?

If it is a very significant handicap, the risk is acceptable and the proposed intervention has an acceptable chance of working
Patient has to be pushing for an intervention; requires good information and realistic expectations

42

EVAR

EndoVascular Aortic Repair