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MD2 Vascular > Arterial Disease and Aneurysms > Flashcards

Arterial Disease and Aneurysms Flashcards

1
Q

List some causes of arterial occlusion

A 
Atherosclerosis
Embolism (cardiac, arterial to arterial)
Pro-coagulant state
Low flow state
Thrombosed aneurysm
Dissection
Fibro-muscular hyperplasia
Arteritis
Entrapment
Adventitial cysts
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2
Q

Define claudication

A

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

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3
Q

Describe the pathophysiology of claudication

A

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

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4
Q

What are the clinical criteria for claudication?

A

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

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5
Q

Where does ischaemic rest pain occur?

A

Most distal part of the limb

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6
Q

Describe the pathophysiology of ischaemic rest pain

A

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

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7
Q

How is ischaemic rest pain defined clinically?

A

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

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8
Q

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

A

Ischaemic rest pain
Ulcers
Gangrene

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9
Q

At what ankle and toe pressure does rest pain occur?

A

Ankle pressure

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10
Q

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

A

Ankle pressure

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11
Q

What is the trans-cutaneous O2 pressure in CLI?

A
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12
Q

What are some possible patterns of lower limb occlusive disease?

A

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

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13
Q

What are the features of aorto-iliac occlusive disease?

A

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

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14
Q

What are the features of femoro-popliteal occlusive disease?

A

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

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15
Q

What are the features of tibial/crural occlusive disease?

A

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

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16
Q

Describe the epidemiology of peripheral arterial disease

A

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)

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17
Q

Management options for claudication

A

Angioplasty +/- stenting
Endarterectomy
Bypass

18
Q

When are angioplasty, endarterectomy and bypass indicated?

A

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

19
Q

What are the risks with endovascular interventions?

A

Chance of access vessel problems

Chance of thrombosis or embolisation

20
Q

What are the risks with open bypass?

A

Wound issues
Cardiac risks
Graft thrombosis

21
Q

Describe the recovery from endovascular procedures vs open bypass

A

Endovascular procedures: quick recovery

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

22
Q

What is the typical cause of sudden/severe ischaemia?

A

Embolus

23
Q

What are the clinical features of sudden/severe ischaemia?

A

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
Q

What is an aneurysm?

A

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

25
Q

Describe the pathogenesis and natural history of aneurysms

A

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
Q

List common sites for aneurysm

A 
Abdominal aorta (infra-renal)
Common iliac
Popliteal
Femoral
Thoracic aorta
27
Q

Describe the risk of aneurysm rupture as related to diameter

A

Uncommon 6cm annual risk is 9%

>8cm annual risk is 25%

28
Q

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

A

20%

29
Q

Describe primary prevention for aneurysm

A

Smoking cessation

HTN control

30
Q

Describe secondary prevention for aneurysm rupture

A

Screening and treatment of aneurysms >5-5.5cm

31
Q

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

A

2.6 mm/year

32
Q

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

A

Minimum +/- 2mm

Commonly +/- 4mm

33
Q

How does ruptured AAA present clinically?

A

Sudden onset abdominal and/or back pain

Collapse

34
Q

What is the typical demographic affected by ruptured AAA?

A

Male

>60 years

35
Q

What are the clinical signs of ruptured AAA?

A

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

36
Q

What are the management options for ruptured AAA?

A 
Prompt repair (open or endoluminal)
No intervention
37
Q

When should “no intervention” be considered for a ruptured AAA?

A

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

38
Q

Maximum time of surveillance before EVAR indicated?

A
  1. 0-3.9cm: 24 months
  2. 0-4.6cm: 12 months
  3. 7-5.0cm: 6 months
  4. 1-5.5cm: 3 months
39
Q

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

A

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

40
Q

What is the management philosophy underlying claudication?

A

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
Q

When is an intervention for claudication reasonable?

A

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
Q

EVAR

A

EndoVascular Aortic Repair

MD2 Vascular (3 decks)

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