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1st year systems ADAM > Arterial Disease of the Limbs - Presentation, Investigation & Therapy > Flashcards

Arterial Disease of the Limbs - Presentation, Investigation & Therapy Flashcards

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1
Q

Name the arteries

A
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2
Q

How do you examine for the aortic pulse?

A

——Above the umbilicus. Use two hands to feel for pulsation vs expansion

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3
Q

How do you feel for the common femoral artery?

A

—Mid-inguinal point, ½ way between the Anterior Superior Iliac Spine and the pubic symphysis

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4
Q

How do you feel for the popliteal artery?

A

—Use both hands to feel deep in the popliteal fossa – leg relaxed into your hands

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5
Q

How do you find the posterior tibial pulse?

A

—: ½ way between the medial malleolus and the achilles tendon

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6
Q

How do you find the dorsalis pedis pulse?

A

Lateral to the extensor hallucis longus tendon

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7
Q

What is the cause of CLI (critical limb ischaemia)?

A

—Atherosclerotic disease of the arteries supplying the lower limb

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8
Q

What are the risk factors for CLI?

A

—Male

—Age

—Smoking

—Hypercholesterolaemia

—Hypertension

—Diabetes

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9
Q

What is stage 1 CLA according to the Fontaine classification?

A

—Stage I: Asymptomatic, incomplete blood vessel obstruction

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10
Q

What is stage 2 CLA according to the Fontaine classification?

A

—Mild claudication pain in limb

—Stage IIA: Claudication when walking a distance of greater than 200 meters

—Stage IIB: Claudication when walking a distance of less than 200 meters

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11
Q

What is stage 3 CLA according to the Fontaine classification?

A

—Stage III: Rest pain, mostly in the feet

Critical limb ischaemia

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12
Q

What is stage 4 CLA according to the Fontaine classification?

A

—Stage IV: Necrosis and/or gangrene of the limb

Critical limb ischaemia

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13
Q

Which leg does claudication usually impact?

A

Bilateral

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14
Q

What is typical past medical history for CLI?

A

—Other signs of atherosclerosis (MI, Stroke?)

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15
Q

What drug might a CLI patient be taking?

A

control of diabetes, aspirin?

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16
Q

What is the significance of a CLA patient occupation?

A

Determines the type of treatment

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17
Q

What are the signs of chronic ischaemia on examination?

A

Ulceration

Pallor

Hair loss

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18
Q

What should you feel during examination of CLA?

A

Capillary refill times

Temperature

Pulses

Peripheral sensation (particularly in diabetics)

STARTING AT TOES AND ALWAYS COMPARING SIDES

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19
Q

How do you auscultate for CLA?

A

Hand held doppler (ultrasound machine)

Listening to the dorsalis pedis and the posterior ribial pulses

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20
Q

What are the special examination tests for CLI

A

Ankle brachial pressure Index
Measures Ankle pressure + Brachial pressure

Buerger’s test

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21
Q

What is the buerger’s test?

A

Elevate legs - pallor
Buergers angle below a 20 degree angle indicates severe ischaemia

Hang feet over the edge of the bed - slow to regain colour, should progress
Dark red colour (hyperaemic sunset foot).

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22
Q

Why does hanging feet over the edge of a bed cause CLI patients’ feet to become hyperaemic?

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A

Normally only 1/3 of the capillaries are open. In CLI all capillaries are open and autoregulation is lost

23
Q

What is peripheral vascular disease treated the same way as?

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A

Should be managed the same way as those with established CHD

24
Q

What is best medical therapy?

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A

Combination of antiplatelets and statins

—BP control: Target <140/85

—Smoking cessation

—Exercise: 150% improvement in walking time – body will develop own collaterals with neo-angiogenesis

—Diabetic control: 10% of PAD patients are undiagnosed diabetics. Tight glycaemic control prevents microvascular disease

25
What type of therapy is best for 1. Moderate symptoms 2. Severe symptoms 3. Critical symptoms
Moderate - BMT only Severe - BMT, angioplasty/stent, surgical bypass Critical - BMT, angioplasty / stent / endovascular reconstruction / surgical bypass
26
What are the possible imaging investigations for CLI?
Duplex (ultrasonography where structure or architecture of the body part is captured and flow or movement of a structure is visualized) CT/MRA Digital subtraction angiogram (angiography)
27
What are the advantages and disadvantages of Duplex?
Advantages: ## Footnote —Dynamic – assess flow as well as anatomy —No radiation/contrast Disadvantages: —Not good in the abdomen (iliacs) —Operator dependent, time consuming
28
What are the benefits of CT/MRA
Advantages: ## Footnote —Detailed – allows treatment planning —First line according to NICE Disadvantages: Uses Contrast and Radiation —Can overestimate calcification, difficulty in low flow states (difficult if there is terrible heart failure and the contrast can’t really reach the feet)
29
What are the possible conduits for surgical bypass?
Reversed saphenous vein
30
What does surgical bypass require?
Inflow A conduit Outflow
31
Why is an autologous conduit better than a synthetic one?
Risk of infection is worse
32
What are the general risks / complications of surgical bypass?
Bleeding, wound infection, pain, scar, DVT, PE, MI, stroke, death (2%)
33
What are the technical risks / complications of surgical bypass?
Damage to nearby vein, artery, nerve, distal emboli, graft failure (stenosis, occlusion)
34
What is reintervention rate for surgical bypass?
18.3 – 38.8% (higher if smoking)
35
What are 5 year patency rates of surgical bypass?
45-73%
36
What are the different ways an embolus can arise?
MI, AF, proximal atherosclerosis (not DVT/PE these are linked to venous disease) Trauma Dissection Acute aneurysm thrombosis
37
What is the point in finding out the onset/duration of symptoms?
Lets you know the likely prognosis
38
What are the 6 P's of presentation?
—Pain —Pallor —Perishingly cold —Paraesthesia —Paralysis —Pulseless —Compare to contralateral limb
39
What are the 6Ps of ALI
Pain Pallor Pulse Deficit Paraesthesia Paresis/Paralysis Poikilothermia (cold)
40
What is the pathophysiology of acute kimb ischaemia
Arterial embolus: MI, AF, proximal atherosclerosis (NOT DVT/PE) Thrombosis: Usually thrombosis of a previously diseased artery. Trauma Dissection Acute aneurysm thrombosis i.e. popliteal
41
What is management of acute limb ischaemia?
ECG, bloods, nil by mouth Analgesia Anticoagulate (heparin - allows chance of blood getting through occlusion)
42
What is management of a salvagable limb in ALI management?
If embolus - embolectomy If thrombus - Endovascular :mechanincal thrombectomy/thrombolysis or open embolectomy +/- bypass
43
What type of anaesthetic is used for embolectomy?
General or local
44
What is the likely cause for ALI?
—30% embolic, 60% thrombosis in situ
45
When does irreversible muscle ischaemia occur?
In 6-8 hours
46
What is the pathophysiology of diabetic foot disease?
Microvascular peripheral artery disease ## Footnote —Peripheral neuropathy – they lose sensation of their foot – more likely chance of trauma —Mechanical imbalance – lose proprioception and walk differently – pressure points different and now damaged —Susceptibility to infection
47
How do you ensure footcare of a diabetic?
Always wear shoes Check fit of footwear Check pressure points of foot regularly Prompt and regular woundcare
48
What is diabetic foot management?
—_Prevention_ _—Good wound care_ _—Tracking infection_ (lymphangitis or cellulitis)– consider systemic antibiotics _—Investigate_ for osteomyelitis, gas gangrene, necrotising fasciitis _—Revascularisation_ —Disease is very distal – attempt distal crural angioplasty / stent —Distal bypass _Amputation_
49
What is compartment syndrome
Muscle ischaemia (irreversable after 6-8 hours) Inflammation, oedema, venous obstruction Tense, tender calf Rise in creatie kinase Risk of renal failure
50
What are the different types of amputations
51
What are the mobility % in amputations
Inside: 80% BKA, 40% AKA Outside: 65% BKA, 43% AKA
52
Which type of amputation requires more energy? BKA or AKA (above or below the knee amputation)
—63% higher in BKA —117% higher in AKA
53
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1st year systems ADAM (52 decks)

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