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1
Q

Definition of Chronic Limb Ischaemia

A

Ankle artery pressure <50mmHg
And either:
Persistent rest pain requiring analgesia for over 2 weeks or ulceration/gangrene

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2
Q

Causes of PAD

A

Atherosclerosis

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3
Q

Risk factors of PAD

A 
Modifiable: 
Smoking 
BP 
DM control 
Hyperlipidaemia 
Exercise

Non-modifiable:
FH
Age
Male

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4
Q

Associated diseases of PAD

A

IHD
Carotid stenosis
AAA

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5
Q

How can PAD present?

A

Intermittent claudication

Critical limb Ischaemia

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6
Q

What are the features of intermittent claudication?

A

Cramping pain after walking a fixed distance which is rapidly relieved by rest
Calf = superficial femoral disease
Buttock = iliac disease

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7
Q

What are the features of critical limb ischaemia?

A

Rest pain - especially at night, usually felt in the foot and patient will hang foot out of bed
Ulceration
Gangrene

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8
Q

What is Leriche’s syndrome?

A 
Aortoiliac occlusive disease
Triad of: 
Buttock pain 
Erectile dysfunction 
Absent femoral pulses
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9
Q

What is Buerger’s disease?

A

Non atherosclerotic disease
Common in young, male, heavy smokers
Acute inflammation and thrombosis of arteries and veins in hands and feet leading to ulceration and gangrene

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10
Q

What are the signs of PAD?

A

Pulses: absent, and increased CRT
Ulcers: painful, punched out, on pressure points
Skin: cold, white, atrophy, loss of hair
Venous guttering
Buerger’s ankle: ankle leg has to be raised to before becoming pale (90 = normal; 20-30 = ischaemia and <20 = severe ischaemia)

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11
Q

Foutaine classification of PAD

A

1) Asymp
2) Intermittent claudication (a) = >200m (b) = <200m
3) Ischaemic rest pain
4) Ulceration / gangrene

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12
Q

Ix in PAD

A

Doppler US: ABPI
Colour duplex US (1st line imaging to assess location and degree)
Magnetic resonance angiography - prior to any intervention
Doppler waveforms: triphasic, biphasic, monophasic
Bloods: FBC, lipids, glucosse, ESR

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13
Q

Management of PAD

A 
Conservative: 
1st line = exercise training 
Stop smoking
Weight loss 
Foot care

Medical:
Risk factors: BP, lipids, DM
Start Clopidogrel daily 75mg and avrostatin 80mg
Analgesia

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14
Q

ABPI - numbers of severity

A 
Raised in DM or CRF
0.8-0.9 = asymptomatic 
0.6-0.8 = claudication 
0.3-0.6 = rest pain 
<0.3 = ulceration and gangrene
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15
Q

Presentation of acute limb ischaemia

A 
6P's
Pulseless 
Painful 
Perishingly cold 
Pale 
Paraesthesia 
Paralysis
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16
Q

General management for acute limb ischaemia

A 
Senior discussion 
NBM 
IV fluids 
Analgesia 
Unfractionated heparin IVI 
Complete occlusion? If yes, urgent surgery. If no, angiogram and observe for deterioration
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17
Q

What is the commonest cause of acute limb ischaemia?

A

Thrombosis in situ

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18
Q

What is a the commonest cause of acute limb ischaemia secondary to embolus?

A

Atrial fibrillation - ECG, Echo, US aorta fem and pop

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19
Q

Why are diabetics more susceptible to ulcers?

A

Diabetic peripheral neuropathy: reduced sensation therefore may not be aware of minor trauma
Peripheral vascular disease: tissue ischaemia can lead to necrosis and is detrimental for wound healing

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20
Q

Types of surgery for PAD

A 
Endovascular revascularisation (percutaneous transluminal angioplast with balloon dilation or stents: good for short stenosis in big vessels, improves inflow so decreases pain 
Bypass surgery indicated if very short claudication distance, symptoms greatly affect QoL or development of rest pain: thrombosis risk
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21
Q

Best investigation to diagnose carotid artery disease

A

Duplex carotid doppler

Also consider: CT angiography, MR angiography

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22
Q

How does carotid artery disease present?

A

Bruits

TIA/Stroke (CVA)

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23
Q

How to manage asymptomatic carotid artery stenosis <70%?

A

Antiplatelets (aspirin) and lower risk factors (smoking, HTN, lipids)

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24
Q

How to manage asymptomatic >70 carotid artery stenosis?

A

Antiplatelets and risk factors +/- carotid endarectomy + stenting

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25
Symptomatic carotid artery stenosis management
If bilateral or ipsilateral >50% then carotid endarectomy
26
Complications of endarterectomy
``` Stroke/death HTN Haematoma MI Nerve injury: hypoglossal ipsilateral tongue deviation), great auricular, recurrent laryngeal ```
27
What is an aneurysm?
Abnormal dilation of a blood vessel >50% of its normal diameter (AAA = >3cm)
28
What is a pseudo aneurysm?
Collection of blood around a vessel wall that communicates with the vessel lumen Usually iatrogenic e.g. puncture
29
What is a dissection?
Vessel dilation caused by blood splaying apart the media to form a channel within the vessel wall
30
Incidence of popliteal aneurysms
Less common than AAA | 50% also have AAA
31
Presentation of popliteal aneurysms
Very easily palpable pulse 50% bilateral Thrombosis and distal embolism is main complication which can lead to acute limb ischaemia
32
Management of popliteal aneurysms
Embolectomy or fem-distal bypass
33
Presentation of AAA
Usually asymptomatic and discovered incidentally May present with back pain or umbilical pain which radiates to the groin Acute limb ischaemia Blue toe syndrome: distal embolus Acute rupture
34
Examination of AAA
Expansile pulsatile mass just above umbilicus Bruits may be heard Rupture: tenderness and shock
35
Investigation of AAA
Abdo US: screening and monitoring | CT/MRI: gold standard
36
Conservation management of AAA
CVS risk factors need to be managed e.g. BP IF AAA <5.5cm then can be regularly monitored by US (<4cm = yearly; 4.5-5cm = 6 monthly)
37
Indications for surgical management
``` Symptomatic (back pain = imminent rupture) Diameter >5.5cm Rapidly expanding (>1cm/year) ```
38
Screening programme for AAA
UK men offered one-time US screen @ 65 years
39
Increased risk of rupture
High BP Smoker Female Strong FH
40
Presentation of rupture
``` Sudden onset of severe abdominal pain Can be intermittent or continuous Radiates to back or flanks Collapse leads to shock Expansile abdominal mass ```
41
Management of rupture
``` High flow oxygen 2 x large bore cannula in each ACF Give fluid if shocked BUT keep SBP <100 Cross-match 10 units of blood Investigate major haemorrhage protocol Analgesia Take to theatre Catheter + CVP line ```
42
What is a thoracic aortic dissection?
Blood splays apart laminar planes of media to form a channel within the aortic wall
43
What is the cause of dissection? (risk factors)
Atherosclerosis (atherosclerotic aneurysm disease) HTN Minority by connective tissue disorder e.g. Marfan's and Ehlers Danlos (features of) Bicuspid aortic valve FH
44
How do dissections present?
Sudden onset, tearing chest pain which radiates to the back Tachycardia and hypertension occur Left/right BP differential Pulse deficits (commonly in proximal dissection) Diastolic murmurs
45
Uncommon ways dissections may present
Altered mental state, paraplegia and hemiparesis - due to subsequent cerebral ischaemia
46
Stanford classification of dissections
A) Proximal (70%) - involves ascending aorta +/- descending. Higher mortality. B) Distal (30%) - involves descending aorta only - distal to L SC artery. Usually best managed conservatively.
47
Investigations for dissections
Bloods: cross-match, FBC, U&E, clotting, amylase ECG: exclude MI (20% will show ischaemia) CT angiography: best to diagnose Trans-oesophageal echo/trans-thoracic echo: if patient haemodynamically unstable (cannot use CT) and need to make diagnosis (CXR, cardiac enzymes to exclude other causes)
48
Management of dissection
``` Analgesia e.g. morphine sulphate If unstable: adrenaline Keep SBP low (labetalol or esmolol) Type A: open repair Type B: if uncomplicated = TEVAR (endovascular aortic repair), if complications = surgery ```
49
Risk factors for varicose veins (primary)
``` Prolonged standing Pregnancy Obesity OCP FH ```
50
Risk factors for varicose veins (secondary)
Valve destruction: DVT, thrombophlebitis Obstruction: DVT Constipation AVM
51
Presentation of varicose veins
``` Cosmetic defect Pain, cramping and heaviness Tingling Swelling Skin changes Ulcers Oedema Thrombophlebitis ```
52
What skin changes can occur in varicose veins?
``` Venous stars Haemosiderin deposition Venous eczema Lipodermatosclerosis Atrophie blanche ```
53
Investigations of varicose veins
``` Duplex Ultrasonography (anatomy, presence of incompetence) If surgery: FBC< U+E, clotting, G+S, CXR, ECG ```
54
Referral criteria of varicose veins
``` Bleeding Pain Ulceration Superficial thrombophlebitis Severe impact on QoL ```
55
Conservation management of varicose veins
Contributing factors: lose weight and relieve constipation Education: avoid prolonged standing and regular walks Class II Graduated Compression Stockings: symptomatic relief and slows progression Skin care: maintain hydration with emollients and treat ulcers rapidly
56
If confirmed varicose veins and truncal reflex. How can you surgically manage?
Endothermal ablation (radio frequency ablation) Endovenous laser treatment of long saphenous If above unsuitable, offer: US guided sclerotherapy If that is unsuitable: offer surgery
57
Venous ulcers
Painless, sloping, shallow ulcers Usually on medial malleolus: gaiter area Associated with haemosiderin deposition (brown pigmentation) and lipodermatosclerosis (champagne bottle legs) and venous eczema RFs: venous insufficiency, DVT, obesity, neuromuscular disorders
58
Arterial ulcers
Hx of vasculopathy and risk factors Painful, punched out, deep lesions Occur at pressure points e.g. heal, tips of and between toes, metatarsal heads Other signs of chronic ischaemia: cold with no capable pulse and low ABPI
59
Neuropathic ulcers
Painless with insensate surrounding skin Warm foot with good pulses (common on plantar surface of metatarsal head and hallux) Pressure and diabetes
60
Marjolin's ulcer
SCC in the ulcer At sites of chronic inflammation Mainly LL
61
Pyoderma gangrenousum
Associated with IBD/RA Can occur at stoma sites Erythematous nodules or pustules which ulcerate
62
Investigations of ulcers
ABPI Duplex ultrasonography can determine anatomy/flow Biopsy may be necessary to look for malignant changes
63
Mx of venous ulcers
``` Refer to leg ulcer community clinic Optimise risks: nutrition and smoking Analgesia Bed rest + elevate leg 4 layer graded compression bandage Pentoxyfylline PO ```
64
Increase venous pressure
RHF Venous insufficiency Drugs e.g. nifedipine
65
Decreased oncotic pressure
Nephrotic syndrome | Hepatic failure
66
Bilateral leg swelling , other causes
Lymphedema
67
Causes of unilateral leg swelling
Venous insufficiency DCT Infection Lymphedema

Vascular (1 decks)

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