Limb Ischaemia, Ulcers, Gangrene Flashcards Preview

MS4 - Vascular > Limb Ischaemia, Ulcers, Gangrene > Flashcards

Flashcards in Limb Ischaemia, Ulcers, Gangrene Deck (45)
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1

Definition of chronic limb ischaemia

Ankle artery pressure <50mmHg (toe <30mmHg)

AND either:

- Persistent rest pain requiring analgesia for ≥2wks

- Ulceration or gangrenes

2

Causes of chronic limb ischaemia

Atherosclerosis

Rarely vasculitis

3

Spectrum of chronic limb ischaemia

1) Intermittent claudication

2) Critical limb ischaemia (fontaine 3/4)

3) Leriche's syndrome

4) Buerger's syndrome

4

Intermittent claudication sx

Cramping pain after walking set distance

 

5

Vessel responisble for intermittent claudication in calf

 superficial femoral disease

6

Vessel responsible for intermittent claudication in buttock

iliac disease

7

Critical limb ischaemian sx

Rest pain (night)

ulceration

gangrene

8

Leriche's syndrome

Aortoiliac occlusive disease

Triad:

-Buttock claudication/wasting

-Erectile dysfunction

-Absent femoral pulses

9

Buerger's disease aka

Thromboangiitis Obliterans

10

Buerger's disease risk factors

Young, male, smoker

 

11

Buerger's disease pathology

Acute inflammation and thrombosis of arteries/veins in hands and feet --> ulceration and gangrene

12

Buergers test

lift leg until pale

≥90: normal

20-30: ischaemia

<20: severe ischaemia

13

Signs of chronic limb ischaemia

Pallor

Pulseless

Pain

Perishingly cold

Parasthesia/paralysis

14

Fontaine classification of chronic limb ischaemia

1) Assymptomatic

2) Intermittent claudication: a. >200m b.<200m

3) Ischaemic rest pain

4) Ulceration/gangrene

15

Rutherford classification of chronic limb ischaemia

1) Mild claudication

2) Moderate claudication

3) Severe claudication

4) Ischaemic rest pain

5) Minor tissue loss

6) Major tissue loss

16

Investigations for chronic limb ischaemia

Doppler waveforms

ABPI

Walk test

Imaging

17

Imaging Ix for chronic limb ischaemia

colour duplex US

CT/MR angiogram with gadolinium contrast

Digital subtraction angiography

18

Doppler waveforms

Normal: triphasic

Mild stenosis: biphasic

Severe stenosis: monophasic

19

Medical mx of chronic limb ischaemia

RFs mx

Beta Blockers  in intermittent (NOT critical limb ischaemia)

antiplatelets

analgaesia

20

Interventional mx of chronic limb ischaemia

Endovascular: percutaneous transluminal angioplasty/stenting

Surgical reconstruction

21

Acute ischaemia definition

< 14 days

22

Severity of acute limb ischaemia

Incomplete: limb not threatened

Complete: limb threatened: Loss of limb unless intervention within 6hrs

Irreversible: requires amputation

23

Causes of acute limb ischaemia

1) Thrombosis in situ (60%)

2) Embolus (30%)

3) Others: graft occlusion, trauma, aortic dissection

24

Where do majority of emboli causing limb ischaemia form?

left atria in AF (80%)

25

Where do majority of emboli causing limb ischaemia get stuck

femoral bifurcation 

26

Investigations of acute limb ischaemia

ECG

CXR

Duplex doppler

27

General treatment of acute limb ischaemia

NBM + Rehydration

Analgaesia

Antibiotics

Unfractionated heparin IV infusion

28

Mx of incomplete limb ischaemia

angiogram and observe

29

Mx of complete limb ischaemia

urgent surgery (embolectomy/bypass)

30

Embolus treatment

 Wire fed through embolus

Fogarty catheter fed over the top, balloon inflated and catheter withdrawn

31

Causes of leg ulcers

1. Venous: commonest

2. Arterial

3. Neuropathic

4. Pressure/trauma

5. Systemic disease: e.g. pyoderma gangrenosum

6. SCC

32

Features of venous leg ulcers

Painless

Shallow ulcers

33

Risk factors for venous leg ulcers

Venous insufficiency

Varicosities

DVT

Obesity

34

Common place for venous ulcers

medial malleolus: “gaiter area”

35

Features of arterial leg ulcers

 Painful

Deep

Punched 

 

36

Common place for arterial ulcers

Heal

Tips of and between toes

Metatarsal heads esp. 5th

37

Features of neuropathic leg ulcers

Painless with insensate surrounding skin

 Warm foot with good pulses

38

Complications of leg ulcers

Osteomyelitis

Development of SCC in the ulcer (Marjolin’s ulcer)

39

Investigations of leg ulcers

 ABPI

 Duplex ultrasonography

Biopsy may be necessary (Look for malignant change: Marjolin’s ulcer)

40

Management of leg ulcers

Graduated compression stockings 

RFs eg smoking 

Analgesia

Bed rest + elevate leg

Pentoxyfylline PO 

41

Classication of gangrene?

Wet: tissue death + infection

Dry: tissue death only

 

42

Gas Gangrene microorganism?

Clostridium perfringes myositis

43

Treatment of gas gangrene?

 Debridement (may need amputation)

 Benzylpenicillin + metronidazole

Hyperbaric O2

44

Synergistic Gangrene microorganism?

 Involves aerobes + anaerobes

 

45

Management of synergistic gangrene?

Debridement

 Benzylpenicillin ± clindamycin