peripheral vascular disease

Question 1

what is intermittent claudication?

Answer 1

• when insufficient blood reaches exercising muscle
• the patient is pain free at rest but after variable periods of exercise develops ischaemic pain in the affected limb, which is relieved by further rest

Question 2

what are the risk factors for intermittent claudication?

Answer 2

• male
• age
• diabetes
• smoking
• hypertension
• hypercholesterolaemia
• fibrinogen
• alcohol

Question 3

what are the non invasive investigations of lower limb ischaemia?

Answer 3

• measurement of ABPI

- duplex ultrasound scanning

Question 4

what are the invasive investigations of lower limb ischaemia?

Answer 4

• magnetic resonance angiography
• CT angiography
• catheter angiography

Question 5

how do you measure ABPI?

Answer 5

• ankle pressure/brachial pressure

Question 6

what are the normal values for ABPI?

Answer 6

• normal = 0.9-0.12
• claudiaction = 0.4-0.85
• severe = 0-4.5

Question 7

what are the different ways to treat lower limb ischaemia?

Answer 7

• guardian therapy
• improvement of claudiaction symptoms
• exercise training and drugs
• angioplasty/stent
• surgery

Question 8

what is the guardian therapy?

Answer 8

• smoking cessation
• lipid lowering
• antiplatelets
• hypertension Rx
• diabetes Rc
• life style issues
• information

Question 9

what exercise should be recommended for lower limb ischaemia?

Answer 9

• 1 hour per day - 30 mins 3 times per week for minimum of 6 months
• 20-200% improvment in walking distance

Question 10

what drugs should be given for lower limb ischaemia?

Answer 10

• cliostozol

Question 11

what surgery would be given to treat lower limb ischaemia?

Answer 11

• endarterectomy

- bypass

Question 12

what is critical limb ischaemia?

Answer 12

• at rest there is pain in toe/foot
• occurs when sleeping and lying down
• can be ulcers/ gangrene
• severe ischaemia + damage (trauma/footwear)

Question 13

what are the symptoms of critical limb ischaemia?

Answer 13

• pain at rest
• toes and forefoot
• requires strong analgesia
• worse at night
• helped by sitting and putting led in a dependent possition
• helped by getting up and walking about

Question 14

what are the critical limb ischaemia risk factors for amputation?

Answer 14

• smoking

- diabetes

Question 15

what is an aneurysm?

Answer 15

• dilation of a vessel by more than 50% of its normal diameter
• normal aortic diameter is 1.2-2cm

Question 16

what is a true aneurysm?

Answer 16

• all 3 vessel walls are intact

Question 17

what is a false aneurysm?

Answer 17

• there is a breach in the vessel wall (surrounding structure act as vessel wall)

Question 18

what are the morphologies or aneurysms?

Answer 18

• saccular
• fusiform
• mycotic - arteries secondary to an infection process, involving all 3 layers of the artery

Question 19

what happens in an abdomial aortic aneurysm?

Answer 19

• medial degeneration
• regulatin of elastin/collagen in aortic wall
• aneyrysmal dilation
• increase in aortic wall stress
• progressive dilation

Question 20

what increases chance of abdominal aortic aneurysm?

Answer 20

• male

- increases with age >65

Question 21

symptoms of AAA?

Answer 21

• mostly asymptomatic
• identified by imaging for other pathology
• surveillance programme
• symptoms may be trashing pain
• may mimic renal colic

Question 22

what happens in an AAA rupture?

Answer 22

• sudden onset epigastric /central pain
• may radiate through to back
• may minic renal colic
• collapse

Question 23

what would you find on examination of a ruptured AAA?

Answer 23

• may look well
• hypo/hypertensive
• pulsatile, expansile mass +- tender
• transmitted pulse
• peripheral pulses

Question 24

what are the outcomes of a ruptured AAA?

Answer 24

• 75% will not make it to hospital
• more retroperitoneal, contained rupture
• free intra-peritoneal rupture is rapidly fatal
• 50% operative mortality

Question 25

how do you manage AAA?

Answer 25

operation may cause more harm than doing nothing | - intervention should be offered at 5.5cm small ones - should just be watched or if it grown 1cm/year

Question 26

how to duplex ultrasound?

Answer 26

- aP diameter - involvement of iliac arteries - but it only tells us there is an aneurysm and its AP diameter

Question 27

what does a CT scan allow us to see?

Answer 27

- shape, size and iliac involvement - allows for management planning - only imagine method to identify ruptured AAA

Question 28

how do you manage AAA?

Answer 28

- laparotomy - clamp aorta + iliacs - dacron graft - tube vs bifurcated graft - endovascular aneurysm repair (EVAR) = exclude AAA from insde the vessel

Question 29

what is acute limb iscahemia?

Answer 29

- sudden loss of blood supply to a limb = occlusion of native artery or bypass graft

Question 30

what are the causes of sudden occlusion (acute limb ischaemia)?

Answer 30

- embolism - atheroembolism - arterial dissection - trauma - extrinsic compression

Question 31

clinical features of acute limb ischaemia?

Answer 31

- pain - pallor - pulseless - perishingly cold - paraesthesia - paralysis

Question 32

how can you ddescribe the pain for acute limb ischaemia?

Answer 32

- severe, sudden onset, resistant to angina | - calcification tenderness with tight compartment intricate muscle necrosis

Question 33

how can you describe the pallor for acute limb ischaemia?

Answer 33

- limb initally white with empty veins | - later capilaries fill with stagnated de oxygenated blood

Question 34

what is the time line for acute limb ischaemia clinical features?

Answer 34

- 0-4 hours = white foot, painful, sensorimotor deficit - 4-12 hours = mottles, blaches on pressure - >12 hours = fixed mottling, non blanching, compartments tender/red - paralysis

Question 35

what is the management of acute limb ischaemia?

Answer 35

``` ABC = resusitate and investigate FBC = U/Es, CK Coag +-troponin ECG = MI, dysrhythmia CXR = underlying malignancy arterial imagine ```

Question 36

what is diabetic foot sepsis?

Answer 36

``` encompasses - diabetic neuropathy - peripheral vascular disease - infection this leads to tissue ulcertaion, necrosis and gangrene which may lead to limb amputation ```

Question 37

what can diabetic foot sepsis come from?

Answer 37

- small punctured wound - infection from the nail plate - from a neuro-ischaemic ulcer

Question 38

why is diabetic foot sepsis a problem?

Answer 38

- the pressure of pus builds up in this rigid compartment rapidly leading to impairment of capillary blood flow and further ischaemia and further tissue damage

Question 39

what are the clinical findings of diabetic foot sepsis?

Answer 39

- pyrexia - tachcardic - tachypnoeic - confused - kassmauls breathing