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Lecture week III COPY > Peripheral Vascular Disease > Flashcards

Peripheral Vascular Disease Flashcards

1
Q

When does PVD arise?

A

Significant narrowing of arteries distal to arch of aorta

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2
Q

Types of PVD

(3)

A
  • Peripheral Vascular Disease
  • Chronic Arterial Insufficiency
  • Chronic Vascular Disease
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3
Q

(3) mechanisms contributing to the development of PVD

A
  • atherosclerosis
  • vasospasm (e.g. Raynaud’s)
  • inflammation/vasculitis
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4
Q

Risk factors for PVD

A
  • smoking
  • DM
  • Hypertension
  • Hyperlipidaemia
  • Fx
  • Sedentary lifestyle
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5
Q

The difference between Atherosclerosis and Acute Limb Ischemia

A
  • Atherosclerosis: Toxins accumulate in tunica intima -> this narrows the lumen of the tube (so we cannot ‚just pull it out’)
  • Acute limb ischaemia: there is a physical blockage (embolism) blocking the outflow
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6
Q

Clinical presentation re progression of PVD

A
  1. Asymptomatic
  2. Intermittent claudication
  3. Critical limb ischaemia (end stage of PVD)

*if we leave claudication stage alone -> it will perhaps stay like that till the end of life

*if we leave critical limb ischaemia alone -> amputation always needed

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7
Q

What’ s pathophysiology of claudication?

A

In claudication, as there is increased demand for oxygen and glucose to exercising muscle -> blockage would not allow enough blood to pass through -> anaerobic respiration -> lactic acid - > pain

*Cramps at certain distance

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8
Q

Does intermittent claudication result in amputation?

A
  • Intermittent claudication does not generally threaten the limb (amputation not usually required)
  • will impact on the life
  • it is a red alarm for vascular disease -> MI, strokes etc common

(20-30% with intermittent claudication will be dead in 5 years - as other arteries e.g. in the brain are also affected)

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9
Q

What artery is most commonly involved in intermittent claudication?

A

Distal femoral a. -> claudication in the calf muscle area

(located just above the knee)

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10
Q

What questions to include in the history from a patient with suspected PVD?

A
  • duration
  • distance before the pain occurs
  • time taken for pain to go away at rest
  • trophic changes: colour changes, nail malformations, hair loss
  • infections/healing
  • medication
  • occupation
  • smoking
  • FHx
  • other risk factors (e.g. HTN, hyperlipidaemia, sedementary lifestyle)
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11
Q

Values and interpretation of ABPI - symptoms that occur with them

A
  • 1 or more -> symptoms free
  • 0.95 - 0.5 -> intermittent claudication
  • 0.5 - 0.3 -> rest pain (critical ischaemia)
  • <0.2 -> gangrane and ulceration (critical ischaemia)
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12
Q

Non-operative management of PVD

A
  • Lifestyle: quit smoking, exercise (1 hr a day for 6 months), weight loss
  • Statins - even if cholesterol is low; for secondary prevention
  • Antiplatelet agents: Aspirin or Clopidogrel
  • BP control: target <140/90
  • Glycaemic control
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13
Q

Is surgery usually indicated in case of claudication?

A

Vascular surgery is very risky, perhaps not provided for people with claudication -> usually for people at risk of amputation due to risks vs benefits -> therefore more focus on non-operative

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14
Q

How do we approach ‘exercise’ advice in Mx of PVD?

A
  • Exercise is not just an advice to exercise
  • it is a formal and supervised programme under direction of specialist nurses -> it trains the muscle to get used to slightly anaerobic situations and that will make them to work more without pain
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15
Q

What about smoking and PVD?

A

Stop smoking -> as smoking will stop co-lateral circulation from forming -> and we want colateral

circulation!

(It has been proved that stop smoking and exercise would double walking distance in 6 months)

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16
Q

Pathophysiology of development of ‘critical limb ischaemia’

A
  • pain even at rest - leg has an inadequate blood flow
  • Tissue may start to die - ulcers (punched out, deep)
  • Gangrene or necrosis - starts with toe

*Pain felt in early stages (just when they switch from claudication to ‘rest pain’) ->

felt in the toes (as further away from main

arterial supply)

17
Q

What’s a warning sign for critical limb ischaemia?

A

patient waking up at night with toes or heel pain

18
Q

Why does pain in critical limb ischaemia come initially at night?

A
  • legs are up (so patient may hang the legs on the side of bed as gravity helps the blood to get to peripheries) -> some patients need to use morphine daily as pain is horrible
  • cardiac output will slow town
  • temperature drops by 0.5 degree -> peripheral vasoconstriction
19
Q

How to assess the severity of PVD (questions about pain) (4)

A

Assessment - severity:

  1. Can they walk? -> if yes, either no PVD or asymptomatic
  2. Can they walk but pain comes while exercise ? -> claudication
  3. Pain at night -> critical ischaemia
  4. Pain all the time -> tissue loss
20
Q

Can the leg appearance and cap refill be normal in the claudicant patient?

A

Yes, this is possible due to collateral circulation

21
Q

How to perform ‘Burger’s test’? (what happens and why)

A

Burger’s test

  1. lifting patient foot up in the air -> foot will go white
  2. Sit patient with the legs down (side of the bed) ->

Toxins from anaerobic respiration (when foot was up) will vasodilate vessels in the foot & foot

goes really red ‘sunset foot’

22
Q

Examples of trophic changes in PVD

A
  • no hair at all
  • veins will collapse down and imprint of filled vein left after that ‘venous scattering’
  • swelling is typical if people have rest pain because that means a patient will sit all day with their foot hanging down
  • shiny foot - skin starts to die off, nails unhealthy/malformation, ulcers form
23
Q

What is the diagnostic Ix for PVD?

A
  • Hx and Examination - KEY (as can diagnose, predict severity by these)
  • scans - to plan surgical treatment ; not needed to diagnose PVD

* this is because the pattern of blocked arteries does not match superficial manifestations

24
Q

What scan is a ‘gold standard’ for PVD?

A

CTA (CT angiography) - gold standard (CT of the whole body) with a dye injected into the vein and timed -> to highlight arterial tree

*good to look at arteries from the knee up as they are bigger; also dye will be white but Ca++ may be white as well, and plaques are filled with Ca so cannot be sure if it’s a plaque or dye)

25
Q

Two broad categories of surgeries for PVD

A
  • open
  • endovascular (keyhole)
26
Q

(2) types of endovascular surgery for PVD

A
  • stenting
  • balloon angioplasty

Balloon angioplasty: catheter with a balloon on it
is passed through the vessel -> inflated so will compress the blockage and widen the lumen and then deflate again

Stent: metal meshwork to make the vessel to stay open -> done as a part of balloon angioplasty

27
Q

(3) types of open surgery for PVD

A
  • endarterectomy
  • bypass
  • amputation
  • *Graft bypass**: goes above the blockage and then below the blockage
  • *Amputation**: we try to avoid, but if the gangrene is there we need to do it - necrosis must be taken off due to infection
28
Q

Acute vs critical limb ischaemia

A

Acute and Critical limb ischaemia are NOT THE SAME

* critical can wait few weeks for treatment (due to often narrow passage left and collaterals)

ACUTE is an EMERGENCY and is not atherosclerosis; here, all of a sudden a vessel has
become blocked by a clot (that may even stuck)

29
Q

6 Ps - signs of acute limb ischaemia

A
  • pallor
  • pain
  • perishingly cold
  • paraesthesia
  • paralysis
  • pulseless
30
Q

Possible causes of Acute Limb Ischaemia

A

- embolism (e.g. cardiac due to MI or AF)

  • thrombosis in situ (cancer, chemotherapy, haematological disorders, atherosclerotic plaque rupture*)

*acute on chronic)

31
Q

(2) aims of treatment of acute limb ischaemia

A
  1. We need to stop the clot from getting bigger - anti-coagulation
  2. Then we need to get rid of the clot and reestablish flow
32
Q

Endovascular option for surgical management of Acute limb ischaemia

A

Endovascular: catheter-directed thrombolysis

Catheter - we put the wire on and then from the
catheter it releases the thrombolytic agent

33
Q

Open options (3) for surgical management of acute limb ischaemia

A
  • embolectomy
  • bypass
  • amputation

Embolectomy - inflating the balloon below the clot and then pull it back together with the clot

Lecture week III COPY (11 decks)

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