Peripheral vascular disease Flashcards
Peripheral artery disease
- Description
Obstruction of lower extremity arteries
- Causing a syndrome of symptoms
- Most common cause is atherosclerosis
Other causes
- Aortic coarctation
- Arterial dissection
- Thrombosis/ embolisnm
Peripheral artery disease
- Risk factor
Smoking
Hyperlipidaemia
Diabetes
HTN
Age >40
Low physical activity
Peripheral artery disease presentation (9)
Claudication
- Intermittent pain, pain in legs with onset during exercise/ walking.
- Lower aorta/ iliac = pain in glutes and hips.
- Common femoral/ Iliac= pain in thigh
- Superficial femoral= pain upper 2/3 of calf
- Popliteal= pain in lower 1/3 calf
- Tibial/ peroneal= pain in foot.
Pain at rest= critical limb ischaemia
Diminished pulse/ pulseless lower extremity
Bruit in artery
- Indicates narrowed artery
Signs of acute limb ischaemia
Erectile dysfunction
- Indicates internal iliac or high artery narrowing
Ulcer/ non-healing wound
Gangrene
Muscle atrophy
Elevation pallor vs dependent rubor
Elevation pallor
- When limb turns pale after it is lifted
- Due to blood unable to overcome narrowed arteries and gravity
Dependent rubor
- When the limb turns red after being lowered
- Due to sudden increased perfusion due to gravity
Critical limb ischaemia
When >1 level of the arterial tree is affected
- Leading poor or no flow to tissue
Ischaemic arterial ulcers
- Cause
- Presentation
Cause
- Poor blood supply, demand> supply.
Starts off as small wounds and does not heal due to poor blood supply.
- Can progress to gangrene
Presentation
- Location= pressure points: toe joint, malleoli, base of heel
- Dry and punched out
- Painful
- Little bleeding.
Ankle brachial pressure index (ABPI)
The ratio of systolic BP in the arm (brachial) compared to the ankle
1-1.4= normal
<0.9= vascular disease
0.6-0.9= mild
0.3-0.6= moderate
<0.3= severe
- Can show false negative in diabetics (>1.4, due to calcification)
If ABI decreases 15-20% fater exercise testing= diagnostic of arterial disease
Toe brachial index
Systolic BP ratio between Toe and brachial BP.
<0.6= Vascular disease
Investigations for PVD
Colour duplex ultrasound
- Assesses location and degree of stensosis
CT angiogram
- Gold standard test
MR angiogram
- No radiation, gold standard
ABI/ exercise ABI
TBI
Lifestyle modification for management of arterial vascular disease
Smoking cessation
Balanced diet
- Low sugar, low saturated fat
Increase in exercise
- Collateral vascularisation
Pharmacological treatment of peripheral arterial disease
Antiplatelet
- Aspirin/ clopidogrel 75mg
Statins/ lipid-lowering drugs
- atorvastatin 80mg
DM control
Weight loss
Analgesia
- Paracetamol + opioid for acute ischaemia
Antihypertensives
- ACEi, ARBs, beta-blockers
Surgical revascularization for critical limb ischaemia
Percutaneous transluminal angioplasty
- For single short segment of blood vessel with uniform occlusion
Open surgery
- Endarterectomy if clot
- Indicated for long segment occlusion
- Multifocal/ calcified lesion
Surgical bypass
- For very long clots or when area of ischaemia is extension
Amputation
- When tissue is non-viable
Acute limb ischaemia
- Viable limb treatment
- Thrombolysis + endovascular revascularisation (angioplasty)
- Urokinase
- Alteplase - Surgical revascularisation
- Thrombectomy/ bypass
- Indicated in large aortoiliac stensosi/ chronic occlusion
- Aortic anuerysm
- Heavy calcified lesions
Venous insufficiency
Persistent elevation of venous pressure causing functional changes in lower extremity.
Main causes
- venous reflux due to poor valves= blood stasis
- chronic obstruction
- Common after episode of DVT
Venous insufficiency presentation
Peripheral oedema, esp ankle swelling
- Proteins enter interstitium and draw in water
Venous ulcers
Corona phlebectatica
- Ankle flar
Lipodermatosclerosis
- Stasis dermatitis
- Inflammation of fat under skin
Varicose veins
Atrophie blanche
- Loss of skin pigmentation due to RBC death
Brown discolouration of leg (haemosiderin)
- Due to extravascularisation from venous hypertension
