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Vascular Flashcards

(90 cards)

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1
Q

Arterial supply of the lower limb

A

1) common iliac -> external iliac -> common femoral

2a) common femoral -> profunda femoris -> perforating branches

2b) common femoral -> superficial femoral -> popliteal

3) popliteal -> anterior + posterior tibial

4) anterior tibial -> dorsalis pedis

5) posterior tibial -> peroneal -> medial & lateral plantar

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2
Q

Profunda femoris runs ___, supplies ___ and superficial femoral runs ___, supplies ___

A

posterolaterally, supplies muscles of thigh

anteromedially, exits femoral triangle into adductor canal, through adductor hiatus into popliteal fossa. Supplies adductor muscles

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3
Q

On angiogram at trifurcation of leg arteries, most lateral to medial ___, ___, ___

A

anterior tibial
peroneal
posterior tibial

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4
Q

Posterior tibial artery runs ___ and becomes plantar arteries

A

posterior to medial malleolus

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5
Q

Femoral artery landmark

A

Mid-inguinal point (b/w pubic symphysis and ASIS)

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6
Q

Popliteal artery landmark

A

Popliteal fossa, palpate against upper end of tibia

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7
Q

Peripheral artery disease includes disease of all the arteries except ___, ___

A

coronary arteries and aorta

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8
Q

Intermittent claudication means?

A

reproducible discomfort of a defined group of muscles that is induced by exercise and relieved by rest

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9
Q

Chronic limb threatening ischemia clinical diagnosis

A

1) Rest pain requiring opioid analgesia >2 weeks
AND/OR

2) gangrene/ulcers over foot
AND
3) objective indication of poor vascular supply to lower limbs (ABPI <0.5 , toe pressure, TcPO2)

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10
Q

Ischemic rest pain presentation

A

pain at night during sleep (BP drop, pts not in dependent position)

pain on lying down, relieved by getting up having a short walk

pain aggravated by lifting the limb

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11
Q

Ischaemic ulcers tend to occur on ___ of the foot, tend to be (characteristic)

venous ulcers occur over the ___, tend to be (characteristic)

Neuropathic ulcers occur over ___

A

lateral malleolus - dry, punctate, deep (punched out, well-circumscribed)

medial malleolus - moist, diffuse, superficial (sloping)

heel, metatarsal heads

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12
Q

Gangrene is ___ tissue that progresses to ___. Caused when ____.

A

cyanotic, necrosis
arterial pressure falls below minimum required for metabolic functions

Gangrene can be wet or dry

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13
Q

Patients with intermittent claudication tend to have symptomatic stabilisation due to

A

1) collateral development
2) patient alters gait to use non-ischemic muscles
3) metabolic adaptation of ischemic muscle

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14
Q

Risk factors of peripheral arterial disease

A

Diseases: diabetes, coronary artery disease, previous stroke

Non-modifiable: age, gender, ethnicity, FH

modifiable: smoking, HT, HLD, diabetes, obesity

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15
Q

Atherosclerosis tends to form at ___

A

branch points (points proximal to bifurcations), bends & tethered segments

*aortoiliac, femoropopliteal, tibial-peroneal segments

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16
Q

What is Buerger’s disease known as? Main treatment?

A

Thromboangiitis obliterans
- inflammatory vasculopathy, non-atherosclerotic

main treatment is smoking cessation

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17
Q

What is Leriche syndrome

A

Occlusion at bifurcation of terminal aorta into common iliac arteries

Pts present with buttock, hip claudication, erectile dysfunction (impotence) Reduced/absent femoral & distal pulses

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18
Q

Tibial-peroneal occlusive disease presents a higher risk of ____ than femoropoliteal occlusive disease due to ___

A

chronic limb threatening ischemia

lack of collateral blood flow to the foot

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19
Q

Tibial-peroneal occlusive disease patients have absent ___, lack of ___, and ___

A

dorsalis pedis & posterior tibial pulse

leg hair

shiny skin

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20
Q

Characteristic description of neurogenic vs vascular claudication

A

neurogenic - pain from “park bench to park bench” (sitting down relieves pain

vascular - pain from “shop window to shop window” (does not have to sit, not walking will relieve pain)

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21
Q

Risk factors for peripheral artery disease

A

Smoking/ex-smoker
Diabetes
HTN, HLD
Hyperhomocysteinemia
Family history of AAA

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22
Q

What is wet gangrene?

A

Infected gangrene - blistering, bacterial infection & putrefaction occurs.

Emergency surgical debridement or amputation required

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23
Q

What is diabetic dermopathy?

A

Atrophic hyperpigmented skin, usually on shin

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24
Q

What do you inspect for when examining PAD patient?

A
  • colour of skin
  • trophic changes (loss of hair, thickening of nails, skin dry)
  • loss of digits/foot
  • presence of ulcers
  • presence of gangrene
  • diabetic skin changes/joint deformities
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25
Landmark of LL pulses
1) DP: 1/3 way down a line joining midpoint of two malleoli to 1st webspace 2) PT: 1/3 way between medial malleolus and heel 3) Popliteal: patient knee bent, press against superior part of tibia at popliteal fossa
26
How to perform Buerger's test
1) Pt lie down. Lift leg straight up until toes turn white 2) Angle at which toes turned white is the Buerger's angle. Less than 20deg = chronic ischemia 3) Drop patient leg over edge of bed. Should have reactive hyperemia (foot turns purple red)
27
What clinical classifications are used for Lower Extremity Arterial Disease?
Rutherford (Grade 0-6) Fontaine (Stage I-IV)
28
Fontaine classification for LEAD
Stage I: asymptomatic Stage IIa: mild claudication Stage IIb: moderate to severe claudication (<200m walk) Stage III: ischaemic rest pain Stage IV: ulceration/gangrene
29
How to measure ABPI
Brachial pressure: higher arm systolic pressure (either left or right) Ankle pressure: higher of ankle systolic pressure using DP or PT (only the leg you are trying to measure) ABPI = AP/BP
30
Interpreting values of ABPI
Normal: >0.9 Claudication: 0.5-0.9 Critical ischemic rest pain: <0.5 >1.4 = non-compressible calcified vessel (perform toe pressure index instead)
31
Normal arterial waveforms on Arterial Duplex ultrasound are ___
triphasic mono or biphasic waves are abnormal
32
What is acute limb ischemia?
Sudden decrease in limb perfusion that threatens limb viability *ischemic ulcers, gangrene, ischemic rest pain
33
Risk factors for acute limb ischemia
1. ***Arterial embolism - emboli from heart or DVT clots 2. *Acute thrombosis - thrombosis of previously stenotic artery (less severe bc collaterals form). Pts tend to have had claudication history 3. Arterial trauma 4. Dissecting aortic aneurysm
34
Quickest to slowest tissues affected by ischemia
Nerves > muscle > skin > bone so numbness comes first, then paralysis, then skin changes
35
Clinical presentation of ALI (6 Ps)
paresthesia pain pallor poikilothermia (inability to regulate temperature) pulselessness paralysis
36
Acute limb ischemia can be classified using
Rutherford criteria (Stage I-III) Stage I - viable: no immediate threat of tissue loss Stage II - threatened: salvageable if properly revascularised Stage III - non-viable: has to be amputated
37
Limbs will die after ___ during episode of ALI
6-8 hours
38
Early ___ is required in acute limb ischemia
anticoagulation with heparin prevents further clot propagation
39
How does compartment syndrome occur?
Prolonged ischemia -> delayed reperfusion causes cell membrane damage, leakage of intracellular content out into interstitium -> swelling of muscle compartments
40
What can carotid artery stenosis lead to?
amaurosis fugax (transient vision loss in one/both eyes) TIA ipsilateral ischemic stroke - hemimotor/hemisensory signs, higher cortical dysfunction
41
Carotid ___ (surgery) is indicated for ___
endarterectomy symptomatic pts with 70-99% stenosis symptomatic MALE pts with 50-69% stenosis asymptomatic with >80% stenosis
42
What is an arteriovenous access? Two types?
Abnormal connection b/w artery & vein that is surgically created. AV fistula - connecting native vein to adjacent artery (autogenous) AV graft - synthetic or biologic grafts
43
When is AV fistula/graft needed?
Pts with impending/established renal failure requiring chronic haemodialysis
44
Types of AV fistula
Brescia-Cimino: cephalic vein + brachial artery Gratz: cephalic vein + radial artery
45
AV grafts have higher risk of ____ than AV fistulas
thrombosis - 10x risk
46
Difference between aneurysm & pseudoaneurysm
Aneurysm - intact attenuated vessel where wall is formed by 3 normal elements: intima, media, adventitia Pseudo - breach to arterial wall, blood accumulates between media and adventitia
47
True aneurysms can be ___ or ___
saccular: only part of circumference fusiform: circumferential dilatation
48
Berry aneurysms occur at ___. Increased incidence in ____.
junction of vessels at Circle of Willis HTN, PCKD, Ehlers-Danlos Syndrome
49
What can cause a false aneurysm?
Iatrogenic - needle, endovascular procedures Trauma
50
Dissecting aneurysm caused by
intimal tear -> blood flows into media -> forces intima and adventitia apart -> formation of a false lumen blood will flow back into the true lumen distally OR ruptures externally
51
What are charcot-bouchard aneurysms?
Microaneurysms that occur at basal ganglia, cerebellum, pons, thalamus Can cause intracerebral haemorrhage
52
Most common aneurysm complication above and below inguinal ligament
above: rupture below: thrombosis & embolism
53
Abdominal aorta bifurcates at __
L4 trachea: T4 common carotid: C4
54
Risk factors for aortic dissection
HTN Age (60-70) Gender (male) Collagen conditions - Marfan's, Ehlers Danlos Pregnancy
55
Which part of the aorta most at risk of dissection?
Ascending and proximal descending Subjected to high pressure blood flow on aortic wall
56
S___ classification of aortic dissection
Stanford Stanford A: involves ascending aorta Stanford B: does not involve ascending aorta
57
D___ classification of aortic dissection
Debakey Type I: involves ascending, arch and descending aorta Type II: involves ascending aorta only Type IIIa: involves descending only, confined to thoracic Type IIIb: involves descending, all the way to abdominal aorta
58
Differential diagnosis for aortic dissection
Heart: myocardial infarction, pericarditis, Aortic aneurysm w/o dissection Respi: pulmonary embolism GIT: acute pancreatitis, GERD, perforated ulcer, PUD
59
Gold standard for diagnosing aortic dissection is ___
CT aortogram
60
Abdominal aortic aneurysm is when abdominal aorta is ___ larger than normal
50% normal: 2cm AAA: >= 3cm
61
Risk factors for AAA
Modifiable: smoking, HTN, HLD Non-modifiable: age, gender (M), connective tissue disorders, family history
62
AAA masses are ___ - fingers are pushed ___ when palpating
expansile upwards & outwards (contracts and expands) vs pulsatile (only transmits pulse)
63
AAA commonly develops (where)___. Should check for concomitant ___ or ___ aneurysm.
below renal arteries femoral/popliteal aneurysm
64
Pts at higher risk for AAA rupture
female COPD saccular aneurysms rapid rate of enlargement
65
Indications for asymptomatic AAA surgery
aneurysm >= 5.5cm increased diameter >5mm/6 months Saccular aneurysm
66
AAA tends to rupture ___ into the ___
posterolaterally retroperitoneal space
67
What is permissive hypotension
maintain systolic BP just high enough to maintain clinically alert patient & sufficient end organ perfusion But not normal BP so can reduce bleeding
68
Two superficial veins of the leg
great and small saphenous vein
69
Course of the great saphenous vein
Medial side of the dorsum -> in front of medial malleolus -> medial side of leg -> posterior leg -> medial thigh -> pierces cribiform fascia at saphenofemoral junction, empty into femoral vein (2.5cm inferolateral to pubic tubercle)
70
What veins join tgt at the saphenofemoral junction?(4)
Great saphenous vein superficial epigastric vein superficial circumflex iliac vein superficial external pudendal vein
71
Course of small saphenous vein
lateral dorsum -> posterior to lateral malleolus -> midline of calf -> pierces deep fascia over popliteal fossa -> empty into popliteal vein
72
How does blood get pushed up the veins of the leg?
1) Calf muscle contraction pushes venous sinuses -> squeeze blood into popliteal vein 2) Intramuscular deep veins open during calf relaxation, pulls blood in from superficial veins through communicating veins 3) Valves in communicating and deep veins prevent backflow of blood into superficial veins
73
Locations of communicating veins
SFJ mid-thigh (Hunterian perforator) distal thigh (Dodd's) below knee (Boyd's) 5,10,15cm above medial malleolus (cockett)
74
Chronic venous insufficiency can result from venous hypertension. Causes of VHT?
1) obstruction to flow: pelvic tumours, pregnancy, DVT 2) failure of venous valves 3) Failure of "venous pump" - inadequate muscle contraction from stroke/muscular weakness
75
What is telangiectasias
spider veins/venous stars - intradermal veins
76
What are varicosities and where do they tend to form?
Dilated, tortuous superficial veins Main tributaries of the saphenous veins - no strong coat of smooth muscle, more superficial
77
What is corona phlebectatica
network of small dilated venules beneath lateral/medial malleolus with severe venous HTN, indicates severe venous disease
78
Hallmark of CVI
pitting oedema
79
Phlegmasia ___ Dolens - caused by ___ Phlegmasia ___ Dolens - caused by ___
Alba - obliterated major deep venous channel (DVT) with sparing of collateral veins. Painful, pitting oedema, blanching (white appearance) Cerulea - obliterated major deep venous channels + collateral veins. Painful, oedema, cyanotic, arterial insufficiency, venous gangrene (blue appearance)
80
What is atrophie blanche?
avascular fibrotic scars (ivory white area with hyperpigmented borders) prone to venous ulcers
81
What is lipodermatosclerosis
Fibrosing area of subcutaneous tissue - firm area of tender, indurated, hyperpigmented skin from severe venous HTN. starts at gaiter region and wraps circumferentially around leg causes "inverted champagne bottle" appearance
82
Characteristics of venous ulcer
Occurs at gaiter region sloping edges, shallow, flat, moist base may be sloughy/granulating
83
CVI is classified by ___
CEAP Characteristic Etiology - congenital, secondary, primary Anatomy - deep, superficial, perforator Pathophysiology - reflux, obstruction, both
84
Risk factors for varicose veins
Age Obesity, parity occupation - long standing posture - crossing legs increased abdominal pressure pelvic tumour family history
85
what is thrombophlebitis
inflammation of wall of a vein with associated thrombosis
86
Symptoms of varicose veins
nonspecific pain, tingling, burning, muscle cramps itchy skin, swelling worsens throughout course of the day, relieved with compression stockings or elevating legs
87
What is a saphena varix
compressible lump at the inguinal region that refills when released
88
landmark of saphenofemoral junction
2.5cm inferolateral to pubic tubercle
89
Investigations for PAD
ABPI TBI (<0.7 abnormal) Arterial duplex ultrasound Transcutaneous oxygen pressure Angiogram
90
What is angiogram with digital subtraction?
Images of underlying bone removed to better visualise arteries Gold standard for evaluating arterial tree prior to revascularisation

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