Vascular - Peripheral Arterial Disease Flashcards
(104 cards)
1
Q
What is the Fontaine classification
A
Outlines the progression of chronic lower limb peripheral aa disease
2
Q
What are the 4 stages of Fontaine classification
A
1 = Asymp 2= Int claudication 3 = ischaemic rest pain 4 = ulceration/gangrene
3
Q
ABPI
A
Ankle-branchial pressure index
Used to assess aa disease
4
Q
ABPI <0.8
A
aa diseasae present
5
Q
ABPI - norm value
A
0.8-1.2
6
Q
ABPI <0.4
A
Critical limb ischaemia
7
Q
What can an ABPI >1.2 mean?
A
False _ve due to calcification
> in diabetics
8
Q
Causes of chronic peripheral aa disease (3)
A
atherosclerosis ++
Fibromuscular dysplasia
Buerger’s disease
9
Q
What is fibromuscular dysplasia
A
Non-inflammatory artery wall thickening
10
Q
What is Buerger’s disease
A
Acute inflammation + thrombsis of lower limb aa/vv
11
Q
Who gets Buerger’s disease
A
Young heavy smokers
12
Q
Buerger’s +ve:
A
Supine Position
Legs held to 45’
Pallor observed + tissue ischaemia
Then ask pt to sit up at 90’ - perfusion will gradually return
13
Q
Intermittent claudication - Sx
A
Ischaemic cramping mm pain on walking, R by rest
Mostly on calf
14
Q
If intermittent claudication felt on thigh/buttock, which aa are affected
A
Internal iliac aa
15
Q
If intermittent claudication felt on calves, which aa = affected
A
Femoral/popliteal aa
16
Q
If buttock intermittent claudication, what else must you ask about + why
A
Penile function
b/c Leriche syndrome
17
Q
Signs intermittent claudication (5)
A
Absent pulses Cold, pale legs Atrophic, hairless + shiny legs Beurgers ankle <20' Aa ulcers
18
Q
What does ischaemic rest pain indicate
A
Critical lower limb ischaemia
19
Q
Classical PS ischaemic rest pain (4)
A
At night on forefoot
Pt wakes from sleep + swings leg off bed
Hx int claudication
Signs aa insifficiency
20
Q
Ix peripheral aa disease (4)
A
Bloods incl FBC, HbA1C, lipids
ABPI
USS duplex
CT angiogram
21
Q
Mx peripheral aa disease if ABPI >0.6 (5)
A
Lifstyle - stop smoking, exercise, W loss Raise heel of shoes Footcare Optimisation of BP/DM Start clopidogrel + atorvastatin
22
Q
Mx peripheral aa disease If ABPI <0.6, highly Sx or Conservative measures have failed (3)
A
PTA
Surgical reconstruction
Or amputation
23
Q
What is PTA
A
Percutaneous transluminal angioplasty
Balloon in narrow segment
24
Q
Why can diabetics present differently w/ peripheral aa neuropathy?
A
Due to presence of peripheral neuropathy
25
What are the 3 main effects of peripheral neuropathy in diabetic aa disease
Sensory neuropathy
Autonomic neuropathy
Motor neuropathy
26
Consequences of Sensory neuropathy in DM peripheral aa disease
Reduces protective reactions to minor injury
| Reduces awareness of Sx infection/ischaemia
27
Consequences of Autonomic neuropathy in DM peripheral aa diseasse
Lack of sweating --> dry, fissured skin --> entry of bacteria
28
Consequences of motor neuropathy in DM peripheral aa disease
wasting of small mm of foot --> loss of arches + development of abnormal P areas in feet
29
Sx of peripheral neuropathy UNACCOMPANIED by aa disease
Stabbing pain in feet
Red + warm w/ strong pulses
Unlikely to be relieved by swinging foot over bed
+/- hyperalgesia + allodynia
30
What is DM w/ critical limb ischaemic likely to present with?
Ulceration
31
What can Ulcers in DM + critical limb ischaemia rapidly progress to?
Gangrene
32
What is Gangrene?
Dead tissue, normally colonised by bacteria
33
Wet gangrene
Infected w/ proliferating organisms
34
Dry gangrene
Colonized but organisms aren't proliferating
35
Why does int claudication occur `
At rest O2 requirement of mm is met by collateral system of profunda femoris
Exercise prdouces a demand that can't be met + mm becomes ischaemic
36
DDx intermittent claudication (5)
```
Spinal stenosis
Venous claudication
MSK (OA/RA)
Peripheral neuropathy
Popliteal aa entrapment
```
37
How is spinal stenosis different to intermittent claudication? (3)
Pain = relieved by sitting down or flexing spine rather than standing still
+ Assoc w/ numbness+ tingling
Pulses = present
38
How is venous claudication different to intermittent claudication (4)
```
Starts as soon as walking starts
Affects whole leg
Bursting in nature
elevate to relieve pain
+ signs vv disease + Hx DVT
```
39
What % of leg ulcers are venous?
85%
40
Vv ulcer - Hx of
DVT
Varicosities
Obesity
41
Do you get pain in vv ulcers?
Rarely
42
Site of vv ulcers
Medial malleolus + gaiter area
43
Ulcer appearance vv ulcer
Shallow w/ flat margin
| + signs vv insufficiency, red + warm
44
Mx of ulcers - if ABPI >0.8 + signs vv disease
4 layer compression bandaging
Leg elevation
Once healed --> LT stockings
45
Mx ulcers if ABPI <0.8
Rx to GP for CV risk mod
Rx to vascular
Tx w/ surgery if necess
46
Sx - chronic small bowel ischaemia (4)
Severe post-prandial colic
PR bleeding
W loss
Malabsorption
47
Ix chronic small bowel ischaemia
Angiography
48
Mx chronic small bowel ischaemia
Angioplasty
49
PS large bowel ischaemia (5)
```
L sided abdo pain
Bloody diarrhoea
Pyrexia
Tachycardia
Leukocytosis
```
50
What can large bowel ischaemia progress into?
Gangrenous colitis, peritonitis + shock
51
Ix large bowel ischaemia
AXR/ Ba enema - thumb printing
| MR angiography = diagnostic
52
Mx large bowel ischaemia
Fl + Abx
| PTA + stenting if severe
53
What is the majority of renal aa stenosis due to?
Atherosclerosis
54
PS RAS (4)
Resistant HTN
Worsening RF after ACEi
Sudden onset pulm oedema
Renal bruits
55
Ix RAS (3)
Renal USS
CT/MRI angiography
Renal angiography = GOLD STANDARD
56
What is seen on USS in RAS
Small kidney
57
Medical Tx RAS (3)
ACEi
Statins
Antiplatelets
58
Surgical Mx RAS (2)
Angioplasty + stenting
59
Conservative Mx of aa occlusive disease (3)
RF Mx
Low dose aspirin
Supervised exercise programmes
60
Causes of acute aa occlusion (4)
Embolus
Thrombus
Trauma
Failure of interventions e.g. stent
61
What is thrombosis predisposed to by?
Virchow's triad
62
Virchow's triad
Endothelial dysfunction
Changes in blood flow
Changes in blood coagulability
63
What is an embolic occlusion?
Occlusion of vessel by a mass of material transported in bloodstream
64
Where do thromboemboli arise from? (4)
LA in AF
LV post MI
Heart valves in endocarditis
Or mural thrombi in AAA
65
Classic Sx acutely ischaemic limb
```
6Ps
Pulseless
Painlful
Pallor
Perishingly cold
Paralysis
Paraesthesia
```
66
What indicates a non-viable limb?
Fixed staining of leg
| Rigid mm
67
What is the max amount of time a Dr has to re-establish flow in an acutely ischaemic limb
6hrs
68
Mx acutely ischaemic limb
```
WITHIN 6hrs
A-E + Resus
IV heparin ASAP
If no blood supply --> surgery
Urgent CT angiogram
```
69
Mx acutely ischaemic limb - embolus Mx
Open embolectomy + Fogarty catheter
70
Mx acutely ischaemic limb - thrombosis Mx
Thrombolysis
| Interval angioplasty to Tx underlying disease
71
What must be observed post op after Mx of acutely ischaemic limb
Reperfusion injury
72
What is a reperfusion injury?
Inflammation + oxidative damage when blood flow is restored to tissue after a long period of anoxia
73
What can reperfusion injury to lead to?
Compartment syndrome
74
Embolus occlusion - onset
V sudden, v severe b/c lack of collaterals
75
Thrombosis occlusion - onset
Insidious onset, < severe Sx as advanced collaterals
76
Embolus occlusion - pulses
Prev normal
| Normal collateral pulses
77
Thrombus occlusion - pulses
Long standing decreased pulses bilaterally
78
Mx of transection
Apply P
| If signif ischaemia --> grafting
79
When Mx transection, do you reapir the aa or vv first and why
VV
| BEcause need to allow vv drainage
80
What is an A-V fistula?
Acquired communication between aa and vv
81
Causes AV fistula (3)
Penetrating trauma
Erosion of aneurysm into vv
Haemodialysis
82
What happens to peripheral vv pressure in AV fistula
Increases
83
Consequence change to peripheral vv pressure in AV fistula (3)
Swelling
Varicosities
Leg ulceration
84
What happens to peripheral aa pressure in AV fistula
Decreases
85
Consequence of change to peripheral aa P in AV fistula
Decrease in stroke volume
| --> LV dilation + failure
86
Sx non-iatrogenic AV fistulae (5)
```
Limb heaviness
Relieved on elevation
Pain
Oedema + prominent vv
Audible murmur /thrill
```
87
Ix AV fistula (2)
Duplex USS
| Contrast CT
88
Reynaud's phenomenon
Episodic digital vasospasm in the absence of an identifiable assoc disorder
89
Reynaud's syndrome
Reynauds occuring 2' to another condition
90
2' conditions causing Reynaud's syndrome (6)
```
CT: systemic sclerosis, mixed CT disease, SLE, Sjogren's, polyarteritis nodosa
Macrovascular disease
Occupational trauma
Dx
Malignancy
AF
```
91
Drugs causing Reynaud's syndrome (2)
B-blockers
| Cytotoxic Dx
92
Triggers Reynaud's (2)
COld exposure
| Emotional stress
93
What are the 3 phases of Reynaud's
Pallor (b/c digital aa spasm)
Cyanosis (b/c accum deoxy blood)
Rubor (erythema b/c reactive hyperaemia)
94
How long do Reynaud's attacks last
Usually <45mins
95
Features of Reynaud's suggesting a 2' cause (4)
Dilated nail fold capillary loops
If PS early childhood or >30
Asymmetrical
Male
96
Ix Reynaud's (6)
```
FBC
U+E
Coag
Glucose
TFT
ANA/RF/APA
```
97
Mx Reynauds (4)
Keep warm
Stop smoking + exacc Dx
Nifedipine
Sympathectomy (severe)
98
What is the thoracic outet
Space between the 1st rib + clavicle
99
What structures pass through the thoracic outlet? (3)
SCA
SCV
Brachial plexus
100
What is thoracic outlet syndrome
Narrowing of thoracic outlet
101
Causes thoracic outlet syndrome (3)
Cervical rib
healed clavicular #
XS mm development
102
PS thoracic outlet syndrome
T1 - wasting mm hand, paraesthesia inner forearm + hand
| Aa Sx - upper limb claudication, post-stenotic dilatation --> thrombosis
103
O/E thoracic outlet syndrome
BP is lower in affected arm
104
Ix thoracic outlet sydrome (2)
Ateriography
| XR
