Arterial Disease- Peripheral And Extracranial

Front 1

Prognosis of mild chronic limb ischemia

Back 1

limb loss risk low <10% amputation in 10 years
5%/year mortality from associated medical comorbidities - often coronary events
worse in claudicants with diabetes who continue to smoke

Front 2

Risk of limb loss and mortality in patients with rest pain/arterial ulcers?

Back 2

30% 3m amp
10%/year mort
if untreated

Front 3

What do you suspect if a popliteal pulse is promenant and easy to feel?

Back 3

popliteal aneurism

Front 4

Most common patterns of arterial disease affecting the lower limb?

Back 4

60% sup fem aa- esp lower end as it passes through the adductor hiatus into the popliteal fossa
30% aorto iliac: lower aorta + common iliac/external iliac + common femoral + profunda femoris
10% combined: DM fem + tibia

Front 5

l`What is Le Riche syndrome?

Back 5

Severe aortoilic disease- buttock and thigh claudication + impotence

Front 6

What ABI is associated with:
intermittent claudication
rest pain
gangrene

Back 6

Normal range >0..95
Intermittent claudication: 0.9-0.4
Rest pain: 0.4-0.15
Gangrene <0.15
Less reliable in DM/CRF as arterial walls may be calcified and non compressable by the blood pressure cuff- resulting in falsely elevated ABI determinants

Front 7

When is angiography used in chronic PVD?

Back 7

After ultrasound on 'intention to treat' basis

Front 8

Success of endovascular procedures in managing PVD?

Back 8

2% major complications
Iliac arteries- 90% success and well-maintained over a period of 5 years
Sup. femoral- worse results, stenting is used

Front 9

Operative mortality of fem-pop bypass?

Back 9

Mortality: 1-2%
5 year patency 50-70%
Best result when autogenous vein used as graft material

Front 10

Operative mortality of aortofemoral bypass?

Back 10

2-5%
5 year patency 80%
Op now infrequently performed as comparable results and lower morbidity of endovascular methods

Front 11

When does restenosis after surgery/bypass occur?

Back 11

In the first 18 months
Usually due to neointimal hyperplasia
Can be detected by ABI/ultrasound

Front 12

Vascular disease patterns in patients with diabetes?

Back 12

calcification of the tibial arteries- esp. in ppl who smoke

Front 13

What does motor neuropathy in diabetics cause?

Back 13

paralysis and atrophy of the small muscles of the foot- produces clawing of the toes with neuropathic ulceration under the metatarsal heads

Front 14

When is the survival of the limb considered threatened in acute limb ischemia?

Back 14

If there is loss of sensation and muscle tenderness/weakness

Front 15

Management of acute limb ischemia?

Back 15

Very high morbidity and mortality: 30% limb loss and 10-20% mortality (majority of deaths due to cardiopulmonary complications)
1. IV heparin infusion
2. If extremity considered threatened- emergent surgical revascularisation (embolectomy with intra-op arteriogran), start oral anticoagulation
2. If viable extremity: consider intra-arterial thrombolysis (30% success)- avoid surgery

Front 16

What is thoracic outlet syndrome?

Back 16

compression of the subclavian artery, vrin and T1 nerve root by cervial ribs/hypertrophic musculature
rx: removal of the first rib, usually by transaxillary approach

Front 17

Difference between complete arterial transsection and partial?

Back 17

With complete: vasospasm occurs and it will stop bleeding
With partial- arterial contraction cannor occur so bleeding can be profuse while the distal pulses remain present

Front 18

What are the clinical signs of vascular injury?

Back 18

pulsatile bleeding, signs of distal ischemia, expanding haematoma, thrill or bruit overlying site

Front 19

Systemic features of reperfusion syndrome?

Back 19

hyperkalemia, myoglobinuria
can result in sudden death, ARDS, cardiac or renal failure

Front 20

Outcome of stroke in australia?

Back 20

1/3 fatal, 1/3 major disability
Commonest cause of death after heart disease and cancer
10% of all mortality in the australian community
50% >75

Front 21

Can the circle of willis compensate for an occluded carotid artery?

Back 21

cannot fully compensate in 20% of individuals

Front 22

What % of strokes are ischaemia/haemorrhagic?

Back 22

70% ischemic (75% atherosclerosis, 15% embolism, 10% small vessel occlusion)
15% haemorrhagic (11% intracranial, 4% SAH)

Front 23

What is the most common pathology of extracranial arterial disease?

Back 23

90% atherosclerosis
10% other: fibromuscular disease, takayasu 'pulseless disease', carotid body tumours (rare, arise from chemoreceptors, highly vascular and occasionally malignant)

Front 24

Who gets fibromuscular dysplasia?

Back 24

young females- irregular webs and dilatations
string of beans signs on angiography
dissection/aneurism

Front 25

Is subclavian steal usually symptomatic?

Back 25

no, usually asymptomatic unless there is co-existent internal carotid stenosis
occurs on the LHS

Front 26

Is carotid bruit a good marker for carotid stenosis?
Why?

Back 26

A poor marker- more indicative of general atherosclerotic disease
1/3 with bruit--> sig stenosis
>90% stenosis: no bruit

Front 27

What can be seen on fundoscopy in amaeurosis fugax?

Back 27

Cholesterol emboli (Hollenhurst plaques) and fibrin-platelet emboli (Fisher plaques)

Front 28

What is a stokes adams attack?

Back 28

Syncope associated with bradycardia
Can be caused by complete heart block or by vertebrobasillar TIA

Front 29

When is carotid angiography used in the diagnosis of carotid stenosis

Back 29

Used if ultrasound findings are uncertain or if the major aortic arch branches need to be imaged in planning carotid stenting

Front 30

what % of people getting CABG have carotid stenosis as well?
How do you test or this?
Is asymptomatic carotid stenosis a risk factor for stroke in these people?

Back 30

8%

test for with duplex doppler

asymptomatic carotid stenosis is not a risk factor for stroke in these people

Front 31

When do you do carotid endarterectomy for symptomatic carotid stenosis?
(Only in centres where mortality <3%)

Back 31

70-99% stenosed, surgically accessible, life expectancy of at least 5 years, absense of significant cardiac, pulm etc. disease that will increase risk of surgery, no prior ipsilateral endarterectomy. Asymptomatic (60-99%) although NNT is greater and benefit is less), tend to do >80% in aus-not for women

50-69%: suggest medical management

Front 32

What increases risk of stroke during CABG for people with carotid stenosis?

Back 32

80-99% stenosed
bilateral >50%
symptomatic

Above benefit from CEA before/during CABG
make sure to keep perfusion pressure >70% during surgery

Front 33

Which people get CEA before CABG and which people get CEA during CABG?

Back 33

Before: chronic stable angina in the absence of a recent MI
Combined: severe left main CAD, diffuse CAD and unstable angina

Front 34

How do you perform a carotid endarterectomy?

Back 34

expose bifurcation
heparinise
core out plaque
patch often used to close the artery to ensure a widely patent lumen and decrease the risk of restenosis
aspirin post-op
occasionally will need bypass e.g. occluded common carotid

Front 35

In which scenarios is carotid angioplasty the method of choice

Back 35

Fibromuscular dysplasia (<3% of patients)
Subclavian artery stenosis causing subclavian steal
Patients ineligible for surgery

Front 36

Complications of CEA

Back 36

2-3% risk of stroke
Labile BP --> post op ICH
hypoglossal/RLX injuiry
Stroke 26-->9% 2yrs (symptomatic)
Benefit greatest at 5 years for asymptomatic

Front 37

Pathophysiology of femoral artery aneurissm

Back 37

turbulent flow beyond fixed stenosis
systemic abnormalities in arterial walls
inflammatory role
M 30x
86% smokers

Front 38

Presentation of femoral artery aneurisms?

Back 38

local sx: 18% local pain/groin mass= only complaint
8% peripheral venous disease
42% sx peripheral arterial disease

Front 39

Indications for surgery in femoral artery aneurism?

Back 39

local sx
limb threatening complications
>2.5cm in diameter