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61 Cards in this Set

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PVD (LL Arterial) - Risk factors for atherosclerosis?
Major Risk Factors:
1) Smoking
2) DM
3) HTN
4) FHx IHD/CVA
5) Hypercholersterolemia / hLipidemia

Minor:
1) Obesity
2) Sedentery lifestyle
3) Hyperhomocysteinemia
Non Modifiable:
- Age
- Sex (men, older women)
- FHx
PVD (LL Arterial) - Lower limb occlusive disease - Presentation
1) Asymptomatic
2) Intermittent claudication
3) Rest pain (critical limb ischaemia)
4) Acute occlusion
PVD (LL Arterial) - Common Sites of occlusive disease on LL
1) Superficial femoral artery (SFA)
2) Aorto-iliac region
3) Popliteal artery
1) Superficial femoral artery (SFA)
- 15cm below inguinal ligament
- Calf pain

2) Aorto-iliac region
- Buttock, thigh, calf pain

3) Popliteal artery
PVD (LL Arterial) - Difference between intermittent claudication and rest pain?
Intermittend Claudication:

WHAT? Cramp like pain
WHERE? SFA (=calf pain), iliac A (butt, thigh, calf)
WHEN? On ambulation
WHAT RELIEVES? Rest

OTHER: Claudication distance is usually constant
DDx: Neurogenic claudication, sciatica, OA
PROGNOSIS: 5% Limb loss @ 5y
Rest pain (critical limb ischaemia)

WHAT? Pain at rest
WHERE? Foot, toes
WHEN? At night, at rest
WHAT RELIEVES? Hanging foot over side of bed, standing/walking

OTHER: Ulceration and gangrene may be present
PROGNOSIS: Indicates imminent loss of limb (50%+ amputation)
PVD (LL Arterial) - Lower Limb Ischaemia - O/E
Look:
1) Skin Atrophy
2) Allopecia
3) Onycholysis
4) Muscle Atrophy
5) Ulceration (toes/feet)
6) Venous guttering

Feel:
1) Cool skin
2) Capillary refill >3s
3) Peripheral pulses reduced/absent
4) Buerger's sign

Listen:
- Auscultate main vessels: Systolic bruit indicates stenosis
Buerger's sign - eleveation of leg causes pallor

Affected limb regains color more slowly, followed by rubur due to reactive hyperaemia
PVD (LL Arterial) - Lower Limb Ischaemia - Types of Gangrene
1) Gangrene - necrosis due to compromised blood supply
2) Dry gangrene: dry necrosis w/o infection (mummified)
3) Wet gangrene: moist necrotic tissue w/ infection
PVD (LL Arterial) - Lower Limb Ischaemia - Features of Gangrene
- Well demarcated
- Patch to entire limb
- Gangrene = soft & boggy dead tissue w/ pus @ line of demarcation
- Starts distally on toes and extends proximally
- Senseless and painless
PVD (LL Arterial) - Lower Limb Ischaemia - Ulceration
- Begins in a pressure area on foot
- Dead tissue is present
- Granulation tissue absent
PVD (LL Arterial) - Lower Limb Ischaemia - Ix
Assess extent of PVD:

1) ABI - SBP ankle:brachial (N=>1, 0.6-0.9=claudication, 0.3-0.6=rest pain)

2) Duplex USS

3) DSA - gold standard but invasive (contrast digital subtraction angiography)

Look for a cause:

4) FBC, U&E, lipids, glucose, syphilis
PVD (LL Arterial) - Lower Limb Ischaemia - Performing a DSA - Checklist?
1) Allergies to contrast?
2) Medications?
3) Coagulopathies? Correct w/ FFP

4) Peripheral pulses - check and document
5) Baseline studies - PT, aPTT, U&E, FBC
6) Withhold aspirin, warfarin, metformin
PVD (LL Arterial) - Lower Limb Ischaemia - Performing a DSA - Pre, intra, post-procedure?
Pre:
1) Shave and prep groin
2) Clear liquids 8h
3) IV fluids

Intra:
1) Seldinger technique via femoral or brachial artery
Cannula > Guide wire > Catheter

Post:
1) Supine
2) Compress wound
3) Distal pulses check
PVD (LL Arterial) - Lower Limb Ischaemia - Performing a DSA - Complications
Contrast:
1) Anaphylaxis
2) Nephrotoxicity

Vascular access:
1) Bleeding
2) Infection
3) Thromboembolic event
4) AV fistula
5) Perforation
6) Nerve damage
7) Pseudoaneurysm
8) Dissection

Tx: Surgery, or amputate
PVD (LL Arterial) - Lower Limb Ischaemia - Mx
Conservative("PACE"):

1) Pentoxifylline (-- blood viscosity)
2) Aspirin
3) Cessation of smoking
4) Exercise

Surgical:

1) Angioplasty - balloon +/- stent
2) Endarterectomy - intima and media 'cored out'
3) Bypass graft - Fem-Pop; Fem-distal (peroneal, ant tib, post tib) ** Note Fem=SFA
Acute limb ischaemia - 5 causes
Intraluminal
- Atheroma
- Thrombus
- Embolis (AF, MI, IE)

Vessel wall:
- Aneurysm, intimal dissection, AV fistula

Extraluminal:
- Compartment syndrome
- Tumour
1) Embolization (AF, MI, endocarditis)
2) Thrombosis
3) Atheromatous lesion
4) Aneurysm (aorta, femoral, popliteal)
4) Vascular trauma
5) Compartment syndrome; fracture, circumferential burns
Acute Limb Ischaemia - Clinical features
P's:
1 (Look)) Pallor
2 (Feel)) Perishing cold
3 (Feel)) Parasthesia
4 (Feel)) Pulse decreased/absent
5 (Feel)) Perishing cold
6 (Move)) Paralysis
Acute Limb Ischaemia - Ix
1) Angiogram
2) ECG
3) USS
Acute Limb Ischaemia - Emergency Mx
1) Heparin bolus + infusion
2) Embolectomy / thrombolysis
<4-6 hours, otherwise irreversible tissue damage = amputation

1) Anticoagulate w/ IV heparin - Bolus followed by constant infusion (prevents further thrombosis)

Definitive Mx:
1) Surgical embolectomy (fogarty baloon catheter)
2) Thrombolysis (tPA)
Draw the Lower Limb Venous System
What is the lesion? Describe it
Venous Ulcer

Site: Gaiter of leg?
Size: 10mm?
Shape: round
Edge: Sloping with new epithelium
Base: Clear and pink (granulation tissue)
Surrounding tissue: normal
Leg Ulcers - Types and their locations
Arterial - Dorsum of foot, tips of toes, lateral malleolus
Venous - Gaiter area, medial side
Neuropathic - Weight bearing areas (plantar)
Neoplastic - Sun exposed areas
Leg Ulcers - Edge characteristics
Punched out - arterial (indicates rapid death and minimal healing)
Everted - SCC (rapid growth, carcinoma)
Rolled - BCC (slow growth, ROdent)
Sloping - Venous (indicates healing)
Leg Ulcers - Describing
1) Site (eg. gaiter=venous)
2) Size, shape, color & tenderness
3) Edge
4) Base/floor
5) Depth
6) Discharge
7) Surrounding skin
8) Regional lymph nodes
1) Site (eg. gaiter=venous)
2) Size, shape, color & tenderness
3) Edge (eg. punched out=arterial)
4) Base/floor
- Ischaemic = dry or necrotic eschar
- Venous - superficial w/ fibrinous exudate & ooze
- Color: Black=necrosis, yellow=sloguh, red=granulation, pink=epithelium
5) Depth (mm, structures involved)
6) Discharge (quantity, type=serous, sanguinous, purulent)
7) Surrounding skin (color, pulses, previous ulcers)
8) Regional lymph nodes (enlargement due to infection or neoplasia)
Leg Ulcers - Causes
1) Venous (75%)
2) Arterial
3) Neuropathic
4) Traumatic
5) Neoplastic
6) Hematological
7) Infective
8) Misc (pyoderma gangrenosum, insect bites)
1) Venous (75%) - varicose veins, post-thrombophelbitis

2) Arterial - Ischaemic (DM, therosclerosis, embolism); Vasculitic (Buerger's disease)

3) Neuropathic - DM, EtOH, spinal cord lesion

4) Traumatic - Pressure sores (decubitius)

5) Neoplastic - SCC, BCC, melanoma, Kaposi's sarcoma

6) Hematological -spherocytosis, sickle cell

7) Infective - Mycobacterial, post-cellulitis, chronic infected isius

8) Misc (pyoderma gangrenosum, insect bites)
Leg Ulcers - Hx
- Onset and duration
- Evolution?
- Suspected cause?
- Pain - ischaemic=painful, venous=some pain, neuropathic=painless
- Bleeding/discharge
- PHx:
Venous=DVT,PE,varicose veins,previous surgery
Arterial=Intermittent claudication,rest pain,CVD
Other:DM, RA, Vasculitis, IBD, chronic skin ulcers
Medications: B-Blockers,ergotamine,corticosteroids,NSAID
SHx - Smoking, EtOH
Venous vs Arterial vs Neuropathic vs Pressure Ulcers

Hx
Venous: Chronic

Ischaemic: Intermittent claudication, rest pain, IHD, CVD

Neuropathic: DM, EtOH

Pressure: Bed bound, immobilized
Venous vs Arterial vs Neuropathic vs Pressure Ulcers

Site
Venous: Medial side, gaiter area

Arterial: Dorsum of foot, toes, lateral malleolus

Neuropathic: Weight bearing areas (plantar)

Pressure Sores: Bony prominences - heels, malleoli, sacrum, hips
Venous vs Arterial vs Neuropathic vs Pressure Ulcers

Pain
Venous: Nil to mild

Arterial: Very painful

Neuropathic: Painless

Pressure: Painful
Venous vs Arterial vs Neuropathic vs Pressure Ulcers

Ulcer features
Venous: Depth=superficial; Edge=sloping; Base=granulation; Discharge=Seropurulent; Healing=some

Arterial: Depth=deep; Edge=punched out; Base=grey-yellow slough,dry; Healing=none

Neuropathic: Depth=Deep, Edge=Punched out, Base=infected

Pressure: Necrotic slough and granulation
Venous vs Arterial vs Neuropathic vs Pressure Ulcers

Rest of limb
Sensation/Pulses/Temp/Oedema

Venous: Present / Normal / Hot & tender / Present

Arterial: Painful / -- ABI / Cold / Absent

Neuropathic: Absent / Bounding / Warm / Absent

Pressure: Variable
Venous vs Arterial vs Neuropathic vs Pressure Ulcers

Other features
Venous: Varicose veins, lipodermatosclerosis, stasis eczema, atrophie blanch

Arterial: Allopecia, atrophy of skin, onycholysis

Neuropathic: Charcot's joints, high arch & clawing of toes

Pressure: Erythema at pressure site
Diabetic Foot

Aetiology and Pathogenesis
"DAMN"
Diabetes
Atherosclerosis
Microangiopathy
Neuropathy

Peripheral neuropathy >> lack of sensation >> trauma to MT and heels >> ischaemia >> pressure ulceration >> angiopathy + infection >> impaired healing
"DAMN"
Diabetes = Glucose ++ infection
Atherosclerosis = Vessel occlusion
Microangiopathy = Thickening of BM in arterioles and caps
Neuropathy = Sensory, motor, autonomic
Diabetic Foot

Sequelae
Gangrene
Infection
Ulceration
Deformity - Charcot joints
Diabetic Foot

Vs Ischaemic
DVT

Risk Factors
Surgery
Travel
OCP
Hypercoagulable state
Immobility
Malignancy
Prior DVT/PE
Thrombophilia
Major medical illness
Age >60y
DVT

Prevention
Cease OCP
Early mobilization post-op
Aspirin for 3/52
Mechanical support (TED, GCS)
Elevate foot

Anti-coagulants:
- SC Heparin 2hrs pre-op, 7-10d post
- High MW: 5000U BD: INR 2-3
- Low MW: enoxaprin 20mg/OD SC
- Warfarin
DVT

Clinical Features
1) Homan's Sign
2) Calf tenderness
3) Warmth and erythema
4) Swelling of calf and leg
5) Venous distension (superficial)
6) Fever & tachycardia
7) Chest signs: PE / MI
DVT

How can heparin be administered? What to monitor?
Administration:
- IV or SC
- Unfractionated (heparin) or LMW (enoxaparin)

- Monitor aPTT (intrinsic pathway) for unfractionated heparin
DVT

Unfractionated Heparin
- 5000-10000U IV lodaing dose
- Continuous infusion @ 1000-2000U/hr

- monitor APTT (target 1.5-2.5x normal)

- Duration: 5-10d

- Contraindications: pregnancy, PUD

- Complications: haemorrhage
DVT

LMW Heparin (enoxaprin, SC)
- 1 mg/kg BD for >5d

- No need for monitoring
Varicose Veins

O/E.Inspection
Look:

- Visible superficial veins (not site, size, course)
- Medial = great saphenous vein
- Posterior calf = short saphenous vein
- Oedema
- Venous stasis signs: induration, pigmentation, eczema & ulceration
Varicose Veins

O/E.Palpation
- Harvey's Test
- Cough impulse at sapheno-femora & sapheno-popliteal junctions; pulse=incompetent SC valves
- Pitting oedema, thickening/tenderness of SC tissues
- Tourniquet test
- Brodie-Trendelenburg test
- Perthe's test
- Tap test
Varicose Veins

Harvey's test
(Varicose Veins)

2 fingers on vein, slide proximal finger to empty, release distal finger to see which way the empty segment fills
Varicose Veins

Tourniquet test
(Varicose Veins)

1) Pt supine, elevate leg 90deg
2) Tourniquet upper 1/3 of thigh
3) Stand pt. If superficial veins above tourniquet RAPID fill = incompetent communicating vein.
4) Move vein distally to locate incompetent valve
Varicose Veins

Brodie-Trendelenburg test (Tap test)
(Varicose veins)
- Compress distal segment
- Pulse proximal segment
- If pulse felt distally = POSITIVE
Varicose Veins

O/E.Auscultation
- AV fistulae @ varicose veins produce bruits
Varicose Veins

Pathophysiology
- Superficial to deep
- Pressure of superficial > deep
- Calf pump
- Incompetent perforator valves = engorged and dilated superficial veins
- Blood flows superficial to deep
- When calf relaxed: Superficial pressure > Deep pressure
- When calf contracted: Blood transmitted PROXIMALLY
- Valves prevent retrograde flow
- Incompetent PERFORATOR veins cause muscle pump to force blood into the superficial system >> engorgement and dilation
Varicose Veins

Aetiology
- Idiopathic
- Pregnancy (hormones, ++ intrabdo pressure)
- Prolonged standing
- Pelvic mass
- AV fistula
- Thrombosis - superficial or deep
- Conginetally weak or absent valves (Klippel-Trelaunay syndrome)
Varicose Veins

Ulceration pathogenesis
- Hydrostatic pressure in superficial veins impair nutrition to SC and dermis
- Skin breakdown, ulceration, dermatitis
Varicose Veins

Ix
- Duplex USS (Gold standard)
- MR Venography
- CT
- Ambulatory venous pressures (needle measurement device)
AAA

Aetiology
1) Atherosclerosis (95%)
2) Degenerative aging
3) Congenital - Marfan's (CT disease)
4) Inflammatory / Infection (Syphillis)
5) FHx/genetic
6) ++ Collagenase/elastase activity
7) Trauma
8) Neoplastic
9) Metabolic / endocrine
10) Dissection
Atherosclerotic (95%)

Congenital:
1) Marfan's Syndrome
2) Ehlers-Danlos syndrome
3) Behcet's disease

Inflammatory
1) Mycotic - bacterial
2) Syphilitic
AAA

Ehlers-Danlos syndrome
CT disorder
AAA

Triad indicating emergency surgery for ruptured AAA
3 P's

1) Pain in the abdomen
2) Pulsatile abdominal mass
3) Pressure low (hypotension)
AAA

Mx based on sizes
- 5 cm = threshold for surgery
- Fusiform more likely to rupture than saccular
- Comorbidities: HTN, smoking, COPD
AAA

Growth rates
- <5cm = 4%/yr
- 5-7cm = 7%/yr
- >7cm = 20%/yr

- Larger aneurysms grow faster due to Laplace's law
Laplace's Law
AAA

Causes for decrease in UO post AAA repair?
Pre-renal
- Post-op ADH release
- Hypovolemia
- Hypotension
- 3rd spacing
- Pump failure: CCF, cardiogenic shock
- Bleeding

Intrarenal
- Kidney parenchyma dysfunction
- Tubular dysfunction: ATN
- Glomerular dysfunction: rhabdomyolysis (myoglobinuria)

Post-renal
- Foley catheter obstruction
- Ureteral/urethral injury
- BPH
- Bladder disfunction - iatrogenic
- Calculi
Carotid Arterial Disease

Significance of a carotid bruit?
1/3 by stenosis of carotid or vertebral arteries

1/3 radiation from aortic valve

1/3 insignificant

Other: Thyroid vessel bruits

- Bruit will not always be heard over a significant carotid stenosis
Carotid Arterial Disease

Ix
- Carotid Doppler USS
- DSA gold standard
- Angiography (risk of thrombus dislodging)
- MR angiography
- MRI/CT brain - space occupying lesion
Carotid Arterial Disease

Mx
General:
- Smoking cessation
- Control DM, hyperlipidemia, HTN
- Antiplatelet drugs

Surgical:
- Carotid endarterectomy - remove diseased intima + shunt
Carotid Arterial Disease

Indications for endarterectomy
- 70% stenosis +
- Recent TIA
- Recovered stroke
- amaurosis fugax
Carotid Arterial Disease

Complications of endarterectomy
- Bleeding (antiplatelet)
- Nerve damage; hypoglossal (CN12), facial (CN7, tongue deviates to ipsilateral side), Vagus (CN10, voice changes)
- Reperfusion syndrome
- Restenosis