Summary
Summary Vascular Revision Posters
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Revision posters for Vascular Diseases
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By: physician786 • 6 year ago
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Peripheral Arterial Disease (PAD)PAD: Most common cause of mortality and morbidity (stroke and MI). PAD = vascular dis
which alter structure and funcQon of aorta, its visceral arterial branches and arteries of lo
occlusive disease affecQng the aorta and all of its branches (except coronaries). Alters per
lumen of artery reduced blood flow unQl occluded. Plaque fracture - thrombus (platelets
Intermi2ent claudica4on: rupture of plaque exposes underlying matrix and releases Qssu
thrombosis over the plaque. This may result in total occlusion of the lumen with worsenin
of acute ischaemia
ManifestaQon of systemic condiQon = atherosclerosis:
• Coronary artery disease (44.6%); Cerebral artery disease (16.6%); PAD: 4.7%
• Occlusion of: Coronary artery à MI and Angina; Cerebral artery à TIAs, stroke; Legs
Hx: PVD most common in LL but occurs in upper limb, GIT, cerebral and renal vessels.
Symptoms are seen where PAD is most severe, but commonly get PAD elsewhere e.g. in b
RF: smoking, hypercholesterolaemia (F/H), HTN, DM and thrombophilia
RF for PAD: cigareOe smoking, DM, HT, hyperlipidaemia. Hypercholesterolaemia is very c
Clinical features – Limbs: Classic symptom of PVD in lower limb = intermi2ent
smaller; therefore, atherosclerosis happens faster
claudica4on; pain in muscle due to ischaemia, brought on by exercise; relieved by rest.
CLI mortality doubled even a^er 5 years. In those with CLI (rest pain or Qssue loss or gang
Cramping in nature. Most common calf (superficial femoral artery disease) or buOock
higher with 5 year survival of less of than 50%.
(aorto-iliac disease). Can vary with temp , worsening in cold. More severe going uphill
IC = intermi2ent claudica4on; mildest form of PAD. Even pt with IC are at about 3-4x incr
Differen4al diagnosis: spinal claudicaQon (pain at rest, relieved by leaning forwards -
to age- and sex-matched controls. 70% occlusion required for symptoms – disease alread
may improve going uphill) and venous claudicaQon (pain ‘bursQng’ and taking longer to
between O2 requirement and O2 delivery. ClaudicaQon/angina: pain relieved by rest, cau
go at rest). Sudden deterioraQon: urgent assessment required
(angina); Pain in calf; IntermiOent claudicaQon: depending on where occlusion determine
More severe disease: rest pain: constant pain, typically in feet, occurs at night when in
Thigh: profunda femoris; Calf: SFA; BuOock: internal iliac artery
bed (due to reduced cardiac output, thus reduced BP and peripheral vasodilaQon; all 3
Angina < Unstable angina (without exerQon) <MI
à decreased blood supply). Relieved: hanging leg out of bed/ walking; gravity increased
IC < Rest pain (leg) < gangrene/ ulceraQon
BF; hanging leg out of bed - cools it, decreases metabolism and thus req less blood flow.
MI, gangrene, ulceraQon: Qssue death
Eventually gangrene (Qssue necrosis) may supervene. Males with aorto-iliac disease
Unsalvageable limb: no revascularizaQon is indicated.
may complain of buOock claudicaQon and impotence (Leriche’s syndrome)
Clinical features - other systems: History to look for symptoms of other areas of
vascular system: Cardiac: MI, angina? GIT: Upper to central abdo cramping, with pain Rest Pain
20mins a^er large meal = mesenteric angina. Renal: Renal HTN. Cerebrovascular. Pain o^en worse at night; pain in foot (hang leg out of bed – gravity). HR reduces during s
CaroQd (anterior circulaQon): strokes, TIAs, transient blindness i.e. amaurosis fugax. night cardiac output decreases à less blood reaches limb. When pts start to get rest pain
Vertebral (posterior circulaQon): dizziness, drop aOacks, bilateral blindness, diplopia, diabeQcs will not experience rest pain due to associated diabeQc neuropathy
verQgo, problems with stance/gait, History: Does pt have arterial disease? Is it reconstrucQble? Can we improve blood flow?
Examina4on: Examine in warm room. InspecQon: limb colour: Ischaemic- white as How do symptoms affect pt?
marble (acute ischaemia)/ varying degrees of pallor, purple/blue cyanosis or red shiny RF: diabetes, cigareOe smoking, HT, hypercholesterolaemia. Drugs: anQplatelet, staQn, an
appearance (chronic ischaemia).Scars from previous vascular procedures. Male
ischaemic leg typically hairless. Vascular examina4on
Buerger’s Angle: angle to which leg raised before coming white (vascular angle): Examine peripheral pulses (require so^ vessels to feel pulse); SensaQon; Skin colour; Look
normally, leg can be raised to 90° and toes stay pink. Severe ischaemia; reduced to 15° CondiQon of the foot/leg: salvageable? Underlying osteomyeliQs? Gross infecQon?
(àpallor) Peripheral pulses: Swollen legs – hard to find pulse; May be good flow despite impalpabl
Following elevaQon, limb placed in dependent posiQon; in presence of severe become calcified and hard: Difficult to feel peripheral pulses in diabeQcs: esp in ESRF
ischaemia, purple/red colour as foot is reperfused. Hand held Doppler – uses USS – check if blood is flowing: picks up movement of blood co
Normal limb: veins full even when pt horizontal; ischaemic foot, veins collapsed and ABPI: Ankle brachial pressure index (ABPI): cuff around ankle. Heavily calcified vessels A
look like pale blue guOers in subcutaneous Qssue; gu2ering of the veins diabeQcs – give spuriously high results. Any ABPI above 1:1 should raise suspicion. Norma
Inspect pressure areas (heel, Qps of toes, ball of foot, 5th MT head) for signs of trophic arteries of body (ankle and arm pressure should be 1:1). Beyond an occlusion, pressure re
changes, ulceraQon, gangrene. Inspect between toes; PalpaQon; Skin temperature if ABPI <0.9, disease is likely to be present. ABPI also tells us the severity of the disease; 0
Capillary refilling Qme: pinch nail/pulp of toe/finger for 2s and observe how long it takes Blood pressure monitors: Squeeze artery shut by increasing pressure in cuff. Release pres
blanched area to return to pink; normal digits immediate; delay >2s indicates ischaemia Due to solidarity of artery e.g. in diabeQcs, cannot use ABPI: therefore we use arterial wa
Palpate and record all pulses (normal, weak or absent); AuscultaQon: listen along course Toe Pressures: cuff around toe: big arteries calcify first; smaller vessels later, thus can me
of major arteries for bruit (neck, abdomen, groin). Measure BP in both arms: exclude Where is the disease?
subclavian disease Duplex Scanning: non-invasive and relaQvely quick; very good for idenQfying disease in fe
ABPI measured in lower limb; gives idea of severity of PVD so good for disease in the aorto-iliac segment. Duplex USS: no radiaQon, no contrast, non
Hard to see iliacs due to gas in stomach; thus use CTA (contrast injected into vessels; nee
CT Angiography: Invasive; Needle can cause damage/ bleeding of artery; Contrast: renal f
Does pa4ent have PAD? ABPI, Waveform, Toe pressures MRA (Magne4c Resonance Angiography): fairly good at showing big vessels. MRA: doesn
Where is PAD? Duplex scanning, CTA, MRA, DSA renal impairment. MRA and CTA: do not require cannulaQon of artery; contrast used is gi
Management: Open repair or endovascular repair paQents don’t like them -are o^en intolerant to being in such enclosed space.
Digital Subtrac4on Angiography (DSA): gives v. clear images; rel easy to interpret; diagno
intervenQon (can proceed to angioplasty or stent a lesion). Invasive procedure, requires c
Aneurysms haematoma, pseudoaneurysm, arterial dissecQon, haemorrhage, thrombosis, embolism,
Abnormally dilated artery; aorta >3cm AP diameter. Infrarenal aorta, popliteal arteries Treatment: RF control: Diabetes control; Smoking cessaQon: NRT/ bupropion/ varneciline
most commonly affected. Males > Females. Age; Family History complicaQons in smokers a^er bypass surgery is at least 3-4x higher than non-smokers; th
Aneurysms grow, press on adjacent Qssues/structures (E.g. ureters and vertebrae), smokers. Pt need to be on a staQn and anQplatelet treatment: AnQplatelet (Aspirin/ Clopi
shoot off emboli and they burst. When aneurysms grow they can burst; 80% aorQc be on staQns (even if cholesterol normal); StaQns have pleoitrophic effects e.g. plaque sta
aneurysm ruptures cause instant death; 20% of ruptures reach hospital as bleed In pt with arterial disease, if limb is salvageable, aim is to improve blood flow to limb to p
posteriorly- 50% of these die when operated on. amputaQons to digits or forefoot, to relieve rest pain and to allow ulcers to heal.
Present: collapse, LOC, abdo pain radiaQng to back, hypotensive, feel pulsaQon in Two broad treatment opQons: 1) Endovascular techniques; 2) Open surgery
stomach .Females tend to rupture earlier Treatment: Endovascular Revascularisa4on: Endovascular techniques include angioplast
Treat when diameter – 5.5cm; below this and rupturing is rare balloon or stenQng (placement of metal splint inside artery to keep this open). Angioplast
When should we intervene? Ruptured aneurysm – emergency repair; SymptomaQc anaestheQc. Occasionally requires stents – improbe patency rate
aneurysm – urgent repair; AsymptomaQc aneurysm - >5.5cm diameter (>5cm in Treatment Op4ons: Open surgery. E.g. Femoral endarterectomy: In pts with disease limi
females); rapid increase in size >1cm/year femoral endarterectomy is the best opQon; involves opening artery in groin, clearing out
Trea4ng Aneurysms: Open repair vs Endovascular repair again, using a patch to avoid narrowing. Femoral endarterectomy: clear occlusion from ar
Open Repair: cut open stomach, clamp, enter sac, remove thrombus, seal artery in E.g. Bypass surgery: Aorto-femoral, axillo-femoral, femoro-femoro, infra-inguinal bypass
tubing, close sac over gra^ segment of artery with new tube. Aorto-illiac disease: aorto-femoral bypass (arQficial gra
Transperitoneal; RetracQon and exposure; Clamping; Opening of Sac; Removal of take blood from axillary/subclavian artery in axillo-bifemoral bypass (using arQficial gra^)
Debris; SelecQon of Gra^ DiabeQcs: femoro-popliteal segment and infrainguinal bypass
Proximal Anastomosis E.g. infra-inguinal bypass: In leg; try to use pt’s own vein; Own Qssue patency rates subst
Distal anastomosis: If distal anastamosis is to aorta, same technique is used above lasts longer. No rejecQon with prostheQcs (only with living Qssue); prostheQcs inc risk infx
bifurcaQon, ensuring that both iliac A orifices are within suture line. If Cis are Above /below knee popliteal. Vein/prostheQc gra^. Put a gra^ in between femoral A and
aneurysmal ,these are incised anteriorly and limbs of bifurcated gra^ are sutured to preference use paQent’s own knee due to beOer patency rates. Use prostheQc gra^ if do
normal iliac artery beyond aneurysm. As distal anastamosis is almost complete both E.g. femoro-distal bypass: bypass from femoral to any artery below infra-geniculate popl
iliacs are back bled and washed out with saline to make sure that any debris is not disease extends to below knee popliteal, and the only open vessel may be a single calf mu
embolised down limb on releasing clamps. Once anastamosis is complete, clamps are opQon = femoro-distal bypass gra^ing; insert gra^ between femoral artery and any of the
released slowly and one at a Qme to reduce risk of declamping hypotension. This should
be closely coordinated with the anaestheQc team. Amputa4ons: Amputate when damage irreversible and unsalveageable digit/limb, or fail
Closure of Aneurysm sac and retroperitoneum: Once adequate intesQnal and lower Digit amputaQons; Below knee amputaQons; Above knee amputaQons; more likely to hea
extremity circulaQon is ensured, aneurysm wall and retroperitoneum are then closed intervenQon; associated with more disability. Chances of becoming fully independent wit
over gra^ to provide a Qssue barrier to reduce risk of aortoenteric fistula. significantly less than for a below-knee amputaQon. Mortality data (BKA + AKA)- rate of m
10.3%. Rate of major complicaQons following amputaQon: 30%; Wound complicaQons; re
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