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And you're ready to stop? Ok, thanks. Um ok. Uh hi, everyone. So we are gonna be doing vascular disease first today. Um I'm sure to and I've delivered some of the lectures before. Uh you've got my email. So if you've got any questions, then um let me know. Um and uh you know, I'm happy to, to go through them uh later as well. So, um let's get started with vascular disease. So there's a few kind of key topics in here that kind of tend to get tested. Um And then some things are less high yield. So I'd say it's better to focus on, on the, on the kind of um stuff that, you know, is more likely to turn up. Um And we'll go through what those are in more detail um throughout. So starting off with peripheral vascular disease, this is definitely one of the ones that is kind of more testable. Um There's a lot of kind of key terms with this really. So, um it's quite important to get what, yeah, to get the definition of each thing down um quite early on. So peripheral vascular disease, we can split into acute and sorry, acute and chronic. Um with acute, we've got acute limb ischemia and with chronic, we've got two types. So we've got intermittent claudication and we have critical limb ischemia. So, intermittent claudication is when you have pain specifically when you exert yourself. Whereas critical limb ischemia is when you only have pain. Um if there is when you have pain even on rest. So, intima claudication is kind of like the milder form because you're only getting it when you're exerting yourself as opposed to critical limb ischemia, which is kind of a more advanced version where you're now getting the pain even at rest. So if we move on, um the thing with acute limb ischemia is the firstly, this is kind of like a sudden drop in um the blood flow uh to the limbs. So you can think of it as a sudden decrease in limb perfusion, intermittent claudication, as we said is pain on exertion. Whereas critical limb ischemia is pain on rest. So it's more of a these both are more chronic. Um but intermittent claudication is kind of the milder form as opposed to um critical limb ischemia. So all of these kind of have the same pathophysiology um from a basic perspective. So, the pathophysiology itself is atherosclerosis which leads to stenosis of the arteries. So, narrowing of the arteries and and this is due to a a load of different factors which are both modifiable and non modifiable risk factors. So we've got things like, uh, smoking, um, diabetes, uh, you know, male sex, older age and so on. Um, and the, the main things to kind of look out for are what are the signs of each? So, something like, um, intermittent claudication usually presents as, um, someone who's coming in saying that they're getting like a cramping pain in their cough. Um, or like, it can also be like in the thighs or the buttocks as well, depending on where the stenosis. Um and they tend to say that they get this pain after they've been walking, you know, x amount of distance. Um and that tends to be intermittent claudication because that's the marker of exertion. Like, you know, once I walk this much distance and that doesn't have to be a long way away. It might be, oh, you know, I was fine before, but now when I walk to the shops, um you know, down the road after I've been walking that far, ii get this like cramping pain. Um And the risk factors are mostly kind of like your standard cardiovascular risk factors that we so acute limb ischemia, you might have heard of the sorry, the sixties, um which are kind of the um it's like a, a way of remembering the kind of signs that uh that present with a acute limb ischemia. So it is pain, pale, pulseless paralysis, paresthesia and perishing cold. Um which kind of makes sense. It's like you know, if you, if you lose blood supply to your limb, you know, a you're not gonna have sensation. So you're gonna get paraesthesia, you're gonna find it difficult to move. So you get your paralysis. Obviously, you're not gonna get a pulse there because there's no blood flow, it's gonna become pale again because of the lack of blood flow. Um and it's gonna become cold um because obviously blood is a way of distributing heat as well. So most patients who are having chronic limb ischemia, so, are intimate claudication or critical limb ischemia tend to be asymptomatic. Um and both legs are generally affected at the same time. So it might go on for a little bit without real that they have this. Um It's not something that presents suddenly like acute limb ischemia does. Um and it tends to be both legs, although if they're presenting acutely, you can have like an acute on chronic presentation where they can present acutely with, you know, one leg being, you know, suddenly worse and even in a chronic stage, one leg might be worse because it has more stenosis than the other leg. But it kind of makes sense that it can happen to both legs just because the sort of underlying factors are like, um you know, your cardiovascular risk factors, which is obviously like the same for both legs. Um You might see that there's a little bit of like hair loss on the leg or um absent femoral pulses or um popliteal pulses or your, you know, dorsalis, your foot pulses. Um because o like on examination um and this is because of the lack of blood flow uh to this region. So things like hair growth do require good blood flow as well. Um So yeah, I think we've covered, please. Um Yeah, so most of most of these presentations are basically due to lack of blood flow to um to the area, intermittent claudication. Um It's generally like it's on exertion and the more you exert yourself, the worse it is. So it might say that, you know, walking is ok, but when I go uphill, it's kind of worse. Um And they might also say something where um when they're sitting on the edge of the bed and like dangling their legs over the edge of the bed, they might say that that helps the pain a little bit and that's because of like the effect of gravity because they're getting more blood flow. Um So yeah, those are like some of the signs that you might see in a question. So we've got something called Berger's Test, um which is a way of assessing um peripheral vascular disease. So basically, I think I've got a picture. So, yeah, so basically you hold um the leg up at a 45 degree angle and hold it there for a few minutes. Um And if the leg becomes a bit pale, then you want to know, you know, what angle the paleness comes up at. So Berger's angle is basically um 20 degrees. If you start seeing that, you know, so if you start seeing that the, the leg becomes pale at less than 20 degrees height, then that's probably um quite severe in ischemia. If it's kind of, you know, nice and pink, even when you've kind of elevated up to 90 degree, you wouldn't go past that. But like if you've gone all the way up to 90 it's still quite pink, then, you know, that's probably quite healthy in terms of Basar perspective. Um So yeah, lift up and, and check and if it's, you know, less than 20 degrees when they become uh when the leg becomes pale, then that's quite severe. Um And then you should swing their legs around the end of the bed. Um And you check for something called reactive hyperemia. So this is basically where it becomes um like a pink color and then red again. So, um the blood flow kind of reenters, um you know, a as a result of the gravity now. Um, so it's because the arterial dilate, um and then you, you have your blood kind of flowing back in and that's called reactive hyperemia. And so it's the color change from your pale back to your um pink bread. So, um the main kind of investigations that you do in for vascular disease, firstly, you do a full cardiovascular risk assessment mostly just because of the fact that it's associated with um a lot of cardiovascular risk factors. Um So this includes things like checking um BP, heart rate, you can do your bloods, like fasting glucose lipids. Um you know, check for diabetes, hypercholesterolemia and so on. You can do an E CG as well um to check for any cardiac issues. Um you can also do some kind of specialist tests. So we first we have the ankle brachial pressure index A BPI. Um And basically the normal range for this is naught 0.9 to 1.2. If you've got an ABP of less than naught 0.9. So this is your ankle, your um ankle, BP to your brachial BP. So in your arm, um and if that's less than naught 0.9 then that's abnormal. Um that suggests that you've got peripheral vascular disease. Um And if it's less than naught 0.5 then that's critical in ischemia. So like if it's less than naught 0.9 it's abnormal, but it's only critical in ischemia when it's below naught 0.5 you can also do color duplex um ultrasound scan and you can also do um MRI um uh magnetic resonance angiogram. Um And both of these is to kind of look directly um to find what the site of uh stenosis is. So it helps to, you know, identify what you might need to do for the management, they're both obviously noninvasive investigations. So, um it's not, it's, it's not hugely high risk. Um but it is quite important because it helps you to visualize um the arteries themselves. And you also don't need contrast for this, which is kind of good. Um because that's something that you would need for normal op. So this is magnetic resonance angiogram. Um So moving on to Lari syndrome. So this is kind of like it's a specific type of um vascular disease. So, um it's also known as Aortoiliac occlusive disease. This is basically when you have um atherosclerosis specifically at the um bifurcation point. So where the aorta becomes the iliac arteries.