Vascular

Question 1

Define intermittent claudication

Answer 1

-> Symptom of ischaemia in a limb, occurring during exertion and relieved by rest.
-> Crampy, achy pain in the calf, thigh or buttock muscles associated with muscle fatigue when walking beyond a certain intensity.

Question 2

Define acute limb ischaemia

Answer 2

• Rapid onset of ischaemia in a limb.
• Either due to thrombus or embolus (secondary to AF)

Question 3

Define critical limb ischaemia and 3 features

Answer 3

• End-stage of peripheral arterial disease
• Features include 1 or more of :

1. Rest pain in foot for >2 wks (pain worse at night, hang it out of bed to ease)
2. Ulceration
3. Gangrene

Question 4

Presentation of acute limb ischaemia

Answer 4

6 P’s

• Pain
• Pallor
• Pulseless
• Paralysis
• Paraesthesia (abnormal sensation or “pins and needles”)
• Perishing with cold

Question 5

What is Leriche syndrome

Answer 5

• Occurs with occlusion in the distal aorta or proximal common iliac artery
• Triad of : Thigh/buttock claudication, absent femoral pulses
  and male impotence

Question 6

Signs of arterial disease on examination

Answer 6

• Skin pallor
• Cyanosis
• Dependent rubor (a deep red colour when the limb is lower than the rest of the body)
• Muscle wasting
• Hair loss
• Ulcers
• Poor wound healing
• Gangrene

Question 7

what test can be done to assess for peripheral arterial disease

Answer 7

-> Buerger’s Test

Question 8

Investigations for peripheral arterial disease

Answer 8

-> Ankle-brachial pressure index (ABPI)
-> Duplex ultrasound – 1st line
-> Angiography (CT or MRI) – using contrast to highlight the arterial circulation

Question 9

Stepwise management of intermittent claudication

Answer 9

1. Lifestyle changes - stop smoking
2. Exercise training
3. Medical treatments : atorvostatin, clopidogrel, naftidofuryl oxalate
4. Surgical options

Question 10

what should all patients with PAD be started on ?

Answer 10

• Atorvastatin 80mg
• Clopidogrel

Question 11

Initial management of acute limb-threatening ischaemia

Answer 11

• Analgesia
• IV unfractionated heparin
• Vascular review

Question 12

Management of critical limb ischaemia

Answer 12

Urgent revascularisation with :

• Endovascular angioplasty and stenting
• Endarterectomy
• Bypass surgery
• Amputation of the limb if it is not possible to restore the blood supply

Question 13

Management of acute limb ischaemia

Answer 13

• Endovascular thrombolysis
• Endovascular thrombectomy
• Surgical thrombectomy
• Bypass surgery
• Endarterectomy
• Amputation

Question 14

Stepwise diagnosis of DVT

Answer 14

• D dimer
• Doppler USS
• CTPA (if PE concerns)

Question 15

How long is anticoagulation continued for in a DVT

Answer 15

• 3mnths if provoked
• 6 mnths in unprovoked
• 3-6 months in active cancer

Question 16

Define varicose veins, reticular veins and telangiectasia

Answer 16

1. Varicose veins : distended superficial veins >3mm.
2. Reticukar veins : dilated blood vessels in skin 1-3mm.
3. Telangiectasia : dilated blood vessels in the skin <1mm.

Question 17

Signs of chronic venous insufficiency

Answer 17

• Brown discolouration to lower legs (haemosiderin)
• Venous eczema
• Lipodermatosclerosis (champagne bottle legs)

Question 18

Special tests for varicose veins

Answer 18

• Tap test : pressure on SFJ and tap vein, feel trill at SFJ
• Cough test : trill when applying to pressure on SFJ and pt coughs
• Trendelenberg’s test
• Perthes test

Question 19

Management of varicose veines

Answer 19

1. Weight loss, staying active, elevating leg and graduated compression stockings
2. Surgical : endothermal ablation, foam sclerotherapy, surgical stripping

Question 20

RF for varicose veins

Answer 20

• Increasing age
• Female
• Pregnancy
• Obesity

Question 21

what is chronic venous insufffiency ?

Answer 21

• When blood does not efficiently drain from the legs back to the heart
• Blood pools in the vein causing venous hypertension

Question 22

what does chronic venous insufficiency result in ?

Answer 22

• Haemosiderin staining (red/brown discolouration of the skin)
• Venous eczema
• Lipodermatosclerosis : hardening and tightening of skin and rissue beneat the skin
• Atrophie blanche : patches of smooth, porcelain-white scar tissue

Question 23

4 common types of skin ulcers

Answer 23

Venous ulcers
Arterial ulcers
Diabetic foot ulcers
Pressure ulcers

Question 24

Causes of aterial and venous ulcers

Answer 24

1. Arterial ulcers : insufficient blood supply to the skin due to peripheral arterial disease.
2. Venous ulcers : due to the pooling of blood and waste products in the skin secondary to venous insufficiency.

Question 25

Features of arterial ulcers

Answer 25

- Occur distally (toes and heels) - Associated with PAD : absent pulses, pallor and intermittent claudication - Smaller and deeper than venous ulcers - Well defined borders - Have a “punched-out” appearance - Pale colour due to poor blood supply Are less likely to bleed - Painful ! - Pain worse at night (when lying horizontally) - Pain is worse on elevating and improved by lowering the leg (gravity helps the circulation)-

Question 26

Features of venous ulcers

Answer 26

- Proximal to medial malleolus - Associated with chronic venous changes : hyperpigmentation, venous eczema and lipodermatosclerosis - Occur after a minor injury to the leg - Larger and more superficial than arterial ulcers - Irregular, gently sloping border - More likely to bleed - Less painful than arterial ulcers - Have pain relieved by elevation and worse on lowering the leg

Question 27

Management of arterial ulcers

Answer 27

- Same as PAD : urgent vascular referral

Question 28

Management of venous ulcers

Answer 28

- Cleaning the wound - Debridement - Dressing the wound - Compression therapy

Question 29

Defintion and types of lymphoedema

Answer 29

- Impaired lymphatic drainage - Primary : rare genetic condition, presents befpre 30 - Secondary : a separate condition affects lymphatic drainage (e.g. after breast cancer surgery due to removal of axillary lymph nodes)

Question 30

Important differential of lymphoedema

Answer 30

- Lipoedema - This is abnormal build-up of fat - Spares the feet, ulike in lymphoedema

Question 31

In what ways can lymphoedema be assessed

Answer 31

1. Negative Stemmer's sign 2. Assessing limb volume 3. Bioelectric impedance spectrometry to measure volume of fluid in the limb 4. Lymphoscintigraphy : to assess structure of lymphatic system

Question 32

Non surgical management of lymphoedema

Answer 32

-> Massage techniques to manually drain the lymphatic system -> Compression bandages -> Specific lymphoedema exercises to improve lymph drainage -> Weight loss if overweight -> Good skin care

Question 33

Surgical management of lymphoedema

Answer 33

Lymphaticovenular anastomosis

Question 34

what is lymphatic filariasis

Answer 34

- Disease caused by parasitic worms spread by mosquitos causing severe lymphoedema

Question 35

How is the severity of carotid artery stenosis classified

Answer 35

1. Mild – less than 50% reduction in diameter 2. Moderate – 50 to 69% reduction in diameter 3. Severe – 70% or more reduction in diameter

Question 36

What may be heard on examination in carotid artery stenosis

Answer 36

Carotid bruit

Question 37

Diagnosis of carotid artery stenosis

Answer 37

Carotid Ultrasound

Question 38

Surgical interventions for carotid artery stenosis

Answer 38

- Carotid endarterectomy - Angioplasty and stenting

Question 39

Injuries caused by carotid endarterectomy

Answer 39

-> Facial nerve injury causes facial weakness (often the marginal mandibular branch causing drooping of the lower lip) -> Glossopharyngeal nerve injury causes swallowing difficulties -> Recurrent laryngeal nerve (a branch of the vagus nerve) injury causes a hoarse voice - Hypoglossal nerve injury causes unilateral tongue paralysis

Question 40

What is Buerger disease (thromboangiitis obliterans)

Answer 40

- Inflammatory condition causing thrombus formation in distal arterial system (hands and feet)

Question 41

What are the notable features of buerger disease

Answer 41

- <50 (usually men 25-35) - NOT having RF for atherosclerosis (other than smoking = strong association)

Question 42

How does Buerger disease present

Answer 42

- Painful, blue discolouration to the fingertips or tips of toes - Pain is worse at night

Question 43

Typical finding on angiograms in buerger's disease

Answer 43

Corkscrew collaterals = new collateral vessels form to bypass affected arteries

Question 44

Management of buergers disease

Answer 44

- Stop smoking - IV iloprost (prostacyclin analogue to dilate blood vessels)

Question 45

Age of screening for AAA

Answer 45

Males aged 65

Question 46

AAA screening outcomes

Answer 46

- <3cm = normal - 3-4.4 = small = rescan 12mnths - 4.5 - 5.4 = rescan every 3 mnths - >5cm = 2wk vascular referral

Question 47

When will AAA be referred 2wk

Answer 47

- >=5.5cm - Symptomatic - Growth of >1cm a year

Question 48

Management of AAA

Answer 48

Elective endovascular repair (EVAR)

Question 49

Diagnosis of varicose veins

Answer 49

Venous duplex USS = retrograde venous flow.

Question 50

First line investigation for PAD

Answer 50

DUplex USS

Question 51

Interpretation of ABPI in PAD

Answer 51

Looks at SBP in ankle compared to that in arm >1.3 - calcification of artery (e.g. DM) 1 : normal 0.6-0.9 : claudication (mild PAD) 0.3-0.6 : rest pain (mod-severe) <0.3 : impending (critical)

Question 52

Define superficial thrombophelbitis

Answer 52

Inflammation of a superficial vein associated with a thrombus. Usually long saphenous vein of the leg

Question 53

when should be measure when suspected superficial thrombophelbitis ?

Answer 53

ABPI to exclude PAD USS to exlcude DVT

Question 54

Management of superficial thrombophebitis

Answer 54

- Topical NSAIDS if mild, oral if more severe - Compression stockings.

Question 55

Presentation of neuropathic ulcers

Answer 55

- Over plantar surface of metarsal head and plantar surface of hallux - Common in diabetics

Question 56

Intermittent claudication affecting the buttock, what vessel

Answer 56

Iliac stenosis

Question 57

Surgical options for intermittent claudication

Answer 57

- Endovascular angioplasty anfd stenting - Endarterectomy - Bypass surgery