Vascular Flashcards

Question

Venous Ulcer mangagement | (general, compression, other)

Answer 1

Refer to leg ulcer community clinic **General Measures** * Optimise risk factors: nutrition, smoking * Analgesia * Bed rest + elevate leg **4 layer compression bandaging if ABPI \>0.8** * Construction * Non-adherent dressing + wool bandage * Crepe bandage * Blue line bandage: light compression * Cohesive compression bandage * Change bandages 1-2 x/wk * Once healed use grade 2 compression stockings for life Other Options * Pentoxyfylline PO: ↑ microcirculatory blood flow * Desloughing c¯ larval therapy * Topical antiseptics: Manuka honey * Surgical: split-thickness skin grafts

Answer 2

**Inspection** * Site; Tips of and between toes, Base of 1st and 5th metatarsals, Heel * Size: mm-cm * Base; Deep: may be down to bone, May be slough but no granulation tissue * Edge: punched-out * Surroundings; Pale, Trophic changes **Palpation**; Painful, Cold surroundings, Sensate, Reduced or absent distal pulses

Answer 3

Large Vessel; Atherosclerosis, Thombangiitis obliterans (Buerger’s Disease) Small Vessel; DM, PAN, RA

Answer 4

***Analgesia***: * Can be extremely painful-\> Combination of drugs administered regularly * Based on the analgesic ladder: titrate to pain * Paracetamol + NSAIDs * Weak opioids: e.g. codeine * Strong opioids: e.g. morphine **Risk Factor Modification**; Stop smoking + Control DM and HTN + Optimise lipids **Medical** * Avoid drugs which may worsen symptoms: e.g. β-B * Low-dose aspirin * IV prostaglandins * Chemical lumbar sympathectomy: Chemical ablation of L1-L4 paravertebral ganglia, Inhibit sympathetic-mediated vasoconstriction, Relief of pain, Often unsuccessful in DM: neuropathy

Answer 5

**Inspection** * Site: pressure areas: Tips of and between toes, Base of 1st and 5th metatarsals, Heel * Size: variable * Shape: corresponds to shape of pressure point * Base: may be deep c¯ bone exposure * Edge: punched-out * Surroundings; Skin looks normal, Charcot’s joints, May be signs of PVD if co-existent arterial disease **Extras** * Blood sugar testing marks on fingers * Insulin injection marks on the abdomen Palpation; * Normal temperature * Normal peripheral pulses * Absent sensation around ulcer * Absent ankle jerks Completion * Full peripheral vascular exam * Cranial and peripheral neuro exam

Answer 6

Any cause of peripheral neuropathy  DM  Alcohol  B12  CRF  Drugs: e.g. isoniazid, vincristine  Every vasculitis

Answer 7

**Sensory** neuropathy: distal limb damage not felt by pt. **Motor** neuropathy: wasting of intrinsic foot muscles and an altered foot shape e.g. Claw toes + prominent metatarsal heads **Autonomic** neuropathy: ↓ sweating → cracked, dry foot

Answer 8

**Inspection** * Arm: ↓ *venous* outflow * Oedema: pitting * Cyanosis * Pallor * Hand: ↓ *arterial* inflow * Raynaud’s * Patchy gangrene * Fingertip necrosis * Hand and Arm: *neurological* complications * Complete claw hand * T1 sensory loss * Radicular pain **Palpation** * Palpate for cervical rib above the supraclavicular fossa * Disappearance of radial pulse on abduction and external rotation of arm

Answer 9

* *Arterial*: Raynaud’s * *Venous*: axillary vein thrombosis or trauma * *Neurological*: cervical spondylosis, Pancoast’s tumour

Answer 10

* X-Ray: cervical rib * Duplex in abduction * Arteriograms of subclavian artery may show kinking * Nerve conduction studies

Answer 11

* Congenital: cervical rib * Acquired: clavicle #, pathological enlargement of 1st rib

Answer 12

?first rib/cervical rib excision

Answer 13

**Key Questions** * What is the main problem you have c¯ your hands? * When do symptoms occur? * Is it precipitated by any specific weather conditions? * Can you describe the colour changes your fingers go through? **Inspection** * Usually bilateral * Dry, red skin * Brittle nails * Ulceration or gangrene on the pulps **Palpation;** Normal radial pulse **Completion;** Ask about symptoms and look for signs of secondary causes of Raynaud’s phenomenon

Answer 14

**Definitions** Phenomenon: characteristic cold-induced changes assoc. c¯ vasospasm Disease: primary Raynaud’s phenomenon occurring in isolation Syndrome: secondary Raynaud’s phenomenon assoc. ¯c other disease Colour Changes (Cold- or emotion-induced) = White → Blue → Crimson **Pathogenesis;** Overactive α sympathetic receptors Or, fixed obstruction in vessel wall **Secondary Causes**: BADCAT  _Blood_: polycythaemia, cryoglobulinemia, cold agglutinin  _Arterial_: atherosclerosis, thrombangiitis obliterans  _Drugs_: β-B, OCP, ergotamine  _Cervical rib:_ → thoracic outlet obstruction  _Autoimmune_: SLE, RA, SS  _Trauma_: vibration injury

Answer 15

Mx * *Conservative; w*ear gloves and avoid cold + Stop smoking * *Medical;* CCBs: e.g. nifedipine + IV prostacyclin * *Surgical ;* Cervical sympathectomy + amputate gangrenous digits

Answer 16

**Inspection** Wet; Putrefaction + Ill-defined, spreading edge Dry; Dry and shrunken + Well demarcated + Features of PVD **Palpation =** Temperature + Distal pulses

Answer 17

**Definition**; Irreversible tissue death from poor vascular supply. Classification * Wet: tissue death + infection * Dry: tissue death only * Pregangrene: tissue on the brink of gangrene Causes of Gangrene * DM: commonest * Embolism and thrombosis E.g. foot trash in AAA repair * Raynaud’s * Thrombangiitis obliterans * Injury: extreme cold, heat, trauma or pressure Mx * Take cultures * Debridement (including amputation) * Benzylpenicillin ± clindamycin

Answer 18

* Involves aerobes + anaerobes * Fournier’s: perineum * Meleney’s: post-op ulceration * Both progress rapidly to necrotizing fasciitis and myositis

Answer 19

***Clostridium perfringes myositis*** *RFs*: DM, trauma, malignancy Presentation * Toxaemia * Crepitus from surgical emphysema * Bubbly brown pus Rx * Debridement (may need amputation) * Benzylpenicillin + metronidazole * Hyperbaric O2

Answer 20

Inspection * Bilateral signs of chronic arterial disease * Amputations: esp. digits * Charcot joints * Ulceration Palpation * Pulses may be preserved due to calcification * ↓ sensation in stocking distribution Completion * Examine the peripheral nervous system * Urinalysis: proteinuria * Fundoscopy: retinopathy

Answer 21

Hx; Control, Complications, Claudication, Previous operations, Other vascular disease, Other vascular risk factors **Diabetic Foot Syndrome** * Microvascular disease * Macrovascular disease; Predominantly below knee cf. non-DM occlusive disease. * Neuropathy * Infection and osteomyelitis **Aetiology of Diabetic Ulcers**; Neuropathic: 45-60% + Ischaemic: 10% + Mixed neuroischaemic: 25-45% * Preservation of Pulses;* Calcification in the walls of the vessels: mediasclerosis -\> Preserves the pulses until late → abnormally high ABPI --\> Use toe pressure instead: \<30mmHg Similar effect is seen in CRF * Problems c¯ Diabetics Undergoing Angiography ;* Often have a degree of _renal_ impairment which can be dramatically worsened c¯ contrast agents. + _Metformin_ must be stopped prior to the procedure to prevent lactic acidosis

Answer 22

**Carotid Endarterectomy Scar:** Beneath the angle of the mandible + Parallel to SCM **Carotid Bruit** : Along course of common carotid: medial to SCM in the anterior triangle + Best heard in expiration ***Completion;*** * If heard bilaterally, listen over precordium to exclude AS * Full peripheral vascular examination * Neurological examination: cerebrovascular event

Answer 23

**Hx**; Previous TIA: esp. amaurosis fugax (Amaurosis fugax will be ipsilateral to stenosis), Previous stroke, Other CV and PV disease, CV risk factors Ix Bedside: * Urine dip: proteinuria in renovascular disease * ECG: ischaemic changes, AF Blood * FBC: anaemia may worsen symptoms * U+E: renovascular disease * Glucose: DM * Lipids: hypercholesterolaemia Imaging * Carotid Duplex US: site and size of stenosis * MRA: more detailed carotid anatomy * Echo: CVD * CT or MRI brain: infarcts

Answer 24

**TIA;** Sudden neurological deficit of vascular origin lasting \<24h (usually lasts \<1h) c¯ complete recovery. _Microemboli_ from the plaque **Stroke:** Sudden neuro deficit of vascular origin lasting \>24h. 3rd leading cause of death in the West. Carotid _atheroembolism_ is the commonest cause

Answer 25

Mx Pts c¯ severe symptomatic stenosis should have CE ASAP after the neurological event. Conservative * Aspirin or clopidogrel * Control risk factors Surgical: Endarterectomy * Symptomatic (ECST, NASCET) * ≥70% (5% stroke risk per yr) * ≥50% if low risk (\<3%, typically \<75yrs) * 6 fold reduction in stroke rate @ 3yrs * Asymptomatic (ACAS, ACST) * ≥60% benefit if low risk **Complications:** * 3% risk of stroke or death * Haematoma * MI * Nerve injury; Hypoglossal: ipsilateral tongue deviation, Great auricular: numb ear lobe, Recurrent laryngeal: hoarse voice, bovine cough

Answer 26

Inspection * Stump anatomical level * Stump health * Evidence of chronic vascular disease Palpation * Soft tissue under skin should move freely over the bone * Proximal pulses Move * Ask pt. to actively flex and extend the knee joint above the amputation * Many pts. have a fixed flexion deformity after BKA * Ask to look @ prosthesis and see pt. walk c¯ it. Completion * Examine other limb for signs of PVD

Answer 27

4D’s Dead: PVD (90%), thrombangiitis obliterans  Dangerous: sepsis, malignancy  Damaged: trauma, burns, frostbite  Damned nuisance: pain, neurological damage

Answer 28

Consideration * Psychosocial implications * Future mobility: 200% more effort to walk after AKA * OT involvement * Level of amputation must be high enough to ensure healing of the stump. * But ↑ mortality c¯ AKA vs. BKA Procedures * Toe: with the metatarsal head * Ray Amputation * Incision on either side of affected digit to the base of the metatarsal * Creates a V shape and narrows foot * Heals by 2 intention * Used if necrosis of digit and muscles of the foot. * Forefoot: transmetatarsal * Below knee: aids rehabilitation * Above knee * Hindquarter / hemipelvicotomy Complications * Pts. often have co-morbidities → ↑ risk * Esp. CVD * Early * Mortality: ~20% for AK * Haemorrhage * Infection: cellulitis, gangrene, osteomyelitis * Scar contractures → fixed flexion * Phantom limb pain: try gabapentin * Poor stump shape inhibiting prosthesis

Answer 29

Inspection * Pulsatile mass in the groin * Surgical scars or puncture sites Palpation * Pulsatile, expansile swelling * Define the anatomical location * Usually mid-inguinal point * Palpate distal pulses Auscultate for a Bruit

Answer 30

Aneurysm is an abnormal dilatation of a blood vessel **True**: involves all layers of arterial wall **False**: Collection of blood around a vessel wall that communicates c¯ the lumen - i.e. a pulsating haematoma. Fibrous tissue forms around haematoma → false sac which communicated c¯ vessel lumen

Answer 31

Aetiology: * Occurs after vessel a laceration / puncture * Traumatic or iatrogenic * Usually in the common femoral A. following puncture for a radiological procedure.

Answer 32

* Ultrasound compression * Thrombin injection * Surgical repair

Answer 33

**Definition**; Abnormal dilatation of a blood vessel \> 50% of its normal diameter. **Classification** * *True Aneurysm:* Dilatation of a blood vessel involving all layers of the wall and is \>50% of its normal diameter. * Two different morphologies * Fusiform: e.g AAA * Saccular: e.g Berry aneurysm * *False Aneurysm*: Collection of blood around a vessel wall that communicates c¯ the vessel lumen. * Usually iatrogenic: puncture, cannulation * *_Dissection_ :* Vessel dilatation caused by blood splaying apart the media to form a channel w/i the vessel wall. Used to be classified as “dissecting aneurysms” but not technically correct as represents a different pathology

Answer 34

**Causes** Congenital: * ADPKD → Berry aneurysms * Marfan’s, Ehlers Danlos Acquired * Atherosclerosis * Trauma: e.g penetrating trauma * Inflammatory: Takayasu’s aortitis, HSP * Infection * Mycotic: SBE * Tertiary syphilis (esp. thoracic) * Salmonella typhi: assoc. c¯ AAA

Answer 35

* Rupture * Thrombosis * Distal embolisation * Pressure: DVT, oesophagus, nutcracker syndrome * Fistula: IVC, intestine

Answer 36

UK Small Aneurysms Trial *Powell, Greenhalgh et al., Lancet 1996* * Asymptomatic aneurysms between 4-5.5cm should be monitored. * Aneurysms ≥ 5.5cm should undergo repair. * Risk of rupture * \<5.5cm: 1% /yr * ≥5.5cm: 10% /yr Screening * MASS trial revealed 50% ↓ aneurysm-related mortality in males aged 65-74 screened c¯ US. * UK men offered one-time US screen @ 65yrs

Answer 37

**Inspection** * Pulsatile popliteal swelling * Ischaemic patches on foot: emboli **Palpation** * If asked just to examine the pulses, start c¯ femorals * Comment on presence and character * Aneurysmal popliteals are very easily palpable * Popliteal aneurysm ≥2cm in diameter * 50% bilateral: examine the other knee * Distal pulses may not be palpable Completion * Complete peripheral vascular examination * Abdominal examination for AAA * Present in 50%

Answer 38

* Popliteal aneurysms represent 80% of all non-aortic aneurysms * Lump behind the knee * 50% present c¯ distal limb ischaemia: thromboembolism * \<10% rupture

Answer 39

**Surgical Indications** * Symptomatic aneurysms * Aneurysms containing thrombus * Aneurysms \>2cm * *Mx** * Acute*: embolectomy or fem-distal bypass * Stable*: excision bypass

Answer 40

**Inspection** * Midline pulsating mass: esp. on deep inspiration * Abdominal scars **Palpation** * Pulsatile and expasile mass on deep palpation in theepigastrium. * Expansile: moves fingers laterally c¯ each pulse * Estimate size using lateral margins of index fingers * Palpate for other aneurysms * Course of common iliacs * Femorals * Popliteals **Auscultation for Bruits** * Aortic * Renal * Iliac **Completion** * Cardiovascular system * Peripheral vascular system

Answer 41

* Presentation: usually incidental finding * Symptoms * Abdominal or back pain * Tenderness over aneurysm * complications * Distal embolic events * Leak * Risk * Other peripheral or cardio-vascular disease * CV risk factors

Answer 42

**Definition** Abnormal dilatation of the abdominal aorta to \>50% of its normal diameter = ≥3cm **Risk Factors** * Male * Age \>60yrs (prevalence: ~5%) * Smoking * HTN * FHx

Answer 43

* Abdo US: used for surveillance and screening * CT/MRI: Ix of choice * Angio: useful to delineate relationship of renal arteries

Answer 44

**When to Operate** Repair aims to avoid complications Operate when risk of complications, esp. rupture, \> risk of surgery. **Indications** * Symptomatic aneurysms * Asymptomatic * ≥5.5cm * Expanding \>1cm/yr **Complications** * Death * MI * Renal failure * Spinal or mesenteric ischaemia * Distal trash from thromboembolism * Anastomotic leak * Graft infection * Aortoenteric fistula **Operative Mortality** * Open * Emergency: 50% * But only 50% reach hospital alive * Elective: 5% (lower in specialist centres) * ↑ if IHD, LVF, CRF, COPD * EVAR: 1% **EVAR** * ↓ perioperative mortality (1% vs. 5%) * No mortality benefit after 5yrs * Significant late complications: e.g. endoleaks * EVAR not better cf. medical care in unfit pts.

Answer 45

**Intermittent Claudication** * Cramping pain after walking a fixed distance * Pain rapidly relieved by rest * *Calf pain* = superficial femoral disease (commonest) * *Buttock pain* = iliac disease: internal or common **Critical Limb Ischaemia: Fontaine 3 or 4** * Ankle artery pressure \<50mmHg (toe \<30mmHg) * And either: * Persistent rest pain requiring analgesia for ≥2wks * Especially @ night * Usually felt in the foot * Pt. hangs foot out of bed * Due to ↓ CO and loss of gravity help * Tissue loss: ulceration, gangrene **Leriche’s Syndrome: Aortoiliac Occlusive Disease** Atherosclerotic occlusion of abdominal aorta and iliacs Triad of: 1. Buttock claudication and wasting 2. Erectile dysfunction 3. Absent femoral pulses

Answer 46

**Modifiable** * Smoking * BP * DM control * Hyperlipidaemia * ↓ exercise Non-modifiable * FHx * PMH * Male * ↑ age * Ethnicity

Answer 47

**Bedside** * ABPI ± exercise ABPI (↓ by 0.2 in PVD) * ECG **Blood** * FBC: anaemia may worsen symptoms * U+E: renovascular disease * Glucose: DM * Lipids: hypercholesterolaemia **Imaging**: assess site, extent and distal run-off * Colour duplex US * CT / MR angiogram: gadolinium contrast * Digital subtraction angiography * Invasive -\> not commonly used for Dx only. * Used for therapeutic angioplasty or stenting

Answer 48

**Non-Surgical Mx** * Walk through pain: may use exercise programs * Optimise risk factor profile * Smoking cessation * Control HTN, lipids and BP * Lose wt. * Antiplatelet and statin for all pts. * Foot care *Prognosis* * ~80% improve or stay the same * 20% deteriorate, 1% lose their limb * 60% mortality @ 5yrs: cardiovascular disease ***Interventional*** * Angioplasty ± stenting * Chemical sympathectomy **Surgical Mx** * Endarterectomy * Bypass grafting * Amputation * *_Bypass Grafting_** * *Indications** * V. short claudication distance (e.g. \<100m) * Symptoms greatly affecting pts. QoL * Development of rest pain * *Pre-op Assessment** *Need good optimisation as likely to have cardiorespiratory co-morbidities.* * *Practicalities** * Need good proximal supply and distal run-off * Saphenous vein grafts preferred below the IL * More distal grafts have ↑ rates of thrombosis **Classification** * Anatomical: fem-pop, fem-distal, aortobifemoral * Extra-anatomical: axillo-fem / -bifem, fem-fem crossover

Answer 49

*presentation*: *Abnormal, Tortuous, dilated veins of the superficial venous system. clearly in the distribution of the LSV in the medial side of the thigh and calve. These can be primary: which 99% are, which replies a failure of the valves and reflux down the superficial venous system. They can be secondary; as a result of blockage in the deep viens and increased pressure on the venous system higher up.*

Answer 50

palpate graft across pubic symphysis (reinforcement rings?) ?bilateral femoral pulses distal to the graft=working

Answer 51

LEFT: Long saphenous vein harvest; (+ stenotomy scar=CABG), arteria graft in the leg (+ scar over femoral artery=Femer-O-popliteal bypass/distal) pulse over scar=in situ graft // RIGHT: PTFE prosthetic material, scar at access site/terminal site. Access popliteal artery from medial above the knee or below the knee (NOT THE BACK)

Answer 52

extra anatomically tunnelling (fem-anterior tivia)

Answer 53

* Dominant peroneal artery; *Reported to be present in 5% of the population, there is absent _dorsalis pedis pulse_ on examination and a pulse just _anterior to the lateral malleolus_ as the foot is supplied by branches of the peroneal vessel* * Persistent sciatic artery; *Rare condition , characterised by a persistent sciatic arterial supply to the lower limb and absence of femoral vessels. May present with claudication*

Answer 54

transmetatarsal amputation

Answer 55

* Charcot joints; painless but hugely deformed joint abnormality

Answer 56

raynaud's phenomenon

Answer 57

Venous malformations: * Bluish * Often raised * Painful sometimes * By far the most common * Not pulsatile * No Bruit * No signal with hand held Doppler * No cardiac compromise

Answer 58

Arteriovenous malformations; like a fistula * Rare * Pulsatile dilated veins * Bruit * Obvious signal on hand held Doppler * May be overgrowth of limb (or steal and no growth) * May be significant shunt and Cardiac failure; high output cardiac failure due to shunt

Answer 59

lymphoedema * PRIMARY * SECONDARY * COMMONEST WORLDWIDE IS FILARIASIS * COMMONEST IN UK IS IATROGENIC * CANCER * OTHER INFECTIOUS CAUSES

Vascular Flashcards

(101 cards)