Vascular

Question 1

Give 5 risk factors for peripheral artery disease

Answer 1

• smoking
• diabetes
• hypertension
• hyperlipidaemia
• increased age
• FHx
• obesity
• inactivity

Question 2

Describe the clinical features of peripheral artery disease

Answer 2

• cramping like pain in calf, thigh or buttocks after walking a fixed distance, releived after standing still/ resting for a minute
• hairloss
• skin changes
• thickened nails
• weak pulses, pale, cold feet
• pain at night, relieved by dangling foot out of the bed
• beurgers angle <20 degrees= severe ischaemia
• ulceration and gangrene (stage 4)

Question 3

What is the definition of critical limb ischaemia?

Answer 3

• rest pain going on for 2 weeks despite analgesia or presence of ischaemia lesions or gangrene

Question 4

give 3 differentials for peripheral vascular disease

Answer 4

• spinal stenosis: pain going down legs on walking variable distances or prolonged standing, relieved by sitting down for 3-10 mins
• acute limb ischaemia
• neuropathy
• sciatica
• lower limb arthritis
• MSK strain

Question 5

How should suspected peripheral artery disease be investigated?

Answer 5

• Bloods: fbc (anaemia will precipitate symptoms), lipids, hba1c, u&e (many need contrast so need renal function check)
• Ankle brachial pulse pressure index (normal is 1-1.3)
• duplex USS of lower limb arteries
• CT w/ contrast (angio) if arterial tree not well visualised on USS or disease is very proximal

Question 6

How is intermittent claudication managed?

Answer 6

• CVS risk factor modification
• supervised exercise programme
• antiplatelet therapy with aspirin or clopidogrel
• angioplasty if supervised exercise programme as not helped
• prescribe naftidrofuryl oxalate if they dont want referal for surgery
• bypass if claudication distance is short and angioplasty fails

Question 7

Give a complication of peripheral artery disease

Answer 7

• sepsis secondary to infected (wet) gangrene
• acute on chronic ischaemia
• amputation

Question 8

Describe the clinical features of chronic mesenteric ischaemia (usually due to atherosclerosis)

Answer 8

• abdo pain 10 mins - 4hrs after eating
• weightloss
• vascular comorbidities
• loose stool, N+V, generalised tenderness and bruits may also be present

Question 9

How is chronic mesenteric ischaemia managed?

Answer 9

• antiplatelet
• CVS risk factor reduction
• mesenteric angioplasty and stending
• end arterectomy or bypass less often used

Question 10

What is the difference between deep venous insufficiency and varciose veins?

Answer 10

deep venous insufficiency is when the veins of the deep venous system become incompetent, usually due to DVT or valvular insufficiency

Question 11

How may deep venous insufficiency present?

Answer 11

• chronically swollen lower limbs
• aching, pruritis in lower limbs
• burting pain and tightness on walking which is relieved by elevation
• venous ulcers (usually medial malleolus)
• varicose eczema, thrombophelbitis, haemosiderin staining, lipodermatosclerosis
• post thrombotic syndrome

Question 12

How is deep venous insufficiency investigated?

Answer 12

• duplex USS and assesment of venous reflux, stenosis and DVT

Question 13

How is deep venous insufficiency managed?

Answer 13

• compression stockings and analgesia
• treat ulcers
• elevate feet where possible to reduce symptoms and disease progression
• little evidence for valvulopasty of venous stents

Question 14

What are the 3 types of varicose veins?

Answer 14

• trunk: dilated, tortuous from long or short saphenous vein or their branches
• reticular: permanently dilated bluish intradermal veins, usually 1-3mm in diameter
• telangiectasia: a confluence of permanently dilated intradermal veins of less than 1mm in diameter

Question 15

What are the 3 causes of varicose veins?

Answer 15

• primary/ simple: valvular failure resulting in dilated superficial veins in lower limb
• secondary: when superficial veins carry reverse flow (which dilates them) as a collateral mechanism compensating for obstructed neighbouring veins
• AV fistula

Question 16

What are the most common presenting complaints of varicose veins?

Answer 16

• cosmetic deformity
• discomfort: localised to vein site, aching, tension, heaviness and itching, particularly if hot or standing long time
• nocturnal cramps

Question 17

Describe the 4 common skin changes with varicose veins

Answer 17

• varicose eczema: eczema along vein site
• haemosiderin staining: extravascularised RBCs make the skin browny/ red around the vein
• lipodermatosclerosis: inflammation leads to skin induration and fibrosis of SC fat
• Atrophe blanche: white scarring in lower leg due to venous hypertension
• thrombophlebitis: bruising and pain along vein length due to inflammation
• also: venous ulcers

Question 18

When should varicose veins be referred to vascular surgeons?

Answer 18

• symptomatic
• lower limb skin changes
• superficial vein thrombosis (hard,painful veins)
• venous leg ulcer (break in skin below knee, not healed in 2 weeks)

Question 19

What are the 2 surgical options fo varicose veins in leicester

Answer 19

Open surgery: long saphenous stripping, saphenfemoral disconnection, multiple avulsions
Endovascular laser ablation: of long or short saphenous veins, under local, combined with foam scleropathy to improve cosmetic appearance

Question 20

How may AAA present?

Answer 20

• with rupture: hypotension, shock, LOC, severe central abdo/ back pain
• asymptomatic, picked up on screening (all men over 65 get an USS)
• pulsatile masses in abdomen

Question 21

How are non ruptured AAA managed?

Answer 21

• USS/ CT angio
• if 3-4.5cm, do yearly duplex USS to monitor
• if 4-5.4 cm 3 monthly USS monitoring
• when >5.5cm, expanding >1cm a year or symptomatic surgery is considered
• CVS risk reduction

Question 22

What are the two surgical options for unruptured AAA repair?

Answer 22

• open repair: prosthetic graft is inserteed via midline laparotomy (used in younger pts)
• endovascular repair: needs 1.5cm normal aorta below renal vessels, lifelong monitoring and more thorough pre op assessment but fewer complications, better survival rate and recovery times.

Question 23

What may cause leg ulcers

Answer 23

• venous disease
• arterial disease (AV malformations, atheroslcerosis)
• vasculitis (SLE, RA, scleroderma, wengers)
• lymphatic insufficiency
• neuropathic (usually diabetes)
• haematological (sickle cell)
• trauma (burns, pressure sore, cold injury)
• neoplasm (BCC, SCC, melanoma)
• others: sarcoid, pyoderma

Question 24

Describe the pathophysiology of venous ulcers

Answer 24

• chronic venous hypertension (due to varicose veins, DVT, CVI)
• get odema in lower limb
• results in impaired tissue perfusion as oxygen and metabolites have to diffuse greater distances to get to tissue cells
• become ischaemic when walking
• then reperfusion injury when rest
• more inflammation- more odema- more tissue fibrosis
• ulceration is last after the other skin changes

Question 25

How should venous ulcers be managed?

Answer 25

- 4 layer compression bandaging if arterial circulation is ok - leg elevation - improve mobility - reduce obesity and improve nutrition - varicose vein surgery if thats the cause - skin grafting in selected pts - monitor for infection

Question 26

What are the 6 signs of acute limb ischaemia

Answer 26

``` pale, pulseless, paraesthesia, perishingly clold, paralysis acute onset (mins- hrs) if embolic, insidious (hrs- days) if thrombotic ```

Question 27

What causes acute limb ischaemia

Answer 27

- 60% are thrombosis of atheromatous plaque - 30% are emboli from AF, post MI, AAA, prosthetic heat valves - 10% untreated compartment syndrome

Question 28

How is an acute limb ischaemia managed?

Answer 28

- arrange, bloods (inc lactate, G&S), ECG, duplex USS, CT angio, urgent vascular review - theraputic dose heparin - if the limb is viable, there are may interventions they may have: percutaneous catheter directed thrombolysis, surgical embolectomy or endovascular revascularisation - if irreversible they need urgent amputation - long term they need clopidogrel or aspirin, treat cause and modify RFs

Question 29

How should a DVT be managed?

Answer 29

- wells score- USS or/ and D dimer - apixaban for at least 3 months (warfarin w/ LMWH to bridge if DOAC contraindicated) - CVS RF modification - if cant get USS within 4 hrs, give anticoag for 24 hrs in interim - if unprovoked do CXR, FBC, serum calcium, LFTs, urinalysis, examine for cancer +/- CT CAP and mammogram

Question 30

How may carotid artery disease present?

Answer 30

- asymptomatic but bruit picked up - TIA (transient cerebral or monocular visual loss) - CVA (usually hemisensory/ motor deficit affecting face arm and leg or loss of higher cortical function (dysphagia, neglect))

Question 31

How is carotid artery disease investigated?

Answer 31

- carotid artery duplex USS - CT or MRI angio where the artery isnt easy to asses on USS (calcification or thick neck) or if distal/ proximal disease suspected

Question 32

How is carotid disease managed?

Answer 32

- CVS risk factor modification - antiplatelets (aspirin or clopidogrel) - carotid endarterectomy (if symptomatic severe stenosis as reduces stroke risk, used if pt fit for surgery)