Vascular

Question 1

ABPI

Answer 1

Ankle-brachial pressure index

• Used to assess the blood supply to the lower limb
• Foot artery occlusion pressure / brachial systolic pressure

Can be used to confirm the presence of PVD and as a baseline measure before treatment

• >1.1 Calcified or incompressible vessels (e.g. in diabetes or renal failure)
  
  • Falsely elevated in diabetic foot due to the vessel calcification
• 0.7-0.9 Mild ischaemia
• 0.4-0.7 Moderate ischaemia
• <0.4 Severe peripheral (critical) ischaemia

Question 2

Duplex Doppler Ultrasonography

Answer 2

Used for assessment and monitoring of blood vessel flow

• Carotid disease
• PVD
• Graft surveillance
• AAA - assessment, monitoring, screening
• Renal artery stenosis
• Venous disease

Question 3

Thrombophlebitis

Answer 3

Superficial venous inflammation that can occur in the presence or absence of a clot

• Most commonly in the lower limbs
• Causes
  
  • Conditions that cause a hypercoagulable state
    
    • Malignancy
    • Pregnancy
  • Conditions leading to venous stasis
    
    • Immobility post-surgery
    • Long haul flights
    • Venous incompetence
    • Varicosities
• Signs and symptoms
  
  • Swelling
  • Erythema
  • Tenderness along the affected vein
  • Hardness if a clot is involved

Question 4

Trendelenburg’s operation

Answer 4

Procedure for primary varicose vein disease secondary to saphenofemoral valve incompetence

Performed

• Under Spinal anaesthesia
• With patient supine and a 30° head-down tilt

It identifies the

• Long saphenous vein at the saphenofemoral junction, AND
• Its tributaries

and is flush ligated to the femoral vein

Then

• The upper 10 cm length of the long saphenous vein is excised

Associated with a high recurrence rate

Contraindications

• Presence of deep vein thrombosis
  
  • As the long saphenous vein provides collaterals > can precipitate venous claudication

Question 5

Dissection of the ascending aorta

Answer 5

AD - a result of a tear in the intima of the aorta and propagation of dissection by blood collection in the intima-media space, leading to separation of the layers within the wall

Aetiology

• Connective tissue disease
  
  • Ehlers Danlos/Marfans/SLE/RA
  • Congenital cardiovascular anomalies (coarctation of the aorta)
• Hypertension (biggest RF)
• Aortic atherosclerosis/Aortitis (e.g. Takayasu’s, tertiary syphilis)
• Trauma

Complications of ascending aortic dissection

• Acute myocardial infarction
  
  • The AAD disrupts the ostia of the coronary arteries > affects the blood supply to the heard > ischaemia or infarction
• Aortic valve incompetence & regurgitation
  
  • Due to dilatation of the aortic root and annulus)
• Haemorrhagic pericardial effusion > tamponade > syncope

Question 6

Venous ulcers

Answer 6

Description

• Usually around the medial malleolus
• Large, shallow
• Painless (unless become infected)
  
  • If infected > aching, oedematous lower limb
• Sloping edges (cf arterial ulcers > punched out edges)
• Surrounded by mottled brown/black skin or areas of venous eczema
• Ass with
  
  • Lipodermatosclerosis
  • Hyperkeratosis of the skin

RF

• Varicose veins (50%)
• Hx of DVT
• Prolonged standing/sitting
• Multiple pregnancies
• HTN
• Previous leg surgery
• Lower limb fractures
• Obesity
• Immobility
• Chronic leg oedema

Question 7

Arterial leg ulcers

Answer 7

Description

• On the dorsum
• Painful, worse at night
  
  • Pts find relief by hanging their leg out of the bed at night

Causes

• Peripheral arterial disease
• Atherosclerosis

RF

• Smoking
• >50 yoa
• Male gender
• HTN
• DM
• Coronary heart disease
• Cerebrovascular disease
• Dyslipidaemia

Positive Buerger’s test

Question 8

Buerger’s test

Answer 8

Examination used in the diagnosis of peripheral arterial disease

• Patient initially supine
• Both legs raised up to 45° & maintained in that position until pallor ensues in the feet (1-2 min)
  
  • Pallor indicates ischaemia > arterial pressure inadequate to overcome effects of gravity)
• Angle of <20° elevation causing pallor > severe ischaemia
• Pt asked to sit up with legs dangling off the side of the couch
• The time to required for pinkness to return in the feet is measured
  
  • 10-15s - Normal > Competent arteries
• In PAD
  
  • Feet become blue (deoxygenated blood)
  • Then red (hyperaemia > post hypoxic vasodilatioN)
    *

Question 9

Kippel-Trenaunay syndrome

Answer 9

Known as Angio-osteohypertrophy syndrome

• A rare disorder ass with sporadic mutations in the somatic cells during fetal development
• Affects the development of bone, soft tissue and blood vessels
• Presents in infancy/early childhood

Triad of

• Port-wine stain (capillary hemangioma) on pt’s face
• Varicose veins & venous malformations
  
  • Superficial or deep veins
• Soft tissue or bone hypertrophy affecting an extremity
  
  • _​_Up to 12cm (in literature)

Question 10

Factors affecting post vascular grafting prognosis

Answer 10

Smoking

Exercise

Healthy diet & good nutritional status (assist in healing and rehab)

Controlling cholesterol

Strict glycaemic control

HTN control

Question 11

Management of suspected AAA in a haemodynamically stable patient

Answer 11

• FAST scan (ultrasound), then
• CT (sensitivity nearing 100%)
  
  • To evaluate in more detail the size & shape of the aneurysm
  • To look for signs of aneurysmal leak or rupture
    
    • Crescent sign (blood within the thrombus)
    • Retroperitoneal haematoma
    • Wall discontinuity
    • Extravasation of contrast in the peritoneal cavity
  • Also measures the length of the neck of the aneurysm
    
    • Useful in defining suitability of pt for EVAR

Question 12

Diabetic foot

Answer 12

Diabetic foot disease is usually painless

Ulcers are punched out with a thick callus

• Falsely elevated ABPI
  
  • Due to blood vessel calcification
• Associated with
  
  • Peripheral neuropathy
    
    • Affecting motor, sensory & autonomic nerve fibres
    • Pt loses awareness of pain, which guards against injury
      
      • Initiates the development of a leg ulcer
    • Ulcers can become infected > sepsis
  • Ischaemia
    
    • Peripheral artery disease

Question 13

Popliteal artery aneurysm

Answer 13

Most common type of peripheral aneurysms

• Most pts asymptomatic
• Sx
  
  • Intermittent claudication
  • Acute limb ischaemia
• Repair
  
  • Open or endovascular
• Indications for repair
  
  • Symptomatic pt with acute limb ischaemia or severe claudication Sx
  • Asymptomatic pt with the presence of a thrombus
    
    • This thrombus - at high risk of fragmentation with flexion & extension of the knee
    • Can lead to occlusion of distal vessels & acute limb ischaemia
  • If microembolisation phenomena already occurred & the pt has only a single patent run-off vessel > ^^ risk of acute limb ischaemia & limb loss

Question 14

Thomboangiitis obliterans (Burger’s disease)

Answer 14

Inflammatory arteritis affecting the tunica intima of small to medium-sized arteries & veins

• Most commonly male pts 20-45
• Characterised by
  
  • Small segmental occlusions of the vessels, most commonly in the limbs
  • Leads to
    
    • Rest pain
    • Raynaud’s syndrome
    • Painful ulceration
    • Gangrene of toes
    • Thrombophlebitis
    • Intermittent claudications can be present, but not usually a major feature

Risk factors

• Smoking
• Chronic gum disease
• Male gender
• Age <45

ESSENTIAL TO STOP SMOKING

Question 15

Causes of secondary Raynaud’s

Answer 15

• B - Blood disorders e.g. polycythaemia
• A - Arterial e.g. atherosclerosis, Buerger’s disease
• D - Drugs e.g. beta blockers, oral contraceptive pill
• C - Connective Tissue Disorders e.g. RA, SLE, Scleroderma, Polyarteritis Nodosa
• T - Trauma e.g. vibration injury