MSRA > Vascular > Flashcards

Vascular Flashcards

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1
Q

What is the most common cause of peripheral vascular disease?

A

Atherosclerosis

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2
Q

What are the symptoms and signs of chronic PAD/ischaemia?

A

SYMPTOMS

  • Intermittent claudication (usually in calf - due to ischaemia of the superficial femoral artery)
  • Erectile dysfunction
  • Rest pain
  • Ask about all CVS symptoms too
  • Gangrene/necrosis

SIGNS

  • Cold, dry skin, lack of hair, absent pulses, ulceration, loss of sensation
  • Buergers angle <20 degrees and cap refill >15s in severe disease
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3
Q

How is chronic lower limb ischaemia classified?

A 
Fontaine classification:
Stage 1 - asymptomatic
Stage 2 - intermittent claudication
Stage 3 - rest pain/nocturnal pain (critical limb ischaemia)
Stage 4 - gangrene/necrosis
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4
Q

What are the DDs for PAD?

A
  • Spinal canal claudication (but all pulses present)
  • Osteoarthritis (more specific to knee)
  • Peripheral neuropathy (numbness, tingling)
  • Popliteal artery entrapment (young patients, normal pulses)
  • Venous claudication (bursting pain on walking, previous history of DVT)
  • Fibromuscular dysplasia
  • Buergers disease (young males, heavy smokers)
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5
Q

What investigations should be done for PAD and how is it managed?

A

Investigations:
BEDSIDE: BP, ABPI, ECG (cardiac ischaemia)
BLOODS: FBC (anaemia, polycythemia), glucose (exclude DM), ESR (exclude arteritis), lipid profile, thrombophilia screen if below 50yo
IMAGING: duplex US (1st line - to assess patency of individual vessels), MR angiography (if more info needed), CT angiography (if MR contraindicated)

Management:
- All pts should take atorvastatin 80mg and clopidogrel
- Supervised exercise programme
- Surgery or amputation if severe <0.4
- Naftidrofuyrl oxalate for those who are not suitable for surgery (vasodilator)

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6
Q

What is critical limb ischaemia?

A

Definede as rest/night pain, requiring opiate analgesia and/or tissue loss (ulceration/gangrene) present for more thatn 2 weeks, in the presence of an ankle BP < 50mmHg

This can be partly relieved by hanging leg out of bed

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7
Q

What is acute limb ischaemia?

A

6 Ps:
Pale, pulseless, painful, paralysed, paraesthetic, perishingly cold

This is a surgical emergency! It is like a DVT in an artery. Often caused by thrombotic (1st)/embolic (2nd) disease or graft occlusion (3rd)

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8
Q

What is Buergers test?

A
  1. Lift both legs to 45 degrees and allow a minute for legs to go pale
  2. If pallor, ask patient to sit up and swing lower legs around to the ground
  3. Positive test is change in colour from white to pink
  4. Flushed red (reactive hyperaemia) is indicative of severe disease
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9
Q

How do you take an ABPI?

A

Measure BP manually at both brachial arteries and take the highest reading.

Using doppler, measure BP of one ankle at both arteries, and take the highest reading.

ABPI = ankle BP/arm BP

Repeat for the other leg

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10
Q

What is a normal ABPI reading - or one for venous disease?

A

1-1.2

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11
Q

What would the ABPI reading be in calcified vessels?

A

> 1.2

This might be in diabetic or elderly patients or a false negative!

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12
Q

What ABPI indicates mild arterial disease?

A

0.8-0.9

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13
Q

What ABPI indicates moderate arterial disease?

A

0.5-0.8

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14
Q

What ABPI indicates severe arterial disease (critical ischaemia)

A

<0.5

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15
Q

How is chronic ischaemia managed?

A

CONSERVATIVE - risk reduction (smoking, diabetes, cholesterol, BP), compression stockings, supervised exercise programmes for claudication

MEDICAL - naftidrofuryl oxalate (vasodilator), risk reduction (statins, clopidogrel/aspirin, antihypertensives)

SURGICAL - percutaneous transluminal angioplasty, stents, bypass procedures

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16
Q

When should angioplasty be given for intermittent claudication?

A

Offer angioplasty for treating people with intermittent claudication only when (all 3):

  • Advice on the benefits of modifying risk factors has been reinforced
  • A supervised exercise programme has not led to a satisfactory improvement in symptoms
  • Imaging has confirmed that angioplasty is suitable for the person
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17
Q

When should bypass surgery be given for intermittent claudication?

A

Offer bypass surgery for treating people with severe lifestyle‑limiting intermittent claudication only when (requires both):

  • Angioplasty has been unsuccessful or is unsuitable
  • Imaging has confirmed that bypass surgery is appropriate for the person.
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18
Q

How is critical limb ischaemia managed?

A

CONSERVATIVE - lifestyle measures, risk reduction

MEDICAL - analgesia and laxatives

SURGERY - angioplasty and stent, major amputation (last resort)

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19
Q

How is acute limb ischaemia managed?

A

This depends on the degree of ischaemia and cause. Surgical intervention required within 4-6 hours to save the limb!

  • Do urgent thrombolysis, angioplasty, embolectomy, bypass graft.
  • Given heparin after procedure and look for source of emboli.
  • Be aware of reperfusion injury and compartment syndrome!
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20
Q

What is reperfusion injury?

A

A potential complication of revascularization in acute limb ischaemia.

  • Release of toxic metabolites
  • Oedema
  • Compartment syndrome
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21
Q

What is an embolectomy?

A

Surgical removal of an embolus, by inserting a catheter with an inflatable balloon

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22
Q

What is angioplasty?

A

The use of a balloon tipped catheter to open up an occluded vessel. Limited to single arterial segment.

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23
Q

What is endartectomy?

A

Surgical removal of plaque from an artery that has become narrowed

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24
Q

What is a bypass graft?

A

Surgical creation of a new pathway for blood to flow, using a graft (from a vein or synthetic). Often used if extensive disease with good distal arteries??

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25
What is Buergers disease?
- Inflammatory arterial dises, present in young male smokers. - Present with claudication in FEET or rest pain in EXTREMITIES - Superficial thrombophlebitis in the veins
26
What is an aneurysm?
Abnormal dilation of an endothelial lined vessel, which is greater than 1.5x its normal diameter
27
What is the difference between true and false aneurysms?
True - abnormal dilatation involving all layers of the arterial wall False (pseudo) - collection of blood in outer layer (adventitia) which communicates iwth the lumen
28
What are the 3 main types of aneurysm?
1. Fusiform - bulges out on all sides forming a dilated artery eg. AAA 2. Sac-like - localised dilatation of a vessel in a small area eg. berry 3. Dissecting - blood leaks between the layers of the vessel wall, often due to a tear eg. aortic dissection
29
What causes an aneurysm?
- Atheroma - Trauma - Infection eg. in IE - Connective tissue disorders eg. Marfans/Ehlers-Danlos - Inflammatory eg. Takayasus aortitis
30
What is the most common site for aneurysm?
Infrarenal abdominal aorta
31
What is an unruptered AAA, what causes it and what are the symptoms?
Aortic aneurysm that spreads >3cm across- due to degeneration of elastic lamellae and smooth muscle loss but often with genetic component. Often asymptomatic until rupture but may have back pain
32
How are AAAs screened for?
Ultrasound scan offered to all men at 65
33
When is surgery offered in unruptured AAA?
First do CT angiography Offer surgery to: 1. Aneurysms above 5.5cm 2. Aneurysms expanding at >1cm/year 3. Symptomatic (pain, thromoembolus, compression)
34
How is unruptured AAA managed?
CONSERVATIVE - smoking cessation, risk reduction, US surveillance every 3 months (4.5-5.4) or 2 years (3-4.44) MEDICAL - none SURGERY - open surgical repair, (EVAR endovascular aneurysm repair is not recommened by NICE currently as more complications)
35
What are the symptoms of ruptured AAA?
- Intermittent/continuous abdo pain, radiating to back, iliac fossae or groin - Collapse - Expansile abdo mass - Shock
36
How is a ruptured AAA managed?
1. Offer immediate bedside US 2. Consider CT angiography 3. Either palliative, open surgery (more likely in men, fewer complications) or EVAR (more likely in women, lower early mortality) - IV abx and cannulae needed if going to theatre
37
What investigations should be done in ruptured AAA?
BEDSIDE: ECG, US BLOODS: Hb, amylase, crossmatch IMAGING: CT angiography
38
What do open repair surgery and EVAR entail?
Open - clamp aorta above leak, insert Dacron graft EVAR - minimally invasive procedure in which an interventional radiologist places a covered stent into the area with the aneurysm so that blood can flow through the vessel.
39
What type of aortic aneurysm is common in Marfans?
Dilated thoracic - presents with chest pain, aortic regurgitation, stridor, hoarseness, SVC syndrome manage with EVAR
40
What is aortitis?
Saccular aneurysms of the ascending aorta, containing calcification. Related to syphilis or Takayasus disease
41
What is an aortic dissection?
1. Spontaneous tear in intima of aorta 2. Dissection extends and branches of aorta occlude sequentially leading to hemiplegia (carotid), paraplegia (anterior spinal artery), abnormal pulses/BP, anuria (renal arteriies) 3. Presents with tearing anterior chest pain (ascending) or intrascapular pain (descending), with collapse
42
What are the two types of thoracic aortic dissection?
Type A (70%) - involve ascending aorta Type B (30%) - do not involve asending aorta This affects MANAGEMENT - type A should be considered for surgery whereas type B might not need it
43
How is thoracic aortic dissection investigated?
CXR - widened mediastinum CT angio CAP - suitable if stable and planningfor surgery TOE - unstable patients
44
How is thoracic aortic dissection managed?
1. Take to ITU 2. Give hypotensives (labetalol) maintaining systolic at 100-110 (CCB 2nd line) 3. (Additionally for Type A) Emergency surgery
45
What are the complications of aortic dissection?
Backward tear: - Aortic incompetence/regurgitation - MI; inferior pattern due to right coronary involvement Forward tear: - Unequal arm pulses and BP - Stroke - Renal failure
46
What investigations should be done for a leg ulcer?
BEDSIDE: Urinalysis, bacterial swab, biopsy BLOODS: FBC IMAGING: Doppler USS/ABPI
47
What is the pathophysiology of venous ulceration?
- Hx of varicose veins, DVT, obsesity - Incomptenent valves in lower leg results in retrograde flow of blood to the superficial system and a rise in capillary pressure - Peri-capillary fibrin cuffing occurs - Impairment of local tissue oxygenation and homeostasis
48
What are the features of venous disease in the leg?
- Leg heaviness and oedema - Haemosiderin pigmentation, pallor, firm surrounding skin, eczema - Champagne bottle leg due to limodermatosclerosis
49
When looking at ulcers what should you assess (BEDS?)
Base - granulation tissue Edge - regular/irregular Discharge - pus/blood/fluid Structures visible - muscle/tendon/tissue
50
What are the features of a venous ulcer (70%), including management?
``` Non-severe pain in legs B - pink and granulating E - irregular, neo-epithelium, very shallow D - yellow-green slough S - none visible ``` Often skin is swollen and surrounded by lipdermatosclerosis or venous eczema. Ulcers located anywhere on lower leg but not usually feet. TREAT: 1. Clean and dress the wound 2. Charing cross 4 layer compression (as long as ABPI(0.8), 3. Consider pentoxifylline (increases blood flow and healing) 4. Analgesia 5. Compression stockings once healed TREAT ASSOCIATED CONDITIONS: - Antibiotics (not routinely, only if infection) - - Treat eczema with topical corticosteroids. - - Debride sloughy necrotic tissues.
51
What are the features of an arterial ulcer (2%), including management?
``` Severe pain in pressure areas B - deep, green or black E - regular, punched out, deep D - very little S - bone/tendon ``` Often skin is not swollen, but there are features of limb ischaemia. Ulcers located on top of foot and above medial mallelolus. TREAT: surgical revascularisation and treat underlying cause
52
What are the features of leg ulceration due to neuropathy?
Occur over weight-bearing areas such as the heel. Test sensation. If diabetic, negative pressure wound therapy is helpful.
53
What percentage of ulcers are mixed arterial and venous?
15%
54
What is gangrene (dry vs wet?)
Death of tissue from poor vascular supply, it is a sign of critical ischaemia. Dry - necrosis in the absence of infection Wet - tissue death and infection
55
How is gangrene managed?
Dry - restore blood supply and amputate Wet - Analgeisa, broad sprectrum IV abx, surgical debridement, amputation
56
What is gas gangrene?
A subset of necrotizing myositis caused by CLOSTRIDIUM PERFRIGENS - presents with rapid onset myonecrosis, muscle swelling, gas production, sepsis and severe pain. RF - diabetes, malignancy, trauma
57
How is gas gangrene managed?
1. Debride and amputate 2. Antibiotics (Pen G) 3. Hyperbaric 02 - reduces number of debridements
58
What is the pathology of varicose veins?
1. .Normally, blood from superficial veins of the leg passes into deep veins via perforator veins. Valves prevent blood from passing deep to superficial beins. 2. Valves become incompetent 3. Venous hypertension and dilatation of the superficial veins 4. Pain, cramps, tingling, heaviness, visible dilated veins
59
What are the RF for varicose veins?
- Prolonged standing - Obesity - Pregnancy - Fam history - COCP
60
What signs are associated with varicose veins?
- Oedema - Eczema - Ulcers - Haemosiderin deposits - Haemorrhage - Phlebitis - Atrophie blanche (white scarring at site of previous healed ulcer) - Lipodermatosclerosis (skin hardness frmo subcutaenous fibrosis caused by chronic inflammation and fat necrosis)
61
How do you examine VVs?
1. With pt standing INSPECT 2. Palpate veins for tenderness and pulses 3. Feel for cough impulse 4. Percussion test (tap VVs distally and palpate for impulse at SFJ) 5. Auscultate over varicosities for bruit 6. Examine abdomen, pelvis and external genitalia in males 7. Doppler US!!
62
How are varicose veins managed?
CONSERVATIVE - avoid standing, elevate legs, stockings, weight loss, regular walks MEDICAL- treat underlying cause ENDOVASCULAR - endovascular radiofrequency ablation/laser ablation, injection scleropathy SURGICAL - saphenofemoral ligation, stripping (nb - invasive treatment should not be for cosmetic purposes alone)
63
What are some risk factors for DVT?
Age, pregnancy, surgery, oestrogen, long haul flights, trauma, immobility, past DVT, cancer, obseity, thrombophilia
64
What are the symptoms and signs of DVT?
DVTs may be asymptomatic; however, there may be asymmetrical leg swelling, unilateral leg pain, dilation or distension of superficial veins, and red or discoloured skin.
65
What investigations should be done in DVT?
BEDSIDE: obs BLOODS: FBC (exclude infection), Ca/LFT (look for malignancy), U&E (before starting LMWH), thrombophilia tests IMAGING: duplex ultrasound, consider CT
66
What is the Wells score?
If the Wells' score is 2 or greater, condition is likely (absolute risk is approximately 40%). People with a score of <2 are unlikely to have a DVT. Criteria: - Active cancer (any treatment within past 6 months): 1 point - Calf swelling where affected calf circumference measures >3 cm more than the other calf (measured 10 cm below tibial tuberosity): 1 point - Prominent superficial veins (non-varicose): 1 point - Pitting oedema (confined to symptomatic leg): 1 point - Swelling of entire leg: 1 point - Localised pain along distribution of deep venous system: 1 point - Paralysis, paresis, or recent cast immobilisation of lower extremities: 1 point - Recent bed rest for >3 days or major surgery requiring regional or general anaesthetic within past 12 weeks: 1 point - Previous history of DVT or pulmonary embolism: 1 point Alternative diagnosis at least as probable: subtract 2 points
67
How can DVTs be prevented?
- Stop COCP 4wks pre-op - LMWH - Graduated compression stockings
68
How is a DVT managed?
CONSERVATIVE - early ambultation, compression stockings MEDICAL - LMWH and warfarin, stop heparin when INR 2-3 and continue warfarin for 3 months (6 months if cancer, lifelong if recurrent) SURGICAL - none
69
What are some DDs for unilateral leg oedmea?
- DCT - Cellulitis - Ruptured Bakers cyst - Insect bites - Tumours - Nec fasc - Trauma - Compartment syndrome
70
What are some DDs for bilateral leg oedema?
Implies systemic disease with increased venous pressure - Right heart failure - Low albumin (renal or liver failure) - Venous insufficiency - Vasodilators (eg. CCBs) - Pelvic mass - Pregnancy
71
What is superficial thrombophlebitis? How is it managed?
- Inflammation associated with thrombosis of one of the superficial veins, usually the LSV of the leg - Do USS to exclude concurrent DVT - Manage with compression stockings and consider prophylactic LMWH for up to 30 days or fondaparinux up to 45 days - If LMWH contraindicated, give 8-12 days of NSAIDs
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