define varicose veins and how they happen
tortuous, twisted lengthened veins.
They happen due to valvular failure (eg. degenerative), resulting in backflow of blood from deep venous to superficial venous system. This results in venous hypertension and dilation, lengthening, tortuosity of vein.
who gets varicose veins?
obese, sedentary (standing/sitting), pregnancy, genetic disposition
how does someone with varicose veins present
- discomfort at site of varicose veins (aching, tension, heaviness, itching)
- worse on hot weather or prolonged standing
- nocturnal cramps
- venous insufficiency symptoms: eg. oedema, varicose eczema, haemosiderin skin staining, ulcers at the medial malleolus, thrombophlebitis, atrophe blanche cosmetic issues eg. discolouration saphena varix = dilation of saphenous vein at saphenofemoral junction, displays cough impulse
what investigations would you do for varicose veins?
duplex US is gold standard
how would you manage varicose veins?
open surgery = saphenofemoral disconnection, long saphenous stripping, multiple avulsions (vein ligation, stripping, avulsion)
endovenous laser ablation of short/long saphenous vein + foam sclerotherapy (improves cosmetic appearance)
conservative = compression stockings
define peripheral vascular disease and who gets it
symptomatic reduced blood supply to limbs
smokers, hyperlipidaemia, hypertension, DM, fam history of CVS disease, old age
what is the disease process of PVD
atherosclerosis (atheromas developing resulting in narrowing and occlusion of an artery)
what is the main 2 ways people with PVD present?
intermittent claudication =
- pain in lower limb elicited by walking.
- pain relieved by rest (esp in calf = superficial femoral artery in adductor canal)
- mechanism of pain = build up of anaerobic metabolites and substance P in muscles due to inadequate arterial supply.
Critcal limb ischaemia = pale, cold, limb with weak/absent pulse.
- particularly bad nocturnal rest pain, relieved by dangling foot out of bed.
- skin breakdown, gangrene.
- mechanism = arterial insufficiency is so severe that there is signif risk of limb loss
how is intermittent claudication different to cauda equina
cauda equina compression is pain radiating down BILATERAL legs, made worse by walking the pain is not relieved by rest or standing still
investigations for PVD?
- fbc, u & es, lipids, etc
- ankle brachial pressure index (ABPI) = can be falsely high in diabetics or elderly or renal failure patients due to calcified vessels
- cardiovascular risk assessments
- arterial duplex scan shows stenosis/occlusion
- angiogram
- CT/MRI
- Doppler US
Management of intermittent claudication
- stop smoking
- reduce cholesterol + statin (atorvastatin 80mg)
- treat diabetes, BP, IHD
- enroll in supervised exercise program
- antiplatelet therapy = 75mg aspirin or clopidogrel
- angioplasty if significant interference with persons quality of life
- surgical bypass of angioplasty is unsuccessful
How would you manage critical limb ischaemia?
URGENT SURGICAL INTERVENTION
- angioplasty alone or with bypass
- urgical bypass eg. femoropopliteal, femorodistal, etc.
- amputation if previous surgical failure or sepsis risk (good pain relief)
Define a leg ulcer and who gets it
- abnormal breaks in skin or mucous membranes.
- 80% associated with venous disease in leg
- pregnant
- obese
- old
- inactive
- people who have experienced leg trauma or venous incompetence
how do leg ulcers happen?
- people with chronic venous hypertension (eg in varicose veins) develop oedema in that lower limb
- results in impaired tissue perfusion
- tissues around ankle become ischaemic and suffer reperfusion injury on walking/elevation of leg (elevation/movement reduces venous hypertension and tissue fluid)
- this leads to an inflammatory process, resulting in further oedema and tissue fibrosis.
How do venous leg ulcers present?
- shallow
- irregular borders
- a granulated base
- venous insufficiency features itching, aching, bursting sensation before ulcer occured
- ulcer usually over medial malleolus
investigations for leg ulcers?
- ABPI (>0.9 = no significant arterial insufficiency)
- blood tests to exclude DM or blood disorders
- assess peripheral arterial pulses
- venous duplex scan
- swabs for microbiology
complications of leg ulcers
cellulitis and infection
how would you manage venous ulcers
- compression bandaging if arterial circulation is fine (ABPI >0.6 before bandaging)
- leg elevation
- improve mobility
- reduce obesity
- improve nutrition
- varicose vein surgery + skin grafting antibiotics for wound infection
How would you manage carotid disease?
- antiplatelet and statin therapy (300mg aspirin OD 2 weeks then 75mg clopidogrel OD) (atorvastatin)
- carotid endarterectomy for those fit for surgery (reduces future stroke risk in patients with severe stenosis)
- CVS exercise weight loss
what to do with patients admitted with stroke
- high flow O2
- swallowing screen assessment
- ischaemic stroke = IV alteplase and 300mg aspirin
- haemorrhagic stroke = correct any coagulopathy + refer to neuro
- Thrombectomy for acute ischaemic stroke (+ IV thrombolysis)
how would you define an AAA
an abdo aortic aneurysm is when its diameter is >3cm
How would an AAA and then a ruptured AAA present?
- pulsatile mass
- distal embolisation resulting in limb ischaemia
- abdo pain, malaise, weight loss
- dense white periaortic fibrosis that can involve adjacent structures = inflammatory aneurysm
- sudden abdo + back pain, collapse, hypotension, circulatory collapse = ruptured AAA
How would you manage an AAA (not ruptured)
US Screening- annually for men >66
Conservative
- smoking cessation
- improve BP, statin/aspirin, weight loss, exercise
- duplex USS and surveillance for <5.5cm (annually for 3.5-3.9cm, every 6 months for >4cm)
Surgical
- if asymptomatic, must be >5.5cm or increasing in size >1cm/year.
- symptomatic - prosthetic graft inserted by “inlay technique” (endovascular or open)
- endovascular has complications eg. endovascular leak and also probably requires repeated intervention and life long surveillance.
- open = laparotomy, reduced survival rate, etc, but it is a more guaranteed long term cure.
What is this?
What is characteristic about it and how would you investigate/ manage it?
Venous ulcer
- shallow
- irregular borders
- granulating base
- characteristically over the medial malleolus
- symptoms of chronic venous insufficiency eg. itching, aching, bursting sensation, varicose eczema, thrombophlebitis, haemosiderin staining, atrophie blanche
Investigations = duplex US, ABPI to see if compression therapy is appropriate, swabs if suspected infection
Management = Multicompotent compression bandaging (ABPI>0.6), Appropriate dressings and emollients, endovenous techniques or open surgery
