15 - Vascular Disease Flashcards
What is embolisation used for?
Blocking off abnormal blood vessels - controls haemorrhage, abnormal growth, abnormal connections
Which is the most commonly injured solid organ in blunt abdominal trauma?
Spleen
How can the biliary system be drained?
Percutaneous transhepatic biliary drainage
ERCP
How can biliary obstruction be treated if ERCP is not an option?
Percutaneous transhepatic cholangiogram and biliary stent insertion
What interventional radiological treatment can be used for urinary tract obstruction?
PCNL - Percutaneous nephrolithotomy for stone removal
Nephrostomy tube insertion for complete obstruction
How can renal cell carcinoma be treated sometimes by IR?
Tumour can be targeted with cryoablation via image guided tumour ablation.
What is the best assessment for active haemorrhage in stable patients?
Triple-phase CT
What is the 30 day amuptation rate for acute limb ischaemia?
Up to 30%
Ps with chronic PVD are more likely to have which chronic diseases?
HF
DM
Which arteries are most commonly involved in symptomatic PVD?
Femoral artery or Popliteal artery
What is the most common cause of chronic ischaemia (PVD)?
> 90% is atherosclerosis
What is it called when there is insufficient perfusion to continue normal cellular processes that threatens the limb?
Absolute ischaemia
What is it called when there is insufficient perfusion to permit full function of the limb but it is ok at rest?
Relative ischaemia - lifestyle changing
What are the 6 Ps of acute limb ischaemia?
What is critical ischaemia?
Combination of gangrene in the leg and pain at rest
What causes acute limb ischaemia?
Any sudden decrease in limb perfusion
- Embolic
- Thrombotic
- Aneurysm
- Trauma
- IVDU
- Dissection
What is the commonest cause of an embolus?
AF
How can you tell whether a limb is salvageable or not?
If no neurosensory deficit = salvagable
If neurosensory deficit - but no limb staining or mottling - get urgent CT angio and urgently revascularise.
If neurosensory deficit + limb staining, mottled discolouration, tissue death = non-salvageable.
What is the Rx for acute ischaemia?
Heparin 5000 IU IV
or
LMWH (Fragmin) S/c
Analgesia
Feet down
What is the difference between unfractionated and LMWH?
Unfractionated
- more monitoring
- shorter half life and quicker to stop if needed
LMWH
- less monitoring
- irreversible
- longer hold life so hard to stop quickly
What imaging can be done for acute limb ischaemia?
Dopler USS
CT Angiogram
Where do emboli often get stuck?
At the bifurcation of a BV
What should you do after embolectomy?
Image proximal arteries to check for aneurysm or clots
Echo - check for valvular disease that could have caused an ambolism
Do 24hr ECH - looking for paroxysmal AF
Anticoagulation
What is the commonest coagulopathy causing hyerpcoagulable state in the UK?
Factor V Leiden
APL Syndrome
What does APL syndrome cause?
Antiphospholipid (AN-te-fos-fo-LIP-id) syndrome is a condition in which the immune system mistakenly creates antibodies that attack tissues in the body. These antibodies can cause blood clots to form in arteries and veins.
Blood clots can form in the legs, lungs and other organs, such as the kidneys and spleen. The clots can lead to a heart attack, strokes and other conditions. During pregnancy, antiphospholipid syndrome also can result in miscarriage and stillbirth.
What is Factor V Leiden?
Factor V Leiden is a blood clotting disorder that raises your risk of abnormal blood clots. It’s the most common blood clotting disorder that’s inherited, or passed down within biological families.
People with factor V Leiden have a mutation in their coagulation factor V (F5) gene. Your F5 gene controls the production of a protein called factor V, which helps your blood clot when needed (such as after an injury). The factor V Leiden mutation changes this protein’s structure. This change causes it to resist other proteins that stop excessive clotting.
What is the Rx for a thrombus?
Thrombolysis + angioplasty/stent of underlying plaque
Can do endarterectomy sometimes
Amputation if limb not salvagable
What does
- intense pain - especially to passive movement
- parathesia in the feet
- pulselessness
following reperfusion of an ischaemic limb indicate?
Compartment syndrome
What is the Rx for compartment syndrome?
Immediate fasciotomy
What are the S&S of PVD?
Intermittent claudication = resolves on rest. Can usually only walk 50-100 yards
What is the management of PVD?
Stop smoking - causes vasoconstriction and reduced serum O2
Antiplatelet
Statin
ACEI
Exercise - need to push through the pain - can improve over time
What should you not use for PVD?
TED stockings - will worsen the ischaemia
Why can diabetics have falsely raised ABPI?
Due to calcification of vessels
What is a normal ABPI?
What does a low or high reading mean?
0.9-1.3
Low = obstruction
High = poorly compressible - arterial calcification - DM, RA, vasculitis, atherosclerosis, advanced CKD.
What surgical options are there for critical ischaemia?
Angioplasty +/- stent
If long occlusion - bypass?
If lots of tissue loss = amputation
If elderly P - palliation
Which vein is usually used for graft in bypass surgery?
Long saphenous vein
Why are veins preferred to artificial grafts for bypass?
Inc thrombosis risk (only 25% at 5 years) and inc risk of infection with artificial grafts
What is an aneurysm?
Dilation of BV to at least 50% more than normal expected diameter
What is the difference between a true and false aneurysm?
True = involves all layers of the vessel wall
False = contained leak of blood outside the vessel wall that communicates with it
What are the RF for AAA?
M (x4 than F)
Age (>60)
Smoking
HT
low HDL
A-C
What is the mortality of a ruptured AAA?
80%
Where can an aneurysm occur?
Anywhere
What can cause an aneurysm?
Degenetation
Congenital
Vasculitic
Connective issue abnormalities
Infected - mycotic
Why do aneurysms occur in the infra-renal aorta?
Bifurcation of the aorta = additional stress
Also - have 58% less elastin in the infra-renal aorta. Elastin is not made in adulthood - slowly degrades which explains why by 60 you get higher incidence of aneurysm.
What age are men screened for AAA in UK?
65
What diagnosis can be done for AAA?
US
CT - first line for acute presentation
What is the S&S of a ruptured AAA?
Severe upper abdo pain radiating to the back
Hypotension
“Ureteric colic”
What is the operative mortality for repair of a AAA?
If elective - 6%
If emergency - 40% for ruptured aneurysms
What is done for conservative management of an AAA?
Correct RF - stop smoking, Rx HT, reduce cholesterol
Keep under surveillance with USS
Which has less mortality - open or endovascular repair?
Endovascular repair (1-2%) whereas open is 5-8%
Why is EVAR only NICE recommended for Ps who can’t have open surgery?
Because it has a double reintervention rate compared to open.
For example - can get endoleak - where the graft is in place but blood gets around and can still rupture the aneurysm sack.
What foot problems can arise from DM?
Infection
Ulceration
Neuropathy
Tissue destruction
What causes injury to diabetic feet?
Combination of neuropathy + peripheral arterial disease
Hard to feel things - get injury - they can’t heal.
What is Charcot foot?
Charcot foot, also known as Charcot arthropathy or Charcot joint, is a serious condition affecting the bones, joints, and soft tissues of the foot and ankle. It is characterized by inflammation, bone destruction, and joint instability, often leading to deformity.
Pathophysiology:
Neuropathy: Leads to a loss of protective sensation, causing patients to continue to walk on an injured foot, exacerbating the damage.
Inflammation: The initial injury triggers inflammation, which can cause further bone resorption and weakening.
Bone and Joint Destruction: Continued stress and lack of proper treatment can lead to fractures, dislocations, and joint destruction.
Deformity: The structural changes can cause significant foot deformities, such as a rocker-bottom foot (midfoot collapse).
Signs and Symptoms:
Swelling: Significant swelling in the affected foot or ankle.
Redness: The foot may appear red and warm to the touch, resembling an infection.
Pain: Surprisingly, there might be minimal pain due to the neuropathy.
Deformity: As the condition progresses, noticeable deformities and changes in foot shape can occur.
Instability: The affected foot or ankle may become unstable and difficult to walk on.
If a P has Charcot foot + ulceration - what is the risk of amputation?
50%
How is Charcot foot managed?
Acute Phase:
Immobilization: The primary treatment involves offloading the affected foot to prevent further damage. This can include total contact casting, removable walking boots, or wheelchair use.
Rest: Minimizing weight-bearing activities to allow the bones to heal.
Chronic Phase:
Custom Footwear: Specialized shoes or orthotics to accommodate deformities and provide support.
Surgery: In severe cases, surgery may be necessary to correct deformities, stabilize the foot, and prevent ulceration.
How should diabetic feet be managed?
What are the RF for varicose veins?
Inc age
F > M
DVT - 10% will develop chronic venous insufficiency
Obesity
Smoking
Pregnancy
Inactivity
How do veins work?
Veins have valves
Flow - superficial veins to deep veins to IVC
Muscles tend to provide a pump to provide venous blood back to the heart
What is a valve which has lost efficiency from continuous pressure - and becomes dilated, elongated, tortuous and thickened?
Varicose veins
What are the Sx of varicose veins?
Heaviness or tension
Feeling of swelling
Aching
Restless legs
Cramps
Itching
Tingling
What can venous insufficiency cause on skin?
Lipodermatosclerosis
Haemosiderin deposit
What can be used to confirm reflux in veins?
Duplex USS
What complications can arise from varicose veins?
Phlebitis
Bleeding
Skin changes
Ulceration
What is Klippel-Trenaunay syndrome?
How does Parkes-Weber syndrome differ from this?
Port wine stain
Soft tissue or bone overgrowth
Venous abnormalities
Parker-Webes has the same but also has AVMs that can cause HF
How can varicose veins be treated?
Conservative - elevation, exercise, weight loss, compression stockings (different from TED)
Invasive
Surgery - high tie and stripping
Catheter or laster ablation
Sclerotherapy
What are possible complications of varicose vein surgery?
Bleeding
Bruising
Infection
Swelling
Nerve Injury
DVT
When can a venous infarction occur?
Rarely - following massive DVT
What are the signs of a venous infarction?
Swelling
Tenderness
Discolouration / Cyanosis
Pulses will be palpable initially
What is Rx of a venous infarction?
Elevation
Fluid resus
Thrombolysis
Many need emergency amputation
How can you differentiate between a venous and arterial cause of an ulcer?
Venous Ulcers:
1. Location:
Typically found on the medial or lateral aspects of the lower legs, particularly around the medial malleolus (ankle).
2. Appearance:
Irregularly shaped with well-defined edges.
Often shallow with a granulating base (red or pink).
May have a yellow fibrinous exudate.
3. Surrounding Skin:
Skin around the ulcer is often edematous (swollen).
Hemosiderin staining (brown discoloration) due to iron deposits from the breakdown of red blood cells.
Lipodermatosclerosis (thickening and hardening of the skin).
4. Pain:
Generally less painful than arterial ulcers.
Pain is often relieved by elevating the leg.
5. Associated Symptoms:
Presence of varicose veins.
Edema in the affected leg, which may improve with leg elevation.
Venous dermatitis (eczema) around the ulcer.
6. Pulses:
Peripheral pulses are usually palpable unless there is significant edema.
Arterial Ulcers:
1. Location:
Typically found on the toes, feet, or areas of trauma (e.g., pressure points such as the lateral malleolus, tips of toes, or between toes).
2. Appearance:
Regular borders with a “punched out” appearance.
Deep with a pale or necrotic base (may appear yellow, brown, or black).
Often dry with minimal exudate unless infected.
3. Surrounding Skin:
Skin around the ulcer is usually thin, shiny, and hairless.
May have a cool or cold temperature to the touch.
Pallor or cyanosis (bluish discoloration) when the leg is elevated.
4. Pain:
Typically more painful than venous ulcers.
Pain is often worse at night or when the leg is elevated (rest pain).
Pain may be relieved by dangling the leg over the side of the bed (dependent position).
5. Associated Symptoms:
Claudication (pain in the calf muscles during exercise due to poor blood flow).
Dependent rubor (redness of the foot when hanging down, which blanches on elevation).
Delayed capillary refill time.
6. Pulses:
Peripheral pulses are often diminished or absent.
How are arterial ulcers managed?
Revascularisation
Dont do compression
If mixed arterial and venous problems - sort arterial first!
Worst case = amputation
How are venous ulcers managed/
Deal with venous problem
Debridement
Sensible dressings
Compression therapy
How does compression therapy work for venous ulcers?
Cuts down inflammation and oedema
Improves tissue perfusion and transfer
Improves venous pump
Avoids maceration of skin
