19 - Vascular Flashcards
What are some examples of peripheral and arterial vascular disease?
Peripheral vascular disease often due to atheromas
What is intermittent claudication and what are some of the causes of this?
Pain in the muscles of the lower limb when walking/exercising that is relieved rapidly by stopping for a few minutes whilst standing up
Often in calf but can be in thighs and buttock too
Due to stenosis due to atheroma in superficial femoral artery (80%), aorto-iliac arteries (15%), calf arteries (5%)
What are some risk factors for peripheral vascular disease?
Most claudicants will have no symptom progression over 5 years but some can progress to amputation
How do you do a peripheral vascular examination in an OSCE for peripheral vascular disease?
https: //geekymedics.com/peripheral-vascular-examination/
- Inspect (e.g bypass scars, amputation)
- Hands
- Arms
- Neck
- Adomen
- Legs/groin
- Offer BP, ABPI, Buerger’s test is suspicion of Chronic Limb ischaemia, CVS exam
How do you do a peripheral venous exam in an OSCE?
https://teachmesurgery.com/examinations/vascular/varicose-vein/
WRITE IN OSCE BOOKLET
How do you work out ABPI?
Can be falsely high due to calcification of arteries in diabetes and renal disease
What pharmacolical treatment should you give to every patient with peripheral vascular disease?
- Antiplatelet (Clopidogrel 75mg)
- Statin (Atoravastatin 80mg)
- ADVISE SMOKING CESSASTION AND OFFER EXERCISE REHABILITATION
What tell tale sign helps you to diagnose critical limb ischaemia?
Pain in the foot at night relieved by dangling the foot out of the bed
How is critical limb ischaemia managed?
What is the definition of acute lower limb ischaemia?
What are some signs of arterial injury?
What fractures/dislocations have a high risk of vascular injury?
- Supracondylar fracture of the humerus in children
- Tibial plateau fracture (lateral bumper fracture)
- Dislocation of knee
- Posterior dislocation of shoulder
How do you do fluid resuscitation in a patient with peripheral vascular trauma?
- Adequate IV access on an uninjured extermity
- Preserve saphenous or cephalic veins and may be needed for repair
When should you suspect retroperiotenal bleeding from a femoral puncture (e.g following femoral artery catheterisation)?
What are varicose veins and what is their pathophysiology?
Tortuous dilated segments of veins that arise from valvular incompetence
Incompetent valves allow blood flow from deep venous system to superficial venous system (at sapheno-femoral junction and sapheno-popliteal junction)
This leads to venous hypertension and dilatation of superficial venous system
What are some causes of varicose veins?
- 98% are primary idiopathic
- DVT
- Pelvic masses (pregnancy, fibroids, ovarian masses)
- AV malformations
What are some risk factors for developing varicose veins?
- Prolonged standing
- Obesity
- Pregnancy
- Family history
- Age
What are the clinical features of varicose veins?
- Often present with cosmetic issues (unsightly veins or discolouration of skin)
- Can have aching, itching skin changes, ulceration, thrombophlebitis, signs of venous insufficiency as they worsen
- Often along short/great saphenous vein course
What are some signs of venous insufficiency?
- Ulceration
- Varicose eczema
- Haemosiderin deposition
- Lipodermatosclerosis
- Atrophie blanche
What is a saphena varix, how are they investigated an manged?
Ix: duplex US
Mx: high saphenous ligation
How are varicose veins classified?
CEAP classification
Clinical features
Aetiology
Anatomical
Pathophysiology
How are varicose veins investigated?
- Duplex US to look for valve incompetence
- Deep venous incompetence, DVT and stenosis must be looked for
How are varicose veins treated non-surgically?
- Compression stockings for the rest of life
- Any venous ulceration from deep venous incompetence then four layer bandaging unless arterial insufficiency (take ABPI, needs to be >0.8)
- Patient education e.g avoid prolonged standing, weight loss, increased exercise to promote calf muscle action
When are patients with varicose veins referred to a vascular clinic for surgical treatment?
NICE criteria:
- Symptomatic primary or recurrent varicose veins
- Lower limb skin changes e.g pigmentation or eczema
- Superficial vein thrombosis e.g hard painful veins
- Venous leg ulcer that has not healed in 2/52
What are the surgical treatment options for varicose veins?
- Vein ligation, stripping and avulsion: Make incision in groin or popliteal fossa, tye off refluxin vein and strip away. Can damage saphenous or sural nerve
- Foam Scleropathy: Inject sclerosing agent into varicosed vein causing inflammatory response closing off vein. Done under US guidance so foam doesn’t get in deep venous system. Only needs local anaesthetic
- Thermal Ablation: Uses radiofrequency or laser catheters to damage vein and closes it off. Done under US guidance and local anaeshetic
What are some complications of varicose vein treatment?
- Veins will worsen over time withut treatment
- Disease recurrence
- Haemorraghe
- Thrombophlebitis (ablation and sclerotherapy)
- Nerve damage (sural and saphenous)
Where are venous ulcers usually found?
Medial malleolus
What causes venous ulceration?
Venous hypertension which is causes by a calf pump failure
What is deep venous insufficiency and what is it caused by?
Similar pathophysiology to varicose veins but just affects deep veins not superficial
Failure of the venous system due to valvular reflux, venous hypertension and obstruction, leading to pain/ulcers/swelling
Usually caused by DVT or valvular insufficiency
What are some risk factors for deep venous insufficiency?
- Increasing age
- Female
- Pregnancy
- Previous DVT or phlebitis
- Obesity
- Smoking
- Long periods of standing
What are some of the presenting features of deep venous insufficiency?
- Chronically swollen lower limbs which can be aching, pruitic, painful
- Venous claudication which is pain on walking which resolves on leg elevation
- Signs like varicose eczema, thromophlebitis, haemosiderin skin staining, lipodermatosclerosis, atrophie blanchae, pitting oedema
- Venous ulcers
What is post thrombotic syndrome?
Syndrome that occurs after DVT
- Heaviness
- Cramps
- Pain
- Pruitic
- Paraesthesia
- Pretibial oedema
- Venous ectasia
- Hyperpigmentation
- Ulceration
How is deep venous insufficiency diagnosed?
- Doppler US: assess extent of venous reflux, look for stenosis, rule out DVTs and varicose veins
- Routine blood tests: FBC, U+Es LFTs and ECHO to rule out other causes such as cardiac
- Document foot pulses and ABPI
How is deep venous insufficiency managed?
Early management reduces long term complications
Conservative (more common)
- Compression stockings, if venous ulcer do 4 layer bandage
- Suitable analgesia
- Elevate foot above level of heart
Surgical (less effective)
- Valvuloplasty
- Venous stenting
What are some complications of deep venous insufficiency?
- Swelling
- Recurrent cellulitis
- Chronic pain
- Ulceration
Less common: DVT, secondary lymphoedema, varicose veins
What is thoracic outlet syndrome and what is it often caused by?
The clinical features that arise from compression of the neurovascular bundle within the thoracic outlet
Neurological (nTOS), Venous (vTOS) and Arterial (aTOS) symptoms
Usualy due to hyperextension injuries, repetitive stress injuries (e.g working over head), external compressive factors (e.g poor posture), anatomical abnormalities (e.g extra cervical rib)
What is the pathophysiology of thoracic outlet syndrome?
Brachial plexus and subclavian artery pass through scalene triangle.
Brachial plexus can get compressed between anterior and middle scalene or against the first rib
Usually lower cord that is irritated (ulnar symptoms)
What are some risk factors for thoracic outlet syndrome?
- Recent trauma
- Repetitive activity occupations or athletes
- Anatomical variations
What are the clinical features of thoracic outlet syndrome?
Depends on arterial, venous and neurological involvement but symptoms often worse with shoulder abduction and extension
On examination look for areas of weakness, numbness, tenderness and any limb ischaemia. Often tenderness over scalene muscles
What are some special tests you can do on examination to look for thoracic outlet syndrome?
- Adson’s manouevre
- Roo’s test
- Elvey’s test
What investigations are done for suspected thoracic outlet syndrome?
- Initial blood tests (FBC and clotting)
- CXR to look for rib abnormalities (most aTOS have bony issues)
- Venous and Arterial Duplex US at rest and in stress potions for aNOS and vNOS
- CT/MRI or venogram
- Nerve conduction studies for nTOS, often to rule out carpal and cubital tunnel
How is each type of TOS treated?
nTOS: physiotherapy to improve mobility in neck and shoulders and relax scalenes. Botulinum toxin injections can help relax scalenes
vTOS: thrombolysis and anticoagulation but most will need surgery to decompress thoracic outlet as well as venoplasty or venous reconstruction
aTOS with acute limb ischaemia: urgent vascular input and embolectomy
What are the methods for surgical decompression of the thoracic outlet?
- Supraclavicular or transaxillary approach
- Can excise first or cervical rib
- Can cut any restrictive bands
What are some complications of TOS surgery?
- Neurological or vascular damage
- Pneumothorax
- Haemothorax
- Chylothorax especially on left as thoracic duct in the outlet
What are some complications of untreated thoracic outlet syndrome?
- Permanent nerve damage
- Aneurysm dilation of subclavian artery leading to embolisation
- Loss of limb function
- Symptom recurrence
What is subclavian steal syndrome and why does it occur?
Syncope or neurological deficits when the blood supply to the affected arm is increased through exercise
Due to proximal stenosing or occlusive lesion in subclavian artery (atherosclerosis, vasculitis, TOS, aortic coarctation repair)
During exercise blood is taken from collateral circulation from reversed blood flow in ipsilateral vertebral artery, leading to syncope
What are some risk factors for subclavian steal syndrome?
Anything that increases the risk of atherosclerosis
- Smoking
- Hyperlipidaemia
- DM
- Smoking
- HTN
What are the clinical features of subclavian steal syndrome?
- During arm exercise blood to posterior cerebral circulation reversed so cerebellar symptoms like vertigo, diplopia, dysphagia, dysarthria, visual loss, syncope
- May have arm claudication (pain or paraesthesia) due to occluding lesions
How is suspected subclavian steal syndrome investigated?
- Duplex US: shows retrograde flow in vertebral artery during exercise
- CXR: to look for external compression of subclavian artery
- CT angiography: definitive investigation to find occlusion
How can the severity of Subclavian Steal Syndrome be classified?
How is subclavian steal syndrome managed?
Conservative
- Statin and antiplpatlet therapy
- Modify any CVS risk factors e.g smoking cessation
Surgical
- Endovascular or bypass techniques for occlusion clearance but risk of stroke and damage to brachial plexus
- Percutaneous angioplasty +/- stenting
What is hyperhidrosis and how can it be classified?
Sweating in excess of that required for regulation of body temperature. Sweating normally controlled sympathetically
Primary: no underlying cause, usually localised to hands, armpits, scalp or feet in symmetrical distribution
Secondary: associated with conditions or medication and can be generalised sweating or focal to areas
What are some causes of secondary hyperhidrosis?
- Pregnancy or menopause
- Anxiety
- Infections (TB, malaria, HIV)
- Malignancy (lymphoma)
- Endocrine disorders (hyperthyroidism, phaeochromocyoma)
- Medication (anticholinesterases, antidepressants, propanolol)
What are the clinical features of hyperhidrosis?
Primary: often bilateral and symmetrical focal sweating, occuring at least one a week, often <25 years when onset, needs to be present >6/12 for diagnosis
Secondary: often generalised sweating usually at night time
What investigations are done for hyperhidrosis?
- Diagnosis through history and exam
- Blood tests: FBC, CRP, U+Es, TFTs, Glucose
- CXR
How are patients with hyperhidrosis managed?
Conservative
- Lifestyle advice e.g avoid spicy foods, loose fitting clothes
- Antiperspirants with aluminium chloride
- Propantheline (anticholinergic)
Surgical (resistant symptoms or affecting QoL)
- Iontophoresis which is putting electrical current through the area with water soaked sponges, only short term
- Botulinum toxins to block nerve supply to sweat glands, lasts 2-6 months and only licenced underarm
- Endoscopic Thoracic Sympathectomy which damages thoracic sympathetic ganglion for palms and face. Risk of damage to lungs and other nerves so last resort
What do you need to warn patients undergoing surgery for hyperhidrosis?
May develop compensatory sweating in other locations
What is a bruit and a thrill?
Bruit: auscultation of turbulent blood flow
Thrill: feeling of turbulent blood flow
What are some blood tests you should do for patients with peripheral vascular disease?
- FBC
- Homocysteine
- Coagulation
- Fasting lipids and glucose
- HbA1c
What should all patients with intermitten claudication be referred for?
Claudication Exercise Programme
What is Leriche Syndrome?
- Bilateral Buttock claudication
- Impotence
- Absent femoral pulses
Due to aorto-iliac obstruction
Where do ulcers form in varicose vein disease?
Around the medial malleolus.
Starts like atrophie blanchae, then lipodermatosclerosis then ulcerates
How do you treat severe peripheral arterial disease or critical limb ischaemia?
- angioplasty
- stenting
- bypass surgery
What does a ruptured AAA usually present like?
Renal colic (loin to groin pain) so always consider this!
