2. Vascular Disease Flashcards
Define Abdominal Aortic Aneurysm and state 2 types
A localized dilation of the abdominal aorta to >1.5x its original diameter OR >3cm.
Can be fusiform (bulges on both sides) or saccular (bulges on one side)
State causes/RF of AAA
- Atheroma (RF: HTN, smoking, hypercholestrolaemia)
- Connective Tissue Disease (Ehler Danlos, Marfans)
- Trauma
- M (F = increased rupture risk)
Whats the difference between true and pseudo-aneurysms?
True aneurysm are dilatations involving ALL layers of the arterial wall
Pseudoaneurysms involve a collection of blood in the outer layer, which communicates with the lumen.
Symptoms and signs of AAA
Majority asymptomatic
Large –> pain or pulsating sensations in the back
Pulsatile and expansive abdominal aortic mass
Ruptured AAA Symptoms and signs
- Severe abdominal pain, radiating to the back/groin (often confused with renal colic)
- Bleeding can result in hypovolaemic shock (low BP/ high HR) which can result in collapse
- Retroperitoneal bleeding may result in Grey Turner’s or Cullen’s Sign
Investigations/Management of AAA
Who is screened?
USS (based on aneurysm size)
1) Small (3-4.4cm) - 1yr follow-up scan
2) Medium (4.5cm-5.4cm) - 3mths follow-up scan; conservative: stop smoking, lose weight, exercise; medical: statins, BP meds, aspirin
3) Large (>5.5cm) or growth >1cm/yr - surgical: open aortic surgery (young pts, longer recovery) OR endovascular repair (less peri-operative mortality, higher risk of further procedures)
All males over 65 screened
Aortic Dissection definition and classification
A tear in the tunica intima resulting in blood accumulation between the inner and outer tunica media (false lumen).
Type A - Tear in the ascending aorta Type B - Tear in the descending aorta (after the left subclavian branch)
Aortic Dissection RF (6)
Hypertension Atherosclerosis Connective tissue disorders - SLE, Marfan’s, Ehler’s Danlos Iatrogenic - angiography/angioplasty Congenital - coarctation of aorta Cocaine
Aortic Dissection Signs and Symptoms
S - Central O - Sudden C - Tearing R - Back A - depends on position of tear: Carotids - blackout, hemiparesis; Coronary - MI, angina; Renal - AKI, renal failure; Coeliac trunk - abdo pain
TC BP > 20mmHg discrepancy b/t arms Wide pulse pressure Radio-radial delay Murmur heard on back below scapula Signs of aortic insufficiencyL collapsing pulse, EDM
Investigations for aortic dissection
Investigations
Bloods
- FBC, U&Es (renal damage)
- X Match 10 units of blood
- Cardiac enzymes (troponin) – usually negative
CXR - Widened mediastinum and aortic notch visible
ECG - often normal, maybe some ischaemia
CT angiography - Visualisation of dissection and intimal flap
- If CT unavailable in acute setting, Transoesophageal Echo very sensitive
Management of Aortic Diseection
Beta blockers + analgesia
Ruptured – haemodynamic support and resuscitation
Type A – Open Surgery
Type B – Endovascular Repair/ conservative management
A 69 year old man with a background of hypertension complained of flank pain all day at work. He then has sudden onset abdominal pain that radiates to his back and groin. He arrives in an ambulance unconscious. The doctor notes Grey Turner’s and Cullen’s signs. What is the most likely diagnosis?
Renal colic
Myocardial Ischaemia
Ruptured AAA
Pancreatitis
Ruptured AAA
A 65 year old gentleman is coming in for screening for a AAA following a letter received in the post. What modality would be used as a screening tool?
Abdominal Ultrasound
Abdominal CT
Abdominal X-ray
Doppler Ultrasound
Abdominal Ultrasound
The same gentleman, 3 years later with a known AAA (last measured 5.2 cm) comes in complaining of severe abdominal pain. What investigation would you use to assess if it has ruptured?
Abdominal Ultrasound
Abdominal CT
Abdominal X-ray
Doppler Ultrasound
Abdominal CT
A 70 year old gentleman with known hypertension presents to A&E with tearing chest pain, radiating to the back. His CXR shows a widened mediastinum. What is the most likely diagnosis?
Aortic Dissection
STEMI
Teitze’s Syndrome
Costochondritis
Aortic Dissection
Which of the following examination findings is not consistent with an aortic dissection?
BP 100/40
Ejection systolic murmur
Collapsing pulse
Radio-radio delay
Ejection systolic murmur
Define Peripheral Arterial Disease
Definition:Narrowing of arteries other than those supplying the brain/heart. Most commonly seen in the legs.
- Intermittent claudification
- Critical Limb Ischaemia
- Acute Limb Ischaemia
Intermittent Claudication Definition, RF
Symptoms
- Cramping muscular pain in the calf, thigh or buttocks precipitated by exercise and relieved by rest (Reproducible claudication distance)
- RF – smoking, HTN, DM, cholesterol
- M >50 yrs alongside CVD
Intermittent Claudication Signs
Reduced peripheral pulses “punched out” ulcers Hair loss Cyanosis Brittle toenails Beurger’s Angle < 20°
Leriche’s Syndrome Definition and signs
Blockage of the abdominal aorta as it bifurcates into the common iliac arteries
Triad
Bilateral Claudication
Erectile Dysfunction
Reduced Femoral Pulses
Critical Limb Ischaemia Triad
(Advanced stages of PAD)
Triad of:
- Rest Pain – burning pain at rest, alleviated by standing
- Arterial Ulcers
- Gangrene
Prognosis of PAD
Intermittent Claudication: 80% chance of improving 5% intervention 1% amputation 15% dead within 5 years
Critical Limb Ischaemia:
90% major intervention
25% major amputation
50% dead within 5 years
Investigations of Claudication
ABPI (Ankle Brachial Pressure Index):
- When the blood pressure in the ankles is lower than the brachial pressure – indicates PAD
- If suspected PAD but normal ABPI – exercise testing ABPI conducted
Doppler Ultrasound:
- Sound waves measuring blood flow through arteries/veins
- Non-invasive and cheap
- Poor visualisation below the knee
Magnetic Resonance Angiography:
- Gold standard for demonstrating anatomy
- Contrast agents may be nephrotoxic
ABPI Index
> 0.95: Normal
0.5-0.95: Claudication
0.3-0.5: Rest Pain
<0.3: Critical Ischaemia
Vessel Calcification (making arteries more difficult to compress) may cause false negatives or high ABPI indices
Acute Limb Ischaemia Definition and 2 causes
Sudden lack of blood flow to the limb – often caused by an embolus or thrombus – surgical emergency
- Thrombus – due to PAD (leading to vessel blockage)
- Embolus – cardiac origin
Acute Limb Ischaemia classification
Viable – No neurological signs + audible doppler at ankle
Threatened – Sensory loss, tense calf, no audible doppler
Dead – Complete neurological deficit, fixed mottling
The 6 Ps of Acute Limb Ischaemia
Pain Pallor Pulselessness Perishingly Cold Parasthaesia Paralysis
NB last 2 = Profound deficits = indicates a non-viable limb
A 65 year old lady with known CVD presents to the GP with pain in her legs. She finds the pain comes on when she is walking to the shops, but is relieved by rest. She has a 40 pack year smoking history. What is the most likely diagnosis?
Acute limb ischaemia
Deep vein thrombosis
Varicose veins
Peripheral arterial disease
Peripheral arterial disease
A 60 year old male with known atrial fibrillation presents to A&E with a sudden onset of a painful, cold leg. The doctor is unable to feel peripheral pulses, and upon examination notes a loss of sensation and paralysis. A venous doppler is inaudible. What is the definitive management?
Embolectomy
Watch and wait
Angioplasty
Amputation
Amputation
A 69 year old heavy smoker complains of pain in his leg when he walks to the bus stop. On examination of his leg, you see shiny skin, patchy hair, weak pulses and brittle toenails. What would be the first line investigation?
Angiography
Doppler Ultrasound
Magnetic Resonance Angiography
ABPI
ABPI
DVT Definition and Causes (broad)
Deep Vein Thrombosis = Formation of a clot (thrombus) in the deep veins, most commonly in the pelvis or leg
Virchow’s Triad: venous stasis, vessel wall injury, blood hypercoagulability
RF for DVT
Acquired
- Age
- Pregnancy
- Trauma
- Surgery
- Cancer
- Oestrogen
Inherited
- Antithrombin Deficiency
- Protein C/S deficiency
- Anti Phospholipid Syndrome
DVT signs and symptoms
Presentation
- 50% asymptomatic
- Leg swelling
- Calf tenderness
- Erythema
Examination Pitting oedema Calf warmth Calf swelling >3cm difference Prominent superficial veins
DVT Investigations
Investigations
Dictated by the Two-Level DVT Well’s Score:
> 2 points => DVT likely:
- Leg Vein USS
- > if –ve perform D-dimer; if D-dimer +ve repeat USS 6-8 days later
<2 points => DVT unlikely:
D-Dimer test-> if +ve perform leg vein USS
NB/ in pregnancy D-Dimer has a high false positive rate!
Management of DVT
Anticoagulation:
Low Molecular Weight Heparin for at least 5 days
Warfarin – start within 24hrs for at least 3 months
Others:
- Inferior Vena Cava filters – temporary measure
- Thrombolytic therapy BUT huge bleeding risk(give if symptoms < less than two weeks, pt normally well w/ good life expectancy and low risk of bleeding)
- Thrombectomy – surgical removal of the clot
DVT prevention
Stop OCP 4 weeks pre surgery
Compression stockings
LMWH for high risk patients
A 38 year old lady presents with swelling in her leg, and associated calf tenderness. She has been taking the OCP for several years. What is the best management for this patient?
Warfarin + LMWH Warfarin Aspirin LMWH + Aspirin LMWH
Warfarin + LMWH
Warfarin is the best long term anti-coagulant
BUT warfarin is paradoxically pro-thrombotic for the first 48hrs
Warfarin inhibits Factors 2, 7, 9, 10 (procoagulant) AND Protein C and S (anticoagulant)
Protein C has a very short half life
Early drop in protein C therefore results in a hypercoagulable state
Heparin is given to combat this; stopped when the INR > 2 OR administered >5 days
A 72 year old gentleman is complaining of pain in his right leg. He is 8 days post operative for a tibia/fibula fracture repair. What is the minimum amount of time the patient must be anticoagulated for?
3 months
6 months
1 year
Lifelong
3 months
A 32 year old woman on the OCP complains of pain in her calf for one day. She does not have any chest pain or shortness of breath. The nurse tells you that the A&E doctors assessed the patient, who scored 2 although she cannot remember the name of the score. What is the most appropriate initial investigation?
D-Dimer MRA Leg Vein USS ABPI CTPA
Leg Vein USS
Arterial Ulcers Definition
= Ischaemic ulcers
Caused by a lack of blood flow commonly due to PAD
Arterial Ulcers Presentation:
In between toes/lateral aspect of foot and ankle “punched out” appearance – well defined Very painful Evidence of gangrene/necrosis Minimal exudate Surrounding skin – cold, shiny, hairless
Venous Ulcers Definition and Pathophysiology
Definition: Ulcers due to inappropriate valvular function – often chronic wounds
Pathophysiology: Valvular incompetence leads to venous hypertension - blood and proteins leak into the extravascular space leakage of fibrinogen and fibrin build up results in reduced oxygen delivery accumulation of leukocytes leads to release of proteolytic enzymes and ROS
Venous Ulcer Presentation:
Found in the “gaiter” region Shallow, irregular, sloping edges Usually painless (some pain on walking) “Wet” – heavy exudate Surrounding skin – oedematous,lipodermatosclerosis, haemosiderin deposition
Neuropathic Ulcers (Not on sofia) - pathophysiology and presentation
Pathophysiology: People with diabetes develop peripheral neuropathy due to various metabolic and neurovascular factors. This leads to a loss of pain/feeling in the toes and feet – blisters and sores appear and pressure injuries therefore go unnoticed Presentation: Ulcers found on the plantar aspect/under the heel Even wound margins Deep ulcer Calloused skin May be pockets of infection Palpable pulses and warm foot
A 75 year old woman with long standing hypertension has had progressive swelling of her legs over the last 3 months. She has consulted her GP because she has developed an ulcer on the anterior aspect of the right shin which weeps serous fluid profusely. What is the cause of the ulcer?
Arterial
Venous
Neuropathic
Rheumatoid Arthritis
Venous
A 62 year old diabetic woman shows you an ulcer on the bottom of her foot. It has a little stone lodged in it, which she hasn’t noticed. On neurological examination, she has no peripheral sensation of light touch up to her mid-foot. What is the cause of the ulcer?
Arterial
Venous
Neuropathic
Trauma
Neuropathic
A 78 year old obese woman presents with an ulcer on the top of her foot and one between her toes. They haven’t healed in two months. They are quite small, look punched out and yellow. She complains her feet are always cold and has a history of coronary artery disease.
Arterial
Venous
Neuropathic
Trauma
Arterial
A 45 year old lady presents with a 4 cm chronic ulcer on the medial aspect of the lower leg. She has a history of pain in the calf on walking. The skin around the ulcer is brown and heavily indurated.
Arterial
Venous
Neuropathic
Trauma
Venous
Varicose Veins Definition and Pathophysiology
Definition: Long, tortuous and dilated veins of the superficial venous system
Pathophysiology:
In healthy veins, there is blood flow from superficial to deep
Valves prevent the flow of blood in the opposite direction
Valvular insufficiency results in venous hypertension and dilation of the superficial veins
Varicose Veins Risk Factors
Obesity
Pregnancy
OCP
Family History
Varicose Veins Signs and Symptoms
Presentation
- Pain
- Unsightly legs
- Cramps
- Tingling/heaviness
- Restless leg
Examination
- Oedema
- Excema
- Ulcers
- Phlebitis
- Atrophie Blanche
- Lipodermatosclerosis
Management of Varicose Veins
Endothermal Ablation
- Radiofrequency Ablation
- Endovenous Laser Treatment
US guided Foam Sclerotherapy
- Foam injected into veins resulting in scarring of the veins, sealing them shut
- Surgery
Ligation and stripping
