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Core Curriculum > 2. Vascular Disease > Flashcards

2. Vascular Disease Flashcards

1
Q

Define Abdominal Aortic Aneurysm and state 2 types

A

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)

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2
Q

State causes/RF of AAA

A
  • Atheroma (RF: HTN, smoking, hypercholestrolaemia)
  • Connective Tissue Disease (Ehler Danlos, Marfans)
  • Trauma
  • M (F = increased rupture risk)
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3
Q

Whats the difference between true and pseudo-aneurysms?

A

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.

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4
Q

Symptoms and signs of AAA

A

Majority asymptomatic
Large –> pain or pulsating sensations in the back

Pulsatile and expansive abdominal aortic mass

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5
Q

Ruptured AAA Symptoms and signs

A
  • 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
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6
Q

Investigations/Management of AAA

Who is screened?

A

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

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7
Q

Aortic Dissection definition and classification

A

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)

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8
Q

Aortic Dissection RF (6)

A 
Hypertension
Atherosclerosis
Connective tissue disorders - SLE, Marfan’s, Ehler’s Danlos
Iatrogenic - angiography/angioplasty
Congenital - coarctation of aorta
Cocaine
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9
Q

Aortic Dissection Signs and Symptoms

A 
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
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10
Q

Investigations for aortic dissection

A

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

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11
Q

Management of Aortic Diseection

A

Beta blockers + analgesia

Ruptured – haemodynamic support and resuscitation

Type A – Open Surgery

Type B – Endovascular Repair/ conservative management

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12
Q

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

A

Ruptured AAA

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13
Q

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

A

Abdominal Ultrasound

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14
Q

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

A

Abdominal CT

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15
Q

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

A

Aortic Dissection

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16
Q

Which of the following examination findings is not consistent with an aortic dissection?

BP 100/40
Ejection systolic murmur
Collapsing pulse
Radio-radio delay

A

Ejection systolic murmur

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17
Q

Define Peripheral Arterial Disease

A

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
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18
Q

Intermittent Claudication Definition, RF

Symptoms

A
  • 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
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19
Q

Intermittent Claudication Signs

A 
Reduced peripheral pulses
“punched out” ulcers
Hair loss
Cyanosis
Brittle toenails
Beurger’s Angle < 20°
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20
Q

Leriche’s Syndrome Definition and signs

A

Blockage of the abdominal aorta as it bifurcates into the common iliac arteries

Triad
Bilateral Claudication
Erectile Dysfunction
Reduced Femoral Pulses

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21
Q

Critical Limb Ischaemia Triad

A

(Advanced stages of PAD)

Triad of:

  1. Rest Pain – burning pain at rest, alleviated by standing
  2. Arterial Ulcers
  3. Gangrene
22
Q

Prognosis of PAD

A 
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

23
Q

Investigations of Claudication

A

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
24
Q

ABPI Index

A

> 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

25
Q

Acute Limb Ischaemia Definition and 2 causes

A

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
26
Q

Acute Limb Ischaemia classification

A

Viable – No neurological signs + audible doppler at ankle

Threatened – Sensory loss, tense calf, no audible doppler

Dead – Complete neurological deficit, fixed mottling

27
Q

The 6 Ps of Acute Limb Ischaemia

A 
Pain
Pallor
Pulselessness
Perishingly Cold
Parasthaesia 
Paralysis

NB last 2 = Profound deficits = indicates a non-viable limb

28
Q

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

A

Peripheral arterial disease

29
Q

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

A

Amputation

30
Q

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

A

ABPI

31
Q

DVT Definition and Causes (broad)

A

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

32
Q

RF for DVT

A

Acquired

  • Age
  • Pregnancy
  • Trauma
  • Surgery
  • Cancer
  • Oestrogen

Inherited

  • Antithrombin Deficiency
  • Protein C/S deficiency
  • Anti Phospholipid Syndrome
33
Q

DVT signs and symptoms

A

Presentation

  • 50% asymptomatic
  • Leg swelling
  • Calf tenderness
  • Erythema
Examination
Pitting oedema
Calf warmth
Calf swelling >3cm difference
Prominent superficial veins
34
Q

DVT Investigations

A

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!

35
Q

Management of DVT

A

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
36
Q

DVT prevention

A

Stop OCP 4 weeks pre surgery
Compression stockings
LMWH for high risk patients

37
Q

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
A

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

38
Q

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

A

3 months

39
Q

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
A

Leg Vein USS

40
Q

Arterial Ulcers Definition

A

= Ischaemic ulcers

Caused by a lack of blood flow commonly due to PAD

41
Q

Arterial Ulcers Presentation:

A 
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
42
Q

Venous Ulcers Definition and Pathophysiology

A

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

43
Q

Venous Ulcer Presentation:

A 
Found in the “gaiter” region
Shallow, irregular, sloping edges
Usually painless (some pain on walking)
“Wet” – heavy exudate
Surrounding skin – oedematous,lipodermatosclerosis, haemosiderin deposition
44
Q

Neuropathic Ulcers (Not on sofia) - pathophysiology and presentation

A 
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
45
Q

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

A

Venous

46
Q

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

A

Neuropathic

47
Q

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

A

Arterial

48
Q

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

A

Venous

49
Q

Varicose Veins Definition and Pathophysiology

A

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

50
Q

Varicose Veins Risk Factors

A

Obesity
Pregnancy
OCP
Family History

51
Q

Varicose Veins Signs and Symptoms

A

Presentation

  • Pain
  • Unsightly legs
  • Cramps
  • Tingling/heaviness
  • Restless leg

Examination

  • Oedema
  • Excema
  • Ulcers
  • Phlebitis
  • Atrophie Blanche
  • Lipodermatosclerosis
52
Q

Management of Varicose Veins

A

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

Core Curriculum (19 decks)

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