4.01 Vascular Surgery - Presentations Flashcards
What are the two common presentations of vascular disease?
- lower limb ulcers
- acutely painful limb
An acutely painful limb that is cold and pale should be treated as what?
Acute limb ischaemia until proven otherwise, and is a surgical emergency.
What are the associated signs of acute limb ischaemia?
Hint: 6 Ps
- pain
- pallor
- perishingly cold
- paraesthesia
- paralysis
- pulselessness
Give some risk factors for acute limb ischaemia.
- atrial fibrillation
- hypertension
- smoking
- diabetes mellitus
- recent myocardial infarction
What investigations are warranted if acute limb ischaemia is suspected?
CT angiogram for confirmation and anatomical delineation, along with urgent vascular review.
In acute limb ischaemia, how long does it take for irreversible tissue damage to occur?
Approximately 6 hours - patients should be sufficiency resuscitated and started on IV heparin whilst decisions for definitive versus conservative treatments are made.
An acutely painful limb that is hot and swollen should be treated as what?
Deep vein thrombosis (DVT) until proven otherwise.
NB pain is often localised to the calf, associated with calf tenderness of firmness.
Give some risk factors for deep vein thrombosis.
- PMHx or FHx of pro-thombotic diseases (e.g. CVA, MI)
- recent immobility
- recent surgery
- COCP
- pregnancy
What score should be calculated in a patient you are suspecting a DVT in?
Comment upon the significance of the score and the subsequent management.
Well’s score should be calculated (see image).
Score ≥1 arrange ultrasound Doppler scan
Score =0 use D-Dimer to exclude DVT.
Outline the management of DVT.
If confirmed by ultrasound Doppler, DVT can be initially treated with therapeutic doses of Low-Molecular Weight Heparin (LMWH), before being swapped to a DOAC for 3-6 months.
NB those with an iliofemoral DVT with severe symptoms require urgent vascular review. Usually presents with complete leg swelling, with a blue or white discolouration.
Give some differentials for an acutely painful limb that is hot and swollen.
- cellulitis
- septic arthritis
- gout
Give some differentials for an acutely painful limb.
- acute limb ischaemia
- DVT
- cellulitis
- septic arthritis
- gout
- radiculopathy
- trauma
Which examinations are imperative when assessing the acutely painful limb?
- cardiovascular
- peripheral vascular
- neurological
- musculoskeletal
What is an ulcer?
An abnormal break in the skin or mucous membrane
Give some causes of ulcers.
- venous insufficiency (most common, 80%)
- arterial insufficiency
- diabetic-related neuropathy
- infection
- trauma
- vasculitis
- malignancy (SCC)
- pressure ulcers
Describe the characteristics of:
a) venous ulcers
b) neuropathic ulcers
c) arterial ulcers
a) shallow ulcers with a granulated base, often with other clinical features of venous insufficiency present
b) painless ulcers over areas of abnormal pressure, often secondary to joint deformity in diabetics
c) found at distal sites, with well-defined borders and evidence of arterial insufficiency
What is the pathophysiology of venous ulcers?
Valvular incompetence or venous outflow obstruction causes impaired venous return, with the resultant venous hypertension causing ‘trapping’ of WBCs in capillaries and the formation of a fibrin cuff around the vessel.
The fibrin cuff hinders oxygen transportation into the tissue, causing the WBCs to become activated and the subsequent release of inflammatory mediators.
The inflammatory mediators cause tissue injury, poor healing and necrosis.
Give the risk factors for venous ulcers.
- increasing age
- pre-existing venous incompetence (incl. varicose veins)
- history of VTE
- pregnancy
- obesity
- physical inactivity
- severe leg injury or trauma
What are the clinical features of venous ulcers?
- painful (esp. at end of day)
- found in gaiter region of legs
Associated symptoms of chronic venous disease, such as aching, itching, or a bursting sensation, will be present before venous leg ulcers appear.
On examination there may be varicose veins with ankle or leg oedema, along with other features of venous insufficiency:
- varicose eczema
- thrombophlebitis
- haemosiderin skin staining
- lipodermatosclerosis
- atrophie blanche
What investigations are warranted following the identification of a venous ulcer?
- confirm venous insufficiency using Duplex ultrasound
- ABPI to assess for arterial components to ulcers
- swab cultures if infection is suspected
What test must be performed before applying mutlilayer compression bandaging for venous ulceration?
ABPI - only apply bandaging if ABPI >0.6
What is the pathophysiology of arterial ulcers?
An ulcer caused by a reduction in arterial blood flow, leading to decreased perfusion of the tissues and subsequent poor healing.
What is the management of venous ulcers?
- leg elevation
- increased exercise
- weight reduction
- multicomponent compression bandaging
- emollients
If there are varicose veins, these can be treated with endovenous techniques or open surgery, as improving venous return will allow for the healing of venous ulcers.
What are the risk factors for arterial ulcers?
Same risk factors for peripheral arterial disease:
- smoking
- diabetes mellitus
- hypertension
- hyperlipidaemia
- increasing age
- family history
- physical inactivity
What are the clinical features of arterial ulcers?
- painful
- develops over a long period of time
- no healing (ie. no granulation tissue)
- cold limbs
- thickened nails
- necrotic toes
- hair loss
On examination the limbs will be cold, and have reduced or absent pulses.
What investigations are warranted following identification of arterial ulcers?
ABPI to quantify the extent of peripheral arterial disease.
The anatomical location of arterial disease can be assessed using clinical examination, followed by imaging.
Imaging modalities include: duplex ultrasound, CT angiography, and/or magnetic resonance angiogram (MRA).
What is the management of arterial ulcers?
Conservative management:
- smoking cessation
- weight loss
- increased exercise
Medical management:
- statin therapy
- antiplatelet (aspirin or clopidogrel)
- optimisation of blood pressure
- optimisation of blood glucose
Surgical management:
- angioplasty
- bypass grafting
What is the pathophysiology of neuropathic ulcers?
Peripheral neuropathy (ie. T2DM) leads to a loss of protective sensation, allowing repetitive stress and unnoticed injuries forming. This results in painless ulcers forming on the pressure points of the limb.
NB concurrent vascular disease will often contribute to their formation and reduced healing potential.
What are the risk factors for neuropathic ulcers?
- diabetes mellitus
- B12 deficiency
Ulcer risk is further compounded by any foot deformity or concurrent peripheral vascular disease.
What are the clinical features of neuropathic ulcers?
- history of peripheral neuropathy (though sometimes may be unaware)
- symptoms of peripheral vascular disease
- burning / tinging in legs
- painless
- warm feet and good pulses
What investigations are warranted upon the identification of neuropathic ulcers?
- random blood glucose or HbA1c
- serum B12 levels
- ABPI and/or duplex ultrasound to assess concurrent arterial disease
- swab if infection suspected
NB if severe infection is suspected, X-ray may be needed to assess for osteomyelitis.
What is the management of neuropathic ulcers?
- diabetic control optimised (HbA1c <7%)
- improved diet
- increased exercise
- regular chiropody
- maintain good foot hygiene
Any signs of infection will warrant swabs taken and antibiotics (e.g. flucloxacillin). Ischaemic tissue may require surgical debridement. Severely infected or necrotic digits may need amputation.
