AAA + other vascular

Question 1

definition of AAA

Answer 1

over 3cm

Question 2

is diabetes a RF for AAA

Answer 2

NO it is a negative RF

Question 3

where do 90% of AAA occur

Answer 3

infrarenal

Question 4

pathophysiology of AAA

Answer 4

normally caused by atherosclerosis (so RF are the same) and the fatty plaque weakens the vessel

Question 5

screening of AAA

Answer 5

abdo US for all men when 65

Question 6

If US shows AAA, what happens next

Answer 6

CT with contrast

Question 7

Mx of a AAA 3-4.4cm

Answer 7

yearly duplex USS

Question 8

MX of AAA if 4.5-5.4

Answer 8

3 monthly USS

Question 9

MX of AAA above 5.5

Answer 9

consider surgery - rupture risk is high

Question 10

surgical options for AAA repair

Answer 10

1) open repair - segment removed and replaced with prosthetic graft (can only do if the individual is fit)
2) endovascular - introduce a graft via femoral arteries and fix the stent across

Question 11

is open /endovascular repair better

Answer 11

open - has less aneurysm rupture and less re intervention
endovascualr gets endoleaks where blood leaks around graft so need surveillance US

Question 12

how do most AAA rupture

Answer 12

80% posteriorly into retroperitoneal space

Question 13

presentation of a ruptured AAA

Answer 13

pain, hypotension and a pulsatile abdominal mass

Question 14

if an AAA increases by what in a year should they be seen within 2 weeks for surgical repair

Answer 14

1cm

Question 15

signs of venous insufficiency (caused by retrograde blood flow due to incompetence of valves)

Answer 15

venous eczema, haemosiderin staining and lipodermatosclerosis

Question 16

how might chronic venous insufficiency present

Answer 16

chronic dull pain and pruritus

Question 17

Investigations for venous insufficiency

Answer 17

Duplex USS (which looks at the competence of valves), footpulses and ABPI and routine bloods to exclude other differentials like infection

Question 18

complications of chronic venous insufficiency

Answer 18

DVT, chronic pain, ulceration, recurrent cellulitis and loss of skin integrity

Question 19

how big is a varicose vein

Answer 19

> 3mm

Question 20

where does a saphena varix occur

Answer 20

at the saphenous femoral junction

Question 21

conservative MX for varicose veins / chronic venous insufficiency

Answer 21

legs elevated, lose weight, prevent long standing, compression stockings (check ABPI)

Question 22

what are the surgical options for varicose veins

Answer 22

vein ligation + stripping / foam sclerotherapy which is where an irritant foam is injected into the vein which then closes the vein off or endothermic ablation where the vein is heated inside to close it off

Question 23

MX of superficial thrombophlebitis

Answer 23

normally responds without Tx but can so compression stockings (make sure to exclude malignancy)
-use NSAID for analgesia (topical for limited and oral for more extensive)

Question 24

Dx of carotid artery stenosis

Answer 24

carotid duplex US and CT angiogram to assess the stenosis

Question 25

LT mx of carotid stenosis

Answer 25

anti platelet, statin, manage HTN and DM, smoking cessation, advise exercise, carotid endarterectomy

Question 26

what is the criteria for doing a carotid endarterectomy

Answer 26

if symptomatic and stenosis is between 50-99%

Question 27

description of a venous ulcer

Answer 27

shallow, irregular border with a granulating base commonly over the medial malleolus / gaiter area

Question 28

Dx of a venous ulcer

Answer 28

clinical but do a duplex US

Question 29

Mx of a venous ulcer

Answer 29

leg elevation, exercise, weight reduction, only prescribe Abx if there is clinical evidence of infection and clean and decried wound and then compression bandaging

Question 30

is a venous or arterial ulcer pain better on elevation

Answer 30

venous is better, arterial is worse

Question 31

what might the preceding hx have for an arterial ulcer

Answer 31

intermittent claudication

Question 32

MX of an arterial ulcer

Answer 32

lifestyle, revascularisaiton (with angioplasty and bypass grafting) and anti platelet meds

Question 33

Ix for a neuropathic ulcer

Answer 33

blood glucose, B12, assess ABPI, may do a X-ray to look for osteomyelitis

Question 34

MX of neuropathic ulcer

Answer 34

Tx underlying cause and offloading pressure and wound dressing with a moist environment

Question 35

who does takayasu arteritis normally affect

Answer 35

young asian woman

Question 36

what is takayasu arteritis

Answer 36

large vessel vasculitis (of aorta)

Question 37

what is acute limb ischaemia

Answer 37

severe, symptomatic hypo-perfusion of a limb occurring for <2 weeks

Question 38

how fast should acute limb ischaemia be corrected in

Answer 38

4-6 hours

Question 39

3 causes of an acute limb ischaemia

Answer 39

1) thrombosis 2) embolism 3) trauma or compartment

Question 40

how does acute limb ischaemia present

Answer 40

6PS

Question 41

Ix for acute limb ischaemia

Answer 41

Ct angiogram

Question 42

Mx of acute limb ischaemia

Question 43

Describe how to perform buergers test

Answer 43

legs held at 45 degree angle, for one minute. If leg goes pale shows PAD as arteries should be able to overcome gravity. The angle at which the pallor occurs is burgers angle. Then get patient to swing legs over the edge of the bed and look for the colour change. It will go blue (deoxygenated blood) and then red

Question 44

firstline Mx for an acute limb ischaemia

Answer 44

1) handheld arterial doppler (to identify if there is a pulse and where the occlusion is) then do ABPI

Question 45

how do we distinguish between thrombus vs embolus causes of acute limb ischaemima

Answer 45

thrombus --> there is preceding claudication, reduced pulses in contralateral limb and may be other evidence of vascular disease like Hx of MI or TIA Embolus --> vvv sudden, no preceding claudication, Hx of a fib

Question 46

Mx of superficial thrombophlebitis

Answer 46

1) duplex US to rule out underlying DVT 2) compression stockings 3) NSAIDS for analgesia 3 guidance is not from NICE but from PASSMED 3) prophylactic LMWH, if this is CONTRAINDICATED then consider NSAIDS

Question 47

why can subclavian steal syndrome produce syncopal symptoms

Answer 47

there is stenotic lesion in subclavian before the vertebral artery comes off so may get reduced cerebral blood flow especially in times of increased use (like pumping up a wheel)

Question 48

three factors of high risk rupture in AAA

Answer 48

1) symptoms 2) >5.5 3) rapidly enlarging by more than 1cm a year

Question 49

what is a marjolins ulcer

Answer 49

squamous cell carcinoma at the site of chronic inflammation eg burns (normally after 20 years)

Question 50

why does a venous ulcer occur,

Answer 50

when there is chronic venous insufficiency from incompetent valves and venous hypertension, the leucocytes can collect and cause ulcers / fibrin cuff may form

Question 51

what is the gold standard IX for chronic venous insufficiency, varicose veins, superficial venous thrombosis

Answer 51

DUPLEX USS

Question 52

when do you refer someone to secondary care with varicose veins

Answer 52

symptomatic, skin changes suggestive of chronic venous insufficiency, previous ulcer, previous bleeding

Question 53

firstline Ix for an acute limb ischaemia

Answer 53

hand held doppler

Question 54

summary of acute limb ischaemia

Answer 54

can be caused by trauma, embolus or thrombus presents with 6Ps Investigations --> handheld doppler to see if pulse, CT angiogram, ECG to see if embolus Mx --> call vascular, IV heparin, revascularisation therapy either thrombolysis, embolectomy with a balloon catheter or bypass surgery. -may need amputation Complications --> the revascularisation can cause big problems, due to oedema from the sudden blood flow. This can cause compartment syndrome. The myoglobin cause cause a AKI. -note paralysis is a late sign, the pain is there all the time and pulselessness is an early sign