General Vascular Flashcards
What are the three conditions in peripheral arterial disease? (PAD)
- Intermittent claudication
- Critical limb ischaemia
- Acute limb ischaemia
If a patient presents with an acutely painful limb presents with the following features, what are the main differentials you think of?
- Cold and Pale
- Hot and Swollen
- Traumatic history
- Neurological signs
- Cold and Pale: acute limb ischaemia
- Hot and Swollen: DVT, cellulitis, MSK related infections
- Traumatic Hx: fractures
- Neurological signs: radiculopathy, MS (central), disc herniation (spinal), infection (peripheral)
What are the symptoms of acute limb ischaemia?
- Pulseless
- Pain
- Pallor
- Paraesthesia
- Perishingly cold
- Paralysis
Top three are usually first to present
How do you investigate and manage a suspected acute limb ischaemia in general terms?
EARLY INVOLVMENT OF VASCULAR TEAM
Ix
- Examine contralateral limb for comparison
- Look at underlying risk factors e.g AF, DM, smoking, HTN
- Arrange CT angiogram and urgent vascular review
Mx
- Emergency as irreversible tissue damage can occur in six hours
- Start on IV heparin
- Analgesia
How do you investigate and manage a DVT in general terms?
Ix
- Swollen hot limb with pain localised to calf
- Calculate Well’s score, if 2 or more do US Doppler
- If <2 do D-dimer
Mx
- Start apixaban or rivaroxaban for 3-6 months. If Cx start LMWH for 5 days first then switch to dabigatran for 3 months
- If iliofemoral DVT then urgent vascular review
What is the clinical difference betweel a politeal vein DVT and an iliofemoral DVT?
- Popliteal: pain, swelling and tenderness localised to calf, conservative management with LMWH and DOACs
- Iliofemoral: pain and swelling in whole leg, may be blue or white leg, needs urgent vascular review
If a patient presents with an acutely painful limb you should consider neurological pathology like radiculopathy. What would the clinical picture be if this was the underlying cause?
- Back pain that radiates to affected area
- Pain worse on movement
- Muscle weakness
- Paraesthesia
- Altered reflexes
How do you assess, investigate and manage a patient that presents with an acutely swollen limb?
- Accurate history
- Vascular and neurological exams of both limbs
- Ensure patient haemodynamically stabilised
- Look for red flags
- CT angiography if suspect acute limb ischaemia
- Routine bloods with G+S
- Analgesia
What is the difference between intra and retroperitoneal AAA ruptures?
Where is rest pain usually felt and what would be the ABPI in this instance?
- Toes or foot
- <0.5
In peripheral vascular diease, why does a patients foot go redder in the diseased limb than the normal limb after Buerger’s test?
Severe ischaemia (during elevation) leads to the release of local vasodilators (e.g. ADP, potassium, hydrogen ions, lactate, carbon dioxide) that subsequently increase the perfusion of the ischaemic foot when back to normal
What is the difference between intra and retroperitoneal AAA ruptures?
Where is rest pain usually felt and what would be the ABPI in this instance?
- Toes or foot
- <0.5
In peripheral vascular diease, why does a patients foot go redder in the diseased limb than the normal limb after Buerger’s test?
Severe ischaemia (during elevation) leads to the release of local vasodilators (e.g. ADP, potassium, hydrogen ions, lactate, carbon dioxide) that subsequently increase the perfusion of the ischaemic foot when back to normal
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 -brachial
- Tibial plateau fracture (lateral bumper fracture) - anterior tibial
- Dislocation of knee- popliteal
- Posterior dislocation of shoulder - axillary
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 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!
