MedEd vascular disease Flashcards
How is PVD classified?
Acute- acute limb ischaemia
Chronic- intermittent claudication or critical limb ischaemia
What form of limb ischaemia is acute vs chronic
acute= acute limb ischaemia chronic= critical limb ischaemia
What is the pathophysiology of PVD?
Atherosclerosis causes stenosis of an artery
What is acute limb ischaemia?
Sudden decrease in limb perfusion
What is intermittent claudication?
Pain on exertion
What is critical limb ischaemia?
Pain at rest
Where is pain in intermittent claudication?
Calf, thigh or buttock
How do you differentiate intermittent claudication from critical limb ischaemia?
IC= pain on exertion CLI= pain at rest
What are risk factors for PVD?
Diabetes Hypertension Smoking Old age (over 40) Males Hyperlipidaemia
What are the 6 ps of acute limb ishcaemia?
Pain Pulseless Perishingly cold Paralysis Parasthesia Pale
How do you remember signs of acute limb ischaemia?
6 Ps and cardiovascular risk factors
What are some signs and symptoms of intermittent claudication and critical limb ischaemia?
Hair loss Brittle slow growing toe nails Numbness in feet/legs Ulcers Absent pulses Atrophic skin
When is pain in intermittent claudication worse? What are the other characteristics of it?
When climbing up a hill
Pain usually comes on at the same distance each time
Pain is at the same spot/area at each time
What will help relieve pain in critical limb ischaemia?
Hanging their legs off the bed to allow blood to flow down
What test is done to confirm chronic PVD? How is it done
Beurger’s test- the leg will develop pallor when you lift it to 45 degrees, then when you swing it off the bed there will be a reactive hyperaemia where it goes back to original colour and then turns red
What investigations are done for PVD?
Cardiovascular risk assessment- BP, HR, bloods, ECG
Ankle brachial pressure index
Colour duplex ultrasound
Magnetic resonance angiogram
How is ankle brachial pressure index calculated and what are normal/abnormal scores?
Systolic blood pressure at ankle/systolic blood pressure of the arm
Normal range= 0.9-1.2
Abnormal= <0.9
Critical limb ischaemia= <0.5
At what angle will the leg be in beurger’s test when there is loss of pallor to indicate severe CLI?
It will loose pallor at 20 degrees
What is Leriche syndrome? How will it present- what is the triad?
aortoiliac occulusive disease
on CT blood will not flow past the iliac arteries
presentation triad: buttock claudication, impotence and absent or weak distal pulses (femoral, popliteal, dorsalis pedis and posterior tibial)
What triad of symptoms is present in Leriche’s syndrome?
Buttock claudication
Absent or weak distal pulses (femoral, popliteal, dorsalis pedis and posterior tibial)
Impotence
What abpi indicates PVD and then chronic limb ischaemia?
PVD= <0.9
CLI=<0.5
What will arterial ulcers look like, where will they appear?
Punched out appearance, well defined edges, pale base
On the distal surface of the foot- between dorsum of foot and toes
What are signs of arterial ulcers?
Hair loss around ulcer Shiny and pale skin around ulcer Calf muscle wasting Absent pulses Night pain
Where will arterial ulcers appear?
Distal surface of the foot
Between dorsum of foot and toes
Why will there be pain at night in arterial ulcers?
Because patients are lying so blood flow to legs is worse
What will venous ulcers look like, where will they appear?
They are large and shallow
They are sloping
Sides are less well defined
In the gaiter region- between knee and ankle (ie shin)
May have other symptoms of venous insufficiency eg itching, swelling and aching
Where will venous ulcers be found?
In the gaiter region- on the shin between the knee and ankle
What are the 4 signs of venous insufficiency?
Stasis eczema
Lipodermatosclerosis
Atrophie blanche
Hemoseriden deposition
What does lipodermatosclerosis look like?
Upside down champagne bottle looking leg
What does lipodermatosclerosis, stasis eczema, atrophie blanche and hemosiderin deposition siginify?
Venous insufficiency
What is the gold standard investigation for arterial ulcer?
Duplex USS of lower limbs
What is the gold standard investigation for venous ulcer?
Duplex USS of lower limbs
Measure the surface area of ulcer to monitor progression
What investigations are done for arterial ulcers?
Duplex USS of lower limb first line
ABPI
Cardiovascular screen: angiography, ECG, bloods (lipids, hba1c, glucose, FBC)
What investigations are done for venous ulcers?
Duplex USS of lower limbs
Measure surface are of the ulcer
ABPI
Swab for microscopy if there are signs of infection
Biopsy if you think its a Marjolin’s ulcer
What is Marjolin’s ulcer?
A venous ulcer which is cancerous- it arises from squamous cell epithelium due to chronic inflammation or injury and develops over years
How are venous ulcers managed?
Graded decompression stockings first to reduce venous stasis
Then debridement and cleaning to stop infection
Antibiotics if its infected
Moisturising cream because venous ulcers dry out the skin
What should you always check for when a patient comes in with a venous ulcer?
Diabetes mellitus
Peripheral vascular disease
What is an AAA?
A localised enlargement of the abdominal aorta where the diameter is over 3cm or more than 50% of whats normal for the patient
What size is an AAA?
Bigger than 3cm or bigger than 50% of the normal diameter for the patient
Where are most AAAs found?
90% are below the renal arteries but above the iliac artery
What are the types of AAA? What defines them?
True aneurysms (when all 3 layers of the artery widen)- sacular (they widen on one side) or fusiform (they widen on both sides) False aneurysms (where one layer of the artery is torn and blood gets into the space)
What are risk factors for AAA?
Male sex
Smoking
Connective tissue disorder (if its weaker aneurysm is more likely)
Old age
Hypertension
Inflammatory disorder (weakens walls of artery)
Who is screened for AAA?
Males over 65
How will ruptured AAA present?
Sudden severe pain in back, abdo or groin
Syncope
Shock
How will unruptured AAA present?
Usually asymptomatic
Found incientally
May have back pain in back, abdo or groin
What are signs of AAA? Include sings for ruptured and unruptured
Pulsatile and laterally expansile mass on palpation
Abdominal bruit
Grey Turners sign if ruptured
What invetsigations are done for AAA?
Bloods- cardiovasc risk screen eg FBC, clotting screen, UEs, LFTs, cross match incase surgery is needed
Abdominal ultrasound- to see if AAA is present
CT angiogram- to see if AAA is ruptured
Magnetic resonance angiogram- if patient has allergy to contrast or renal impairment
What is the initial and gold standard investigation for AAA? What is the limitation and what is done instead?
Abdo ultrasound- you can’t tell if its ruptured just if its present
To tell if its ruptured CT angiogram is done instead
If they are allergic to contrast or have renal impairment do magnetic resonance angiogram
What is the limitation of abdominal ultrasound when imaging AAA?
It cannot detect rupture of AAA it can only tell you if AAA is present
What investigation is the gold standard in determining if AAA has ruptured?
CT angiogram
What is aortic dissection?
A tear in the aortic intima allows blood to flow into a new false channel in between the inner and outer layers of the tunica media
What condition is the same as aortic dissection?
False abdominal aortic aneurysm
What are the 2 systems of classifying aortic dissection?
DeBakey
Stanford
What is a type I aortic dissection?
Tear both before and after the aortic arch
What is a type II aortic dissection?
Tear just before the aortic arch
What is a type IIIa aortic dissection?
Tear just after the aortic arch
What is a type IIIb aortic dissection?
Tear just after the aortic arch but below the level of the diaphragm
What is the most common type of aortic dissection?
Type II
What are risk factors for aortic dissection?
Male Smoking Hypertension Coarctation of the aorta Crack cocaine use
What is coarctation of the aorta?
Congenital narrow aorta
What are symptoms of aortic dissection?
Central tearing pain which will radiate to the back from
Symptoms due to blockage:
Block of carotid= blackout and dysphagia
Block or coronary artery= angina and MI
Block of subclavian= LOC
Block of renal artery= anuria and renal failure
What arteries might be blocked due to aortic dissection and how will this manifest?
Carotid= blackout and dysphagia Coronary= MI and chest pain Renal= anuria and renal failure Subclavian= LOC
What are signs of aortic dissection?
Hypertension Blood pressure difference between arms of more than 50% Murmur on the back behind left scapula Signs of aortic regurg Signs of connective tissue disease
Who is most likely to have an aortic dissection?
Old male with hypertension and connective tissue disease
What murmur is associated with aortic dissection and where will it be heard?
Aortic regurg
Best heard on the back behind the left scapula
What is the gold standard investigation for aortic dissection?
CT angiogram
What are investigations for aortic dissection?
Bloods- cross match, UE, LFT, troponin, CK
ECG (often normal)
CT angiogram
Chest x ray
What will CXR in aortic dissection show?
Loss of contour of aortic knuckle
Widened mediastinum
Globular heart
What will you see on CT angiogram in aortic dissection?
There will be a clear line in the aorta and the blood will be flowing into the new channel (the side it is flowing into will be more white)
How can you differentiate between aortic dissection and false AAA?
Dissection= pain higher up near chest
False AAA= pain lower down nearer flank/abdominal region
What murmur is associated with aortic dissection?
Aortic regurgitation
What are varicose veins?
Subcutaneous, permanently dilated veins >3mm in diameter when measured in standing position (most often superficial veins of the lower limb)
How can blood flow in varcose veins be described?
Turbulent and not unidirectiomal
When are varicose veins most prominent?
When standing up
What are RF for varicose veins?
Increasing age Female sex Obesity Family hx Caucasian
What is the pathology of varicose veins?
Imcopetent valves in veins
What is the most common cause of varicose veins?
Idiopathic
What are causes of varicose veins?
Primary- idiopathic
Secondary- venous outflow obstruction (pregnancy, ascites, ovarian cysts, pelvic malignancy), DVT and AV malformations
What are the main symptoms of varicose veins?
Visible dilation of veins Leg aching worse when standing Swelling Itching Bleeding
What must you do when diagnosing varicose veins?
Assess the patient standing up
What are signs of varicose veins?
Veins feel hard
Tap test- tap distally and feel thrill over saphenofemoral junction, or tap and feel blood flow distally due to blood flow in the wrong direction
Auscultation for bruits
Trendelenburg test
How is Trendelenburgs test carried out and what is an abnormal result?
Lie the patient down and lift their leg up and massage it distal to proximal to empty it of blood
Tie a tourniquet on their leg above the knee and ask them to stand up and observe how long it takes to refill
If the vein refills quickly (normal time is 30-35 seconds) it means there is valvular imcompetence
How do you work out where exactly the incompetence is in a valve using the trendelenburg’s test?
If the vein refills at a normal time, the incompetence must be higher so tie the tourniquet higher and try again
What is the normal time the vein will take to refill in trendelenburg’s test? What is abnormal?
30-35 seconds
Abnormal is quick refilling
How do you differenitate between deep and superficial valve problems using trendelenburg’s test?
Quick refilling with the tourniquet on= deep valve problem
Take the tourniquet off and even quickler refilling= also a superificial valve problem
What is the gold standard investigation for varicose veins? Why is it useful?
Duplex ultrasound- it shows you exactly where the valvular incompetance is and can help rule out DVT
How are varicose veins managed?
First line conservation= loose weight if obese and exercise, leg elevation, compression stockings
Second line endovascular treatment= radiofrequency ablation (put catheter in vein and heat to 120 degrees to destroy endothelium and close the vein), endovenous laser ablation (uses lasers to close vein instead of heat) or microinjection sclerotherapy (inject liquid into multiple parts of a vein to compress it and encourage normal blood flow for a few weeks or inject foam to damage the vein and close it)
Surgery- stripping of long saphenous vein, saphenofemoral ligation, avulsion of varicosities
What is the best treatment for varicose veins besides conservative treatment?
Endovascular surgery
When can surgery not be done in varicose veins and why?
When it involves the short saphenous vein due to damage to structures
What are complications of varicose veins?
Venous ulcer
Stasis eczema
Lipodermatosclerosis
Hemosiderin deposition
Post sclerotherapy- skin staining, local scarring
Post surgery- heamorrhage, infection, recurrence, parasthesia, pernoneal nerve injury
What are the 2 major complications of all surgery
Haemorrhage
Infection
What is gangrene?
Tissue necrosis
What are the 3 types of gangrene?
Wet
Dry
Gas
What causes gangrene?
Tissue ischaemia
Infarction
Physical trauma
What organism causes gas gangrene>
Clostridium perifringens
What are RFs for gangrene?
Diabetes Immunosupresion Steroid use PVD Ulcers
What do the different types of gangrene look like?
Dry- most common, looks dry, tissue is black
Wet- associated with pus and bad smell due to anaerobes
Gas- overlying oedema with discolouration and crepitus
What are RF for DVT?
Obesity Pregnancy Smoking Hospital admission Polycythaemia
What are signs anf symptoms of DVT?
Painless Erythema Warmth Varicosities Swollen limb
What is a defining point about DVTs?
They are painless
What is Homan’s sign?
Forced passive dorsiflexion of the ankle causes deep calf pain
What is Homan’s sign used for?
Helps identify DVT
What sign might help identify DVT?
Homan’s sign
What is used to calculate risk of having a DVT?
Well’s criteria
What is used to calculate likelihood of having a PE?
Well’s score
What is the difference between Well’s criteria and score?
Well’s criteria= risk of developing DVT
Well’s score= likelihood of having a PE
What is the first line investigation for DVT?
Doppler ultrasound
What investigations are done for DVT? Why?
Doppler ultrasound- best to image
Impedence phlethysmography
D dimer- if negative DVT is unlikely
ECG, CXR, ABG- if PE is suspected
How is DVT managed?
DOAC (apixaban/ rivaroxiban) or LMWH (first initiation therapy) for 3 months if provoked, if unprovoked for 6 months
DOAC given more commonly
For prevention= give compression stockings, advise physical acitivity
Give 2 examples of DOACs?
Apixaban
Rivaroxiban
What might you insert in DVT and how does it work? When might you use it?
IVC (inferior vena cava) filter- doesn’t stop you from getting a DVT but it will stop the DVT from becoming a PE because it can’t travel from the legs past the IVC into the lungs
Use it if all anticoagulation is contraindicated
