MET3 Revision: Vascular Flashcards

1
Q
A
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2
Q

Define critical limb ischaemia [3]

A

Critical limb ischaemia is the end-stage of peripheral arterial disease, where there is an inadequate supply of blood to a limb to allow it to function normally at rest.

  • Far extreme of intermittent claudification: rest pain (often constant) due to inadequate supply of blood to a limb
  • < 50 mmHg at ankle
  • Gangrene & ulcers
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3
Q

Define intermittent claudification [1]
Describe the pain expereince in intermittent claudification

A

Intermittent claudication:

  • a symptom of ischaemia in a limb, occurring during exertion and relieved by rest.
  • It is typically a crampy, achy pain in the calf, thigh or buttock muscles associated with muscle fatigue when walking beyond a certain intensity.
  • Patients describe a crampy pain that predictably occurs after walking a certain distance. After stopping and resting, the pain will disappear.
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4
Q

Describe the presenting features of critical limb ischaemia [3]

A

Pain at rest: this pain is typically described as a burning or aching sensation and is often worse at night

Non-healing wounds: Patients with CLI may develop non-healing wounds on their feet or legs. These wounds may be small or large and may be accompanied by drainage or an odour

Gangrene: In severe cases of CLI, patients may develop gangrene, which is the death of tissue due to lack of blood flow. Gangrene can cause the affected area to turn black and emit a foul odour

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5
Q

Define acute limb ischaemia [1]

A

Refers to a rapid onset of ischaemia in a limb.

Typically, this is due to a thrombus blocking the arterial supply of a distal limb, similar to a thrombus blocking a coronary artery in myocardial infarction

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6
Q

Name [1] and describe the classification used for PAD [4]

A

Fontaine classification

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7
Q

Describe the therapy options for PAD? [6]

A

Diabetic control:
- Reduce HbA1C by 1-2%

Cholesterol control:
- Artovastatin 80mg (all patients)
- Simvastatin 40mg

BP control

Antiplatets:
- Clopidogrel - 1st line
- Aspirin

Anti-oxidants & vitamins

Management of claudification:
- supervised exercise programmes: reduce symptoms by improving collateral blood flow. exercise till point of pain
- Vasoactive drugs:
Naftidrofuryl oxalate (5-HT2 receptor antagonist that acts as a peripheral vasodilator)

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8
Q

Describe the surgical treament options for PAD [3]

A

Angioplasty:
- inserting a catheter through the arterial system under x-ray guidance
- at the site of the stenosis, a balloon is inflated to create space in the lumen. A stent is can be ( but not always) inserted to keep the artery open

Endarterectomy
- cutting the vessel open and removing the atheromatous plaque

Bypass surgery
- using a graft to bypass the blockage
- may have to remove valve in a vein
- can use prosthetic graft if needed (Goretex / PTFE)
- veins last longer that prosthetic grafts}

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9
Q

What are the 6Ps of acute limb ischaemia? [6]

A

Pale
Pulseless
Painful
Paralysed
Paraesthetic
Perisingly cold

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10
Q

How do you manage acute limb ischaemia? [6]

A

Acute emergency!

Endovascular thrombolysis:
- inserting a catheter through the arterial system to apply thrombolysis directly into the clot

Endovascular thrombectomy:
- inserting a catheter through the arterial system and removing the thrombus by aspiration or mechanical devices

Surgical thrombectomy
- cutting open the vessel and removing the thrombus

Endarterectomy
Bypass surgery

Amputation of the limb if it is not possible to restore the blood supply

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11
Q

Which test is used to assess PAD in the leg? [1]

A

Buerger’s test

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12
Q

Describe how Buerger’s test is used to assess PAD in the leg [2]

A

Two parts:

1. Part One
- lie patient on their back (supine).
- Lift the patient’s legs to an angle of 45 degrees at the hip.
- Hold them there for 1-2 minutes, looking for pallor.
- Pallor indicates the arterial supply is not adequate to overcome gravity, suggesting peripheral arterial disease.
- Buerger’s angle refers to the angle at which the leg is pale due to inadequate blood supply. For example, a Buerger’s angle of 30 degrees means that the legs go pale when lifted to 30 degrees.

2. Second Part
- The second part involves sitting the patient up with their legs hanging over the side of the bed. Blood will flow back into the legs assisted by gravity. In a healthy patient, the legs will remain a normal pink colour. In a patient with peripheral arterial disease, they will go:
* Blue initially, as the ischaemic tissue deoxygenates the blood
* Dark red after a short time, due to vasodilation in response to the waste products of anaerobic respiration

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13
Q

Describe the first line diagnostic tool to diagnose PAD? [2]

A

The ankle-brachial index (ABI) is a non-invasive tool for the assessment of vascular status:

The ratio of systolic blood pressure (SBP) in the ankle (around the lower calf) compared with the systolic blood pressure in the arm. These readings are taken manually using a Doppler probe.

For example, an ankle SBP of 80 and an arm SBP of 100 gives a ratio of 0.8 (80/100).

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14
Q

What are the results of normal, mild, moderate & severe PAD from ABI? [4]

A

0.9 – 1.3 is normal
0.6 – 0.9 indicates mild peripheral arterial disease
0.3 – 0.6 indicates moderate to severe peripheral arterial disease
Less than 0.3 indicates severe disease to critical ischaemic

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15
Q

An ABPI above 1.3 can indicate [] of the arteries, making them difficult to compress. This is more common in diabetic patients.

A

Calcification

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16
Q

Describe the presentation of AAA [3]

A

Most patients are asymptomatic.

Pulsatile & expansile mass

It may be discovered on routine screening or when it ruptures:
* Severe abdominal pain that may radiate to the back or groin
* Haemodynamic instability (hypotension and tachycardia)
* Pulsatile and expansile mass in the abdomen
* Collapse
* Loss of consciousness

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17
Q

Whar are the indications for AAA surgery? [3]

A

AAA >5.5cm
Rapid AAA enlargement: >1cm/yr
Symptomatic

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18
Q

Describe the surgical procedures used to treat AAA [2]

A

Open AAA surgery:
- cross clamp the AA above & below aneursym
- open aneursym and remove clot
- stitch in graft

Endovascular aneurysm repair (EVAR)
- A wire is passed under fluoroscopic guidance through the aneurysm sac and a stent-graft is inserted to occlude the aneurysm from the inside
- local anaesthetic

19
Q

Describe the risk of open surgery to treat AAA [5]

A

Open surgery:
- cross clamping the aorta generates a huge increase in afterload and the cardiac stress this causes can result in on-table cardiac arrest.
- general anaesthetic and laparotomy are significant insults and if the patient has a very poor baseline function then they may not be able to survive the procedure: mortality - 5/10%
- MI
- Multiorgan failure
- Paraplegia: due to stoppage of blood supply to spinal cord
- Haemorrhage
- Infections (near bowel)
- Hernia

20
Q

What imaging is used for initial diagnosis [1] and confirmation [1] of AAA?

A

Ultrasound is the usual initial investigation for establishing the diagnosis.

CT angiogram gives a more detailed picture of the aneurysm and helps guide elective surgery to repair the aneurysm.

21
Q

The severity of the aortic aneurysm depends on the size.

The severity of the aortic aneurysm depends on the size:

Normal: less than [] cm
Small aneurysm: [] – [] cm
Medium aneurysm: [] – [] cm
Large aneurysm: above [] cm

A

The severity of the aortic aneurysm depends on the size:

Normal: less than 3cm
Small aneurysm: 3 – 4.4cm
Medium aneurysm: 4.5 – 5.4cm
Large aneurysm: above 5.5cm

22
Q

Define the term arterial dissection [1]

A

Disruption to the intimal layer (due to trauma, iatrogenic or spontaneous).
Blood doesn’t flow in normal channel & perfuse vessel & organs
Acts like a localised aneursym
A false lumen full of blood is formed within the wall of the aorta.

23
Q

Describe the pathophysiology of aortic dissection [2]

A

Tear in the tunica intima of the wall of the aorta, allowing blood to flow between the layers of the wall of the aorta.

A false lumen full of blood is formed within the wall of the aorta.

24
Q

Describe the clinical presentation for aortic dissection [5]

A
  • Severe chest pain
  • Chest AND abdominal pain
  • Aortic regurgitation; diastolic murmur
  • Hypertension
  • Bicuspid valve disease
  • Differences in blood pressure between the arms (more than a 20mmHg difference is significant)
  • Radial pulse deficit (the radial pulse in one arm is decreased or absent and does not match the apex beat
25
Q

Which is the area that most common for aortic dissection to occur? [1]

A

The right lateral area of the ascending aorta is the most common site of a tear of the intima layer, as this is under the most stress from blood exiting the heart}

26
Q

What are risk factors for aortic dissection? [3]

A

Hypertension:
- can be triggered by events that temporarily cause a dramatic increase in blood pressure, such as heavy weightlifting or the use of cocaine

Previous cardiac surgery

Genetic CT disorders
- Marfans syndrome
- Ehlers Danlos}

27
Q

Describe how the Standford [2] and Debakey Systems [4] are used to classifiy aortic dissections

A

The Stanford system:
Type A – affects the ascending aorta, before the brachiocephalic artery
Type B – affects the descending aorta, after the left subclavian artery

Debakey system:
Type I – begins in the ascending aorta and involves at least the aortic arch, if not the whole aorta
Type II – isolated to the ascending aorta
Type IIIa – begins in the descending aorta and involves only the section above the diaphragm
Type IIIb – begins in the descending aorta and involves the aorta below the diaphragm

28
Q

Describe the managment of type A & B aortic dissections [2]

A

Type A:
- open aortic arch replacement with graft
- Beta blockers to control BP: labetalol, metoprolol (or verapamil)

Type B:
- Thoracic endovascular aortic repair (TEVAR): catheter inserted via the femoral artery inserting a stent graft into the affected section of the descending aorta
- Beta blockers to control BP: labetalol, metoprolol (or verapamil)

29
Q

Describe the pathophysiology of varicose veins [3]

A

The deep and superficial veins are connected by vessels called the perforating veins (or perforators): allow blood to flow from the superficial veins to the deep veins.

When the valves are incompetent in these perforators, blood flows from the deep veins back into the superficial veins and overloads them.

This leads to dilatation and engorgement of the superficial veins

30
Q

Describe the clinical complications of varicose veins [10]

A

1. Swelling at ankles

2. Discomfort

3. Itching

4. Varicose eczema

6. Lipodermatosclerosis

7. Bleeding

8. Ulceration: high pressure clip off arterioles supplying oxygen to the skin in the extremities, leading to itchiness and dryness of the skin. If people itch the skin, they can break down and become an ulcer.

9. Haemosiderin: rbc red cells leaking out of insufficient veins that breaks down and Hb breaks down and becomes oxidised

10. Thrombophlebitis: inflammation of the superficial veins of the legs; constant pain that causes it to be hard, and painful

31
Q

Describe this complication of varciose veins [1]

A

Superficial thrombophlebitis

32
Q

What is this complication of varicose veins? [1]

A

Lipodermatosclerosis

33
Q

Describe the conservative [1], medical [1] and surgical [3] treatment of varicose veins

A

Conservative:
- Leg elevation
- Class 1/2 compression hosiery
- Weight loss

Medical:
- Topical relief for thrombophlebitis

Surgical:
- Endothermal ablation – inserting a catheter into the vein to apply radiofrequency ablation
- Foam sclerotherapy – injecting the vein with an irritant foam that causes closure of the vein
- Stripping – the veins are ligated and pulled out of the leg}

34
Q

A 65-year-old man attends an abdominal aortic aneurysm (AAA) screening offered by his GP. On ultrasound, it is revealed that he has a supra-renal aneurysm that is 4.9 cm in diameter. When questioned he says he has no symptoms.

How should this patient be managed?

12-monthly ultrasound assessment
3-monthly ultrasound assessment
6-monthly ultrasound assessment
Referral to stop smoking services
Urgent referral to vascular surgery

A

A 65-year-old man attends an abdominal aortic aneurysm (AAA) screening offered by his GP. On ultrasound, it is revealed that he has a supra-renal aneurysm that is 4.9 cm in diameter. When questioned he says he has no symptoms.

How should this patient be managed?

12-monthly ultrasound assessment
3-monthly ultrasound assessment
6-monthly ultrasound assessment
Referral to stop smoking services
Urgent referral to vascular surgery

35
Q

How often do you AAA rescan for
3 - 4.4 cm Small aneurysm [1]
4.5 - 5.4 cm Medium aneurysm [1]
≥ 5.5cm Large aneurysm [1]

A

3 - 4.4 cm; Small aneurysm: Rescan every 12 months
4.5 - 5.4 cm Medium aneurysm: Rescan every 3 months
≥ 5.5cm; Large aneurysm; Refer within 2 weeks to vascular surgery for probable intervention

36
Q

Describe how you treat superifical thrombophlebitis [3]

A

NSAIDs
Compression socks: reduces chance of DVT
LMWH: reduces chance of DVT

37
Q

A 66-year-old man reports that he is struggling to walk his dog as he finds that his calves are intensely painful after about 10 mins. A lower limb examination is normal aside from absent posterior tibial and dorsalis pedis pulses. His past medical history includes a myocardial infarction 3 years ago and he also smokes 30/day.

Given the likely diagnosis, which one of the following medications should he be prescribed daily for secondary prevention of cardiovascular disease?

Clopidogrel 300mg
Atorvastatin 40mg
Clopidogrel 80mg
Simvastatin 20mg
Aspirin 300mg

A

A 66-year-old man reports that he is struggling to walk his dog as he finds that his calves are intensely painful after about 10 mins. A lower limb examination is normal aside from absent posterior tibial and dorsalis pedis pulses. His past medical history includes a myocardial infarction 3 years ago and he also smokes 30/day.

Given the likely diagnosis, which one of the following medications should he be prescribed daily for secondary prevention of cardiovascular disease?

Clopidogrel 300mg
Atorvastatin 40mg
Clopidogrel 80mg
Simvastatin 20mg
Aspirin 300mg

38
Q

What doses of atorvastatin and clopidogrel should be prescribed for PAD? [2]

A

Atorvastatin 80 mg
Clopidogrel 80 mg

39
Q

A 55-year-old lady with claudication is assessed and an ABPI is performed. Results show an ABPI value of 1.3. Which of the following conditions may lead to this abnormal result?

Hypothyroidism

Hypercalcaemia

Type 2 diabetes

Peripheral arterial disease

Previous deep vein thrombosis

A

A 55-year-old lady with claudication is assessed and an ABPI is performed. Results show an ABPI value of 1.3. Which of the following conditions may lead to this abnormal result?

Hypothyroidism

Hypercalcaemia

Type 2 diabetes

Peripheral arterial disease

Previous deep vein thrombosis

40
Q

Peripheral arterial disease:

  • Buttock pain would indicate claudification in which vessel? [1]
  • Calf pain would indicate claudification in which vessel? [1]
A

Buttock pain: internal iliac artery
Calf pain: femoral vessels

41
Q

How do you determine if CLI is treated with open surgical revasc or angioplasty & stent? [1]

A

Multifocal: open revasc
Focal stenosis or thrombus: angioplasty and stenting

42
Q

You investigate a patient who is demonstrating stenosis. How do you determine if this patient needs open surgery or endovascular revascularization? [2]

A

Open surgery: long segments (> 10 cm)
Endovascular: short segments ( < 10 cm)

43
Q

You investigate a patient who is demonstrating signs of CLI.

How do you determine from the vessel affected if this patient needs open surgery or endovascular revascularization? [2]

A

Open surgery: lesions of common femoral artery and infrapopliteal disease
Endovascular: short segments: aortic iliac disease