Other Vascular Conditions Flashcards
Causes of lower limb ulcers
Ulcers - abnormal breaks in skin/ mucous membranes
Majority venous origin 80%
Other causes: arterial insufficiency, diabetic related neuropathy
Rarer: infection, trauma, vasculitis, malignancy (Sqcc)
Less mobile: pressure over bony prominence
Describe venous ulcers and their pathophysiology
Shallow, granulated base, other clinical features of venous insufficiency, irregular borders
Medial malleolus classically
Most common leg ulcer
Vascular incompetence/ venous outflow obstruction -> impaired venous return -> hypertension -> trapping WBCs capillaries -> fibrin cuff -> inflammatory mediators -> tissue injury, poor healing, necrosis
Clinical features of venous ulcers
Painful (worse end of day)
Often gaiter region
Associated chronic venous disease symptoms (aching, itching, bursting sensation)
Varicose veins
Leg oedema
Venous insufficiency (varicose eczema, thrombophlebitis, haemosiderin, lipodermatosclerosis, atrophie Blanche)
Investigations for venous ulcers
Clinical
Venous insufficiency confirmed - duplex USS
Ankle brachial pressure index - assess arterial component, if compression therapy useful
Microbiology swabs + antibiotics if infection
Thrombilia + vasculitis screening young
Management of venous ulcers
Conservative: Leg elevation Exercise WL Nutrition
Antibiotics - evidence infection
Multi component compression bandaging - 30-75% heal after 6months (ABPI >0.6)
Dressings
Emollients
Varicose veins - endovenous or open surgery
Describe an arterial ulcer
Distal sites, well defined borders, evidence arterial insufficiency, reduction arterial blood flow, small deep lesions, necrotic base
Clinical features of arterial ulcers
Intermittent claudication Critical limb ischaemia (pain night) Chronic Cold limbs Thickened nails Necrotic toes Hair loss Reduced pulses
Investigations for arterial ulcers
Ankle brachial pressure index
Extent peripheral arterial disease >0.9 normal
Location - duplex USS, Ct angiography, MRA
Management arterial ulcers
Critical limb ischaemia - vascular review
Conservative: smoking, WL, exercise
Medical: CVS risks (statin, antiplatelet, Bp, glucose)
Surgical: angioplasty or bypass grafting
Maybe skin reconstruction
Describe a neuropathic ulcer
Painless over areas of abnormal pressure, often secondary joint deformity diabetics, a result of peripheral neuropathy, repetitive stress & unnoticed injuries
Punched out appearance
Clinical features of neuropathic ulcers
History of peripheral neuropathy or symptoms of peripheral vascular disease
Burning/ tingling legs
Single nerve involvement (mononeuritis multiplex)
Amotrophic neuropathy
Peripheral neuropathy (glove & stocking distribution) Warm feet & good pulses
Investigations for neuropathic ulcers
Blood glucose levels
Arterial disease - ABPI +/- duplex
Microbiology swab - signs of infection
Deep infection - X-ray
Extend peripheral neuropathy: 10g monofilament or Ipswich touch test + vibration sensation with 128Hz tuning fork
Management of neuropathic ulcers
Diabetic foot clinics Diabetic control optimised Improved diet Exercise CVS risk factors Chiropody
Infection - antibiotics
Ischaemic/ necrotic - surgical debridement/ amputation
Neuropathic ulcers can be seen alongside Charcot’s foot, what is it?
Neuroarthropathy loss joint sensation -> trauma & deformity
Swelling, distortion, pain, loss of function
Loss of transverse arch - rocker bottom sole
Specialist review
How do varicose veins come about?
Incompetent valves -> blood flow deep to superficial -> venous hypertension + dilation
98% primary idiopathic
Secondary causes: deep venous thrombosis, pelvic masses, arteriovenous malformations
RFs: Prolonged standing Obesity Pregnancy FH
What is a saphenous varix & why is it confused with femoral hernias? How can it be identified & managed?
Dilation of saphenous vein at saphenofemoral junction in groin
Displays cough impulse (mistaken femoral hernia)
- duplex USS
✅ High saphenous ligation
What is the CEAP classification of varicose veins?
Clinical features: C0 - no visible/ palpable signs venous disease C1 - telangiectasia/ reticular veins C2 - VV C3 - oedema C4a - pigmentation/ eczema C4b - lipodermatosclerosis / atrophie Blanche C5 - healed venous ulcer C6 - active venous ulcer
aEtiology: Ec - congenital Ep - primary Es - secondary En - no venous cause
Anatomical:
As superficial, Ap perforating, Ad deep, An no venous location identified
Pathophysiology:
Pr reflux, po obstruction, pr,o both, Pn no venous pathophysiology identified
Management of varicose veins
Non-invasive:
Education
Compression stockings if intervention not appropriate
4 layer bandaging venous ulceration
Surgical: If Symptomatic Lower limb skin changes Superficial venous thrombosis Venous leg ulcer
- ligation, stripping, avulsion
- foam sclerotherapy
- thermal ablation
❌haemorrhage, thrombophlebitis, DVT, disease recurrence, nerve damage
What investigation should be performed prior to compression bandaging?
Ankle-brachialpreseure index
Which term describes tapering of legs (inverted champagne bottle?)
Lipodermatosclerosis
How does deep venous insufficiency come about?
Chronic disease caused by deep venous thrombosis or valvular insufficiency
Failure of venous system (incompetent valves deep venous system)
Primary - defect vein wall/ valvular
Secondary - defect secondary damage
RFs: older, female, pregnant, previous DVT/ phlebitis, obesity, smoking, standing long periods, FH
A lady comes in with chronically swollen lower limbs which become achey, pruritic and painful, she sometimes get venous claudication. What do you think is wrong? What May you find on examination?
Deep venous insufficiency
Examination: varicose eczema, thrombophlebitis, haemosidderin skin staining, lipodermatosclerosis, atrophie Blanche, venous ulcers
May have post thrombotic syndrome - heaviness, cramps, pain, pruritic, paraesthesia, pretibal oedem, skin induration, hyperpigmentation, venous ectasia, red, ulcers - villalta scale
What is atrophie Blanche?
Localised round, white atrophie regions surrounded by dilated capillaries
Differentials for leg swelling and investigations
Deep venous insufficiency - Doppler USS
Renal/ hepatic/ ❤️ disease - FBC, U&Es, LFTs, EChO
Management of deep venous insufficiency
Conservative
Compression stockings, analgesia, 4 layer bandage ulcers, elevate
Surgical
ValvuLoplasty if symptoms deteriorating
Post thrombotic syndrome with occluded iliac vein - stenting
What is thoracic outlet syndrome? Fisk factors?
Clinical features that arise from compression of neurovascular bundle within thoracic outlet
- neurological (nTOS) >95%
- venous
- arterial
Women, muscular, middle aged, hyperextensive injuries, repetitive stress (spasm, haemorrhage, swelling scalene), external compressing factors, anatomical abnormalities, clavicular fractures
RFs: trauma, repetitive motion, athletes, anatomical variations
Name 3 special tests for thoracic outlet syndrome
- adson’s manoeuvre
Palapate radial pulse with arm abducted 30dc, turn head look affected shoulder then fully abduct/ extent/ LR - decreases/ loss pulse
Roo’s test - abduct + ER shoulder affected 90dc, bend elbow, open & close hands slowly 3mins - worsening symptoms
Elvey’s test - extend arm 90dc elbow extended & wrist dorsiflexed, tilt ears to each shoulder - loss radial pulse/ worsening symptoms
Investigations for thoracic outlet syndrome
- bloods
- CXR (bony abnormalities e.g. cervical ribs, fracture callus)
- duplex USS
- CT
- venogram
- Nerve conduction studies
- MRI
Management of TOS
Neurogenic - physiotherapy, WL, botulinum toxin A injections
vToS - thrombolysis, anti-coag, venoplasty, venous stent
aTOS (acute limb ischaemia) - urgent vascular input
Surgery:
Decompression (supraclavicular/ transaxillary)
A man undergoes a transaxillary surgical decompression for left TOS. Post op he develops dyspnoea, chest is dull to percussion - what is likely diagnosis?
Damage to thoracic nerve -> chylothorax
What is the term for sweating in XS of that required for regulation of body temp? How is it caused?
- hyperhidrosis
>6months, once a week+
Increased sympathetic stimulation thoracolumbar autonomic fibres -> eccrine (water) sweat glands (not apocrine oily)
- primary no underlying cause, often localised, often symmetrical, 1/3 FH, often stop sleep
- secondary underlying condition e.g. meds, systemic, often generalised
Causes:
Pregnancy, menopause, anxiety TB/ HIV/ malaria, malignancy, hyperthyroidism, phaeochromocytoma, carcinoid syndrome, anticholinesterases, antidepressants propranolol
Medication and surgical management of XS sweating?
Propantheline only anticholinergic agent licensed for use
Surgical: iontophoresis (weak electric current through water soaked sponges)
Botulinum toxin injected (block nerves 2-6months)
Endoscopic thoracic sympathectomy (damage sympathetic ganglion, major op)
A patient presents with a sudden onset hot & swollen limb what is most likely? What would your next steps be? How would you manage it once confirmed?
Assessment DVT - pain localised calf tenderness/ firmness
History/ FH: pro-thrombotic disease + immobility/ surgery
Well’s score calculated <1 - Doppler USS or D-dimmer
✅LMWH -> long term anticoag
Differentials: cellulitis, MSK infections
