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Vascular > Passmedicine > Flashcards

Passmedicine Flashcards

1
Q

What is the ankle branchial pressure index?

A

Ratio of systolic BP in lower leg to that in the arms

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2
Q

What is an ABPI <1 indicative of?

A

Lower BP in legs than arms

Indicative of peripheral arterial disease

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3
Q

In which patients might you do an ABPI?

A

Those with leg ulcers

Those with suspected PAD - e.g. smoker with intermittent claudication

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4
Q

Why is it essential to measure APBI in those with leg ulcers?

A

Venous ulcers are treated with compression bandaging + doing this in a patient with PAD could further restrict blood flow to the foot

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5
Q

ABPI >1.2 = ?

A

Calcified, stiff arteries (may be seen in advanced age, diabetics)

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6
Q

ABPI = 1-1.2 =?

A

Normal

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7
Q

ABPI = 0.9-1 =?

A

Acceptable

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8
Q

ABPI <0.9 =?

A

PAD

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9
Q

ABPI <0.5 =?

A

Severe PAD - treat urgently

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10
Q

What value of ABPI is considered generally acceptable for use of compression bandaging?

A

0.8 or above

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11
Q

What causes abdominal aortic aneurysm?

A

Failure of the elastic proteins within the ECM

Most aneurysms caused by degenerative disease

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12
Q

What layers of the aorta are typically dilated in an AAA?

A

Usually all of the layers

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13
Q

What is the normal diameter of the aorta in those >50?

A

F - 1.5cm

M - 1.7cm

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14
Q

What diameter of infrarenal aorta is considered aneurysmal?

A

3cm+

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15
Q

What is the pathophysiology of AAA?

A

Primary event is loss of intima with loss of elastic fibres from the media
Process assoc. w increase in proteolytic activity + lymphocytic infiltration

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16
Q

What are RFs for AAA?

A

Smoking
HTN
Syphilis
Connective tissue dx (EDS, Marfans)

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17
Q

What is the screening for AAA?

A

All men 65y are offered screening with a single abdominal USS

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18
Q

At what ABPI do intermittent claudication symptoms start?

A

0.9-0.8

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19
Q

At what ABPI do those with PAD get rest pain but still have intact pedal pulses and no skin changes?

A

<0.5

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20
Q

At what ABPI do those with PAD get gangrene + ulcers?

A

<0.3

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21
Q

What action is required if an aorta diameter is <3cm on screening?

A

No further action

This is normal

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22
Q

What action is required if an aorta diameter is 3-4.4cm on screening?

A

Small aneurysm - rescan every 12m + optimise RFs (e.g. stop smoking)

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23
Q

What action is required if an aorta diameter is 4.5-5.4cm on screening?

A

Median aneurysm

Rescan every 3m + optimise RFs (e.g. stop smoking)

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24
Q

What action is required if an aorta diameter is >=5.5cm on screening?

A

Refer within 2 weeks to vascular surgery for probable intervention

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25
Q

What aneurysms are at high risk of rupturing?

A

Symptomatic

Aortic diameter =>5.5cm or rapidly enlarging (>1cm/year)

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26
Q

How should high risk aneurysms be managed?

A

Refer within 2 weeks to vascular surgery

Treat with elective endovascular repair/open repair if unsuitable

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27
Q

What happens in EVAR?

A

Stent placed into abdominal aorta via femoral artery to prevent blood collecting in the aneurysm

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28
Q

What is a common complication of EVAR?

A

Endo-leak (stent fails to exclude blood from aneurysm)

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29
Q

What are the only two situations that require urgent AAA surgery as opposed to elective?

A

Symptomatic aneurysm or emergency rupture

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30
Q

What is PAD strongly linked to?

A

Smoking

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31
Q

How is PAD managed?

A 
Quit smoking
Treat co-morbs (HTN, DM, obesity)
80mg atorvastatin 
Clopidogrel 75mg
Exercise training
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32
Q

How is severe PAD managed?

A

Angioplasty
Stenting
Bypass surgery

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33
Q

When might amputation be used in PAD?

A

Those with critical limb ischaemia who are not suitable for other interventions

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34
Q

What drugs are licensed for PAD?

A

Naftidrofuryl oxalate

Cilostazol

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35
Q

What is naftidrofuryl oxalate?

A

Vasodilator

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36
Q

What is cilostazol?

A

Phosphodiesterase III inhibitor - has antiplatelet and vasodilator effects

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37
Q

What are the three main patterns of presentation seen in those with PAD?

A

Intermittent claudication
Critical limb ischaemia
Acute limb threatening ischaemia

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38
Q

Define critical limb ischaemia

A

1+ of:
Rest pain in foot for >2w not helped by analgesia
Ulceration
Gangrene

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39
Q

What do patients with critical limb ischaemia often describe helping their pain?

A

Hanging their leg out of bed at night to ease the pain

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40
Q

What ABPI is suggestive of critical limb ischaemia?

A

<0.5

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41
Q

What are the symptoms of acute limb ischaemia?

A 
6Ps - 
Pale
Pulseless
Paraesthesia
Pain 
Paralysis
Perishingly cold
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42
Q

What are the features of intermittent claudication?

A

Intermittent aching/burning in legs following walking
Can typically walk a predictable distance before symptoms start
Usually relieved within minutes of stopping
Not present at rest

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43
Q

How do you assess someone presenting with intermittent claudication?

A

Check femoral, popliteal, posterior tibialis and dorsalis pedis pulses
ABPI
Duplex USS is first line
MRA should be performed prior to any intervention

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44
Q

Stenosis of the femoral vessels leads to symptoms where?

A

Calves

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45
Q

Stenosis of the iliac vessels leads to symptoms where?

A

Buttocks

46
Q

What symptoms do you get with aortic dissection?

A

Chest pain

47
Q

What does the position of the chest pain tell you about the location of an aortic dissection?

A

Ant chest pain –> ascending aorta

Back pain –> descending aorta

48
Q

What do you see on X-ray in an aortic dissection?

A

Widening of the aorta

49
Q

What imaging is used to diagnose an aortic dissection?

A

CT

50
Q

What is the treatment of aortic dissection?

A

Medical - type B

Surgery - type A

51
Q

What is a cervical rib?

A

Supernumery fibrous band arising from C7 vertebra

52
Q

What can a cervical rib cause?

A

Thoracic outlet syndrome

53
Q

What is involved in the treatment of a cervical rib?

A

Surgical division of rib

54
Q

What is subclavian syndrome

A

Proximal stenotic lesion of subclavian artery –> retrograde flow through vertebral or internal thoracic arteries –> decrease in cerebral blood flow –> syncopal symptoms

55
Q

What imaging is useful for subclavian steal syndrome?

A

Duplex +/or angiogram allows you to delinate lesion

56
Q

What is Takayasu’s arteritis?

A

Large vessel granulomatous vasculitis that leads to intimal narrowing

57
Q

Who tends to get Takayasu’s arteritis?

A

Young Asian females

58
Q

How does Takayasu’s arteritis present?

A

Features of mild systemic illness, followed by a pulseless phase with symptoms of vascular insufficiency

59
Q

How is Takayasu’s arteritis treated?

A

Systemic steroids

60
Q

What is patent ductus arteriosus?

A

Ductus arteriosus is a normal foetal vessel that should close spontaneously after birth but doesn’t

61
Q

What does PDA lead to?

A

High pressure, oxygenated blood entering the pulmonary circuit, can lead to symptoms of congestive cardiac failure

62
Q

What condition is coarctation of the aorta associated with?

A

Turner’s syndrome

63
Q

What are symptoms of coarctation of the aorta?

A 
Symptoms of arterial insufficiency, e.g. syncope/claudication
BP mismatch (e.g. in lower vs upper limbs)
64
Q

How do you treat coarctation of the aorta?

A

Angioplasty/surgical resection

65
Q

What types of things may affect upper limb circulation?

A

Embolic events
Inflammatory disorders
Venous diseases
Stenotic lesions (internal + external)

66
Q

If the subclavian/axillary arteries are occluded why might you not get symptoms all the time?

A

Collateral vessels around shoulder joint may provide alternative pathways for flow

If inc. metabolic demand collateral flow will be insufficient + vertebral arteries will have diminished flow –> syncope etc.

67
Q

Where is the most common place for an upper limb emboli to lodge?

A

Brachial artery

68
Q

Whereis the second most common place for an upper limb embolus to lodge?

A

Axillary artery

69
Q

What are the features of an axillary/brachial embolus?

A

Sudden onset: pain, pallor, paresis, pulselessness, paraesthesia

70
Q

What are the sources of emboli in axillary/brachial embolus?

A

Cardiac arrhythmia (e.g. AF), mural thrombus

71
Q

What tends to cause most arterial occlusions?

A

Atheroma

72
Q

What are features arterial occlusion in the upper limb?

A

Claudication, ulceration, gangrene

Proximal lesions may –> subclavian steal syndrome

73
Q

Why do you not get acute ischaemia in atheroma arterial occlusions?

A

Progressive nature of disease allows for development of collaterals

74
Q

Who does Raynaud’s tend to affect?

A

Young females

75
Q

What part of the body does Raynaud’s tend to affect most?

A

Hands

sometimes feet

76
Q

What colour do your fingers go in Raynaud’s?

A

White –> blue –> red

77
Q

How do you treat Raynaud’s?

A

Calcium antagonists

78
Q

How does upper limb venous thrombosis present?

A

Gradual onset upper limb swelling + discomfort

Sensation + motor function normal

79
Q

What may cause upper limb venous thrombosis?

A

Pre-existing malignancy (esp. breast cancer)

Due to repetitive use of limb, e.g. painting a ceiling

80
Q

How is upper limb venous thrombosis diagnosed?

A

Duplex USS

81
Q

How is upper limb venous thrombosis treated?

A

Anticoagulation

82
Q

What % of cervical ribs are bilateral?

A

70%

83
Q

What signs may you see in cervical ribs?

A

Compression of subclavian artery may –> absent raidla pulse

+ve Adsons test

84
Q

What is Adson’s test?

A

Lateral flexion of neck away from symptomatic side + traction of symptomatic arm leads to obliteration of radial pulse

85
Q

When might you get surgery for a cervical rib?

A

If evidence of neurovascular compromise

86
Q

How is acute limb ischaemia managed?

A

Surgical intervention to save the leg (symptoms <6h ago high probability of success of surgery)

87
Q

What causes most venous leg ulcers?

A

Venous hypertension (due to chronic venous insufficiency)

88
Q

What are other causes of venous hypertension other than chronic venous insufficiency?

A

Calf pump dysfunction

Neuromuscular disorders

89
Q

What causes ulcers to form in venous hypertension?

A

Capillary fibrin cuff or leucocyte sequestration

90
Q

What are the features of chronic venous insufficiency?

A

Oedema
Brown pigmentation (haemosiderin deposition)
Lipodermatosclerosis (champagne bottle legs)
Eczema

91
Q

Where do venous ulcers tend to be?

A

Above the medial malleolus

92
Q

Are venous ulcers painful?

A

No

93
Q

What is deep venous insufficiency related to?

A

Previous DVT

94
Q

What is superficial venous insufficiency associated with?

A

Varicose veins

95
Q

How do you diagnose venous insufficiency?

A

Look for reflux

Duplex USS looks at anatomy/flow of vein

96
Q

How do you manage venous ulcers?

A

4 layer compression banding after excluding arterial dx

97
Q

If a venous ulcer fails to heal after 12w or is >10cm2 what treatment might be considered?

A

Skin grafting

98
Q

What is a Marjolin’s ulcer?

A

Squamous cell carcinoma

99
Q

Where do Marjolin’s ulcers occur?

A

On sites of chronic inflammation, e.g. burns/OM after 10-20y

100
Q

Where do you tend to find arterial ulcers?

A

Toes/heel

101
Q

Are arterial ulcers painful?

A

Yes

102
Q

What may you see in arterial ulcers?

A

Areas of gangrene

103
Q

What other signs may you find in the leg of someone with an arterial ulcer?

A

Cold leg
No palpable pulses
Low ABPI

104
Q

Where do you commonly find neuropathic ulcers?

A

Plantar surface of metatarsal head and plantar surface of hallux

105
Q

What causes neuropathic ulcers?

A

Pressure

106
Q

How are neuropathic ulcers managed?

A

Cushioned shoes to reduce callous formation

107
Q

What two conditions is pyoderma gangrenosum associated with?

A

Inflammatory bowel disease

RA

108
Q

What is the appearance of pyoderma gangrenosum?

A

Erythematous nodules/pustules which ulcerate (looks like margherita pizza with red base and yellow toping)

109
Q

Where might pyoderma gangrenosum occur?

A

At stoma sites

110
Q

How is pyoderma gangrenosum treated?

A

Steroids

111
Q

What can an ABPI >1 indicate?

A

Vessel calcification (common in diabetics)

112
Q

What is the biggest risk factor for thrombo-embolic acute limb ischaemia?

A

AF

Vascular (2 decks)

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