Peripheral vascular Flashcards
Peripheral arterial disease
- due to atherosclerotic obstruction of arteries, often with co-existing cerebral or coronary artery disease
- asymptomatic mostly
- claudication (cramping pain in calf/thigh/buttock after walking for a given distance, then relieved by rest)
- ulceration, gangrene, foot pain at rest = critical ischaemia
- 6Ps = acute limb ischaemia
+ diminished pulses
Ix
- ABPI <0.9 (<0.5 is CLI)
- exlcude DM, and arteritis (CRP)
- bloods
- ECG
- colour duplex USS
- MRI /CT if considering surgery
Mx
- risk factor modification essential - stop smoking, exercise
- medication for HTN, cholesterol, lipids, antiplatelet (clopidogrel)
- surgery - endovascular revascularisation, surgical bypass, amputation
Abdominal aortic aneurysm
= enlargement of aorta >1.5x normal size (>3cm)
- 4x more in men, 85% below kidneys
- asymptomatic (or maybe abdo/back pain), only symptomatic when ruptures (pain, hypovolaemic shock) -> 90% mortality
- feel pulsatile expansile mass
Ix and Mx
- abdo USS
- CT scan
- surveillance and aggressive risk management
- EVAR if >5.5cm or expanding at >1cm/yr (open surgery if younger/fitter)
All men screened by USS aged 65
- if normal, (<3cm), no further scans
- if 3-4.4cm, recall in 12mo
- if 4.5-5.4cm, recall every 3mo
- if >5.5cm, vascular surgery referral in 2weeks
Arterial embolism
= sudden interruption of blood flow to organ or limb due to embolus -> ischaemia / infarction
- if embolus is small and ischaemia is chronic, body will create collateral arteries to compensate
- if in a limb, claudication
- if in an organ, dysfunction (oliguria, stroke etc)
- usually thromboembolism (blood)
- can be cholesterol embolism (plaques), fat (bone fracture), air, septic (pus)
RFs
- AF, mitral stenosis, hypercoagulability, endocarditis, recent surgery, IV therapy, bone #, atherosclerosis, CVS disease (smoking age HTN etc)
Ix
- doppler USS
- ABPI
- echo
- ECG
- MRI / CT
- blood cultures
Mx
- anticoagulants - warfarin, apixaban
- antiplatelets - aspirin, clopidogrel
- thrombolytics - alteplase
- vasodilators
- surgery - embolectomy, arterial bypass
Raynaud’s phenomenon
= vasospasm in digits causing pain and white (pallor) -> blue (cyanosis) -> red (reactive hyperaemia) colour change
Primary = idiopathic, Raynaud's disease (FHx, female) Secondary = underlying cause eg CTD (scleroderma, SLE, RA, Sjogren's)
Ix
- digital artery pressure before and after hands are cooled
- doppler USS
- ANA (SLE)
- FBC and CRP
Mx
- rarely need - stop smoking, keep warm
- medical - prostacyclin analogue (iloprost), analgesia, aspirin
- surgical
Carotid artery disease/stenosis
- usually atherosclerotic plaque at the point of bifurcation of the cervical carotid artery
- common cause of stroke
- asymptomatic
- cervical bruit
(stroke or TIA)
RFs
- older age, smoking, CVS disease
Ix
- duplex USS - revascularisation therapy if >50% stenosis and symptomatic, >70% if asymptomatic
Mx
- antiplatelets, lifestyle
- revascularisation (carotid endarterectomy or stenting)
Varicose veins
= subcutaneous permanently dilated veins (3mm or more diameter when standing) due to valve incompetence
- dilated tortuous veins, ± pain, cramps, tingling, heaviness, restless legs, oedma, ulcers
RFs
- age, fhx, female
- prolonged standing, obesity, pregnancy
Ix
- examination
- duplex USS
Mx
- education re standing, elevating legs, weight loss, exercise
- compression stockings
- endovascular treatment -radiofrequency ablation, endovenous laser ablation, injection sclerotherapy
- surgery - ligation / phlebectomy
Chronic venous insufficiency
= functional changes in lower extremities, due to persistently elevated venous pressures
- often long-term sequalae of DVT, more in age, fhx, smoking, prolonged standing
Skin changes - hyperpigmentation, lipodermatosclerosis (upside down Champagne bottle), atrophie blanche, varicose eczema
Leg ulcers
Venous changes - telangiectasias, corona phlebectasia, varicose veins
Leg fatigue, aching, heaviness
Ix and Mx
- duplex USS
- compression stockings, moisturiser
- endovenous ablation, injection sclerotherapy
Venous ulcers
- due to improper functioning of venous valves, leading to stasis and ulceration (often just above the medial malleolus)
- takes 4-6 weeks to heal
- shallow, superficial, irregular shape
- painful (oedema and inflammation), ± itching
RFs
- previous DVT
- varicose veins
- reduced mobility - OA, injury, obesity, paralysis
Mx
- clean and dress wound, moisturise
- compression bandage, elevation
- control smoking / alcohol / glucose
- abx if infection
Critical limb ischaemia
- complication of PAD ‘acute on chronic’ emergency
- atherosclerosis -> complete occlusion
6 Ps - pain - pallor - pulseless - perishingly cold - paraesthesia - paralysis (non-viable if tissue loss / nerve damage)
RFs
- smoking, diabetes, lipids, CVS disease, age
Ix
- Buerger’s test (<20 degrees for pallor)
- cap refill >15s
Mx
- assess limb viability
- analgesia, antiplatelet therapy
- EV stent or bypass / intra-arterial thrombolysis if viable
- if not, amputation
Gangrene
= tissue necrosis from poor vascular supply, sign of critical ischaemia
Dry = no infection, line of demarcation from black tissue. RFs atherosclerosis, diabetes. Wet = infection, less clear cut line, less common in limbs (more in bowel), poorer prognosis. Can be nec fasc (group A strep) Gas = necrotising myositis, from Clostridium perfringens, rapid spread Fournier's = nec fasc in scrotum / perineum
Ix
- ABPI
- blood cultures
- CT (abscess?)
Mx
- ischaemic gangrene - IV heparin, thrombolysis, surgical revascularisation, amputation
- infection - surgically debride, broad spec abx
Deep vein thrombosis
- calf warmth / tenderness / swelling / erythema
- usually form just behind a valve in the soleus vein
RFs: Travel Hypercoagulable (HRT) Recreational drugs Old Malignancy Birth control pill Obesity/obstetrics Surgery/smoking Immobilisation Sickness
Ix
- Wells score, then D dimer, if -ve and Wells<1 then clear
- if Wells >2, then D dimer and USS, if USS clear then repeat in 1 week
- thrombophilia tests before anticoagulation
- look for malignancy
Mx
- may resolve spontaneously
- prevention better than cure (stop COCP pre surgery, mobilise early, LMWH, TEDs)
- LMWH treatment dose or DOACs
- IVC filter if active bleeding or anticoags fail
Renal artery stenosis
- narrowing of >50% reduction of diameter by angiography
- 90% caused by atherosclerotic plaques
- if younger and female, fibromuscular dysplasia
- often presents with refractory hypertension
+ unexplained kidney dysfunction, CAD, abdo bruits, unexplained pulmonary oedema
-> CKD
Ix
- U+Es
- urinalysis
- aldosterone:renin ratio (should be low, if high then maybe Conn’s syndrome)
- CT angio
Mx
- lifestyle
- statin, antiplatelets, antihypertensives
- renal artery stenting/angioplasty
Ischaemic bowel disease
Always suspect when abdo pain + AF (+ age, smoking, MI, vasculitis, hear defects)
Acute
- small bowel, SMA or mesenteric vein thombosis, or non-occlusive disease
- acute severe abdo pain + out of proportion to clinical findings + rapid hypovolaemia
± diarrhoea, haematochezia / melaena
- risk septic peritonitis, SIRS
- treat with fluid resus, abx, LMWH, laparotomy
Chronic = intestinal angina
- severe, colicky post-prandial abdo pain, weight loss, upper abdo bruit
Chronic colonic ischaemia = ischaemic colitis
- low flow in IMA
- LLQ pain ± bloody diarrhoea
Buerger’s disease
= thromboangiitis obliterans
- non-atherosclerotic vasculitis, occluding small and medium arterioles
- suspect in PAD of young men who smoke
- ulcers, gangrene, claudication, absent pulses etc
Ix
- arterial doppler
- FBC + coagulation
- antibody screen for rheumatological vasculitis
Mx
- smoking cessation
- vasodilators (nifedipine)
- oral abx
- analgesia
- sympathectomy
Lymphoedema
- painless unilateral swelling of extremity or genitalia
(positive Stemmer’s sign - can’t pinch skin on second toe) - only clinically evident when 80% lymphatic drainage is non-functional
Causes
- cancer treatment (esp breast), surgery or radiotherapy
- nematode infection, filariasis
- trauma
Ix - lymphoscintigram
Mx
- skin care, compression bandaging, elevation, exercise, physio to manually drain
- treat nematode infection
