Peripheral vascular disease Flashcards
Causes of ‘claudication’ in presence of normal peripheral pulses
Neurogenic claudication (spinal stenosis)
Anaemia
Beta-blockers
Critically ischaemic limb (6 Ps)
- Pain
- Pallor
- Pulseless
- Perishingly cold
- Paraesthesia
- Paralysis (best indicator of danger to limb)
ABPI Measurements
- > 1 Normal
- 0.5 -1 Intermittent claudication
- 0.3 - 0.5 Rest pain I critical limb ischaemia
- <0.3 Gangrene + ulceration
Diabetic foot features
• Peripheral neuropathy
o Loss of ankle jerk and vibration sense
o Accidental injury I tissue damage•
o Charcot joints (neuropathic arthropathy)
- Large vessel arterial disease•
- Small vessel arterial disease•
• Autonomic neuropathy
o Reduced sweating
o Dry, cracked skin*
o Infection•
How to Present Your Findings In the common case of a patient with obvious varicose veins
- There are varicose veins in the distribution of the [long I short I both] saphenous systems
- There [is I is no] saphena varix
- Trendelenburg’s test suggests [saphenofemoral I mixed saphenofemoral and perforator] incompetence
- There [are I are no] associated features of chronic venous insufficiency [See over]
- There [is I is no] evidence of superficial thrombophlebitis
Varicose veins
• Occur as a result of valvular incompetence
o Structural predisposition (familial tendency)
o Factors that increase venous pressure: prolonged standing, obesity, pregnancy
• Sites of incompetence
o Saphenofemoral junction (SFJ) - typically causes long saphenous vein (LSV) varices
o Saphenopopliteal junction (SPJ) - typically causes short saphenous vein (SSV) varices
o Perforating veins linking deep veins and saphenous systems
• Often associated with signs of chronic venous insufficiency
Management of varicose veins
• Conservative
o Elastic support hose
o Weight loss
o Regular exercise
o Avoid prolonged standing
• Injection .sclerotherapy
o Suitable for small varices below knee due to incompetence of local perforators
o Not satisfactory for varices associated with SFJ incompetence (recurrence inevitable)
• Surgery
o SFJ incompetence & LSV varices
- SFJ ligated (a so-called ‘high tie’)
- LSV usually stripped from knee to groin (reduced chance of recurrence)
• Stab avulsions of remaining varices
o SPJ incompetence & SSV varices
- SPJ ligated (SSV not stripped due to risk of damaging sural nerve)
- Stab avulsions of remaining varices
• New techniques
o Ultrasound-guided foam sclerotherapy
o Radiofrequency or laser obliteration of LSV I SSV
Causes of chronic venous insufficiency
1. Valvular incompetence of deep veins (90%)
o Primary (aetiology same as for varicose veins)
o Secondary {damaged by DVT)
- Obstruction of deep veins by DVT (10%)
(Chronic venous insufficiency 2’ to DVT is also known as ‘post-thrombotic syndrome’)
What is Superficial thrombophlebitis
- Inflammation and thrombosis almost invariably occurring in varicose veins
- Redness and tenderness follow line of vein
- Thrombosis may spread to deep system and cause DVT
What are factors that increase venous pressure predisposing to varicose veins?
- prolonged standing
- Obesity
- Pregnancy
For varicose veins where are the sites of incompetence?
• Sites of incompetence
o Saphenofemoral junction (SFJ) - typically causes long saphenous vein (LSV) varices
o Saphenopopliteal junction (SPJ) - typically causes short saphenous vein (SSV) varices
o Perforating veins linking deep veins and saphenous systems
How do you manage a patient with superficial thrombophlebitis?
• Management
o Analgesia
o NSAIDs
o Support stockings o Active exercise
- Underlying vein usually removed as recurrence is common
- Propagation towards deep veins is an indication for IV heparin
When do you use injection sclerotherapy?
• Injection .sclerotherapy
o Suitable for small varices below knee due to incompetence of local perforators
o Not satisfactory for varices associated with SFJ incompetence (recurrence inevitable)
What are the conservative management of varicose veins?
• Conservative
o Elastic support hose
o Weight loss
o Regular exercise
o Avoid prolonged standing
