Phlebitis, PAD Flashcards
What is superficial thrombophlebitis?
Superficial vein becomes inflamed & forms a clot within
Which vein is normally affected by thrombophlebitis?
Long saphenous
What are the risk factors for thrombophlebitis?
Obesity Thrombophilia Smoking COCP Pregnancy IVDU/ IV infusion
What is migratory thrombophlebitis?
Recurrent thrombosis in superficial veins at various sites
What conditions is thrombophlebitis associated with?
Polyarteritis nodosa
Buerger’s disease
How does superficial thrombophlebitis present?
Erythema
Swelling
Tenderness
ALL ALONG VEIN
What are signs of varicose vein thrombophlebitis?
Hard, tender knot within vein
Erythema & bleeding at site
How does septic thrombophlebitis present?
Often with long-term cannula/IVDU Local irritation Hard lump Fever, tachy, hypoT N&V
What investigation should be avoided in superficial thrombophlebitis?
Venography- contrast medium may aggravate condition
How is superficial thrombophlebitis managed?W
1) Elastic support
2) Exercise
3) Analgesia- TOP NSAID (Naproxen)
4) LMWH: Tinz 1m
What is the mechanism of PAD?
Signif obstruction to blood flow
↓oxygenation of limbs
Characteristic claudication pain during exercise
Obstruction worsens → rest pain (critical limb ischemia)
Skin ulceration → gangrenous necrosis → amputation of necrotic limb
How does acute PAD occur?
Embolus
How does chronic PAD occur?
Atherosclerosis
How does functional PAD occur?
Vasospasm (transient)
What are the signs of chronic upper limb PAD?
Pulse deficit
Arm pain/pallor/paraesthesia/perishingly cold
Unequal BP in arms
If there is upper limb claudication what condition should be considered?
Takayasu’s
Which vessel is most commonly affected in chronic upper limb PAD?
Subclavian artery + brachiocephalic trunk
Which vessel is most commonly affected in chronic lower limb PAD?
Superficial femoral artery
What are the signs of chronic lower limb PAD?
Ischaemic pain- intermittent claudication
Throbbing/cramping/tightness
Pain relieved by resting/hanging leg over bed
Commonly U/L
How does acute limb ischaemia present?
6 P's!! Rapid onset High severity Dusky leg Mottling
What is Leriche’s syndrome?
Claudication Pain in buttock/thigh Absent femoral pulse Male impotence Due to saddle aorta-iliac obstruction
How does critical limb ischaemia present?
Ischaemic rest pain
Ulcers/gangrene
6 P’s
Pulse deficit
How is PAD investigated?
Assess ALL pulses ABPI Doppler probe Duplex USS- 1st LINE IMAGING Contrast MR angio
What do the different ABPI values represent?
> 1.2- calcified stiff arteries = advanced age or PAD
1.0-1.2 = normal (0.9 – 1.0 = Ok)
< 0.9 = likely PAD
< 0.5 = Critical PAD requires urgent referral
< 0.1 = ACUTE ISCHAEMIC LIMB
How is ABPI calculated?
highest ankle pressure / highest arm pressure
What different sounds can be heard with a doppler probe?
Triphasic = normal Biphasic = Abnormal Monophasic = PAD
In PAD who gets duplex USS?
ALL patients who require revascularisation
How quickly does acute limb ischaemia need to be treated?
4-6hours
What is the Rutherford classification for acute limb ischaemia?
Dusky leg = Viable → Arteriography
White leg/paralysis = Threatened → Surgery
Fixed staining/mottled/ tense muscle = Irreversible → TLC/amputation
How is acute limb ischaemia treated?
Analgesia + UFH if for surgery
Surgical embolectomy fails → angiogram
If due to thrombosis → Alteplase
How is critical limb ischaemia treated?
Revascularisation via angioplasty/bypass
Amputation
How is chronic limb PAD treated?
Exercise program Analgesia Treat co-morbidities Clopidogrel if Sx Naftidrofuryl oxalate (VasoD) Surgery: Angioplasty + stent or bypass
What is given long term post-intervention in acute limb ischaemia?
Warfarin
What is the mechanism of a reperfusion injury?
Neut migrate to reperfused tissue = inflammation
Limb oedema due to ↑capillary permeability → compartment syndrome
Leakage from damaged cells
Acidosis, ↑K+ (arrhythmia), myoglobinaemia (ATN → AKI, ↑urine Na+ ↓osmolality)
Describe venous ulcers
- Caused by chronic venous insufficiency
- Sloughy, painless, superficial oedema, mottled- brown/black
- Above ankle - below knee
Describe arterial ulcers
- Toes & heels
-Punched out, circular, painful, gangrenous
-Pain worse when lying, better when legs lowered
-No palpable pulses
Hx = PAD, claudication
Describe neuropathic ulcers
- Due to pressure & lack of sensory innervation
- Plantar surface of hallux & metatarsal head
- Painless
What are varicose veins?
Leakage @ venous valves
Retrograde flow
Deep veins can tolerate pressure but superficial veins cannot
Become dilated & torturous
Which vein is usually affected in Varicose veins?
Saphenous
What are the Sx of varicose veins?
INITIALLY: Itching, discomfort, heavy feeling, ↓Exercise tolerance, night cramps, burning sensation
THEN: dull aching pain & cramps, visible, large veins, chronic venous insufficiency
What are signs of chronic venous insufficiency?
Ulcers Lipodermatosclerosis (hardened, indurated skin) Pigmentation Telangiectasia Eczema
How are varicose veins investigated?
Duplex USS- DIAGNOSTIC
Examination
Trendelenburg test: Assess valvular competency
Perthe’s test: Assess deep venous patency
How are varicose veins managed?
Conservative: Avoid long standing, elevate legs, compression stockings, lose weight
Endovascular Tx: Radiofrequency ablation, laser ablation, injection sclerotherapy (foam)
What is a complication of varicose veins?
Saphena Varix: Dilatation in saphenous.v at confluence w/ femoral vein→ transmits a cough impulse- can be mistaken for inguinal/femoral hernia, inspect = bluish tinge
