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Year 3 - Met3a > Vascular 1 > Flashcards

Vascular 1 Flashcards

1
Q

What layer does atherosclerosis affect

A
  • effects the intimal of the artery
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2
Q

what can atherosclerosis casue

A
  • aneurysm and rupture
  • occlusion by thrombus
  • critical stenosis
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3
Q

what makes up a plaque

A
  • Cells (SMC, macrophages and other white blood cells)
  • ECM - collagen, elastin and prostaglandins
  • Lipids
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4
Q

What is intermittent claudication

A

Pain in the limb brought on by exertion - it is relieved at rest, and recurs on similar effort
- muscle is in pain as it is not getting enough oxygen as it requires

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5
Q

How do you measure intermittent claudication

A

Measure it in terms of how far someone can walk on the flat

- usually can rest by standing for 2 or 3 minutes and then they can go on again

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6
Q

What condition can have a similar presentation to intermittent claudication

A

spinal ischaemia can have a similar presentation

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7
Q

What is critical limb ischaemia

A
  • can be seen as the extreme of intermittent claudciation
  • rest pain (constant pain and opiate analgesia) and tissue loss
  • less than 50mmHg at ankle
  • blood flow is so little that they get pain without doing anything
  • often get pain at night
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8
Q

In critical limb ischaemia what is the blood pressure at the ankle

A
  • less than 50mmHg at ankle
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9
Q

How common is peripheral artery disease

A

Population 55-74yrs:
• 25% asymptomatic PAD
• 5% – claudication
– 23% of claudicants will develop CLI over 10 yrs

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10
Q

if you measure the systolic pressure at the ankle and divide that by systolic pressure in the arm the lower it is the

A

higher the risk of death

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11
Q

what is the mortality of peripheral vascular disease

A
  • PAD has a greater mortality rate than Cerebrovascular / Coronary artery disease
  • 3% death per year
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12
Q

describe the outcomes of critical limb ischaemia

A
  • 90% require reconstruction / angioplasty
  • 25% amputation rate
  • 50% die within 5 yrs (MI, CVA)
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13
Q

When examinaing patients with critical limb ischaemia what do you have to think about

A
  • nerves - sensation - damaged first
  • movement
  • pain
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14
Q

What investigations do you use for peripheral vascular disease

A
  • ABPI (confounders) -Duplex
  • MRA / CTA
  • Diagnostic angiogram
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15
Q

What are the risk factors for peripheral vascular disease

A
  • smoking
  • diabetes
  • hypertension
  • hypercholestrolemia
  • hyperhomocysteinemia
  • C reactive protein
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16
Q

What are the treatment options for peripheral vascular disease

A

• Conservative
– Lifestyle modification (exercise)
- diets - reduce refined sugar and fats
– Stop smoking

• Medical
– Risk factor optimisation

• Surgical
– Endovascular - Angioplasty
– Open - Surgical bypass
– Adjuncts

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17
Q

What medicines are used to control peripheral vascular disease

A

Diabetes control
- Reduce HbA1C by 1%- 21% reduction in complications

Cholesterol control

  • Simvastatin 40mg -24% reduction in revascularisation
  • HDL protective, LDL causes atherosclerosis

Blood pressure control
- HOPE study 26% reduction in events

Anti-platelets
- Aspirin 75mg 23% reduction in events

Anti-oxidants and vitamins
-Omega-3 fish oils

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18
Q

What happens in an angioplasty

A
  • use a balloon and stent and expand the balloon
  • this can expand the vessel and increae blood flow
  • can also use a stent to keep the artery open
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19
Q

What are the risks and benefits of angioplasty

A

Risk

  • failure to dilate
  • re-stenosis
  • surgical salvage e.g. if you rupture the vessel or cause dissection of the vessel
  • amputation
  • death
  • contrast anaphylaxis
  • renal dysfunction is less than 24 hours

benefits

  • minimally invasive
  • short stay
  • quick recovery
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20
Q

what is bypass surgery preserved for

A
  • preserved for patients with critical limb ischaemia
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21
Q

What is a prosthetic graft made out of

A

PTFE/Dacron

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22
Q

What veins do they use in a periperhal vascualr disease bypass surgery

A
  • Long saphenous vein (most common)
  • human umbilical vein
  • PTFE (least common)
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23
Q

What are the risks and benefits for bypass surgery

A

Risks

  • graft failures
  • MI
  • infection
  • limb loss
  • death
  • in bed for longer

Benefits

  • save limb
  • retain indepedence
  • wound healing
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24
Q

if patients are going to live longer than 2 years then it is better to do a …… in peripheral vascular disease

A

bypass than an angioplasty as bypass survives better at the moment

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25
Q

How do you deifne an aneurysm

A

Localised dilatation of an artery greater than twice normal diameter

26
Q

Where do abdominal aortic aneurysms happen

A

Below the level at which the renal arteries come of

27
Q

What is the commonest peripheral abdomen

A

Popliteal anuerysm

28
Q

in patients with abdominal aortic aneurysm how common it is to have a popliteal aneurysm

A
  • 10% of those with a AAA have a popliteal aneurysm

* 50% of those with a popliteal aneurysm have a AAA

29
Q

How many popliteal aneruysms are bilateral

A

• 50% of popliteal aneurysms are bilateral

30
Q

What is the definition of an abdominal aortic aneurysm

A

Aortic diameter >3cm

31
Q

What is the growth of aneurysms a year

A
  • tends to grow +/- 10% a year
32
Q

What is the prevalence of an abdominal aortic aneurysm

A
  • 9% prevalence in men over 65

* 12% incidence in hypertensive men

33
Q

What is the mortality of an abdominal aortic aneurysm

A

• Mortality at rupture 90%

34
Q

What is the pathogensis of abominal aortic aneurysms

A
  • Intimal atherosclerosis
  • Mural thrombus
  • Destruction of elastic lamellae

inflammatory response is due to imbalance of matrix degrading proteinases and inhibitors

Autoimmune responses is increased

  • cytokines
  • chemoattractants
  • peptide growth factors
35
Q

What are the altered gene products found in abdominal aortic aneurysms

A
  • Increased proteolysis (MMP-1, MMP-9)

* Increased inflammation – (cytokines, Chlamydia Ag / Ab, Adhesion molecules)

36
Q

What are the risk factors for abdominal aortic aneurysms

A
  • 1-5% positive family history
  • ethnicity - higher in northern europeans compared to asians and africans
  • smoking - relative risk is 2 and there is increased expansions
  • hypercholesterolaemia
  • hypertension
37
Q

Name the three types of aneurysm

A
  • saccular aneurysm
  • fusiform aneurysm
  • ruptured aneurysm
38
Q

how is diabetes linked to aneurysm

A
  • slower growth of an aneurysm
39
Q

What are the indications for surgery for abdominal aortic aneurysm

A
  • greater than 5.5cm in diameter
  • rapid enlargement greater than 1cm a year
  • symptomatic abdominal aortic aneurysm
40
Q

How does open abdominal aortic aneurysm surgery work

A
  • put a clamp on the aorta where it starts and ends

- open up the sac of the anueryms - take out the clot and then stitch the graft in

41
Q

What is the risk of open abdominal aortic aneurysm surgery

A
  • Mortality (5-10%)
  • Myocardial Infarction
  • Multi-organ failure
  • Paraplegia
  • Haemorrhage
  • Infections (Wound / Graft)
  • Fistulae
  • Hernia
42
Q

How does endovascular abdominal aortic anuerysm work

A
  • use delivery sheaths to put stents up to seal in the healthy neck below the arteries going to kidneys and below all the aneurysms
  • this reduces the pressure and over time the sac gets smaller
43
Q

What are the beneftis and costs of endovascular abdominal anuerysm

A

pros

  • 1% mortality rate
  • decreased insult
  • 2 day hospital stay
  • can be percutaneous

cons

  • cost - have to do surveillance
  • surveillance
  • re-interventions
  • durability - 9 years after the procedure if you have an open surgery your mortality is less than the endovascualr abdominal anuerysm
44
Q

who is screened for an abdominal aortic aneurysm

A
  • men
  • over aged 65
  • more than 3cm go onto a surveillance programme
45
Q

How do you screen abdominal aortic aneurysm

A

Single trans- abdominal ultrasound

46
Q

What is an arterial dissection and what can cause it

A
  • disruption to the intimal layer this could be due to iatrogenic, traumatic and spontaneous
  • means that the blood cannot get into the vital branches of that blood vessel
  • now have a channel of blood near where the wall is weak therefore you can get a localised aneurysm
47
Q

What is the pain like in aortic dissection

A
  • Severe tearing central to chest pain radiating to back
48
Q

What are the risk factors for aortic dissection

A
  • hypertension

Genetic/connective tissue

  • bicuspid aortic valve
  • marfans syndrome
  • ehlers danlos
  • any connective tissue disorder
49
Q

How can you diagnose aortic dissection

A

CTA

50
Q

What are the types of aortic dissection

A

Type A

Type B

51
Q

Where are the types of aortic dissection

A

Type A
- nearest the heart

Type B
- further down after brachiopcehalic and caroitd and subclavian

52
Q

What are the differences between type A and type B aortic dissection

A

Type A
- 95% mortality without immediate surgery (1% per hour)

Type B
- immediate and strict blood pressure control and monitoring - may need surgery to prevent sudden aortic catastrophy

53
Q

What is the epidemiology of varicose veins

A
  • 1/3 population 18-65 years
  • Probably genetic link (familial)
  • 120,000 Varicose vein procedures /year UK
54
Q

What causes varicose veins

A
  • happens when blood comes down the vein
  • get a big column of blood sitting in the vein and then the vein ends up getting stretched
  • back pressure from the little veins emptying into the veins get larger
  • this is the varicose veins
55
Q

What do you look for in history, examination and investigation of varicoe veins

A

History

  • Family history
  • previous DVT
  • previous long bone

Examination

  • bleeding
  • skin problems

Investigation

  • patent deep veins
  • confirm root cause
56
Q

How do you describe varicose veins

A
  • Dilated
  • tortuous
  • incompetent
  • refluxing
  • aching if they have been standing for a while
57
Q

How do you treat varicose veins

A

Conservative

  • leg elevation
  • class I compression hosiery

Medical
- topical relief

Surgical

  • open ligation and stripping
  • foam sclerotherapy - injection of a sclerosant that works as a poision against the lining of the vein that causes it to close up
  • endovenous solutions - such as laser therapy - close the vein and force the blood to go in a vein that does work
58
Q

Name the three surgical treatments for varicose veins

A
  • open ligation and stripping
  • foam sclerotherapy
  • endovenous solutions
59
Q

What are the complications of varicose veins

A
  • Swelling
  • Discomfort
  • Itching
  • Varicose eczema
  • Haemosiderin deposition • Lipodermatosclerosis
  • Bleeding
  • Ulceration
60
Q

what are the early and late compications of tratmetn in open ligation

A

Early

  • bleeding
  • bruising
  • discomfort
  • infection
  • DVT/PE - life threatening complication

late

  • recurrence
  • parasthesia
61
Q

What are the benefits of the endovenous surgery

A
  • One hour treatment time
  • Immediate ambulation
  • Can be performed in physician’s office
  • Much less expensive
  • complications are mild and infrequent

Year 3 - Met3a (43 decks)

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