vascular Flashcards
Aneurysm definition
localised dilatation with permanent diameter >1.5x normal. True are formed by arterial wall, false has another tissue
fusiform aneurysm
symmetrical
Saccular aneursym
asymmetrical (berry)
False aneurysm
Leaking blood pools around vessel (can look fusiform)
Common aneurysm sites
Aorta (normally abdominal, and often below renal artery branches. Can also get thoracic (50% ascending aorta) -incidence increasing).
Popliteal is most common peripheral aneurysm - associated with AAAs. More common in men.
Aneurysm RF
Smoking, male>60, DM, HTN, high LDL, CT disorders, coarctation of aorta, pregnancy
Aneurysm complications
Intact often asymptomatic, but can compress nearby structures.
Berry aneurysm can cause intense headache
Thoracic aneurysm near aortic valve can prevent valve shutting and give aortic insufficiency due to backflow
Ruptured AAA can show Grey-Turney’s sign (but also seen in pancreatitis)
Aneurysm rupture
Hypotension, tachycardia, syncope, anaemia, expansile abdo mass, shock, severe left flank pain, vomiting, collapse
Aneurysm investigation and surveillance
USS shows location and can FU on development
CT angiography shows detailed image.
AAA screening for men >66 (but consider in higher risk too (COPD, vascular/CV issues, european origin, FHx AAA, hyperlipidaemia, HTN, smoking (ex and current)
On screening:
3.0-4.5 means 2 yearly surveillance
4.5-5.4 is 3 monthly surveillance
Also look at Risk modification
Management of aneurysm rupture
A->E (urgent issues, analgesia, ECG, inform ITU)
Bloods + crossmatch (wide bore cannula, blood tests, coag screen)
Fluids admin in hypotension
Major haemorrhage protocol
Vascular team involvement
Abdo USS to check size and rupture evidence
Surgical management (EVAR or open in complex cases)
Management of unruptured
Surgery is symptomatic, or asymptomatic and >5.5cm, or >4.0cm but growing by more than 1cm/year
Popliteal aneurysm signs and symtpoms
Often asymptomatic, but many have palpable/pulsatile mass behind knee. Can cause mass effects (tibial nerve compression, leg pain, paraesthesia, popliteal vein compression (Swelling)
Can lead to acute complication with thrombosis and acute limb ischaemia (pallor, cold leg, pain, parasthesia)
Investigating popliteal aneurysm
Duplex USS (vessel patency, thrombus development) CT/MR as alternative for accurate measure of lumen diameter
Popliteal aneurysm management
Conservative if <2cm (duplex surveillance) or surgical (EVAR/open)
Aortic dissection
Intima tears, tunica media separation and false lumen development. Common in first 10cm of aorta, but needs weakness to predispose (weakness can give aneurysm or dissection)
DeBakey 1
Intimal tear in ascending aorta, but descending also involved
De Bakey 2
Only ascending involvement
De Bakey 3
Only descending involvement
Stanford A
Ascending involvement involved (De Bakey 1 and 2)
Stanford B
Descending only (De bakey 3)
Aortic dissection risk factors
HTN (main one), smoking, hyperlipidaemia, thoracic AA, aortic valve abnormalities, FHx of dissections, previous cardiac surgery, trauma, cocaine/amphetamine use, CT disease
Aortic dissection Signs and symptoms
Sharp chest pain radiating to back
Weak pulse in downstream artery
May have difference in BP between right and left arm
Hypotension in rupture (and shock)
Aortic dissection Investigations
CXR widened mediastinum (due to widened aorta)
TOE (false lumen detection)
CT angiogram
Aortic dissection complications
1) pericardial tamponade due to backflow in false lumen
2) Rupture
3) False lumen compresses nearby branch (E.g. subclavian/renal artery) and leads to ischaemia
Management of aortic dissection
A->E, stabilise haemodynamically
Vascular team involvement
Can medically manage stable patients with BP reduction (ant hypertensive and beta blockers)
Surgical management if increasing aortic diameter, compromise of branches, imepending rupture or thoracic cavity bleed. Resect and replace area.
Popliteal vein
Formed by anterior tibial, posterior tibial and fibular vein. Small saphenous empties in.
Become femoral vein in thigh
Femoral vein
Was popliteal vein, great saphenous vein empties in.
Varicose veins
Tortuous dilated veins due to incompetent valves. Allow reflux into superficial veins
Varicose veins RF
Age, female, obesity, inactivity, pregnancy, smoking, standing for long periods
Varicose veins clinical features
Enlarged, tortuous veins
Pruritis
oedema
Yellow/red brown skin (haemosiderin release)
Generalised or local leg pain, worse on standing but better on walking.
varicose vein complications
Venous ulcer (shallow, sloping/gradual outline. Minimal pain. Large. Wet with exudate. Often medial malleolus)
Thrombophlebitis (superficial vein inflammation -red and painful)
Excessive bleeding from trauma
Venous eczema (dry, scaly legs)
Lipodermatosclerosis (localised, chronic skin/subcut inflammation with painful, hardened skin)
Investigations for Varicose vein
Clinical diagnosis (Hx and examination) but can do duplex USS for vein/valve structure and check for retrograde flow
Management of varicose veins
Conservative with compression stockings (CI in arterial disease)
Surgical management with radiofrequency ablation (FLT), chemical ablation/sclerotherapy) or surgical stripping (if not accessible/deep)
Primary lymphoedema
Intrinsic genetic abnormality of lymphatic system
Secondary lymphoedema
Damage to normal lymphatic: Cancer treatment infection trauma immobility venous oedema Obesity HF Advanced cancer/liver disease
Venous thrombi
Not from atheroma, but often at valve sites due to valves providing site of turbulence.
Can:
1) lye and resolve
2) organise (scar tissue obliterates lumen)
3) Recanalisation (scar tissue but with remaining thrombus in lumen - inflammatory)
4) embolism
Embolism types
Can be numerous small emboli that are asymptomatic (result in idiopathic pulmonary HTN), larger emboli that cause SOB and chest pain and Long emboli (lodge at pulmonary vessel bifurcation - acute outcome)
Virchow’s triad
Hypercoagulable state, stasis and vessel wall injury
Hypercoagulable state factors
Oestrogen therapy Pregnancy Sepsis/sever infection Malignancy Nephrotic syndrome Myeloproliferative disorder Congestive heart disease Inherited Thrombophilias: (Factor V Leiden, antithrombin deficienct, protein C/S deficiency, prothrombin varient, dysfibrinogenaemia (rare) Acquired thrombophilia: antiphospholipid/lupus anticoagulant (autoimmune)
Stasis factors
Age Venous insufficiency/varicose veins Obesity Immobility (>3 days bed rest) Continous travel (3h+flight/car in prev 4 weeks) Hospitalisation
Vessel wall injury factors
Trauma/surgery
Indwelling venous catheter
Chemical irritation/chemo
Moderate DVT risk factors
Inherited thrombophilia Malignancy Pregnancy Oestrogen therapy Indwelling central line, Congestive HF Arthroscopic knee surgery
Most significant Risk factors for DVT
Trauma to lower leg/pelvis Major trauma Hip/knee arthroplasty Major general surgery Spinal cord injury
Measurement of calf swelling
10cm distal to tibial tuberosity
Wells score for DVT
Points for localised tenderness, leg swelling/calf swelling, collateral veins on affected leg, pitting oedema, cancer Hx, bedrest Hx, DVT Hx, paralysis/paresis/immobilisation of leg recently. -2 points if alternative diagnosis more likely.
DVT likely if 2 points or more.
If not, then D dimer can be used.
Diagnosis
Doppler USS. Use if Wells >2, High clinical suspicion or low Wells but positive D dimer
May Thurner syndrome
Right common iliac artery compresses left common iliac vein
