Vascular Flashcards
What is the definition of an abdominal aortic aneurysm
an increase in diameter of the aortic below the diaphragm of >50% of the normal diameter/>3cm
RFs for abdominal aortic anuerysm
male age smoking HTN hyperlipidaemia family hx
sx of abdominal aortic aneurysm
most are asx- found on screening or incidentally
- abdo pain
- back/loin pain
- distal embolism (limb ischaemia)
- aortioenteric fistula (bloody stool)
signs of abdominal aneurysm
- pulsatile mass on abdo jusy above umbilicus
- retroperitoneal haemorrhage are rarely present - grey turner (bruising of flank)
- shock, syncope if ruptured
what is the screening for aortic aneurysm
abdo USS for all men in 65th year
ix for aortic aneurysm
uss
CT with contrast
management of abdo aortic aneurysm
- 3-4.4cm- yearly USS
- 4.5-5.4cm- 3 monthly USS
Repair if
- symptomatic
- growth >4cm and growing >1cm in 1 year
- > =5.5cm
- open or endovascular repair (via femorals)
- smoking cessation
- HTN control
- statin and aspirin
- wt loss
- exercise
what is a potentially serious complication of aortic aneurysm repair that occurs post-operatively
endovascular leaking
- proper seal not achieved around graft
- often asx, so USS in f/u is required
- if left untreated, may cause a rupture
sx and signs of ruptured AAA
- abdo/back pain
- syncope
- vomiting
- haemodyn unstable
- pulsatile mass on abdo
- tender abdo
classic triad (50% of cases)
- flank/back pain
- hypotension
- pulsatile abdo
management of ruptured AAA
- ghihg flow O2
- IV access- 2x wide bore cannulas
- urgent FBC, UE, X match for minimum of 6U
- aim for BP <=100mmHg
- open repair if unstable
- CTA if stable in order to plan repair
causes of thoracic aortic aneurysm
connectvie tissue issues biscuspid aortic valv trauma aortic dissection aortic arteritis (Takayasu) tertiary syphillis
sx thoracic aortic aneurysm
normally asx and found incidentally
- pain localise to location
(ant aorta- ant. chest, aortic arch- neck, descending aortia- between scap)
- back pain- spinal cord compression
- hoarse voice- L recurrent laryngeal
- distended neck vessels and facial oedema- SVC compression)
- sx of HF- aortic valve involvement
- dyspnoea/cough- trachea/bronchial compression/sx of HF
sx of thoracic aortic rupture
- sudden onset pain in back, chest, neck and/or abdo
- haemodynamically unstable
ix for ?thoracic aortic aneurysm in someone who has chest/back pain
- CT chest with contrast
- transoesophageal echo
- FBC, UE, clotting
- ECG
- CXR- wide silhouette, enlarged aortic knob, tracheal deviation
Management of thoracic aortic aneurysm
- statin- atorvostatin
- aspirin
- BP control
- smoking cessation
- surgery- >5.5cm if in ascending aortic or arch/ >6cm in descending aorta
- people with Marfan’s / have had previous dissection– surgery (high risk)
- ongoing imaging as recurrence is not uncommone- CT or MRI
What is aortic dissection
- tunica intima tears, causing blood flow between the tunicaintima and tunica media
definition of acute and chronic aortic dissection
acute- <=14d
chronic >14d
what is a retrograde aortic dissection
- goes towards the aortic valve/up the root of the aorta
complications that can occur due to retrograde dissection of the aorta
valve prolapse,
bleeding into pericardium
therefore cardiac tamponade
Classification used for aortic dissection
- Stanford
A- Ascending aorta, propogates to arch and descending aorta (T1, T2)
B- does not involve the ascending aorta (T3) - DeBakey
T1- originates from ascending aorta and goes to at least the arch
T2- confined to ascending aorta
T3- originates distal to the subclavian artery in the descending aorta
RF for dissection or thoracic aortic aneurysm
- HTN
- age
- male
- fam hx
- smoking
- BMI
sx of aortic dissection
- tearing sensation in chest
- radiates to back (classically)
pathophysiology of aortic anryeusm
- degradation of tunica media- which provides elasticity and strength to the wall
- leads to dilatation of the vessel
- can be caused by atherosclerosis, trauma, infection, arteritis, connective tissue disorders
signs of aortic dissection
- tachycardia and hypotension
- new aortic regurg murmur
end organ hypertension:
- UO
- paraplegia
- lower limb ischaemia
- abdo pain due to isch
- reduced GCS
ix for ?aortic dissection
- FBC, UE, LFT, coag
- X match at least 4u
- trop (?MI)
- ABG
- ECG
- **CT angio
- transoesophageal echo may also be useful
Management of aortic dissection
A-E
- high flow O2
- IV access with cautious fluid resus (<110mmHg)
- surgery
- if uncomplicated type B (not involving asc aorta)- labetolol/CCB, as retrograde dissection is high risk in this type
^^ do surgery in B only if pt is not stable
complications of aortic disseciton
- aneurysm
- rupture
- aortic regurg
- MI (coronary artery dissection)
- cardiac tamponade
- stroke, paraplegia
classificaiton of carotid artery disease
- Mild= <50% diameter reduction
- Moderate- 50-69%
- Severe 70-99%
- total 100%
sx of carotid artery disease
TIA
- stroke
- likely to be asx due to collateral supply from the contralateral internal carotid artery, vertebral artery via circle of willis
sign of cartoid artery disease
- carotid bruits
ix for ?carotid artery disease
- stroke/TIA- urgent non-contrast CT head
- duplex USS or CT angio of carotids done as screening after all strokes/ TIAs
- bloods- FBC, UE, clotting, lipid profile, glucose
- ## ECG (AF)
immediate management of ?carotid artery disease
Short term- stroke management:
- high flow O2
- blood c=glucose optimisation
- swallowing screen assessment
- ischaemic stroke- IV alteplase within 4.5hours, 300mg aspirin
- haemorrhagic- correct coagulopathy, refer for surgery
- thrombectomy if evidence of ischaemic and occlusion of anterior circulation on CT angiography
LT management of carotid artery disease
Long term
- aspirin 300mg OD for 2w, then clopi 75mg OD
- statin
- HTN and DM control]
- smoking cessation
- regular exercise
- wt loss
- carotid endaterectomy if 50-99% occlusion
risks of ccarotid endarterectomy
- stroke (embolisation)
- hypoglossal N damage
- glossopharyngeal N damage
- vagus N damage
- MI
- bleeding
- infection
sx of glossopharyngeal damage
- pain in nasopharynx/ear/throat
- dysphagia
- taste impaired over post 1/3 tongue
- impaired sensation over post 1/3 tongue, palate
- absent gag reflex
sx of hypoglossal damage
- paralysis of 1/2 of tongue (deviates to side is damaged)
- fasciculations
- slurred speech
- difficultly eating and swallowing
sx of vagus nerve damage
- hoarseness
- dysphagia, dysarthria
- aspiration
- nausea, vomiting, slow HR, low BP
- uvula deviation away from lesion
skin changes seen in chronic venous disease
- lipodermatosclerosis - inflammation of SC fat, pain/hardening of skin, redness, often tapering at the ankles (champagne bottle)
- haemosiderin deposition- brown discolouration
- atophie blanche- white scarring
- venous eczema
ix for ?venous disease
ABPI_ normal (0.8-1)
- doppler USS and/or venography
- swab for cultures of ulcers
Management of venous disease
- leg elevation
- increase exercise, wt reduction, smoking cessation
- compression bandaging (not if also have arterial disease)
- dressings (alignate, hydrocolloid), emollients
- vein stripping/ablation if varicose veins also present
- fluclox if infected
ix for ?arterial disease of lower leg
- ABPI <0.8
0. 8- mild, 0.5-0.7- mod, <0.5- severe - dupplex USS
- MRA/CTA
management of peripheral arterial disease eg ulcers
- smoking cessation, weight loss, exercise
- statin
- dual antiplatelet- aspirin , clopi
- BP and glucose control
- fluclox is infected
intermeittment claudication
- artorvostatins 80mg
- clopi 75mg
- naftidrofuryl oxalate
- angioplasty, stening
- endarterectomy
- bypass
Crticial limb
- angioplasty, stenting
- bypass
- amputation
Acute limb isch
- endovasc thrombolysis/thrombectomy
- surgical thrombectomy
- endarterectomy
- bypass
- amputation
hx of chronic limb ischaemia
- cramping pain in calf after walking
- relieved by rest
ix for chronic limb ischaemia
- ABPI
- doppler USS
- MRA, CTA
Management of chronic limb ischaemia
- walk until yu feel moderat epain, rest , walk again- repeat for 30-45mins
- walk for 3 or more days a week
- statins
- control HTN
- aspirin, clopidogrel
- angioplasty
what is critical limb ischaemia
- chronic limb ischaemia progressing to rest pain
sx of critical limb ischaemia
6 Ps are late signs (pallor, pain, paraesthesia, pulselessness, perishingly cold, paralysis)
- lack of hair
- aterial ulcers that are non healing, necrotic patches
- burning, stabbing pains with relentless, increasing intensity
- pain only relieved by opioids
- may radiate up leg into groin
- loss of sensation and movement
- rubor- foot may be flushed as capillaries dilate in response to ischaemia
ix critical limb ischaemia
ABPI
angiograms- MRA, CRA
tx critical limb ischaemia
- aspirin, clopi
- statin
- angioplasty
- surgery- stent, bypass
- amputation
3 causes of acute limb ischaemia/threatened limb
- embolisation- AF, post MI, abdo arotic aneurysm , prosthetic valves
- thrombosis in situe (plaque rupture)
- trauma, incl compartment syndrome
sx of acute limb ischaemia
6 Ps- acute
- pain!
- pallor!
- pulselessness!
- perishingly cold
- paralysis
- paraesthesia
- suddent onset
- mottled, non blanching rash, with hard woody muscles- irreversible
- note– can be acute-on-chronic
Clasificaion of acute limb ischaemia
I- viable
- non sensory, motor deficit
- audible dopplers
IIA- marginally threatened
- salvageable
- minimal sensory loss
- no motor deficit
- inaudible arterial doppler
IIB- immediately threatened - salvageable 0 sensory loss - mild/mod motor deficit - inaudible arterial doppler
III- irreversible
- major tissue loss
- mottle, non blanching rash with hard, woody muscles
- total sensory loss, paralysis
- inaudible arterial and venous dopplers
Ix for ?acute limb ischaemia
- routine bloods, lactate, thrombophilia screen if <50yo, G&S
- NV exmination of both limbs
- ECG
- Doppler USS of both limbs
- **MRA/CTA
tx acute limb ischaemia
- high flow O2
- IV acess
- IV heparin
- surgery- embolectomy via catheter, by pass, intraarterial thrombolysis , angioplasty, amputation
LT
- exercise, weight loss, smoking cessation
- aspirin, clopi
- warfarinf, DOAC
- ta underlying conditions (AF)
- OT/PT
what is reperfusion injury
- release of substances from damaged cells- K, H, myoglobin
- causing hyperkalaemia, acidosis, AKI respectively
- the oedema from abnormal capillary permeability following reperfusion can also cause compartment syndrome
how to prevent reperfusion injury
- monitor UEs closely
- quick haemdialysis if needed
what scoring system do you use to assess the risk of someone with AF risk of stroke
CHA2DS2-VASc
Cong HF (1) HTN- >140.90 (1) Age >=75 (2) DM (1) Stroke/TIA/thomboembolism (2) Vascular disease (peripheral, MI) (1) Age 65-74 (1) Sex category- female (1)
1- consider antiplt/antocoag
>=2- anticoag unless CIed
what scoring system do you use for someone on an anticoagulant to assess their risk of bleeding
HASBLED
- HTN (>160mmHg)
- abnormal renal/liver function Cr >200, bilirubin >2x bilirubin or AST/ALP/AP >3x
- stroke
- bleeding (major) or predisposition
- Labile INR (in 2-3 range <60% of time)
- Elderly (>65)
- Drugs (antiplatelets, NSAIDs) or alcohol (
DVT sx
painful calf red swollen warm calf firmness if iliofemoral- blue leg, white leg
What score do you use to decide ix of ?DVT
Well’s
how do you ix a DVT according to well’s score
0- mod sensitivity d-dimer for all
-ve- no further imaging
+ve - USS
+ve USS- anticoag
1-2- high sensitivity d-dimer testing
- negative- no further ix
- positive- anticoag
> =3
- USS for all
tx DVT
DOAC- apix or rivarox
or - LMWH for 5d then dabigtran
