Vascular Flashcards
1
Q
What is the definition of an abdominal aortic aneurysm
A
an increase in diameter of the aortic below the diaphragm of >50% of the normal diameter/>3cm
2
Q
RFs for abdominal aortic anuerysm
A
male age smoking HTN hyperlipidaemia family hx
3
Q
sx of abdominal aortic aneurysm
A
most are asx- found on screening or incidentally
- abdo pain
- back/loin pain
- distal embolism (limb ischaemia)
- aortioenteric fistula (bloody stool)
4
Q
signs of abdominal aneurysm
A
- pulsatile mass on abdo jusy above umbilicus
- retroperitoneal haemorrhage are rarely present - grey turner (bruising of flank)
- shock, syncope if ruptured
5
Q
what is the screening for aortic aneurysm
A
abdo USS for all men in 65th year
6
Q
ix for aortic aneurysm
A
uss
CT with contrast
7
Q
management of abdo aortic aneurysm
A
- 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
8
Q
what is a potentially serious complication of aortic aneurysm repair that occurs post-operatively
A
endovascular leaking
- proper seal not achieved around graft
- often asx, so USS in f/u is required
- if left untreated, may cause a rupture
9
Q
sx and signs of ruptured AAA
A
- abdo/back pain
- syncope
- vomiting
- haemodyn unstable
- pulsatile mass on abdo
- tender abdo
classic triad (50% of cases)
- flank/back pain
- hypotension
- pulsatile abdo
10
Q
management of ruptured AAA
A
- 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
11
Q
causes of thoracic aortic aneurysm
A
connectvie tissue issues biscuspid aortic valv trauma aortic dissection aortic arteritis (Takayasu) tertiary syphillis
12
Q
sx thoracic aortic aneurysm
A
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
13
Q
sx of thoracic aortic rupture
A
- sudden onset pain in back, chest, neck and/or abdo
- haemodynamically unstable
14
Q
ix for ?thoracic aortic aneurysm in someone who has chest/back pain
A
- CT chest with contrast
- transoesophageal echo
- FBC, UE, clotting
- ECG
- CXR- wide silhouette, enlarged aortic knob, tracheal deviation
15
Q
Management of thoracic aortic aneurysm
A
- 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
16
Q
What is aortic dissection
A
- tunica intima tears, causing blood flow between the tunicaintima and tunica media
17
Q
definition of acute and chronic aortic dissection
A
acute- <=14d
chronic >14d
18
Q
what is a retrograde aortic dissection
A
- goes towards the aortic valve/up the root of the aorta
19
Q
complications that can occur due to retrograde dissection of the aorta
A
valve prolapse,
bleeding into pericardium
therefore cardiac tamponade
20
Q
Classification used for aortic dissection
A
- 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
21
Q
RF for dissection or thoracic aortic aneurysm
A
- HTN
- age
- male
- fam hx
- smoking
- BMI
22
Q
sx of aortic dissection
A
- tearing sensation in chest
- radiates to back (classically)
23
Q
pathophysiology of aortic anryeusm
A
- 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
24
Q
signs of aortic dissection
A
- tachycardia and hypotension
- new aortic regurg murmur
end organ hypertension:
- UO
- paraplegia
- lower limb ischaemia
- abdo pain due to isch
- reduced GCS
25
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
26
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
27
complications of aortic disseciton
- aneurysm
- rupture
- aortic regurg
- MI (coronary artery dissection)
- cardiac tamponade
- stroke, paraplegia
28
classificaiton of carotid artery disease
- Mild= <50% diameter reduction
- Moderate- 50-69%
- Severe 70-99%
- total 100%
29
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
30
sign of cartoid artery disease
- carotid bruits
31
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)
-
32
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
33
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
34
risks of ccarotid endarterectomy
- stroke (embolisation)
- hypoglossal N damage
- glossopharyngeal N damage
- vagus N damage
- MI
- bleeding
- infection
35
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
36
sx of hypoglossal damage
- paralysis of 1/2 of tongue (deviates to side is damaged)
- fasciculations
- slurred speech
- difficultly eating and swallowing
37
sx of vagus nerve damage
- hoarseness
- dysphagia, dysarthria
- aspiration
- nausea, vomiting, slow HR, low BP
- uvula deviation away from lesion
38
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
39
ix for ?venous disease
ABPI_ normal (0.8-1)
- doppler USS and/or venography
- swab for cultures of ulcers
40
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
41
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
42
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
43
hx of chronic limb ischaemia
- cramping pain in calf after walking
| - relieved by rest
44
ix for chronic limb ischaemia
- ABPI
- doppler USS
- MRA, CTA
45
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
46
what is critical limb ischaemia
- chronic limb ischaemia progressing to rest pain
47
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
48
ix critical limb ischaemia
ABPI
| angiograms- MRA, CRA
49
tx critical limb ischaemia
- aspirin, clopi
- statin
- angioplasty
- surgery- stent, bypass
- amputation
50
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
51
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
52
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
53
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
54
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
55
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
56
how to prevent reperfusion injury
- monitor UEs closely
| - quick haemdialysis if needed
57
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
58
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 (
59
DVT sx
```
painful calf
red
swollen
warm
calf firmness
if iliofemoral- blue leg, white leg
```
60
What score do you use to decide ix of ?DVT
Well's
61
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
62
tx DVT
DOAC- apix or rivarox
or - LMWH for 5d then dabigtran
