Vascular Flashcards
What are indications for amputation? 3Ds
Dead limb - gangrene
Deadly limb - wet gangrene, spreading cellulitis
Dead useless limb - gross deformities
What are the benefits of above knee amputation?
Quick to do
Heals reliably
What are the potential complications of amputation? (early)
Haemorrhage
Ischaemia
Infection
Wound dehiscence
What are the potential complications of amputation? (late)
Pain from unresolved infection
Adherent to bone and an amputation neuroma
Phantom limb
Phantom pain
What is aortic dissection?
Tearing of intima media
Blood pools in the media layer
How does someone with Aortic dissection present?
Tearing chest pain radiating through the back
Tachycardia
Hypotension
New AR murmur
What is a AR murmur?
Aortic regurgitation murmur
Valves cannot close and become leaky
Define aortic dissection
Injury to the innermost of the aorta allows for blood to flow between the aortic walls forcing them apart
What are the two ways of classifying Aortic Dissection?
Stanford (Type A or B)
Debakey (Type I, II and III)
What bedside investigations would you do in aortic dissesction?
ECG to exclude other cardiac pathology
A to E assessment
What bloods for possible aortic dissection?
FBC U&Es LFTs Coag Lactate Trop Group and save Cross match 10 units of blood
What imaging do you do for aortic dissection?
CT with contrast
See the artery with a line going through it
Define acute limb ischaemia
Sudden decrease in limb perfusion that threatens the viability of the limb = VASCULAR EMERGENCY
What are the causes of acute limb ischaemia?
Embolic
Thrombotic
Traumatic
Stent-related
What are the 6Ps of acute limb ischaemia?
pain, pallor, perishingly cold, pulselessness, paresthesia, paralysis
What are the investigations for acute limb ischaemia?
ECG to look for AF
Doppler USS
Routine + serum lactate, dying tissue
CT/MR angiogram with contrast
Digital subtraction angiography
What is thrombus association with?
AF because of stasis
How do we manage acute limb ischaemia?
Referral to tertiary vascular centre
Embolectomy or Thrombolysis
Bypass or angioplasty in long thrombotic occlusions
What is done in prep for surgery for patients with acute limb ischaemia?
IV Heparin
IV fluids
NBM
What are the complications of acute limb ischaemia?
Reperfusion injury Compartment syndrome Release of substances from damage muscle cells: K+ --> hyperkalaemia H+ --> acidosis Myoglobin can result in AKI
What is chronic limb ischaemia?
Symptomatic reduction of blood supply to the limbs
aka
Peripheral arterial disease
What can be caused by chronic limb ischaemia?
Intermittent claudications - cramping pain after walking a fixed distance
What defines critical limb ischaemia?
ABPI < 0.5
Persistent rest pain
What is the classification of chronic limb ischamia?
Stage I - asymptomatic
Stage II - Intermittent claudication
Stage III - Ischaemic rest pain
Stage IV - gangrene
What is ABPI?
Ankle brachial pressure index (ABPI)
The ABPI is the ratio of the ankle systolic blood pressure to the brachial systolic blood pressure
Normal is 1
Why might the ABPI be greater than 1?
Pressure in leg higher than brachial caused by calcification
How can we manage chronic limb ischaemia conservatively?
Regular exercise
Healthy diet/Weight loss
Smoking Sensation
How can we manage chronic limb ischaemia medically?
Statin
Anti-platlet
Optimise diabetes
How can we manage chronic limb ischaemia surgically?
Bypass using vein conduit or PTFE
OR
Angioplasty with/without stenting
Amputation
What are the main features of an arterial ulcer?
Lower legs and tops of feet or toes Painful Symmetrical with well defined border Cool, pale or bluish surrounding skin Loss of leg hair Faint or absent ankle pulses
Define carotid artery stenosis
Narrowing of the lumen on the carotid artery, most commonly die to atherosclerosis plaque
What are the main features of carotid artery stenosis?
Previous TIA Amaurosis fugax - black curtain (hypo perfusion of ophthalmic artery) Peripheral vascular disease IHD Valvular disease/replacements Carotid bruit, best heard on expiration
What are the bedside investigations for carotid artery stenosis?
Urine dip to check for proteinuria
ECG to look for ischemic changes, AF
What bloods for carotid artery stenosis?
FBC to look for anaemia
U+Es
Glucose/HbA1c
Lipids
What imaging is done in carotid artery stenosis?
Carotid duplex US to assess size and extent of stenosis
How would we conservatively manage carotid artery stenosis?
Smoking cessation Regular exercise Weight loss SALT referral OT/PT
How would we medically mange carotid artery stenosis?
Anti-platelet
Manage RFs e.g. T2DM or HTN
How would we surgically manage carotid artery stenosis?
Assessment for CEA (Carotid Endearcterectomy)
- surgical procedure to remove plaque
Criteria: acute, non-disabling stroke
symptomatic stentosis
What are the components of a vascular examination?
Inspection - ulcers, paleness Palpation - cap refill, pulses, temp Auscultation - carotid Sensation Buerger's test
What pulses should we be checking?
Temporal Common carotid Brachial Radial Femoral Popliteal Posterior tibialis
What is Buerger’s test?
Measure angle at which limb goes pale when raised
Less than 20 degrees is indicative of chronic limb ischaemia
What is peripheral arterial disease?
Atherosclerotic disease affecting the legs
Powerful marker of CVD risk
How prevalent is PAD?
30% of the adult population
How does PAD present?
Claudication
Rest pain becomes localised to toes, bad at night
Tissue loss
Gangrene
What differentials should be considered alongside PAD?
Spinal canal stenosis
Osteoarthritis
Non-atheroscerlotic e.g. entrapment syndromes
What are the risk factors for PAD?
Smoking
Dyslipidaemia
Hypertension
Diabetes
What exams for PAD?
CV
AAA
Pulse palpation
What investigations for PAD?
Doppler
ABPI
Toe pressure
TCPO2
What imaging for PAD?
DUS
CTA
MRA
Intra arterial DSA
Describe the natural history of PAD?
50% asympto
40% intermittent claudication
10% critical leg ischaemia
5 year outcomes
- 73% stable claudication
- 16% worsening claudication
- 7% leg bypass surgery
- 4% major amputation
How do we manage PAD conservatively?
Smoking cessation Diabetes control Statin BP control Antiplatelet
Improve walking distance
How can we improve walking distance in PAD?
Supervised exercise
Vasoactive drugs
Revascularisation
Amputation (last resort)
What typically causes embolic acute limb ischaemia?
AF
What typically causes thrombotic acute limb ischaemia?
Previous PAD disease
History v important when distinguishing between embolic and thrombotic
What percentage of patients will develop diabetic foot ulcer?
25% of those with diabetes
Why is DFD so important?
High rates of amputaiton and mortality
Costs NHS more than 1B£ a year
How do you manage diabetic foot sepsis?
Surgical emergency Sepsis 6 Foot x-ray Bloods Microbiology Emergency debridement
What is the FAST acronym for stroke?
Face
Arms
Speech
Time
What is the investigation pathway for stroke?
ECG Duplex CTScan Decision re intervention Rapid intervention for max gain
What defines a AAA?
Abnormal dilation >50% its normal size
What are risk factors for AAA?
Male
HTN
Smoking
Genetics
How do AAAs present?
Asympto normally OR Pressure Rupture Thrombosis Embolisation
Expansile and pulsatile
When do we operate on AAAs?
Size > 5.5cm but 5cm threshold for females
Increase > 1 cm in a year\
Repair of aorto-iliac disease
Informed patient preference
What are the two ways of surgically repairing an AAA?
Open
Endovascular
How to you choose between open and endovascular?
Low risk - open
High op risk - EVAR
What are signs and symptoms of venous disease?
Pain Discomfort Heaviness Varicose veins Oedema Skin discolouration (brown) Lipodermatoscelrosis (champagne bottle legs) Ulceration
What are the RFs for venous disease?
Age FH Gender Pregnancy Obesity Reduced mobility at work Smoking Decreased fibre intake and constipation
What does elevated venous pressure result from?
Muscle pump
Valvular reflex in deep and superficial veins
Venous obstruction
What are the investigations for venous disease?
Duplex US
Venogram
What are characteristics of venous ulcers?
Superficial
Wet
What is the treatment of venous ulcers?
Compression
and offer surgery to reduce risk of reoccurrence
What investigation is done for varicose veins?
DUS
What are the indications for treatment for varicose veins?
Bleeding
Symptomatic primary or recurrent v. veins
Skin changes
Superficial vein thrombosis (hard, painful veins)
Venous leg ulcer
What is the treatment for varicose veins?
Compression stockings
Venous ablation - under US guidance, radio frequency probe generates heat (thermal
0
Mechnochemical venous ablation
Foam therapy can be used as a part of mechnochemical or by itself
What is gangrene?
complication of necrosis characterised by the decay of body tissues
can be:
- infectious (wet)
- ischaemic (dry)
What is the most common cause of gangrene?
Critically insufficient blood supply associated with diabetes and smoking
What are 1st line investigations for gangrene?
FBC (raised WCC) Metabolic panel (Hyponatraemia common) LDH (haemolytic anaemia) Blood cultures if suspected infection CRP
What is the treatment for necrotising fasciitis?
Intensive supportive care
Surgical debridement +/- amputation
Local irrigation
ABs
What is the treatment for ischaemic gangrene?
IV heparine
Surgical revascularisation
Thrombolytic therapy
What is arterial thrombosis?
Blood clot in artery
What are the risks of arterial thrombosis?
MI
Stroke
TIA
Critical limb ischaemia
What are RFs for atherosclerosis?
getting older
smoking
an unhealthy diet
a lack of exercise
being overweight or obese
regularly drinking excessive amounts of alcohol
other health conditions, including high blood pressure, high cholesterol and diabetes
a family history of atherosclerosis
being of south Asian, African or African-Caribbean descent
What are the treatments for arterial thrombosis?
Throbolytic medication
Embolectomy to surgically remove clot
Angioplasty to widen affected artery
CABG (coronary artery bypass graft to divert blood around blocked artery)
