Vascular Flashcards
what is aortic dissection
tear in the tunica intima of the aorta
RF for aortic dissection
HTN, recent heart surgery, bicuspid aortic valve, Connective tissue disorders (marfan’s, ED), pregnancy, syphilis, cocaine use
How do you classify Aortic Dissection
Stanford Type A: ascending aorta (2/3 of cases)
Stanford type B: descending aorta (1/3)
How do you manage stanford TA
aortic root replacement surgey
how do you manage stanford TB
Bed rest and beta blockers
classical sx of aortic dissection
Tearing central chest pain
radiates to back
What is BP like in aortic diss
May be high or low
>20mg difference BP between arms
what murmur could you hear with aortic diss
AR
How do you investigate definitively Aortic diss
Stable: CT Angio
Unstable (cannot be taken to CT): TOE/TTE
What preliminary ix are necessary if suspecting aortic diss
ECG (ischaemia)
CXR (widened mediastinum)
FBC (haemoglobin)
X match, group and save
What are the three presentations of Peripheral Arterial Disease
- Intermittent claudication (Chronic Limb Ischaemia)
- Critical Limb Ischaemia
- Acute life-threatening Ischaemia
What is intermittent claudication
Decreased arterial supply to the limbs usually due to atherosclerosis
leading to increased oxygen demand upon exercise that cannot be met by the local vasculature
What are RF of intermittent claudication / PAD
MODIFIABLE:
smoking
dyslipidaemia
hyperglycaemia
HTN
NON-MOD:
- male gender
- increased age
- PMH / FH
- genetic RF
How does chronic limb ischaemia progress(fontaine classification)
- asymptomatic
- intermittent claudication
- ischaemic pain at rest
- ulceration / gangren
how does intermittent claudication present
CRAMPING pain in calves or buttocks after walking a determined distance
resolves with rest
this is reproducible
no pain if at rest
due to increased oxygen demand that cannot be met during exercise by the local vasculature
If intermittent claudication causes pain in the calves / buttock, which arteries are affected?
calves = SFA
buttock: = common / internal iliac
What are clincal findings for intermittend claudication?
PULSE pattern will tell you where blocklage is
No ulcers
Buerger’s negative
ABPI >0.5
How do you investigate intermittent claudication?
Exercise treadmill ABPI
Duplex
Angiography (CT / MR / digital subtraction)
how do you manage intermittent claudication
- Conservative: LIFESTYLE CHANGES
- stop smoking
- improve diet
- improve exercise, try to walk through the pain (as this will increase collateral circulation) - Medical: RF control
- stop smoking
- treat HTN
- antiplatelet (clopi)
- statin
What is leriche’s syndrome
peripheral artery disease affecting the AORTIC BIFURCATIOJn
opresents as buttock / thigh pain + erectile dysfunction
with weak or absent femoral pulses
What is critical limb ischaemia
significant arterial stenoosis causing severe impairment of blood flow to limbs, presenting with at least one of the following:
- ABPI <0.5 or ankle artery pressure >40
- Ischaemic pain >2 weeks
- Rest pain or tissue loss (ischaemic lesion / gangrene / ulceration)
ARTERIES are not able to meet BASELINE DEMAND
How do you manage critical limb ischaemia
Same as intemrittent claudication (modify RF)
- Endovascular repair (angioplasty or stenting)
- surgical tecnique (bypass or embolectomy)
What is acute limb ischaemiA
SUDDEN drop in blood supply to the limb
it threatens limb viability (if not managed within 6 hours, limb will be lost)
what causes acute limb ischaemia?
ACUTE CAUSE - either thrombosis or embolus
what are the 6 Ps of acute limb ischaemia
Pain
pallor
perishingly cold
pulseless
paralysis
parasthesia
what is the management of acute limb ischemia
NBM, IV hydration, analgesia
Unfractionated heparin to prevent clot extension
If embolic cause: embolectomy
If thrombotic cause: angioplasty with stent, thrombolysis, bypass, ampitation
when is thrombolysis viable in acute limb ischaemia?
With ACUTE ON CHRONIC limb ischaemia (i.e. the limb still has some viable collaterals. so it is not as severe)
what is Buerger’s disease
recurrent inflammation and thrombosis of arteries and veins in lower limbs, with uncertain aetiology
what is the biggest RF for buerger’s disease
SMOKING q
what is Buerger’s disease presentation
Raynauds of LL
intermittent claudication
pain at restn
sensitivity to cold
absent peripheral pulses
what are key investgations for PAD
Cardiovascular risk assessment (blood glucose, cholesterol, BP, ECG)
- ABPI
- Duplex USS
- CT / MR angiograpy
Consider Intra arterial Digital subtraction angiography (gold standard view of anatomy and therapeutic potential with angioplasty)
What are ABPI ranges
Normal: 0.9-1.2
0.8-0.9 = mild
0.5-0.8 = moderate
<0.5 = severe
>1.2 = indication of abnormal calcification (stiff arteries)
What ABPI should you refer to vascular surgeons
<0.8 or >1.3
what is amangement of PAD
asymptomatic / intermittent claudication: risk factor modification
- conservative: quit smoking, WL, exercise, foot care
- medical: atorvastatin 80mg + clopi 75mg
sym,ptomatic:
- angioplasty, stenting, bypass
- lst resort: amputation
what is deep venous insufficiency
inability of veins to drain blood adequately due to DVT / valvular insuff + varicose feins
RF deep vain insuff
advanced age, female, pregnancy, prior DVT / phlebitis, smoking, obesity
signs of chronic venous insuff
lipodermatosclerosis
haemosiderin deposition
venous ulcers
vemnous eczema
hhow do you manage chronic venous insuff
compression bandages
surgical graft
how do you diagnose a DVT
Well’s score
>=2 : DVT likely, so perform USS leg <4 hours > if positive, DOAC 3m (provoked) or 6m (unprovoked)
if USS negative, check D dimer. if D dimer positive, repeat USS in 1 week
<2: DVT unlikely, check D dimer within 4 hours. If D dimer +ve, do USS
what further investigation must you do for unprovokedc DVT
CT Abdo to identify possible malignancy
what is the difference in loaction between venous and arterial ulcer
venous in GAITER region (between middle calf and medial malleolus)
arterial in pressure points on foot/toes
what is the difference in aspect between venous and arterial ulcer
venous = shallow, flat margins. slough at base with granular tissue
arterial = punched out, deep irregular shape, minimal exhudate
what are coexisting signs with venous disease
haemosiderin deposition
lipodermatosclerosis (champagne bottle)
venous ulcers
varicose eczema (dry, flaking)
pitting oedema
thrombophlebitis
bleeding
what are coexisting signs with arterial ulceration
thin shiny skin
hairless
pallor on leg elevation
absent/weak pulses
what is an AAA
dilatation of aorta to >50% normal diameter / >3cm
RF AAAA
HTN
smoking
hypercholesteraemia
Males (higher AAA risk), females (higheer rupture risk)
what kind of screening is offered for AAA
to men 65+
single abdominal USS
what outcomes of AAA screening dictate management
>5.5 >> 2 week vasc referral
4.5 to 5.5 >> fu scan 3 months
3 to 4.5 >> fu scan 12 months
How do you manage AAA
Emergency: open or endovascular repair (depending on center)
Non-ruptured:
- conservative mx (with followup) if aneurysm <5.5cm diameter
- elective repair once risk of rupture becomes grearer than risk of surgery
what are tx for varicose veins
- endothermal ablation
- foam sclerotherapy
- surgical stripping (rarely don)
what is the typical pain in critical limb ischaemia
critical limb ischaemia: pain at rest
often in sleep
relieved by DEPENDNCY (hanging foot off side of bed)
what are the two types of gangrene
wet (infected)
dry ( noo infection)
what is the pathophys difference between critical limb ischaemia and acute limb ischaemia
ALI is SUDDEN drop in arterial perfusion
Due to thombosis (stenosed vessel with plaque rupture) or embolus (AF/valve disease)
What are common sites of aneurysmal disease
Abdominal aorta (infrarenal)
Popliteal artery
Complications of aneurysmal disease
rupture
embolus
thrombodsis
DVT
fistula (if syphilic)
S/S varicose veins
dragging, aching pain
swelling
itching
restless leg
night cramps
RF varicose veeins
pregnancy
lots of standin g
obesity
DVT valve distruction, AV malformation
what tests can you do on varicose veins
Cough impulse
Tap test (chevrier’s test - tap proximally and feel for impulse distally)=
Tourniquet test (apply tourniquet to compress SFJ > stand patient > id distal veins do not fill, this means this area is controlled and the incompetent valve is ABOVE tourniquet)
How do you do Buerges test
Lift both legs up slowly
One leg will blanche - due to reduced arterial perfusion (note what degree angle this is - the smaller the angle, the more severe the PAD)
Then swing legs across the bedside - the blanched foot will become hyperaemix (so brick red)
what does a midline laparotomy expose in vascular surgery?
the abdominal aorta
what does a groin scar indicate?
femoral access scar
midline laparotomy + (bilat) groin scar = which surgery?
(bilateral) aortofemoral bypass
groin scar + medial leg scar =
femoral popliteal bypass
what does the medial leg scar give access tpo
long saphenouus vein harvest
arterial anatomy to LL
Aorta bifurcates into R and L common iliac
COMMON ILIAC bifurcates into internal and external iliac
EXTERNAL ILIAC > common femoral > profunda femorios & supperficial femoral
superficial femoral travels through ADDUCTOR CANAL to become the policteal arteri
POPLITEAL ARTERY branches off fiirst the anterior tibial, then splits into posterior tibial (medial) and fibular (lateral)
Anterior tibial becomes dorsalis pedis
which drug can be prescribed as finial line in intermiittent claudication
naftidrofuryl oxalate (potent vasodulator)
which two drugs must ALL patents with PAD be on
Statin (atorvastatin) + anti-platelet (clopidogrel)
what other condition other than size do you need to refer abdominal aortic aneurysm to vascular surgeons for
if RAAPIDLY ENLARGING
so >1cm growth per annum in size
how do you differentite thrombys / embolus in ALI?
Thrombus: patient will have pre-existng claudication, absent or reduced pulses in the other limbs, widespread vascular disease
Embolus: no prior claudication, sudden onset painiful leg, obvious source of embolus (AF, MI)
which systemic condition is linked to vessel calcification> abnormal ABPI readings
T2DM
what does the presence of abdominal pain in the context of AAA indicate?
that there is HIGH LIKELYHOOD OF RUPTURE
what is the difference in timeline of sx between when you should use ABPI and handheld doppler
ABPI if suspecting chronic/critical limb ischaemia
Doppler if suspectinig acute limb threatening ischamia!
indications for referring pts with venous disease to vasc ssurgeoons
- varicose veins sx (‘heavy’ or ‘aching’ legs)
- skin changes associated with chronic venous insufficiency (e.g. venous eczema or haemosiderin deposition)
- ssuperficial thrombophlebitis
- venous leg ulcer (active or healed)
what tx can vasc surgeons do for patient with venous disease
- endothermal ablation
- injection / foam sclerotherapy
- surgery (ligation / stripping)
