Vascular

Question 1

What is peripheral arterial disease (PAD)?

Answer 1

Refers to narrowing of the arteries supplying the limbs and periphery, reducing the blood supply to these areas. It usually refers to the lower limbs, resulting in symptoms of claudication.

Question 2

What is intermittent claudication?

Answer 2

Symptom of ischaemia in a limb, occurring during exertion and relieved by rest. It is typically a crampy, achy pain in the calf, thigh or buttock muscles associated with muscle fatigue when walking beyond a certain intensity?

Question 3

What is critical limb ischaemia?

Answer 3

This is the end stage of peripheral arterial disease, where there is inadequate supply of blood to a limb to allow it to function normally at rest.

Question 4

What is acute limb ischaemia?

Answer 4

Acute limb ischaemia refers to a rapid onset of ischaemia in a limb. Typically, this is due to a thrombus (clot) blocking the arterial supply of a distal limb, similar to a thrombus blocking a coronary artery in myocardial infarction.

Acute limb ischaemia refers to a rapid onset of ischaemia in a limb. Typically, this is due to a thrombus (clot) blocking the arterial supply of a distal limb, similar to a thrombus blocking a coronary artery in myocardial infarction.

Question 5

What is atherosclerosis?

Answer 5

Atherosclerosis is a combination of atheromas (fatty deposits in the artery walls) and sclerosis (the process of hardening or stiffening of the blood vessel walls). Atherosclerosis affects the medium and large arteries. It is caused by chronic inflammation and activation of the immune system in the artery wall. Lipids are deposited in the artery wall, followed by the development of fibrous atheromatous plaques.

Question 6

What are the non modifiable and modifiable risk factors of atherosclerosis?

Answer 6

Non modifiable- age, family history, male
Modifiable- smoking, alcohol consumption, poor diet (high in sugar and trans fat and low in fruit, vegetables an omega 3s)
Low exercise, sedentary lifestyle, obesity, poor sleep, stress

Question 7

What are the end results of atherosclerosis?

Answer 7

Angina 
MI 
TIA 
Stroke 
Peripheral arterial disease
Chronic mesenteric ischaemia

Question 8

What is intermittent claudication?

Answer 8

A sign of peripheral arterial disease
Its crampy pain that occurs after walking a certain distance, after stopping and resting the pain will disappear.
The most common location is the calf muscles, but it can also affect the thighs and buttocks.

Question 9

What is the presentation of critical limb ischaemia?

Answer 9

Pain at rest
Ulcers
Typically causes a burning pain, this is worse at night when the leg is raised as gravity no longer helps pull blood into the foot.

Question 10

What is Leriche syndrome?

Answer 10

This occurs with occlusion of the distal aorta or proximal common iliac artery, there is a clinical triad of…

1) thigh/ buttock claudication
2) absent femoral pulses
3) male impotence

Question 11

What are signs of arterial disease on inspection?

Answer 11

Skin pallor
Cyanosis
Dependent rubor (a deep red colour when the limb is lower than the rest of the body)
Muscle wasting
Hair loss
Ulcers
Poor wound healing
Gangrene (breakdown of skin and a dark red/black change in colouration)

Reduced skin temperature
Reduce sensation
Prolonged capillary refill time (more than 2 seconds)
Changes during Buerger’s test

Question 12

What is the buergers test?

Answer 12

This is used to assess for peripheral arterial disease in the leg, it involves two parts…

1) the first part involves the pt lying on their back (supine) and lifting the patients legs to an angle of 45 degrees at the hip. Hold the patient there for 1-2 minutes, looking for pallor. Pallor indicates peripheral arterial disease, as the arterial supply is not adequate enough to overcome the gravity.

The buergers angle refers to the angle at which the leg is pale due to inadequate blood supply. For example a buergers angle of 30 degrees means that the leg will go pale when lifted to 30 degrees.

The second part involves sitting the patient with their legs hanging over the side of the bed, blood will flow back into the legs assisted by gravity. In a healthy pt the legs will remain a normal pink colour, in a patient with peripheral arterial disease, they will go:

Blue initially as the ischaemic tissue deoxygenates the blood and dark red after a short time due to vasodilation in response to the waste products of anaerobic respiration.

Question 13

What do arterial ulcers present like?

Answer 13

Smaller than venous ulcers
Deeper than venous ulcers
Have well defined borders
Punched out appearance 
Occur peripherally (on toes) 
Have reduced bleeding 
Are painful

Question 14

What do venous ulcers Present like?

Answer 14

Caused by impaired drainage and pooling of blood in the legs

Occurs after minor injury to legs
More superficial
Irregularly, gently sloping borders
Affects the gaiter area of the leg (from the mid calf down to the ankles)
Less painful than arterial ulcers
Occurs with other signs of chronic venous insufficiency- haemosiderin staining and venous eczema

Question 15

What are the investigations done for venous ulcers?

Answer 15

ABPI
Duplex ultrasound
Angiography (CT or MRI)

Question 16

What is the ABPI? How do you measure it?

Answer 16

Ratio of the systolic blood pressure in the ankle (around the lower calf) compared to the systolic blood pressure in the arm
The readings are taken manually using a doppler probe, for example: am ankle SBP of 80 and an arm SBP of 100 would be 80/100= 0.8

Question 17

What would the following APBIs indicate

A) 0.9-1.3
B) 0.6-0.9
C) 0.3-0.6
D) <0.3

Answer 17

A) normal
B) mild PAD
C) moderate to severe PAD
D) <0.3 severe disease to critical ischaemia

Question 18

In what type of patients can you not do ABPI for peripheral artery disease?

Answer 18

Diabetics
An ABPI above 1.3 can indicate calcification of the arteries, making them difficult to compress, this is more common in diabetic patients.

Question 19

What are the managements of intermittent claudication?

Answer 19

Can use lifestyle modifications and exercise training

Medical treatments- atorvastatin, clopidogrel, NAFTIDROFURYL OXALATE (5HT2 receptor
antagonist that acts as a peripheral vasodilator)

Surgical options…

1) endovascular angioplasty and stenting
2) endarterectomy
3) bypass surgery

Question 20

What is the management of critical limb ischaemia?

Answer 20

Patients with critical limb ischaemia require urgent referral to the vascular team. They require analgesia to manage the pain.

Urgent revascularisation can be achieved by:

Endovascular angioplasty and stenting
Endarterectomy
Bypass surgery
Amputation of the limb if it is not possible to restore the blood supply

Question 21

What is the management of acute limb ischaemia?

Answer 21

Patients with acute limb ischaemia need an urgent referral to the on-call vascular team for assessment.

As an FY1 give IV heparin

Management options include:

Endovascular thrombolysis – inserting a catheter through the arterial system to apply thrombolysis directly into the clot
Endovascular thrombectomy – inserting a catheter through the arterial system and removing the thrombus by aspiration or mechanical devices
Surgical thrombectomy – cutting open the vessel and removing the thrombus
Endarterectomy
Bypass surgery
Amputation of the limb if it is not possible to restore the blood supply

Question 22

What are varicose veins?

Answer 22

Distended superficial veins that are >3mm in diameter, they usually affect the legs

Question 23

What is the pathophysiology behind varicose veins?

Answer 23

The deep and superficial veins are connected by vessels called the perforating veins (or perforators), which allow blood to flow from the superficial veins to the deep veins. When the valves are incompetent in these perforators, blood flows from the deep veins back into the superficial veins and overloads them. This leads to dilatation and engorgement of the superficial veins, forming varicose veins.

Question 24

What happens in chronic venous insufficiency?

Answer 24

When blood pools in the distal veins, the pressure causes the veins to leak small amounts of blood into the nearby tissues. The haemoglobin in this leaked blood breaks down to haemosiderin, which is deposited around the shins in the legs. This gives a brown discolouration to the lower legs.

Pooling of blood in the distal tissues results in inflammation. The skin becomes dry and inflamed, referred to as venous eczema.

The skin and soft tissues become fibrotic and tight, causing the lower legs to become narrow and hard, referred to as lipodermatosclerosis.

Question 25

What are the risk factors for varicose veins?

Answer 25

``` Increasing age Family history Female Pregnancy Obesity Prolonged standing- ie: occupations involving standing for a long time DVT ```

Question 26

What is the presentation of varicose veins?

Answer 26

Varicose veins present with engorged and dilated superficial leg veins, they are asymptomatic or have symptoms of: - heavy or dragging sensation in the legs - aching - itching - burning - oedema - muscle cramps - restless legs

Question 27

What are the special tests done for varicose veins?

Answer 27

Tap test- apply pressure to the saphenofemoral junction and tap the distal varicose vein, feeling for a thrill at the SFJ, a thrill suggests incompetent valves between varicose veins and SFJ Cough test- apply pressure to the SFJ and ask the pt to cough, feeling for thrills at the SFJ, again a thrill suggests a dilated vein at the SFJ. Trendelenburgs test with the patient lying down, lift the affected leg to drain the veins completely. Then apply a tourniquet to the thigh and stand the patient up. The tourniquet should prevent the varicose veins from reappearing if it is placed distally to the incompetent valve. If the varicose veins appear, the incompetent valve is below the level of the tourniquet. Repeat the test with the tourniquet at different levels to assess the location of the incompetent valves. Perthes test – apply a tourniquet to the thigh and ask the patient to pump their calf muscles by performing heel raises whilst standing. If the superficial veins disappear, the deep veins are functioning. Increased dilation of the superficial veins indicates a problem in the deep veins, such as deep vein thrombosis. Duplex ultrasound can be used to assess the extent of varicose veins. It is an ultrasound that shows the speed and volume of blood flow.

Question 28

What is the management of varicose veins?

Answer 28

Weight loss if appropriate Staying physically active Keeping the leg elevated when possible to help drainage Compression stockings (exclude arterial disease first with an ABPI) Surgical options- stripping, sclerotherapy (injecting the vein with an irritant foam that causes closure of the vein), endothermal ablation

Question 29

What are the complications of varicose veins?

Answer 29

``` Prolonged and heavy bleeding after trauma Superficial thrombophlebitis (thrombosis and inflammation in the superficial veins) Deep vein thrombosis All the issues of chronic venous insufficiency (e.g., skin changes and ulcers) ```

Question 30

What is chronic venous insufficiency?

Answer 30

This is when the blood does not efficiently drain from the legs back up to the heart, usually this is the result of damage to the valves inside the veins. The damage may occur with age, immobility, obesity, prolonged standing or after a DVT, it is often associated with varicose veins. The valves are responsible for ensuring blood flows in one direction as the leg muscles contract and squeeze the veins. When the valves are damaged, the pumping effect of the leg muscles becomes less effective in draining blood towards the heart. Blood pools in the veins of the legs, causing venous hypertension. Chronic pooling of blood in the legs leads to skin changes. The area between the top of the foot and the bottom of the calf muscle is the area most affected by these changes. This is known as the gaiter area.

Question 31

What skin changes may you get with chronic venous insufficiency?

Answer 31

Haemosiderin staining= a fed/brown discolouration caused by haemoglobin leaking into the skin Venous eczema (or varicose eczema)= a dry, itchy, flaky, scaly, red cracked skin, they are caused by chronic inflammatory response in the skin Lipodermatosclerosis= tightening of the skin and tissue beneath the skin, chronic inflammation causes the subcutaneous tissue to become fibrotic (turning to scar tissue). Inflammation of the subcutaneous fat is called panniculitis Narrowing of the lower legs causes inverted champagne bottle appearance Atrophie blanche- refers to patches of smooth, porcelain white scar tissue on the skin, often surrounded by hyperpigmentation Cellulitis/poor healing after injury/skin ulcers Pain

Question 32

What does the management involve?

Answer 32

Keeping the skin healthy Improving venous drainage to legs Managing any complications The skin can be kept healthy by; Monitoring skin health and avoiding skin damage Regular use of emollients Topical steroids to treat flares of venous eczema Very potent topical steroids to treat flares of lipodermatosclerosis Improving venous drainage to the legs involves; Weight loss if obese Keeping active Keeping the legs elevated when resting Compression stockings (exclude arterial disease first with ABPI) Management of complications; Anx for infection Analgesia for pain Wound care for ulceration

Question 33

What are the different types of leg ulcers you can get?

Answer 33

Venous Arterial Pressure Diabetic foot

Question 34

How do venous ulcers occur?

Answer 34

Due to pooling of blood and waste products in the skin, secondary to venous insufficiency

Question 35

What are diabetic foot ulcers?

Answer 35

Occur in diabetics due to peripheral neuropathy meaning a lot of pts don’t notice when they have injured themselves or have poorly fitting shoes Additionally, damage to both the small and large blood vessels impairs the blood supply and wound healing. Raised BP, immune system and autonomic neuropathy also contribute to ulceration and poor healing. Osteomyelitis (infection in the bone) is an important complication

Question 36

What is a commonly used risk assessment tool to assess pressure ulcers?

Answer 36

Pressure ulcers typically occur in patients with reduced mobility, where prolonged pressure on particular areas (e.g., the sacrum whilst sitting) lead to the skin breaking down. This happens due to a combination of reduced blood supply and localised ischaemia, reduced lymph drainage and an abnormal change in shape (deformation) of the tissues under pressure. Extensive effort should be taken to prevent pressure ulcers, including individual risk assessments, regular repositioning, special inflating mattresses, regular skin checks and protective dressings and creams. The Waterlow Score is a commonly used risk assessment tool for estimating an individual patient’s risk of developing a pressure ulcer.

Question 37

How can you distinguish between arterial and venous ulcers?

Answer 37

Typically arterial ulcers… - occur distally, affecting the toes or dorsum of the foot - are associated with peripheral arterial disese, with absent pulses, pallor and intermittent claudication - are smaller than venous ulcers - deeper than venous ulcers (punched out) - well defined borders - pale colour due to poor blood supply - less likely to bleed - are painful - have pain worse at night - have pain worse on elevating and improved by lowering the leg (gravity helps circulation) Typically, venous ulcers: Occur in the gaiter area (between the top of the foot and bottom of the calf muscle) Are associated with chronic venous changes, such as hyperpigmentation, venous eczema and lipodermatosclerosis Occur after a minor injury to the leg Are larger than arterial ulcers Are more superficial than arterial ulcers Have irregular, gently sloping border Are more likely to bleed Are less painful than arterial ulcers Have pain relieved by elevation and worse on lowering the leg

Question 38

What investigations can be done for venous/arterial ulcers?

Answer 38

Ankle-brachial pressure index (ABPI) is used to assess for arterial disease. This is required in both arterial and venous ulcers. Blood tests may help assess for infection (FBC and CRP) and co-morbidities (HbA1c for diabetes, FBC for anaemia and albumin for malnutrition). Charcoal swabs may be helpful where infection is suspected, to determine the causative organism. Skin biopsy may be required in patients where skin cancer (e.g., squamous cell carcinoma) is suspected as a differential diagnosis. This will require a two week wait referral to dermatology.

Question 39

How do you treat arterial ulcers?

Answer 39

The management of arterial ulcers is the same as peripheral arterial disease, with an urgent referral to vascular to consider surgical revascularisation. If the underlying arterial disease is effectively treated, the ulcer should heal rapidly. Debridement and compression are not used in arterial ulcers.

Question 40

How do you manage venous ulcers?

Answer 40

Patients require input from experienced nurses, such as the district nurses or tissue viability nurses. Good wound care involves: Cleaning the wound Debridement (removing dead tissue) Dressing the wound Compression therapy is used to treat venous ulcers (after arterial disease is excluded with an ABPI). Pentoxifylline (taken orally) can improve healing in venous ulcers (but is not licensed). Antibiotics are used to treat infection. Analgesia is used to manage pain (avoid NSAIDs as they can worsen the condition).

Question 41

What is an abdominal aortic aneurysm?

Answer 41

Dilation of the abdominal aorta with a diameter more than 3cm, often the first time a pt becomes aware of an aneurysm is when it ruptures, causing life threatening bleeding into the abdominal cavity.

Question 42

What are the risk factors for abdominal aortic aneurysm?

Answer 42

``` Men Increased age Smoking Hypertension Family history Existing cardiovascular disease ```

Question 43

What is the screening for a triple A?

Answer 43

All men in England are offered a screening ultrasound scan at age 65 to detect asymptomatic AAA Early detection of an AAA means preventative measures can stop it from expanding further or rupturing Patients an aorta diameter above 3cm are referred to a vascular team (urgently if more than 5.5cm)

Question 44

What is the presentation of AAA?

Answer 44

Most pts are asymptomatic It may be discovered on routine screening or when it ruptures Other ways it can present; Non specific abdo pain Pulsatile and expansile mass in the abdomen when palpated with both hands As an incidental finding o abdo X ray, US scan or CT scan

Question 45

How do you diagnose AAA?

Answer 45

Ultrasound is the usual initial investigation for establishing the diagnosis. CT angiogram gives a more detailed picture of the aneurysm and helps guide elective surgery to repair the aneurysm.

Question 46

How do you manage unruptured triple A?

Answer 46

Stop smoking Healthy diet/exercise Optimising management of diabetes, hypertension, hyperlipidaemia

Question 47

Triple As should have follow up scans, how often should they have them?

Answer 47

Yearly for patients 3-4.4cm | 3 monthly for patients 4.5-5.4cm

Question 48

When should you do elective repair for pts with triple A?

Answer 48

If they are symptomatic If it is growing more than 1cm per year Diameter above 5.5cm Surgery methods used: - open repair via. Laparotomy - endovascular aneursym repair

Question 49

What are the DVLA rules for pts?

Answer 49

Inform the DVLA if they have an aneurysm above 6cm Stop driving if it is above 6.5cm Stricter rules apply to drivers of heavy vehicles (e.g., bus or lorry drivers)

Question 50

What does a ruptured AAA present like?

Answer 50

Severe abdominal pain that may radiate to the back or groin Haemodynamic instability (hypotension and tachycardia) Pulsatile and expansile mass in the abdomen Collapse Loss of consciousness

Question 51

How do you diagnose ruptured AAA?

Answer 51

CT angiogram can be used to diagnose or exclude ruptured AAA in haemodynamically stable patients.

Question 52

What does aortic dissection mean?

Answer 52

Aortic dissection refers to when a break or tear forms in the inner layer of the aorta, allowing blood to flow between the layers of the wall of the aorta. There are three layers to the aorta, the intima, media and adventitia. With aortic dissection, blood enters between the intima and media layers of the aorta. A false lumen full of blood is formed within the wall of the aorta. Intramural refers to within the walls of the blood vessel.

Question 53

Where do aortic dissections normally occur?

Answer 53

So the Stanford system can be used which indicates where the dissection occurs… Type A= affects the ascending aorta, before the brachiocephalic artery Type B= affects the descending sorta after the left subclavian artery

Question 54

What are the risk factors of aortic dissection?

Answer 54

Aortic dissection shares the same risk factors as peripheral arterial disease… - age - sex (male) - smoking - hypertension - poor diet - reduced physical activity - raised cholesterol Hypertension is a big risk factor!! Dissection can be triggered by events that temporarily cause a dramatic increase in blood pressure- heavy weightlifting or use of cocaine Conditions or procedures that affect the aorta increase the risk of a dissection, such as: Bicuspid aortic valve Coarctation of the aorta Aortic valve replacement Coronary artery bypass graft (CABG) Conditions that affect the connective tissues can also increase the risk of a dissection, notably: Ehlers-Danlos Syndrome Marfan’s Syndrome

Question 55

What are the features of aortic dissection?

Answer 55

``` Ripping or tearing chest pain The pain may migrate over time Hypertension Blood pressure differences between the arms (>20mmHg) Radial pulse deficit Diastolic murmur Focal neurological deficit (limb weakness or paraesthesia) Chest and abdominal pain Collapse (syncope) Hypotension as the dissection progresses ```

Question 56

How do you diagnose aortic dissection?

Answer 56

ECG and CXR are used to exclude other causes such as: MI MI can occur in combination with aortic dissection and treatment of the Mi can cause fatal progression of the aortic dissection CT angiogram is the initial investigation to confirm the diagnosis and generally can be performed very quickly MRI angiogram

Question 57

What is the management of aortic dissection?

Answer 57

Aortic dissection is a surgical emergency and needs immediate involvement of experienced seniors, vascular surgeons, anaesthetists and intensive care teams. There is a very high mortality. Analgesia (e.g., morphine) is required to manage the pain. Blood pressure and heart rate need to be well controlled to reduce the stress on the aortic walls. This usually involves beta-blockers. Surgical intervention from the vascular team will depend on the type of aortic dissection. Type A may be treated with open surgery (midline sternotomy) to remove the section of the aorta with the defect in the wall and replace it with a synthetic graft. The aortic valve may need to be replaced during the procedure. Type B may be treated with thoracic endovascular aortic repair (TEVAR), with a catheter inserted via the femoral artery inserting a stent graft into the affected section of the descending aorta. Complicated cases may require open surgery.

Question 58

What are the complications of aortic dissection?

Answer 58

``` Myocardial infarction Stroke Paraplegia (motor or sensory impairment in the legs) Cardiac tamponade Aortic valve regurgitation Death ```

Question 59

What is carotid artery stenosis?

Answer 59

Narrowing of the carotid arteries in the neck, usually secondary to atherosclerosis. Plaques build up in the carotid arteries, reducing the diameter of the lumen. There is a risk of parts of the plaque breaking away and becoming an embolus, travelling to the brain and causing an embolic stroke.

Question 60

All patients with TIA are investigated for carotid artery stenosis (due to emboli), what can you do to check for this carotid artery stenosis?

Answer 60

Carotid ultrasound

Question 61

What is the presentation of carotid artery stenosis?

Answer 61

Usually is asymptomatic Usually diagnosed after TIA or stroke A carotid bruit may be heard on examination, this is a whooshing sound heard with a stethoscope over the affected carotid artery, the sound is caused by turbulent flow around the stenotic area during systole (contraction of the heart)

Question 62

What is the management of carotid artery stenosis?

Answer 62

Conservative management involves addressing modifiable risk factors and medical therapy: Healthy diet and exercise Stop smoking Management of co-morbidities (e.g., hypertension and diabetes) Antiplatelet medications (e.g., aspirin, clopidogrel and ticagrelor) Lipid-lowering medications (e.g., atorvastatin) Surgical interventions are considered where there is significant stenosis. The options are: Carotid endarterectomy Angioplasty and stenting

Question 63

What is an endartectomy?

Answer 63

Endarterectomy involves an incision in the neck, opening the carotid artery and scraping out the plaque. This is the first-line treatment for most patients requiring surgical intervention. A key complication of the procedure is stroke (around 2%). During endarterectomy, nearby nerves can be injured. This may be temporary or permanent. Symptoms depend on the nerve: Facial nerve injury causes facial weakness (often the marginal mandibular branch causing drooping of the lower lip) Glossopharyngeal nerve injury causes swallowing difficulties Recurrent laryngeal nerve (a branch of the vagus nerve) injury causes a hoarse voice Hypoglossal nerve injury causes unilateral tongue paralysis

Question 64

What does angioplasty and stenting for carotid artery stenosis involve?

Answer 64

Angioplasty and stenting is an alternative to endarterectomy. This is an endovascular procedure. A catheter is inserted into the femoral artery in the groin, passed through the aorta under x-ray guidance, up to the affected carotid artery. A balloon is inflated in the narrowed area to widen the lumen (angioplasty), and a stent is left in place to keep it open (stenting).

Question 65

What should you do if D dimer is raised, US negative but you are suspecting DVT?

Answer 65

stop anticoagulation and repeat US in 1 week