Vascular Flashcards
At which level does the aorta bifurcate to the iliac arteries?
L5
What is the most important risk factor for aortic dissection? What are other risk factors?
Main RF = Hypertension
Others= Marfan's syndrome Ehlers-Danlos Turner's syndrome Coarctation of the aorta Truama
How does aortic dissection present?
Severe tearing chest pain which radiates to the bacjok
Weak/absent pulses
Aortic regurgitation - Early diastolic murmur with rumbling character
What are the two types of aortic dissection and how are they managed?
Type A = Ascending Aorta = Surgery - Midline sternotomy, remove section of aorta and replace with synthetic graft
Type B = Descending Aorta = Beta-blockers –> IV Labetalol
How is aortic dissection diagnosed?
CT Angiogram chest/abdo/pelvis
If they are unstable then TOE
What is seen on imaging in aortic dissection?
A false lumen
What is seen on CXR in aortic dissection?
Widened mediastinum
What is an abdominal aortic aneurysm?
Dilation of the abdominal aorta of more than 3cm
Who is offered a scan for AAA?
All men at 65
What is the first line scan for AAA?
Abdominal ultrasound
What is the diagnostic imaging for an AAA?
CT Angiogram
What is the most common cause of an AAA?
Arterial disease - HTN, diabetes, smoking
How does an AAA present?
Usually asymptomatic until rupture
May be a pulsatile mass in the abdomen
How do you manage an AAA which is between 3 and 4.4cm?
Monitor annually
How do you manage an AAA which is between 4.5cm to 5.5cm?
Monitor every 3 months
How do you manage an AAA over 5.5cm?
Repair
Which AAAs should be repaired?
Over 5.5cm
Symptomatic
Growing more than 1cm per year
When should a patient with an AAA stop driving? When does the DVLA need to be informed?
Inform DVLA at 6cm
Stop driving at 6.5cm
How does a ruptured AAA present?
Severe abdominal pain - may radiate to back
Hypotension
Tachycardia
May be collapse/loss of consciousness
How is a ruptured AAA managed?
Immediate vascular review
What is the stepwise progression of peripheral arterial disease?
- Intermittent claudication
- Critical limb ischaemia
- Acute limb-threatening ischaemia
What are features of intermittent claudication?
Aching/burning pain in leg following walking
Relieved within minutes of stopping
Not present at rest
How does critical limb ischaemia present?
1 or more of…
Rest pain in foot
Arterial ulceration
Gangrene
Patients often hang leg off bed to ease pain
How does acute limb-threatening ischaemia present?
6 P’s
Pale Pulseless Painful Paralysis Parasthaesia Perishingly cold
How is peripheral arterial disease assessed?
Check pulses
Handheld doppler
ABPI
How does an arterial ulcer present?
Small, deep Well-defined border Punched out appearance Usually peripheral - e.g on toes Painful
How does a venous ulcer present?
Usually after injury to leg Large Irregular borders Often affects gaiter area Less painful than arterial
Other signs of venous disease - venous eczema, varicose veins, lipsclerodematosis
How is peripheral arterial disease managed?
STOP SMOKING
Treat any co-morbidities
Start patient on statin 80mg and clopidogrel 75mg
Surgical options for severe PAD/acute limb ischaemia:
Thrombus= Endovascular angioplasty + stenting, Bypass
Embolus= Endarterectomy
What is Leriche syndrome?
Triad of..
Thigh/buttock claudication
Absent femoral pulses
Impotence
How do you interpret an ABPI?
1.0-1.2= normal <0.9 = likely PAD <0.5 = severe PAD
How are venous ulcers managed?
Compression bandaging (ensure that arterial disease has been ruled out)
What is superficial thrombophlebitis and how is it managed?
Inflammation and thrombosis of one of the superficial veins - usually the long saphenous vein
NSAIDs
Compression stockings
What skin changes are seen in venous insufficiency?
Varicose veins
Haemosiderin staining
venous eczema
Lipodermatosclerosis - hardening/tightening of skin
How are varicose veins managed?
If pregnant - will usually improve after delivery
Compression stockings
Surgical options - ablation, sclerotherapy, stripping
What is Buerger disease?
inflammatory condition - thrombus formation in the small and medium sized blood vessels
Strongly associated w/ smoking
How does Buerger disease present?
Painful blue discolouration of fingertips/tips of toes
What is seen on angiogram in Buerger disease?
Corkscrew collaterals
How is Buerger disease managed?
Stop smoking
What 2 medications should all patients with PAD be prescribed?
Statin + clopidogrel
What can cause a falsely raised ABPI in a patient with PAD?
Diabetes - due to sclerosis of the vessels
How is ABPI calculated?
ABPI = Systolic BP of the ankle / Systolic BP of the arm
How to diagnose an aortic dissection in an unstable patient?
Transoesophageal echo
Which AAAs should be monitored annually?
3cm to 4.4cm
Which AAAs should be monitored every 3 months?
4.4cm to 5.4cm
Venous ulcer vs. arterial ulcer
Size, depth, border, location, appearance, pain
Size: Arterial smaller than venous
Depth: Arterial deeper than venous
Border: Arterial is well demarcated, venous is poorly defined
Location: Arterial is usually peripheral (toes), venous is usually in the gaiter area
Appearance: Arterial appear punched out, venous occurs with haemosiderin staining, venous eczema, liposclerodermatosis and varicose veins
Pain: Arterial are painful, venous are less
What are skin signs of venous insufficiency?
Venous ulcer Haemosiderin staining Venous ulcer Liposclerodermatosis Varicose veins
What is ABPI and how is it interpreted?
Ankle pressure / Brachial pressure
<0.9 = arterial disease <0.5 = severe disease
What does the ABPI need to be for compression stockings/bandage?
At least 0.8
What is superficial thrombophlebitis and how is it managed?
Inflammation/thrombosis of one of the superficial veins- usually the long saphenous vein
Management = NSAIDs + compression stockings
What is Takayasu’s Arteritis and how does it present? How is it managed?
A type of large vessel vasculitis
Presents with a mild systemic illness then a pulseless phase - symptoms of vascular insufficiency
Managed with oral prednisolone
Associated with raised ESR
What are the two types of acute limb-threatening ischaemia and how can you tell the difference between the two?
Can either be due to a thrombus or an embolus
Thrombus - pre-existing claudication with sudden deterioration, no obvious source of emboli, reduced/absent pulses in other limb, evidence of widespread vascular disease (e.g. MI, stroke)
Embolus - sudden onset, no history of claudication, obvious source of embolus (e.g. AF), no evidence of PAD in other limb
How is acute limb-threatening ischaemia managed?
Thrombus - endarterectomy or bypass
Embolus - immediate embelectomy
Can you diagnose PAD using ABPI in diabetics?
No as it can be abnormally high
How urgently should someone with an AAA >5.5cm/rapidly enlarging/symptomatic see a vascular surgeon?
Within 2 weeks
Should someone with an AAA <5.5cm need to see a vascular surgeon?
Yes, within 12 weeks
