Vascular Flashcards
Appearance of venous ulcers?
Shallow
Irregular boarders
Odema, haemosidrin deposition (brown), eczma, painless
Pt may also have varicose veins as these are secondary venous insufficiency
Where are venous ulcers commonly found?
Medial malleolus/gaiter region
What is the pathophysiology of venous ulcers?
Valvular incompitence/venous outflow obstruction
Impaired venous return
Venous HTN causes trapping of WBC in capillaries and the formation of a fibrin cuff around the vessel hindering oxygen transportation into the tissue
WBC activation
Release of inflammatory mediators
Tissue injury and poor healing necrosis
Clinical features of a venous ulcer
Painful, worse at the end of the day Before ulceration - Aching - Itching - Bursting sensation Associated varicose eczma Haemosiderin skin staining Thrombophlebitis Lipodermatosclerosis Atrophie blanche Ankle/leg odema
Management of venous ulcers
Leg elevation Exercise Weight loss Improved nutrition Abx if clinical evidence of wound infection Multicomponent compression bandaging changed 1-2 times a week (ABPI>0.6 before bandaging applied) Dressings and emollients Treatment of coccurent varicose veins
What are the causes of neuropathic ulcers?
Peripheral neuropathy (DM, B12 def)
Alcohol
Concurrent peripheral vascular disease
Foot deformity
Neuropathic ulcer appearance
Punched out appearence
Variable size/depth
Clinical features of neuropathic ulcers
Single nerve invovlement
Amotrophic neuropathy
Peripheral neuropathy, glove and stocking distribution with warm feet
Burning/tingling
Where do neuropathic ulcers usually occur?
Pressure areas
Management of neuropathic ulcers
Specialised diabetic foot clinics Diabetic and CVS disease control optomisation Improved diet Exercise Regular chiropody Ischemic/necrotic tissue debridment Amputation of necrotic didgits
What is Charcots Foot
Neuroarthopathy where by a loss of joint sensation results in continual unnoticed trauma and deformity occuring. Deformity predisposes patient to neuropathic ulcer formation.
How does Charcot’s Foot present?
Swelling Distortion Pain Loss of function Rocker bottom sole - deformity causing loss of the transverse arch
What do arterial ulcers look like?
Small Deep Well definied Little granulation tissue compared to venous ulcers (more necrotic) PUNCHED OUT Will be on heels/toes
Cool extremities low APBI
Clinical features of arterialulcers
Hx of imtermittent claudication/critical limb ischemia Cold limbs with reduced/absent pulses Thickened tonails Necrotic toes Hair loss
Risk factors for arterial ulcers
Obesity HTN FHx Smoking DM (microvascular and macrovascular complications) Hyperlipidemia Physical inactivity Increasing age
Pathophysiology of arterial ulcers
Atherosclerosis
Reduced tissue perfusion
Poor wound healing
Medical management of arterial disease
Statins
Antiplatelets
CBG optimisation
BP control
Surgical mamagement of arterial disease
Angioplasty +/- stenting
Bypass grafting in extensive disease
Management of arterial ulcers
Optimisation of underlying arterial disease
If non healing depsite adequete blood supply skin graft may be offered
Pressure ulcer staging
Stage 1 Epidermis
Stage 2 Dermis
Stage 3 Adipose and fascia
Stage 4 Muscle and bone
What are risk factors for DVT?
Previous DVT Phlebitis Smoking Increasing age Female FHx Obesity Pregnancy Long periods of standing Immobility Mallignancy Recent surgery
What is Virchow’s triad?
Endothelial injury
Stasis of blood flow
Hypercoagulability
Clinical features of DVT
Lower limb swelling Puritis Pain Thrombophlebitis Erythmatous Warm skin around painful Lipodermatosclerosis Haemosiderin skin staining Atrophi blanche Pedal odema
How is DVT investigated?
Doppler USS if D-dimer positive OR Wells>=2
Foot pulses
ABPI
D dimer if Wells score < 2 to rule out DVT
ABPI Values
Severe arterial disease < 0.5
Moderate arterial disease 0.8-0.5
Mild arterial disease 0.9-0.8
In diabetics/calcification ABPI will be higher than healthy patients
Initial management of DVT
Treatmet dose apixaban or rivaroxaban
Consider catheter directed throbolysis in oateitns with sympotmatic iliofemroal
Long Term Anticoagulation in VTE
DOAC
Warfarin
LMWH
How long should patients continue anticoagulation for after a DVT
3 months if reversable cause
Beyond 3 months of unclear cause or recurrent VTE
3-6 months in active cancer
What is the first line anticoagulant in pregnancy?
LMWH
Complications of DVT
PE
Chronic venous insufficiency
Post thrombotic sydrome
What are the mechanical methods of thromboprophylaxis
Antiembolic stockings
Imtermittent pneumatic compression
What are the pharmacological methods of thromboprophylaxis?
Low molecular weight heparin, enoxaparin, deltaparin, etc
What invesitgations should be carried out after an unprovoked DVT?
Antiphospholipid syndrome (check antiphospholipid antibodies) Hereditary thrombophilias (only if they have a first-degree relative also affected by a DVT or PE)
Risk factors for AAA
Smoking HTN Hyoerlipedemia Family history Male Increasing age NOTE DM IS PROTECTIVE
Patients with AAA are often asymptomatic, when they are not how might they present?
Abdominal pain Back pain Loin oain Distal embolisim producing limb ischemia Aortoenteric fistula Pulsatile mass at umbilical level
At what age is AAA screening offered to men?
65 years
What radiological investigations should be conducted in suspected AAA?
- USS
2. Ct scan with contrast if 5.5cm+ (determine suitability for endovascular proceedures)
Up to what size is an AAA suitable for USS monitoring?
5.5cm
How often should a 3-4.4cm AAA be monitored
Once a year
How often should a 4.5-5.4cm AAA be monitored?
Every 3 months
What size AAA disqualifies road users from driving until repaired?
6.5cm
What are the indications for surgical intervention in AAA?
AAA > 5.5cm
AAA expanding more than 1cm/year
Symptomatic
Treatment of AAA
Open repair (midling laparotomy or long transverese incision, replaced with prosthetic graft) Endovascular repair (graft via femoral arteries, stent fitted)
Compare endovascular vs open repair of an AAA
Endovascular: decreased hospital stay and 30 day mortarlity
Open: reduced rate of reintervention and aneurysm rupture
Complications of a AAA
Rupture
Retroperitoneal leak
Ebolisation
Aortoduodenal fistula
What are the risk factors for a AAA rupture?
Diamteter of aneurysm
Smoking
HTN
Female
How might a ruptured AAA present?
Abdominal pain Back pain Syncope Vommiting Haemodynamical compromise Pulsitile tender abdominal mass
Management of a ruptured AAA
Highflow O2
Two large bore canula
Urgent bloods with crossmatch for 6U
Maintain permissive hypotension (<100mmHg, as to not dislodge any clots, but ensure oatient is cerebrating)
Transfer to vascular unit
Unstable: immediate theatre transfer for open repair
Stable: CT angiogram to determine whether endovascular repair may be suitable
Stage 1 Chronic Limb Ischemia
Asymptomatic
Stage 2 Chronic Limb Ischemia
Intermittent claudication
Stage 3 Chronic Limb Ischemia
Ischemic rest pain
Stage 4 Chronic limb ischemia
Ulceration and/or gangreen
Pathophysiology of chronic limb ischemia
Atherosclerosis (or sometimes vasculitis) causes reduced blood supply to the limb
Risk factors for chronic limb ischemia?
Family hisotry DM Increasing age Obesity Inactivity Hyperlipidemia Smoking HTN
Describe and explain Buerger’s test
Lie patient supine, raising their legs until they have gone pale.
Lower the patients legs until colour retuens
The angle at which the limb goes pale is termed Beurgers angle (<20 degrees indicated severe ischemia)
What is claudication distance?
Distance which can be tolerated before pain occurs (relieved by rest)
Clinical features of intermittent claudication
Cramping pain
Calf/buttock/thigh
What is critical limb ischemia
Ischemic rest pain >2 weeks, requiring opiate analgesia AND/OR presence of ischemic lesions or gangrene objectively attributable to the arterial occlusive disease +/- ABPI < 0.5
Clinical signs that can be ellicited on exmaination of a patient with critical limb ischemia?
Limb hair loss Atrophic skin Ucleration Gangrene Thickened nails
What is the difference between neurogenic claudication and intermitten claudication?
Neurogenic
Symptoms on initial movement
What radiological investigations can patients with critical limb ischemia undergo?
Doppler USS to assess severity and location of any occlusion
Further imaging via CT angiogram or MRA
What is a normal Doppler USS
Triphasic
What is an occlusion on a doppler USS
Monophasic
Medicalmanagement of CLI
Lifestyle
Statins
Antiplatelet therapy
Optomise diabtic control
Surgical management of CLI
Angioplasty +/- stent
Bypass grafting
Amputation
Open surgery (endarectomy embolectomy)
Which vessel does CLI usually involve?
SFA
What does p1-3 mean in terms of artery involvemet in CLI
P1 above knee
P2 behind knee
P3 below knee
What are varicose veins?
Which veins are usually involved?
Swollen superficial veins which recieve blood flow from the deep venous system due to incompitent valves.
Usually long and short saphenous veins.
Risk factors for varicose veins?
DVT Genetics Surgery Obestiy Advancing age Pelvic masses
Clinical features/presentation of Varicose Veins
Skin discolouration Aching Itching Ulceration Thrombophlebitis Haemosiderin deposition Venous eczma Bleeding Odema
What is the management of varicose veins
Exercise Weight loss Reduced standing Compression stockings Four layered bandaging for any venous ulcers Vein ligation, stripping Foam sclerotheraoy Thermal ablation
Varicose Veins + Concurrent DVT
Cannot treat superficial incompitence aa the venous blood will have no route back
Non surgical management
How to homocysetine levels affect vascular disease?
Higher levels higher incidence
Which test is a gold standard for diagnosis of peripheral vascular disease?
CT arteriogram
What are the 5 P’s of arterial insufficiency?
Pain Pallor Perishingly cold Paralysis Pulselessness
When should red cell tranfusion be given?
Hb<70g/L
Hb<80g/L + patient has ACS
What is the immediate treatment for an aortic dissection?
IV labetalol
Allows for rapid control to slow progress of dissection
Features associated with venous insufficiency?
Haemosiderin deposition (brown pigmentation)
varicose veins
Venous ulcers, usually above the medial malleolus
Lipodermatosclerosis (champagne bottle legss)
Eczma
In peripheral arterial disease with critical limb ischemia what kind of surgical revascularisation is most suitable for low risk patients?
Open, e.g. open bypass graft
What should all patients with peripheral arterial disease should take?
Clopidogrel
Atorvastatin
How is claudication affecting the femoral vessels likely to present?
Calf pain
How is claudication affecting the illiac vessels likely to present?
Buttock pain
Treatment for Giant Cell Arteritis?
High dose steroids to prevent irreversable blindeness
60mg prednisolone OD
Blood pressure findings in aortic dissection?
Difference of more than 20mmHg between the left and right arms
What is Wegners granulomatosis?
Wegener’s granulomatosis is a vasculitis that affects both small and medium-sized vessels and therefore the presenting symptoms can vary hugely depending on the organ affected. For example, the patients may complain of nose bleeds and a saddle nose. This is secondary to nasal septum perforation. C-ANCA is specific for Wegener’s granulomatosis as it is present in over 80% of patients. Wegener’s granulomatosis can also be associated with P-ANCA in rare cases.
In Raynaud’s phenomenon with extremity ischaemia, what condition should be considered?
Burgers disease - thromboangiitis obliterans
Management of PAD with critical limb ischemia
Percutaneous transluminal angioplasty - This is used in patients who are at high risk and have short segment stenosis of <10cm.
Surgical bypass - This is indicated in patients with long segment stenosis of >10cm.
Chronic limb ischemia vs critical
Chronic: IC - crampy, muscular, calf thigh (common iliac) or buttock (femoral), relieved on rest, hair loss and AD
Critical: chronic rest pain more than 2 weeks, ulceration, gangrene, absent foot pulses, hanging leg off bed
Thrombus vs embolus
Thrombus clot in the blood vessel
Embolus a thrombus that has mobilised
Buttock pain which artery
Common iliac
Calf and thigh pain which artery
Femoral
What is a clue as to whether or not a patient with critical limb ischemia has a salvageable limb?
Paralysis - not salvageable
Progression of critical limb ischemia?
Pain Pallor Cold Pulse absent Parathesia PARALYSIS - loss of limb
What ABPI indicates heavy calfication
> 1.3
What ABPI is normal
0.8-1.3
What APBI is indicative of peripheral arterial disease
Less than 0.8
What ABPI indicates severe peripheral arterial insufficiency
Less than 0.5
Pharmacological management of peripheral arterial disease?
STATIN + CLOPIDOGREL (+ NAFTIDROFURLY OXALATE)
What size abdominal aorta is an AAA?
Over 3cm
What kind of expansion of an AAA warrants surgical intervention?
1 cm in a tear or 0.5cm over 6 months
What size AAA warrants 2ww for surgery?
Over cm 5.5
Following an intital screening of AAA which pts are called back in 12 months
3-4.4
Which patients would be invited back for repeat AAA screening in 3 months?
4.5-5.4
What is an aortic dissection?
A tear in the tunica intima of the aorta which creates a false lumen
Classification of aortic dissection?
Stanford: Type A - ascending Type B - descending
What might be seen on CXR in aortic dissection?
Widened mediastinum
Pulse abnormalities in aortic dissection
Pulse deficits - 20mm/hg between arms
Radial radial delay
Absent peripheral pulses
Common veins for varicose
Great saphenous and small saphenous
Pathophysiology of varicose veins
Venous insufficiency
Valvular incompetence
Inc pressure in veins
Indications for referral of varicose veins to secondary care?
Skin changes
Superficial vein grin is is
Ulcer
What’s an atrophic Blanche
Star shaped ivory white atrophic scar
Clinical diagnosis
It occurs after a skin injury, when the blood supply is poor and healing is delayed.
What is an ulcer?
Break in skin hasn’t healed for two weeks
Brief pathophysiology of compartment syndrome
Hypoxia
Leaky vessels
Odema
Pressure increase compartment
What intracompartmemt pressure is diagnostic of compartment syndrome
> 40mmHg
What intracompartment pressure should raise suspicion of compartment syndrome?
> 20mmHg
