Vascular Flashcards
What 2 vascular procedures may result in a midline laparotomy scar?
Aortobifemoral bypass
Open AAA repair
Risk factors for AAA
Modifiable
- Hypertension
- Diabetes
- Hypercholesterolaemia
- Smoking
Non-modifiable
- Age
- Ethnicity
- Sex
- Connective tissue disorders
Screening for AAA
One off USS scan for all males at 65yo
Monitoring of incidental AAAs
If 3-4.5cm and asymptomatic: See vascular team within 12w, then USS every year
If 4.5-5.5cm and asymptomatic: USS every 3 months
If grows to more than 5.5cm, or grows >1cm in 1 year or is symptomatic but unruptured, needs elective surgical intervention
Old/frail = EVAR Young/healthy = open AAA repair
Risk factors for varicose veins
Obesity
Pregnancy
Standing for long periods
Age
Skin changes associated with chronic venous insufficiency
Lipodermatosclerosis - extravasation of lipids leads to immune cell recruitment and fibrotic response
Venous eczema - venous stasis causes cutaneous inflammatory dermatitis
Atrophie blanche - angular white scar developing as a result of ulceration
Haemosiderin deposition
Indications for referral for varicose veins
Severe symptoms
Skin changes (haemosiderin, lipodermatosclerosis)
Venous ulceration
Superficial vein thrombophlebitis
Mx of varicose veins
Conservative
- Avoid prolonged standing
- Full length graduated compression (if no PAD)
- Weight loss
- Exercise
Surgical
- Band ligation of saphenous vein
- Injection sclerotherapy
- Radiofrequency ablation
Management of superficial vein thrombophlebitis
Conservative + avoid DVT
- NSAID analgesia
- Compression stockings
- Exercise
Refer for varicose vein Tx
Venous ulcer features
Located in gaiter area (superior to medial malleolus)
Painless
Sloped edge, margins not well defined (as chronically healing
Associated skin changes of venous insufficiency, and varicose veins
Arterial ulcer features
Punched out well defined lesions
Painful
Found distally in between toes or on soles of feet
Neuropathic ulcer features
Found on pressure points e.g. balls of feet
Occur as a result of repetitive unrecognised trauma
Gradually deepens with time, may develop associated gangrene
Bypass types, indications, procedure and complications
Thoraco-femoral Aorto-femoral Aorto-bifemoral Iliofemoral Femoro-popliteal Femoro-femoral
For larger vessels artificial (Dacron, PTFE) grafts may be used, for smaller vessels the long saphenous vein is generall used in an autologous graft
Presentation of intermittent claudication
Leg pain on exertion - distance normally reproducible, progressively shortens as disease worsens
Relieved by rest
Definition of critical limb ischaemia
Rest pain/tissue loss
Claudication lasting >2 weeks
Ankle pressure <40mmHg
Management of intermittent claudication
RF modification + CV prevention
Conservative
- Weight loss
- Exercise programmes
- Stop smoking
Medical
- Diabetes control
- Hypertension control
- High dose statin
- 75mg clopidogrel lifelong
Surgery
- Open/endovascular bypass surgery
- Amputation (last resort)
Ix for peripheral vascular disease
- ABPI
- Duplex US
- Digital subtraction angiography
ABPI figures
0.9-1.2 = normal >1.2 = vascular calcification 0.5-0.9 = Moderate ischaemia 0.3-0.5 = Severe ischaemia <0.3 = Critical limb ischaemia
Indications for limb amputation
- Dead (severe PAD, thromboangiitis obliterans)
- Dangerous (sepsis, malignancy)
- Damaged (trauma, burns, frostbite)
- Damned nuisance (intractable pain, neurological damage)
Causes of thoracic outlet syndrome
- Hyperextension injuries
- Repetitive stress
- Extrinsic compression (e.g. poor posture)
- Anatomical abnormalities e.g. cervical rib
Symptoms of thoracic outlet syndrome
- Venous
○ DVT
○ Limb swelling
- Nervous
○ Paraesthesia
○ Motor weakness
○ Muscle wasting
- Arterial (common in patients with bony abnormalities)
- Claudication SxCauses of SVCO
Malignant
- Lung cancer
- Lymphoma
Non-malignant
- Aortic aneurysm
- Benign mediastinal tumours
- Thrombosis
Arterial ulcer Mx
Conservative
- Exercise programmes
Medical
- Pain relief
- CV prevention (statin, antiplatelet, BP, DM)
Surgical
- Angioplasty
- Bypass grafting
Venous ulcer Mx
Conservative
- Full length graduated compression (clean and dress ulcer first)
- Exercise
- Weight reduction
Medical
Pentoxifylline
Treat varicose veins: Ligation/Sclerothearpy
What are the standard diagnostic Ix that are used in vascular pathology
Bedside
ABPI
Imaging Duplex US (2D USS + doppler) Digital subtraction angiography MR angiography CT angiography
Definitive Ix for acute limb ischaemia
CT angiography
Mx of acute limb ischaemia
Immediate
Morphine
Oxygen
IV heparin
Prep for threatre (G+S, clotting)
Definitive
Embolectomy with fogarty (if embolic disease)
Thrombolysis (if thrombotic)
Fontaine staging of PVD
1: Asymptomatic
2: Intermittent claudication (mild, moderate and severe)
3: Rest pain
4: Minor tissue loss (ischaemic ulcers on digits)
4b: Major tissue loss
Types of amputation
Above knee
Below knee
Transmetatarsal
Hallux/toe
Decision depends on disease process, co-morbidity of patient etc.
True aneurysm vs pseudoaneurysm
True aneurysm: Bulging of all layers of vessel wall
Pseudoaneurysm: Damage to the wall allows blood to extravasate and pool in surrounding tissue
Most common AAA locations
90% infrarenal
Juxtarenal
Suprarenal
Referral time for incidental AAA
> 5.5cm = within 2w
3 - 5.5cm = within 12w
Varicose Veins Ix
ABPI (compression contraindicated in severe PVD)
Duplex US
Superficial veins: Visualise and measure size of incompetent segments
Deep veins: Rule out DVT
Complications of DVT
PE
Chronic venous insufficiency: Post-thrombotic syndrome (valvular damage from DVT leads to long term incompetence)
Bleeding from anticoagulation/HIT
Compression stockings vs full length graduated compression
Both can be used for the Tx of venous ulcers and varicose veins
Graduated compression gives better oedema control, and is more suitable for active ulceration
Graduated compression has to be applied by a trained professional; compression stockings are preferred in people who are able to self-care
