Vascular

Question 1

What is peripheral arterial disease?

Answer 1

Narrowing of arteries supplying limbs and periphery, reducing blood supply to these areas. Usually lower limb claudication.

Question 2

What is intermittent claudication?

Answer 2

Cramping leg pain due to ischaemia in a limb, occurring during exertion and relieved by rest.

Question 3

What is critical limb ischemia?

Answer 3

End-stage of peripheral arterial disease, where there is an inadequate supply of blood to a limb to allow it to function normally at rest. The features are pain at rest, non-healing ulcers and gangrene. There is a significant risk of losing the limb.
6Ps:
pain, pallor, pulseless, paralysis, parasethesia, perishing cold

Question 4

What is acute limb ischemia?

Answer 4

Rapid onset limb ischemia - usually a clot in the arterial supply of the distal limb

Question 5

Define necrosis and gangrene.

Answer 5

Necrosis = tissue death

Gangrene - due to inadequate blood supply

Question 6

What is atherosclerosis?

Answer 6

Atheromas (fatty deposits in artery walls) and hardening and stiffening of the blood vessel walls (sclerosis). Caused by chronic inflammation and activation of immune system in artery wall. Lipids deposited first followed by fibrous atheromatous plaques. These cause stiffening, hypertension, heart strain; stenosis, and can rupture –> ischemia.

Question 7

What is Leriche syndrome?

Answer 7

Leriche syndrome occurs with occlusion in the distal aorta or proximal common iliac artery. There is a clinical triad of:

Thigh/buttock claudication
Absent femoral pulses
Male impotence

Question 8

How can you differentiate arterial and venous ulcers?

Answer 8

Arterial ulcers are caused by ischaemia secondary to an inadequate blood supply. They are painful, esp at night when elevated; peripheral, punched out, smaller, deeper, well defined borders, “punched-out”, reduced bleeding
Venous ulcers are caused by impaired drainage and pooling of blood in the legs.
Occur after a minor injury to the leg. Larger, superficial, irregular, gently sloping borders, gaiter area - mid-calf to ankle (more proximal),
signs of chronic venous insufficiency (e.g., haemosiderin staining and venous eczema), less painful and pain is worse on lowering the leg

Question 9

How is peripheral arterial disease diagnosed?

Answer 9

Ankle-brachial pressure index (ABPI) = ratio of systolic blood pressure (SBP) in the ankle (around the lower calf) compared with the systolic blood pressure in the arm, taken manually using a Doppler probe.

0.9 – 1.3 = normal
0.6 – 0.9 = mild PAD
0.3 – 0.6 = moderate to severe PAD
< 0.3 = severe disease to critical ischaemic

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

Question 10

What is the management for intermittent claudication?

Answer 10

Lifestyle change to manage modifiable risk factors for atherosclerosis - stop smoking, diet
Optimise medical treatment of comorbidities
Exercise training
Medical - atorvastatin 80mg, clopidogrel 75mg OD, naftidrofuryl oxalate (5-HT2 antagonist that dilates peripheral blood vessels)
Surgical - Endovascular angioplasty and stenting. Endarterectomy (cutting vessel open and removing plaque), bypass surgery. Think similar to cath lab

Question 11

How is critical limb ischemia managed?

Answer 11

Urgent referral to vasc team, analgesia, revascularisation with EVAS, endarterectomy, bypass or amputation if unable to revascularise

Question 12

How is acute limb ischemia managed?

Answer 12

Urgent referral to vascular.
Endovascular thrombolysis, endovascular thrombectomy, surgical thrombectomy, endarterectomy, bypass surgery, amputation if unable to revascularise.

Question 13

What can cause stroke in someone with a DVT?

Answer 13

Septal defect (VSD, ASD)

Question 14

What are thrombophilias? Give 5 examples

Answer 14

Thrombophilias are conditions that predispose patients to develop blood clots. Eg:
Antiphospholipid syndrome
Factor V Leiden 
Antithrombin deficiency
Protein C or S deficiency
Hyperhomocysteinaemia
Prothombin gene variant
Activated protein C resistance

Question 15

How is VTE prevented?

Answer 15

Every patient admitted to hosp is assessed for risk, receive prophylaxis unless contraindicated (eg already on anticoags). This is usually with LMWH. Anti-embolic compression stocking are also used, contraindicated in significant peripheral artery disease.

Question 16

How does a DVT present? Where do you measure the leg?

Answer 16

Calf or leg swelling 10cm below the tibial tuberosily, >3cm difference
Dilated superficial veins
Tenderness to the calf (particularly over the site of the deep veins)
Oedema
Colour changes to the leg

Question 17

How is VTE diagnosed?

Answer 17

1. D Dimer - exclude VTE where there is low suspicion. Raised in pneumonia, malignancy, HF, surgery, pregnancy
2. Doppler - repeat in 1 week if negative but likely DVT
3. CTPA or VQ for PE (eg CTPA CI in significant kidney impairment so cant have contrast)

Question 18

How is VTE managed?

Answer 18

DOAC eg apixaban. Guideline change in 2020 from using LMWH.
Catheter directed thrombolysis for iliofemoral DVT.
Long term anticoag eg with DOAC:
3 months if reversible cause then review
6 months if uprovoked OR irreversible underlying cause eg APLS, cancer
IVC filter in rare cases of recurrent PE or unsuitable for anticoagulation.

Question 19

How do you investigate an unprovoked DVT?

Answer 19

Review medical history, physical exam, baseliine blood results. Ask about FHx of VTE - hereditary thrombophilia. We no longer routinely do imaging.
If not continuing on anticoagulation, consider APLS antibodies

Question 20

What are varicose veins?

Answer 20

Distended superficial veins measuring more than 3mm in diameter. Caused by valve incompetency from DVT, obesity, pregnancy, increasing age
May present with heavy sensation in legs, aching, oedema, cramps, restless legs, CVI

Question 21

What are reticular veins?

Answer 21

Dilated blood vessels in the skin measuring less than 1-3mm in diameter

Question 22

What is telangiectasia?

Answer 22

Dilated blood vessels in the skin measuring less than 1mm in diameter, also known as spider veins or thread veins.

Question 23

What is chronic venous insufficiency and what are 3 signs?

Answer 23

When blood pools in the distal veins, the pressure (venous hypertension) 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 –> dry, inflamed skin aka venous eczema.
The skin and soft tissues become fibrotic and tight, causing the lower legs to become narrow and hard, referred to as lipodermatosclerosis.
Inflammation of sc fat - panniculitis
Inverted champagne bottle appearance
Atrophie blanche - smooth white tissue

Question 24

What is a saphenous varix? How can you diagnose it?

Answer 24

Dilated vein at saphenofemoral junction. Cough test - apply pressure at the SFJ and ask patient to cough, feel for thrill

Question 25

What is the Trendelenburg's test?

Answer 25

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.

Question 26

What is Perthes test?

Answer 26

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

Question 27

What is the management for varicose veins?

Answer 27

Varicose veins in pregnancy often improve after delivery. Conservative: Weight loss if appropriate Staying physically active Keeping the leg elevated when possible to help drainage Compression stockings (exclude arterial disease first with an ankle-brachial pressure index) Surgical: Endothermal ablation – inserting a catheter into the vein to apply radiofrequency ablation Sclerotherapy – injecting the vein with an irritant foam that causes closure of the vein Stripping – the veins are ligated and pulled out of the leg

Question 28

Give 3 complications of varicose veins.

Answer 28

``` 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 29

What is the management of chronic venous insufficiency?

Answer 29

Keep skin healthy - monitor, emollients eg diprobase, topical steroids for venous eczema, potent topical steroids for lipodermatosclerosis flares. Improve venous drainage - wt loss, activity, elevation, compression stockings (exclude PAS with ABPI first) Manage complications - cellulitis, pain, ulceration

Question 30

What is an ulcer? Give 4 types.

Answer 30

Wound/break in skin that does not heal or heals slowly due to underlying pathology. Venous, arterial, diabetic foot, pressure.

Question 31

What is a diabetic foot ulcer?Why do they occur and what is an important complication?

Answer 31

Diabetic neuropathy --> injury to foot and don't notice. Vascular damage --> impaired blood supply and wound healing Hyperglycemia, immune suppression and autonomic neuropathy --> poor healing. Risk of osteomyelitis (bone infection)

Question 32

What causes pressure ulcer? What scoring system is used to assess risk of pressure ulcer?

Answer 32

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.The Waterlow Score is a commonly used risk assessment tool for estimating an individual patient’s risk of developing a pressure ulcer.

Question 33

How are ulcers diagnosed and investigated?

Answer 33

ABPI Bloods - infection, co-morbidity, albumin for malnutrition Charcoal swab for infection Skin biopsy for cancer eg SCC --> 2ww

Question 34

How are arterial ulcers managed?

Answer 34

Same as PAD - urgent referral to vasc for surgical revascularisation. Should heal after that.

Question 35

How are venous ulcers managed?

Answer 35

Vasc surgery if suspected arterial component Tissue viability/specialist leg ulcer clinics in complex or non-healing ulcers. Wound care - cleaning, debridement (removing dead tissue), dressing Derm where alternative diagnosis suspected Pain clinic if pain difficult to manage. *NSAIDS can worsen* Diabetic ulcer service if diabetic ulcer Compression therapy (exclude PAD) Pentoxifylline PO can help but not licensed Abx for infection

Question 36

What is lymphoedema?

Answer 36

Chronic condition caused by impaired lymphatic drainage. Tissues in areas affected become swollen with excess, protein-rich fluid. These areas are prone to infection. Primary - rare, genetic, early onset Secondary - eg to breast cancer surgery due to axillary lymph node clearance

Question 37

What is lipoedema?

Answer 37

Abnormal build-up of fat tissue in the limbs, often the legs. The feet are spared in lipoedema, unlike lymphoedema. This affects women more often than men. It can cause pain, psychological distress and significantly affect the patient’s quality of life.

Question 38

How is lymphoedema diagnosed and assessed?

Answer 38

Stemmer's sign - pinch skin at toe/finger, if you can't make a little tent, it is positive for lymphoedema. Limb volume calculated using circumferential measurements, water displacement, and perometry (square frame with perpendicular light beams moved along the limb, measuring outline and volume) Bioelectric impedance spectrometry - measures electrical resistance through the tissues Lymphoscintigraphy - nuclear medicine - radioactive tracer injected, gamma camera used to assess structure of lymphatic system

Question 39

What is the management for lymphoedema?

Answer 39

Specialist service Conservative: Manual lymphatic drainage (massage), Compression bandages, lymphoedema exercises to improve drainage, wt loss, skin care Surgical - lymphatricovenular anastamosis. Connect lymph vessels to veins to allow drainage. Abx for cellulitis CBT and antidepressants if indicated DONT take blood/insert cannula/do BP or give any injections into a limb with lymphoedema!!

Question 40

What is lymphatic filariasis?

Answer 40

Infection from parasitic worms spread by mosquitos. The worms live in the lymphatic system and cause severe lymphoedema 'elephantiasis'. Afria, Asia.

Question 41

What is an AAA?

Answer 41

Abdominal aortic aneurysm -= dilation of abdominal aorta >3cm in diameter.

Question 42

Give 4 risk factors for AAA.

Answer 42

Male, increased age, smoking, hypertension, family history, CVD

Question 43

Describe the screening process for AAA.

Answer 43

Males age 65 and women >70 with risk factors have ultrasound. Normal = <3cm 3-4.4 = small, refer to vasc (routine), follow up yearly 4.5-5.5 = medium, refer to vasc (routine), follow up 3-monthly. >5.5 = large, urgent referral to vasc

Question 44

How does AAA present?

Answer 44

Aysmptomatic until rupture | May have non specific abdo pain, pulsative and expansile mass

Question 45

What is the management of AAA?

Answer 45

Manage RFs - smoking, diet, exercise, optimise management of comorbidities 3-4.4 = small, refer to vasc (routine), follow up yearly 4.5-5.5 = medium, refer to vasc (routine), follow up 3-monthly. >5.5 = large, urgent referral to vasc Elective repair if large, symptomatic or growing more than 1cm per year. This can be done with open repair or EVAR. DRIVING - inform DVLA is >6cm, stop driving if >6.5cm, stricter if HGV

Question 46

How does AAA rupture present?

Answer 46

Haemodynamic instability, pain radiating to back or groin, collapse, pulsatile expansile mass in abdomen. Risk of rupture 5% for 5cm, 40% for 8cm. Mortality 80% in rupture.

Question 47

What is the management for ruptured AAA?

Answer 47

Surgical emergency Permissive hypotension to reduce blood loss Theatre is haem unstable CT angio if haem stable

Question 48

What is aortic dissection?

Answer 48

Break or tear in the tunica intima of aorta allowing blood to enter between tunica intima and tunica media (a false lumen). Most commonly affects the right lateral area of the ascending aorta, as this is under the most stress from blood exiting the heart.

Question 49

How is aortic dissection classified?

Answer 49

The Stanford system: Type A – affects the ascending aorta, before the brachiocephalic artery Type B – affects the descending aorta, after the left subclavian artery The DeBakey system: Type I – begins in the ascending aorta and involves at least the aortic arch, if not the whole aorta Type II – isolated to the ascending aorta Type IIIa – begins in the descending aorta and involves only the section above the diaphragm Type IIIb – begins in the descending aorta and involves the aorta below the diaphragm

Question 50

Give 5 risk factors of aortic dissection.

Answer 50

Same as for PAD Hypertension especially dramatic increase eg weightlifting and cocaine. Bicuspid aortic valve, co-arctation of aorta, aortic valve replacement, CABG CTDs: EDS, Marfan's

Question 51

How does aortic dissection present?

Answer 51

Sudden onset severe tearing chest and/or abdo pain, anterior or posterior depending on where aorta affected, may radiate, may not have chest pain --> easily missed! Htn, >20mmHg difference in BP between arms, radial pulse deficit - does not match apex beat in one arm, diastolic murmur, focal neurological deficit, collapse, hypotension (late)

Question 52

How is aortic dissection diagnosed?

Answer 52

ECG (exclude MI - may co-occur, thrombolysis could cause fatal progression of the AD) CXR CT angio first MRI angio for more detail and to plan management

Question 53

What is the management of aortic dissection?

Answer 53

High mortality, surgical emergency Analgesia Control BP and HR eg with beta blockers Surgical: Type A --> open surgery (midline sternotomy) Type B --> Transthoracic Endovascular Aortic Repair

Question 54

Give 4 complications of aortic dissection.

Answer 54

MI, Stroke, paraplegia, aortic regurg, cardiac tamponade, death

Question 55

What is carotid artery stenosis? How does it present?

Answer 55

Narrowing of carotid arteries in neck, usually due to atherosclerosis. Risk of embolic stroke. Patients with TIA/stroke are investigated for carotid artery stenosis with USS. Usually asymptomatic, may have carotid bruit during systole

Question 56

How is CAS categorised?

Answer 56

Mild - <50% reduction in diameter Mod - 50-69% Severe - >70%

Question 57

What is the management for carotid artery stenosis?

Answer 57

Conservative: Reduce risk factors, manage co-morbidities, antiplatelets, statins Surgery if severe: Carotid endarterectomy (complications: stroke (2%), nerve injury (facial, glossopharyngeal, recurrent laryngeal) Angioplasty and stenting

Question 58

What is Buerger disease?

Answer 58

Aka thromboangiitis obliterans Inflammatory condition that causes thrombus formation in small and medium sized blood vessels in hands and feet. Causes painful, blue fingertips/toes, worse at night, risk of gangrene. Affects young men (25-35) who smoke, without other RFs for atherosclerosis.

Question 59

How does Buerger disease present? How is it diagnosed?

Answer 59

Males under 50 with no other RFs for atherosclerosis, other than smoking Angiogram - corkscrew collaterals

Question 60

How is Buerger disease managed?

Answer 60

STOP SMOKING including nicotine | IV iloprost = prostacyclin analogue, dilates blood vessels.