Vascular Flashcards
List the definitions for the following:
- Ischaemia
- Necrosis
- Gangrene
Ischaemia - inadequate oxygen supply to the tissues, as a result of reduced blood supply
Necrosis - death of tissue
Gangrene - death of tissue, specifically as a result of reduced blood supply
Outline the pathophysiology of peripheral arterial disease and how it leads to symptoms
Narrowing of the arteries supplying the (lower) limbs, which reduces blood supply to these areas and leads to claudiation
List features of end stage peripheral arterial disease
- Pain at rest
- Non-healing ulcers and gangrene
Acute limb ischaemia - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Rapid onset of ischaemia in a limb
- Typically occurs due to obstruction by a thrombus within the arterial supply in the distal aspect of a limb (can also occur due to compartment syndrome)
Presentation:
Sudden onset of the 6 P’s
1. Pain
2. Pallor
3. Paralysis
4. Pulseless
5. Paraesthesia
6. Perishingly cold
Investigations:
- Routine bloods including serum lactate, ECG and group and save
- Doppler ultrasound
- CT angiogram
Management:
Surgical emergency -salvageability within 6 hrs
- Endovascular thrombectomy
- Endovascular thrombolysis
- Bypass surgery
- Angioplasty
- Amputation
Also
- Bolus of heparin
- Analgesia
Outline 3 vascular changes that occur as a result of atherosclerosis
- Stiffness…resulting in hypertension
- Stenosis…resulting in reduced blood flow
- Plaque rupture (thrombus formation)
List modifiable and non-modifiable risk factors for atherosclerosis
Modifiable:
- Hypertension
- Alcohol intake
- Diet
- Exercise / sedentary lifestyle
- Smoking
- Stress
- Poorly controlled co-morbidities e.g. diabetes
- Poor sleep
Non-modifiable:
- Age
- Genger (male)
- Family history
List co-morbidities that increase the risk of atherosclerosis
- Diabetes
- Hypertension
- CKD
- Inflammatory conditions
- Atypical anti-psychotics
List the end results/consequences of atherosclerosis (what it predisposes you to)
- Angina / MI
- TIA / stroke
- Peripheral arterial disease
- Chronic mesenteric ischaemia
Outline the presentation of someone with intermittent claudication
- ‘Crampy’ pain
- Commonly in calves, but also buttocks and thighs
- Onset after walking a certain distance
List the 6 P’s of critical limb ischaemia
- Pain
- Pallor
- Paralysis
- Pulseless
- Paraesthesia
- Perishingly cold
Signs of peripheral arterial disease
- Ulcers
- Poor wound healing / gangrene
- Pallor
- Cyanosis
- Rubor if limb is below rest of the body
- Hair loss
- Muscle wasting
Explain the Buerger’s test
Used to assess peripheral arterial disease - 2 parts
Part 1:
- Patient lies down
- Elevate leg at 45 degrees and hold for 1-2 minutes
- If pallor, indicates peripheral arterial disease
(if no disease legs will remain pink)
Part 2:
- Patient hangs legs over the bed
- If blue initially then dark red, indicates peripheral arterial disease
(if no disease legs will remain pink)
List investigations for peripheral arterial disease
- Ankle-brachial pressure index
- Duplex ultrasound
- Angiography
Outline the management for peripheral arterial disease
Conservative:
- Risk factor modification
- Smoking cessation
- Weight management
- Supervised exercise programme
Medical:
- Analgesia (vasodilators work well e.g. Naftidrofuryl oxalate)
- Medications to reduce risk factors e.g. optimum diabetes control
Surgical:
- Endovascular revascularisation (minor stenosis)
- Surgical revascularisation (significant stenosis)
- May need an amputation
When might an amputation be required in perihperal arterial disease
Amputation if there is:
- Critical limb ischaemia unsuitable for other interventions
- Intractable pain (pain that can’t be helped with analgesia)
- Unresolving ulcer
- Severe loss of function
Ankle brachial index - describe the test, how it’s calculated and outline values and their meaning
Ankle brachial index:
- Ratio of the systolic blood pressure in the arm compared to the ankle
- Calculated by:
Ankle systolic reading / Brachial systolic reading = RATIO
Values:
>1.3 = artery calcification
0.9-1.3 = normal
0.6-0.9 = mild PAD
0.3-0.6 = moderate PAD
<0.3 = severe PAD
List some common thrombophilias
- Anti-phospholipid syndrome
- Factor 5 Leiden
- Protein C or S deficiency
Deep vein thrombosis (DVT) - state the following:
- Pathophysiology
- Risk factors
- Methods of prophylaxis
- Presentation
- Wells Score
- Diagnosis
- Management
- Long term anticoagulation (options and duration)
Pathophysiology:
- Development of a blood clot in the venous circulation (most commonly in lower limbs)
- The clot is then at risk at embolising to a distant site e.g. lungs causing a PE
- Commonly a result of a hypercoaguable state or blood stasis
Risk factors:
- Previous DVT
- Immobility
- Pregnancy
- Long haul travel
- Cancer
- Thrombophilia / polycythaemia
- Oestrogen based hormone therapy
- Smoking
Methods of prophylaxis:
- Limit risk factors if possible
- LMWH e.g. Enoxaparin
- Compression stockings
Presentation:
- Erythema
- Swelling
- Tenderness
- Oedema
- Dilated superficial veins
Wells Score:
- Takes into account risk factors and clinical presentation
- Score > 2 means likely to be DVT
Diagnosis:
- D-dimer (sensitive but not specific, more helpful for excluding DVT)
- Doppler ultrasound
- If pulmonary embolism suspected, CTPA
Management:
- Immediate anti-coagulation -> recommenced Apixaban or Rivaroxaban
- Catheter-directed thrombolysis if symptomatic DVT
Long term anticoagulation:
- DOAC
- Warfarin
- LMWH
- 3 months if reversible cause found
- 3-6 months if active cancer
- > 3 months if unclear cause
If unable to use anticoagulation - inferior vena cava filter
Varicose Veins - state the following:
- Pathophysiology
- Risk factors
- Presentation
- Diagnosis
- Special tests
- Management
- Complications
Pathophysiology:
- Incompetent valves, resulting in to bidirectional flow
- Reduced venous return leads to dilation and engorgement of veins and venous pooling
- Incompetence due to weakening of walls, particularly impactful if perforating veins
Risk factors:
- Age
- Female sex
- Family history
- Pregnancy
- Obesity
- Occupations with long periods of standing
- DVT (damage to vessels)
Presentation:
- Engorged or dilated veins
- Aching sensation
- Itching / burning
- Oedema
- Restless legs
- Muscle cramps
Diagnosis:
- Duplex ultrasound
- Carry out special tests
Special tests:
1. Tap test
2. Cough test
3. Trendelenburg test
4. Perthes test
Management:
Conservative treatment
- Weight loss
- Activity
- Elevate legs when resting
- Compression stockings
Surgical
- Endothermal ablation
- Sclerotherapy
- Venous stripping
Complications:
- Prolonged and heavy bleeding after trauma
- Superficial thrombophlebitis
- DVT
- Chronic venous insufficiency
Chronic venous insufficiency - state the following:
- Pathophysiology
- Risk factors
- Key presentation features seen
- Complications
- Management
Pathophysiology:
- Occurs when there is not complete drainage of blood from the legs back to the heart
- Results in venous hypertension which then leads to skin changes over time
- Often due to damage to the veins
Risk factors:
- Age
- Immobility
- Obesity
- Occupations with long periods of standing
- DVT
Key presentation features seen:
- Most commonly affects Gaiter area of legs
- Haemosiderin staining (haemoglobin leaks into skin)
- Venous eczema (chronic inflammatory response)
- Lipodermatosclerosis (chronic inflammation of subcut tissue)
- Atrophie blanche
Complications:
- Cellulitis
- Poor healing post-injury
- Ulcers
- Pain
Management:
- Keep skin healthy e.g. emollient use
- Improve venous drainage e.g. weight loss, elevate legs on resting
- Managing any complications e.g. wound care or antibiotics if infections
State the different types of leg/peripheral ulcers
Arterial ulcers:
- Due to insufficient blood supply
Venous ulcers:
- Due to blood pooling and waste products
Diabetic ulcers:
- Damage to blood vessels from diabetes leads to reduced blood supply and wound healing
Pressure ulcers:
- Occurs due to reduced mobility
- Leads to skin breakdown by: reduced blood supply, reduced lymph drainage and localised ischaemia
Compare the following for arterial and venous ulcers:
Common location:
Associated with which disease:
Small or large:
Deep or shallow:
Border:
Likely to bleed:
Painful:
Made worse by:
Made better by:
Common location:
- Arterial: distal (dorsum of foot or toes)
- Venous: Gaiter area
Associated with which disease:
- Arterial: peripheral arterial disease
- Venous: chronic venous insufficiency
Small or large:
- Arterial: small
- Venous: large
Deep or shallow:
- Arterial: deep
- Venous: shallow
Border:
- Arterial: well defined
- Venous: poorly defined
Likely to bleed:
- Arterial: less likely
- Venous: more likely
Painful:
- Arterial: more painful
- Venous: less painful
Made worse by:
- Arterial: elevating leg
- Venous: lowering leg
Made better by:
- Arterial: lowering leg
- Venous: elevating leg
Skin ulcers - state the following:
- Pathophysiology
- Types of ulcers
- Investigations to investigate cause
- Management for arterial and venous ulcers
Pathophysiology:
- Wounds or breaks in the skin that heal slowly due to underlying pathology
- May become bigger with time or become more difficult to heal
Types of ulcers:
- Arterial
- Venous
- Diabetic
- Pressure
Investigations to investigate cause:
- Ankle-brachial pressure index (assess for arterial disease)
- Blood tests (infection or co-morbidities)
- Skin swabs (infection)
- Skin biopsy (?skin cancer)
Management for arterial and venous ulcers:
General:
- Analgesia or pain management clinic
- Tissue viability referral
- Good wound care
- Antibiotics if infected
Arterial:
- Manage underlying condition
- Vascular surgery
Venous:
- Compression therapy
Lymphoedema - state the following:
- Pathophysiology
- Assessment
- Management
Pathophysiology:
- Chronic condition caused by impaired lymphatic drainage of an area
- Primary lymphoedema = rare, genetic condition
- Secondary lymphoedema = acquired e.g. after breast cancer surgery
- Individuals have a higher risk of infection in the area of impaired drainage (reduced lymph node function)
Assessment:
- Stemmer’s sign
- Limb volume measurement
- Bioelectric impedance spectrometry
- Lymphoscinitgraphy
Management:
Non-surgical techniques
- Massage therapy or exercises
- Weight loss
- Compression bandages
- CBT / antidepressants
- Antibiotics if infections
Surgical techniques
- Lymphaticovenular anastomosis surgery
Abdominal aortic aneurysm (not ruptured) - state the following:
- Pathophysiology
- Risk factors
- Screening
- Presentation
- Diagnosis
- Classification
- Management
Pathophysiology:
- Dilation of the abdominal aorta > 3cm (most commonly intra-renal)
- High mortality rate if ruptures (80%)
Risk factors:
- Male
- Age
- Smoking
- Hypertension
- Family history
- Existing cardiovascular disease
Screening:
- Offered to all MEN > 65 yrs
- Ultrasound scan to detect asymptomatic AAA early
- Only offered to women > 70 yrs, with risk factors
Presentation:
- Most patients are asymptomatic
- Pulsatile and expansile mass in abdomen
- Non-specific abdominal pain
- May be an incidental finding on screening / during other investigations
Diagnosis:
- Ultrasound
- CT angiogram for a more detailed picture (e.g. prior to surgery)
Classification:
Based on aorta diameter
- Normal < 3cm
- Small (3-4.5cm)
- Medium (4.5-5.5cm)
- Large (> 5.5cm)
Management:
- Reduce any modifiable risk factors e.g. stop smoking
- Depends on size
- Monitor if small (once yearly) or medium (3 monthly)
- Surgery if symptomatic, growing > 1cm per year or > 5.5cm
- Surgery either open (elective) or EVAR (emergency)
Ruptured abdominal aortic aneurysm - state the following:
- Presentation
- Explain the concept of permissive hypotension
- State the investigation to diagnose/exclude ruptured AAA in haemodynamically stable patients
Presentation:
- Severe abdominal pain that may radiate to back/groin
- Haemodynamic instability
- Pulsatile and expansile mass
- Collapse
- Unconscious
Permissive hypotension:
- When you accept a lower blood pressure when doing fluid resuscitation, to reduce blood loss
State the investigation to diagnose/exclude ruptured AAA in haemodynamically stable patients:
- CT angiogram
Aortic dissection - state the following:
- Pathophysiology
- Risk factors
- Presentation
- Diagnosis
- Classification
- Management (for both types)
- Complications
Pathophysiology:
- A break or tear in the wall of the tunica intima layer of the aorta (most commonly ascending aorta or aortic arch)
- This creates a false lumen between the tunica intima and tunica media
Risk factors:
- Hypertension
- Male
- Age
- Smoking
- Coarctation (aortic narrowing)
- Bicuspid aortic valve
- Marfan’s syndrome
- Ehlers-Danlos
Presentation:
- Severe ‘ripping’ chest pain (may migrate forward or backward)
- Difference in BP between arms
- Radial pulse deficit
- Diastolic murmur
- Hypotension or collapse
Diagnosis:
- CT angiogram or MRI angiogram (more detail but longer)
- May want to do a transoesophageal echo
- Chest x-ray and ECG to rule out other causes
Classification:
Stanford classification
Type A - first part of the aorta (ascending)
Type B - second part of the aorta (descending)
Management:
- Analgesia
Surgery
- Type A = Midline sternotomy, repair affected area with synthetic graft
- Uncomplicated type B = Medical management, control/lower BP and heart rate e.g. b-blockers, may need EVAR if complications occur
Complications:
- Cardiac tamponade
- Stroke
- MI
- Aortic valve regurgitation
Carotid artery stenosis - state the following:
- Pathophysiology
- Risk factors
- Presentation and one potential positive finding on examination
- Investigations
- Outline severity classification
- Management
Pathophysiology:
- Narrowing of the carotid arteries leading to stenosis, usually secondary to atherosclerosis
- Part of plaque may break away, leading to embolic stroke
Risk factors:
- Male
- Age
- Smoking
- Hypertension
- Hypercholesterolaemia
- Obesity
- Diabetes mellitus
- Family history of cardiovascular disease
Presentation:
- Usually asymptomatic, commonly diagnosed after a stroke/TIA
- May hear a carotid bruit on auscultation (whooshing sound during systole)
Investigations:
- Carotid ultrasound
- CT or MRI angiogram
Severity classification:
- Mild = <50% diameter reduction
- Moderate = 50-70% diameter reduction
- Severe = >70% diameter reduction
Management:
Conservative
- Reduce modifiable risk factors
- Manage co-morbidities
Surgery
- Carotid endarterectomy (narrowing >50%)
- Angioplasty / stenting
Buerger Disease - state the following:
- Pathophysiology
- Presentation
- Outline key feature seen on angiogram
- Management
Pathophysiology:
- Inflammatory condition that causes thrombus formation in small and medium sized distal arteries
- Also known as thromboangitis obliterans
- VERY strong association with smoking
Presentation:
- Typically young male with smoking history (25-35 yrs)
- Painful, blue discolouration of fingers/toes
- Pain is worse at night
- May have associated ulcers, gangrene or amputation
Key feature seen on angiogram:
- Corkscrew collateral vessels on angiogram (bypasses affected vessels)
Management:
- Stop smoking!! Usually results in significant improvement
Outline cranial nerves that can be damaged during a carotid endarterectomy and how they would present
Nerve damage can be temporary or permanent
- CN7 (Facial nerve) - unilateral face droop
- CN9 (Glossopharyngeal nerve) - difficulty swallowing
- CN10 (Recurrent laryngeal nerve) - hoarse voice
- CN12 (Hypoglossal nerve) - unilateral tongue weakness/paralysis
Explain the significance of triphasic, biphasic and monophasic pulses with respect to arterial disease
Helps to localize any occlusion or stenosis
Normally, waveform should be triphasic, corresponding to the three phases of a heart beat (systole, diastole, elastic recoil)
Biphasic pulse = mild to moderate disease
Monophasic pulse = significant disease
Outline the values for ABPI and what symptoms you get within each range
> 1 = Symptom free
0.95 - 0.5 = Intermittent claudication
0.5 - 0.3 = Rest pain
< 0.2 = Gangrene and ulceration
Outline the difference between an aneurysm and a pseudoaneurysm
Aneurysm
- Dilation of an artery that involves all three layers of the arterial wall (intima, media and adventitia)
- More common in: males, increasing age, smokers and family history
Pseudoaneurysm
- Collection of blood between the media and adventitia layers only
- Typically caused by direct trauma to the vessel
Acute mesenteric ischaemia - state the following:
- Pathophysiology
- Types of occlusion
- Presentation
- Investigations
- Management
Pathophysiology:
- Sudden decrease in the blood supply to the bowel
- Results in bowel ischaemia, can be fatal
Types of occlusion:
- Thrombus
- Embolism e.g. AF or aortic dissection
- Non-occlusive cause e.g. hypotension
- Venous occlusion and congestion e.g. coagulopathy, malignancy
Presentation:
- Acute onset of constant, generalised abdominal pain and tenderness, out of proportion to clinical findings
- Associated N&V
Investigations:
- Gold standard: CT scan with IV contrast
- ABG (for lactate and acidosis)
- Routine bloods
Management:
- Early senior involvement and ITU input
- Fluid resuscitation (IV fluids) and fluid balance chart
- Broad-spectrum antibiotic prophylaxis (in case of perforation)
- Eventually surgery to either re-vascularise bowel with thrombectomy or resect bowel if ischaemic
Chronic mesenteric ischaemia - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Gradual decrease in the blood supply to the bowel, which reduces over time
- Occurs secondary to atherosclerosis (in coeliac trunk, SMA or IMA)
- Patients are generally asymptomatic due to collateral vessels, however any addition strain can cause symptoms e.g. after eating
- Generalised abdominal tenderness
Presentation:
- Abdominal pain 10mins - 4hrs after eating
- Weight loss
- Concurrent vascular comorbidities e.g. stroke
- Loose stool
- N&V
Investigations:
- Gold standard: CT angiography
Management:
- Early senior involvement and ITU input
- Fluid resuscitation (IV fluids) and fluid balance chart
- Broad-spectrum antibiotic prophylaxis (in case of perforation)
- Eventually surgery to either re-vascularise bowel with thrombectomy or resect bowel if ischaemic
Outline how the presentation varies between vascular claudication and neurogenic claudication
- Distance
- Relieved by (sitting/standing)
- Resolves in (secs/mins)
Vascular:
- Fixed distance
- Relieved on standing
- Resolves in seconds
Neurogenic:
- Variable distance
- Relieved on sitting
- Resolves in mins
Outline the scars for the following endovascular procedures:
- Femero-popliteal bypass
- Femoral-femoral bypass
- Axillo-femoral bypass
- Ileo-femoral bypass
Femero-popliteal bypass:
- Vertical groin scar
- Distal lower limb scar
Femoral-femoral bypass:
- 2 vertical groin scars
Axillo-femoral bypass:
- Scar over the left pectoral region (left chest)
- Scar over left groin
Ileo-femoral bypass:
- Oblique left iliac fossa scar (access the iliac arteries)
- Vertical groin scar (access the femoral arteries)
