Vascular Flashcards
What are the 6 Ps of acute limb ischaemia
Pain
Pallor
Pulselessness
Paraesthesia
Perishing cold
Paralysis
Give an overview of acutely painful, cold and pale limbs
Treat as acute limb ischaemia until proven otherwise
Ask about: AF, HTN, smoking, diabetes, recent MI
CT angiogram, urgent vascular review
Get irreversible tissue damage in 6 hours
Start on IV heparin whilst decisions being made
Give an overview of acutely painful, hot and swollen limbs
Assess for potential DVT
Ask about: pro-thrombotic disease, recent immobility, recent surgery
What investigations are needed for acutely painful limb
Document neurovascular status at initial clerking
CT angiography
Routine bloods (+ group and save)
Give an overview of lower limb ulcers
Abnormal breaks in skin or mucous membrane
Most are venous
Often related to diabetic neuropathy
What are the 3 types of lower limb ulcers
Venous: shallow, granulating base, clinical features of venous insufficiency
Neuropathic: painless, over areas of abnormal pressure, often due to joint deformity in diabetes
Arterial: at distal sites, well-defined borders, evidence of arterial insufficiency
What are venous ulcers
Caused by venous insufficiency
Shallow
Irregular border
Granulating base
Characteristically over medial malleolus
Prone to infection (often present with cellulitis)
What are the risk factors for venous ulcers
Increasing age
Pre-existing venous incompetence
Pregnancy
Obesity
Physical inactivity
Severe trauma
How might venous ulcers present
Painful (worse at end of day)
In gaiter region of leg
Aching, itching, bursting sensation
May have varicose veins
Leg oedema
What investigations are needed for venous ulcers
Duplex ultrasound
Ankle brachial pressure index
Swab culture
Thrombophilia/vasculitis screen (young patients)
What is the management for venous ulcers
Leg elevation
Increase exercise
Weight loss
Antibiotics (if infected)
Multicomponent compression bandaging
Can operate on varicose veins
Give an overview of arterial ulcers
Due to reduced arterial blood flow
Small, deep lesions
Well-defined border
Necrotising base
At sites of trauma/pressure areas
What are the risk factors for arterial ulcers
Smoking
Diabetes
Hypertension
Hyperlipidaemia
Increasing age
Family history
Obesity
Physical inactivity
How might arterial ulcers present
History of intermittent claudication/critical limb ischaemia
Pain
Develop over a long period of time
Cold limb
Thickened nails
Necrotic toes
Hair loss
Reduced/absent pulses
Sensation maintained
What investigations are needed for arterial ulcers
Ankle brachial pressure index (> 0.9 = normal, 0.9 - 0.8 = mild, 0.8 - 0.5 = moderate, < 0.5 = severe)
Duplex ultrasound
CT angiography
MRA
What is the management for arterial ulcers
Urgent vascular review
Smoking cessation
Weight loss, exercise
Statins
Antiplatelets
Manage HTN and diabetes
Angioplasty (+/- stenting)
Bypass grafting (extensive disease)
What are neuropathic ulcers
Due to peripheral neuropathy
Painless ulcers on pressure points
What are the risk factors for neuropathic ulcers
Diabetes
B12 deficiency
Foot deformity
Peripheral vascular disease
How might neuropathic ulcers present
History of peripheral neuropathy
Burning
Tingling
Single nerve involvement
Punched out appearance
Glove and stocking distribution neuropathy
Good pulses
What is carotid artery disease
Buildup of atherosclerotic plaque in common or internal carotid artery
Causes stenosis and occlusion
Can cause ischaemic stroke (plaque rupture, atheroembolism)
What are the risk factors for carotid artery disease
> 65
Smoking
Hypertension
Hypercholesterolaemia
Obesity
Diabetes
History of cardiovascular disease
How might carotid artery disease present
Usually asymptomatic
TIA/stroke
Carotid bruit
What investigations are needed for carotid artery disease
Urgent non-contrast CT head
Routine bloods
Glucose
ECG
Duplex ultrasound (estimate degree of stenosis)
CT angiography
What is the acute management for carotid artery disease
Oxygen
Blood glucose optimisation
Ischaemic stroke: alteplase, aspirin
Haemorrhagic stroke: correct coagulopathy, refer to neurosurgery
Thrombectomy
What is the long term management for carotid artery disease
Antiplatelet therapy (aspirin, clopidogrel)
Statin
Aggressive management of hypertension and diabetes
Smoking cessation
Lifestyle advice
Carotid endarthrectomy
What is abdominal aortic aneurysm
Dilation of abdominal aorta to > 3 cm
What are the risk factors for abdominal aortic aneurysm
Smoking
Hypertension
Hyperlipidaemia
Family history
M>F
Age
How might abdominal aortic aneurysm present
Usually asymptomatic
Abdominal/back/loin pain
Distal embolisation (limb ischaemia)
Shock
Syncope
Pulsatile mass in abdomen
Signs of retroperitoneal haemorrhage
Describe the screening programme for abdominal aortic aneurysm
Abdominal ultrasound
Men > 65
If found: surveillance or elective repair
What investigations are needed for abdominal aortic aneurysm
Ultrasound
CT with contrast (once diagnosis confirmed)
What is the management for abdominal aortic aneurysms < 5.5 cm
Monitor with duplex ultrasound ( 3 - 4.4 = yearly, 4.5 - 5.4 = 3 monthly)
Smoking cessation
Better BP control
Statins
Antiplatelet therapy
Weight loss
Exercise
What are the indications for surgery in abdominal aortic aneurysm
> 5.5 cm
Expanding > 1 cm per year
Symptomatic AAA in otherwise fit patient
(In unfit patients, can leave until 6 cm)
What are the 2 methods of surgery for abdominal aortic aneurysm
Open repair
Endovascular repair (introduce graft through femoral artery)
Give an overview of ruptured abdominal aortic aneurysm
Abdominal/back pain, syncope, vomiting, haemodynamic instability, pulsatile abdominal mass, abdominal tenderness
Oxygen, IV fluids
Unstable patients: open repair
Stable patients: CT angiogram (see if suitable for endovascular repair)
What is aortic dissection
Tear in tunica intima of aortic wall
Causes blood to flow between tunica intima and media, which split
Acute (< 14 days) or chronic (>14 days)
M>F
Associated with connective tissue disorders
50 - 70
In which directions may aortic dissection progress
Anterograde: towards iliac arteries
Retrograde: towards aortic valves
What are the classification systems for aortic dissection
Stanford classification: type A (involves ascending aorta), type B (doesn’t involve ascending aorta)
DeBakey classification: type 1 (originates in ascending aorta), type 2 (confined to ascending aorta), type 3 (originates distal to subclavian artery in ascending aorta)
How might aortic dissection present
Tearing chest pain
Radiates to back
Tachycardia, hypotension
New aortic regurgitation murmur
What investigations are needed for aortic dissection
Routine bloods (+ troponin + crossmatch)
ABG
ECG
CT angiogram (first line)
Transoesophageal ECHO
What is the management for aortic dissection
Oxygen, IV fluids
Lifelong antihypertensives
Surveillance imaging
Surgical repair
Why does thoracic aortic aneurysm develop
Degeneration of tunica media (artery loses structural integrity)
What are the risk factors for thoracic aortic aneurysm
Family history
Hypertension
Atherosclerosis
Smoking
Obesity
M>F
Advancing age
How might thoracic aortic aneurysm present
Usually incidental finding
Pain: anterior chest (ascending aorta), neck (aortic arch), between scapulae (descending aorta)
Back pain
Hoarse voice (damage to left recurrent laryngeal nerve)
Distended neck veins
Symptoms of heart failure
Dyspnoea/cough
What investigations are needed for thoracic aortic aneurysm
Routine bloods
ECG
CXR (widened mediastinal silhouette, enlarged aortic knob, possible tracheal deviation)
CT chest with contrast
Transoesophageal ECHO
What is the management for thoracic aortic aneurysm
Statins
Antiplatelet therapy
Smoking cessation
Surgery for: ascending aorta > 5.5 cm, aortic arch > 5.5 cm, descending aorta > 6 cm
What is acute limb ischaemia
Sudden decrease in limb ischaemia that threatens viability of limb
Complete or partial occlusion of artery can lead to rapid ischaemia and poor functional outcome
Irreversible tissue damage in 6 hours
What investigations are needed for acute limb ischaemia
Routine bloods (+ serum lactate + thrombophilia screen)
ECG
Doppler ultrasound
CT angiography
What is the management for acute limb ischaemia
Oxygen, IV fluids
Start heparin
Surgery
HDU admission post-op
Lifestyle advice
Antiplatelet therapy
Consider anticoagulants
What is chronic limb ischaemia
Peripheral artery disease that causes symptomatic reduction in blood supply to limb
Usually due to atherosclerosis
What are the risk factors for chronic limb ischaemia
Smoking
Diabetes
Hypertension
Hyperlipidaemia
Increasing age
Family history
Obesity
Physical activity
What are the stages of chronic limb ischaemia
Stage 1: asymptomatic
Stage 2: intermittent claudication
Stage 3: ischaemia at rest
Stage 4: ulceration or gangrene
What is critical limb ischaemia
Advanced form of chronic limb ischaemia
Pain at rest for > 2 weeks
Presence of ischaemic lesion or gangrene
ABPI < 0.5
How might chronic limb ischaemia present
Limb pale and cold
Weak/absent pulses
Hair loss
Skin changes
Thickened nails
What investigations are needed for chronic limb ischaemia
Clinical diagnosis
Ankle brachial pressure index
Doppler ultrasound
CT angiography or MR angiography
What is the management for chronic limb ischaemia
Lifestyle advice
Statins
Antiplatelet therapy
Optimise diabetic control
Surgery (angioplasty, bypass graft)
Amputation
What is acute mesenteric ischaemia
Sudden decrease in blood supply to bowel
How might acute mesenteric ischaemia present
Generalised abdominal pain
Out of proportion to clinical signs
Nausea and vomiting
At late stage, global peritonism
What investigations are needed for acute mesenteric ischaemia
ABG
Routine bloods
CT with contrast (oedematous bowel, loss of bowel wall enhancement, pneumatosis)
What is the management for acute mesenteric ischaemia
Urgent resus
Broad spectrum antibiotics
Early ITU input
Excision of necrotic/non-viable bowel
Revascularisation of bowel
What is chronic mesenteric ischaemia
Reduced blood supply to bowel
Due to atherosclerosis in: coeliac trunk, superior mesenteric artery, inferior mesenteric artery
> 60s
F>M
How might chronic mesenteric ischaemia present
Postprandial pain (10 mins - 4 hrs after eating)
Weight loss (malabsorption)
Change in bowel habits
Other vascular event
Nausea and vomiting
Generalised abdominal tenderness
Abdominal bruit
What investigations are needed for chronic mesenteric ischaemia
Routine bloods
CT angiography
What is the management for chronic mesenteric ischaemia
Smoking cessation
Antiplatelet therapy
Statins
Endovascular or open procedure (stenting, bypass)
What is a pseudoaneurysm
Breach to artery wall, causing accumulation of blood between tunica media and adventitia
Direct communication between vessel lumen and aneurysm lumen
Usually following damage to vessel wall
Most common in femoral artery
How might pseudoaneurysm present
Pulsatile, tender, painful lump
Possible limb ischaemia
If infected: erythematous, tender, purulent discharge, systemic features of sepsis
What investigations are needed for pseudoaneurysm
Distal pulse status
Duplex ultrasound (gold standard)
CT
Routine bloods
Blood cultures
Pus swab and culture
What is the management for pseudoaneurysm
Ultrasound-guided compression
Ultrasound-guided thrombin injection
Endovascular stenting
Surgery (repair artery directly)
What are varicose veins
Tortuous dilated segments of vein, associated with valvular incompetence
Mostly idiopathic
What are the risk factors for varicose veins
Prolonged standing
Obesity
Pregnancy
Family history
How might varicose veins present
Cosmetic concerns
Aching
Itching
If left untreated: skin changes, ulceration, thrombophlebitis, bleeding
Can have clinical features of venous insufficiency: ulceration, varicose eczema, haemosiderin deposition
What investigations are needed for varicose veins
Duplex ultrasound
What is the management for varicose veins
Education
Compression stockings
4-layer bandaging
Surgery
What is thoracic outlet syndrome
Compression of neurovascular bundle as it passes through thoracic outlet
Compression of: brachial plexus, subclavian artery, subclavian vein
Give an overview of subclavian steal syndrome
Syncope or neurological deficit when blood supply to the affected arm is increased through exercise
Due to proximal stenosing lesion or occlusion of subclavian artery
Blood drawn away from collateral circulation
