Vascular Flashcards
Vascular dx
What is the definition of an abdominal aortic aneurysm?
A localised enlargement of the abdominal aorta where the diameter is >3 cm or >50% larger than normal diameter.
What are the 3 types of aneurysms?
True (tear in all 3 layers of artery wall):
1. Saccular
2. Fusiform
- False aneurysms- tear in the tunica intimacy creating a false lumen
What are the risk factors for AAA?
Smoking
Male
Connective tissue disorders- Marfan’s, Ehlers-Danlos syndrome
Old age
HTN
Inflammatory disorders
What are the presenting symptoms of un-ruptured AAAs?
Majority are asymptomatic- incidental finding
May complain of pain/pulsation in the back/abdo/groin
What are the risk factors for AAAs?
Male
CTD
Hypertension
Hypercholesterolaemia
Smoking
What is the mortality rate of ruptured AAAs?
90%
What is the presentation of a ruptured AAA?
Sudden, severe abdominal pain, radiating to the back
Syncope
Shock signs
What are the signs of an AAA? (ruptured or not)
- Pulsatile & laterally expansile mass on palpation
- Abdominal bruit
IF RUPTURED:
- Grey Turner’s/Cullen’s- retroperitoneal bleeding
- Low BP/high HR - hypovolaemic shock
What is the screening criteria for AAAs?
Males >65yrs
What are the investigations for suspected AAA?
BEDSIDE
- Abdominal Ultrasound- GOLD STANDARD
- Can detect presence of AAA but not whether it has ruptured or not
BLOODS
- FBC, clotting screen, U&Es, LFTs
- Cross match in case surgery is needed
IMAGING (detect rupture)
- CT Angiogram
- Magnetic resonance angiogram – contrast allergy/renal impairment
What is the management plan for small AAAs (3.5-4.4cm) and medium AAAs (4.5-5.4cm)?
Follow up scan in 1 year (small) or 3 months (medium)
CONSERVATIVE: smoking, exercise, weight loss
MEDICAL:
- statins
- aspirin
- BP management
What is the management plan for large AAAs (5.5cm+)?
Open aortic surgery
Endovascular repair
What are the cons of open aortic surgery?
Longer recovery time hence done on young patients
What are the cons of endovascular repair?
Less peri-op mortality but greater risk of needing more procedures
What is the definition of an aortic dissection?
A tear in the tunica intima causing blood accumulation between the inner and outer tunica media (false lumen)
What are the 2 classification systems for aortic dissections?
DEBAKEV
Type I –> Type IIIb
STANFORD
Type A- ascending aorta tear
Type B- descending aorta tear (after the left subclavian)
What are the risk factors of an aortic dissection?
HTN
Atherosclerosis
Iatrogenic (angiography/plasty)
Congenital- coarctation of aorta
Crack cocaine
Smoking
Male
Connective tissue disorders
What are the presenting symptoms of aortic dissections?
Sudden central tearing pain, radiating to the back
Symptoms caused by blockages to branches of the aorta
What can happen if the tear affects the carotids/subclavian?
Hemiparesis
Blackouts
What can happen if the tear affects the coronary arteries?
Angina
MI
What can happen if the tear affects the renal arteries?
AKI
Renal failure
What can happen if the tear affects the coeliac trunk?
Abdominal pain
What can you find on examination of a Pt with aortic dissection?
- Tachycardia
- BP difference of >20mmHg (50%) between upper limbs
- Murmur below scapulae
SIGNS OF CAUSE
- Radio-radial delay (if coarctation of aorta)
- Wide pulse pressure
- Hypertension
- Signs of aortic regurgitation (collapsing pulse)
- Signs of connective tissue disease
What are the two key signs of aortic insufficiency?
High volume collapsing pulse
Early diastolic murmur (aortic regurgitation)
What investigations would you do for aortic dissection and why?
BLOODS
- FBC, U&E/LFT- check for downstream organ damage.
- Xmatch- 10 units of blood for hypotension
- Cardiac enzymes- mimics MI
ECG
CXR
GOLD STANDARD- CT angiogram
What would you see in a CXR of a Pt with aortic dissection?
Widened mediastinum
Loss of contour of aortic knuckle/visible aortic notch
Globular heart
Why would you do a CT angiography of a Pt with aortic dissection?
Visualise the location of the dissection
Which is the best diagnostic intervention for aortic dissection?
CT angiogram- needs to be ordered as soon as aortic dissection is suspected
A 69 year old man with a background of hypertension complained of flank pain all day at work. He then has sudden onset abdominal pain that radiates to his back and groin. He arrives in an ambulance unconscious. The doctor notes Grey Turner’s and Cullen’s signs. What is the most likely diagnosis?
A. Renal colic
B. Myocardial ischaemia
C. Ruptured AAA
D. Pancreatitis
C. Ruptured AAA
A 65 year old gentleman is coming in for screening for a AAA following a letter received in the post. What modality would be used as a screening tool?
A. Abdominal ultrasound
B. Abdominal CT
C. Abdominal X-ray
D. Doppler ultrasound
A. Abdominal Ultrasound
A 65 year old gentleman with a known AAA (last measured 5.2 cm) comes in complaining of severe abdominal pain. What investigation would you use to assess if it has ruptured?
A. Abdominal ultrasound
B. Abdominal CT
C. Abdominal X-ray
D. Doppler ultrasound
B. Abdominal CT
A 70 year old gentleman with known hypertension presents to A&E with tearing chest pain, radiating to the back. His CXR shows a widened mediastinum. What is the most likely diagnosis?
A. Aortic dissection
B. STEMI
C. Tietze’s syndrome
D. Costochondritis
A. Aortic dissection
Which of the following examination findings is not consistent with an aortic dissection?
A. BP 100/40
B. Ejection systolic murmur
C. Collapsing pulse
D. Radio-radio delay
B. Ejection systolic murmur
What is intermittent claudication?
Cramping muscular pain in the calf, thigh, or buttocks, PRECIPITATED BY EXERCISE and alleviated by rest
What are the risk factors for peripheral vascular disease?
Cardiovascular RFs:
- Smoking
- Diabetes mellitus
- Hypertension
- Male
- >40yrs
- Hyperlipidaemia
What are the signs of acute limb ischaemia? (6Ps)
- Pain
- Pale
- Pulseless
- Parasthesia
- Perishingly cold
- Paralysis
Both legs are often affected at the same time, although the pain may be worse in 1 leg.
What is Leriche’s syndrome?
Narrowing of the abdominal aorta as it bifurcates into the common iliacs
What is the triad seen in Leriche’s syndrome?
Bilateral claudication
Erectile dysfunction
Weak femoral pulses
What is the triad of critical limb ischaemia?
Rest pain (Alleviated by standing)
Arterial ulcers
Gangrene
What is the prognosis for intermittent claudication?
80% chance of improvement
5% intervention
1% amputation
15% dead in 5 years
What is the prognosis for critical limb ischaemia?
90% intervention
25% amputation
50% dead in 5 years
What are the different indices (levels) of ABPI?
> 0.95- normal
0.5-0.95-claudication
0.3-0.5- rest pain
<0.3- critical ischaemia
What can cause false negatives in ABPIs?
Calcification of vessels
What other investigations can be done for claudication?
Doppler USS
Magnetic resonance angiography
What is acute limb ischaemia?
Sudden lack of blood flow to a limb
What are the two causes of acute limb ischaemia?
Thrombus- due to peripheral arterial disease
Embolus- from the heart
What are the 3 grades of acute limb ischaemia?
VIABLE
-no neuro signs + audible Doppler
TREATENED
-sensory loss + tense calf + no audible Doppler
DEAD
-complete neurological deficit, fixed mottling
A 65 year old lady with known CVD presents to the GP with pain in her legs. She finds the pain comes on when she is walking to the shops, but is relieved by rest. She has a 40 pack year smoking history. What is the most likely diagnosis?
A. Acute limb ischaemia
B. Deep vein thrombosis
C. Varicose veins
D. Peripheral arterial disease
D. Peripheral arterial disease
A 60 year old male with known atrial fibrillation presents to A&E with a sudden onset of a painful, cold leg. The doctor is unable to feel peripheral pulses, and upon examination notes a loss of sensation and paralysis. A venous Doppler is inaudible. What is the definitive management?
A. Embolectomy
B. Watch and wait
C. Angioplasty
D. Amputation
D. Amputation
A 69 year old heavy smoker complains of pain in his leg when he walks to the bus stop. On examination of his leg, you see shiny skin, patchy hair, weak pulses and brittle toenails. What would be the first line investigation?
A. Angiography
B. Doppler ultrasound
C. Magnetic resonance angiography
D. ABPI
D. ABPI
What is a DVT?
Formation of a clot in the deep veins
What is Virchow’s triad?
Venous stasis
Endothelial damage
Hypercoagulability
What are the inherited risk factors for DVTs?
Antithrombin deficiency
Protein C/S deficiency
Antiphospholipid syndrome
What are the acquired risk factors for DVTs?
Age
Pregnancy
Trauma
Surgery
Immobility
Previous DVT
Cancer
Oestrogen
What is the presentation of a DVT?
50% asymptomatic
Leg swelling
Calf tenderness
Erythema
What is found on examination of a DVT?
Pitting oedema
Calf warmth
Calf swelling >3cm difference
Prominent superficial veins
What is the scoring used for DVTs?
Well’s score
If the Well’s score is >=2 what investigation do you do?
Leg vein USS
If the Well’s score is >=2 and the USS is -ve what investigation do you do, and what would you do if THAT finding was positive?
D-dimer
If D-dimer is positive, repeat USS in 6-8 days
If the Well’s score is <2 what investigation do you do, and what would you do if THAT finding was positive?
D-dimer
If D-dimer is positive, perform USS
What management would you provide for a Pt with a DVT?
LMWH for 5 days
Warfarin within 24h for at least 3 months
When would you consider thrombolytic therapy?
If the symptoms have been less than two weeks, the Pt is well, has a good life expectancy and at a low risk of bleeding
What surgical procedure can be offered for a DVT?
Thrombectomy
What preventative management can be offered for a DVT?
Stop OCP 4 weeks before surgery
Compression stockings
LMWH for high risk Pts
Why is LMWH given with warfarin?
Warfarin inhibits F2,7,9,10, Protein C and S
Hence it has an initial pro-coagulative phase
LMWH is given to counteract this
A 38 year old lady presents with swelling in her leg, and associated calf tenderness. She has been taking the OCP for several years. What is the best management for this patient?
A. Warfarin + LMWH
B. Warfarin
C. Aspirin
D. LMWH + Aspirin
E. LMWH
A. Warfarin + LMWH
A 72 year old gentleman is complaining of pain in his right leg. He is 8 days post operative for a tibia/fibula fracture repair. What is the minimum amount of time the patient must be anticoagulated for?
A. 3 months
B. 6 months
C. 1 year
D. Lifelong
A. 3 months
A 32 year old woman on the OCP complains of pain in her calf for one day. She does not have any chest pain or shortness of breath. The nurse tells you that the A&E doctors assessed the patient, who scored 2 although she cannot remember the name of the score. What is the most appropriate initial investigation?
A. D-Dimer
B. MRA
C. Leg Vein USS
D. ABPI
C. Leg Vein USS
What is the cause of an arterial/ischaemic ulcer?
Lack of blood flow causing ischaemia, commonly due to PAD
What is the appearance of an arterial/ischaemic ulcer?
Distal (dorsum of foot & between toes)
Punched out appearance (well defined)
Very painful
Gangrene/necrosis
Minimal exudate
Surrounding skin- hairless, cold, shiny
Pale base (grey granulation tissue)
What is the cause of a venous ulcer?
Inadequate valvular function causes leakage of blood and protein into extravascular spaces.
Build up of fibrinogen and fibrin causes reduced O2 delivery
Leukocyte accumulation releases proteolytic enzymes and ROS
What are the characteristics of a venous ulcer?
- Located in the “gaiter” region (more proximal)
- Shallow, irregular
- Usually painless (may be itchy)
- Wet
What is the cause of a neuropathic ulcer?
Diabetics with peripheral neuropathy
Loss of pain sensation in blisters/pressure injuries
What are the characteristics of a neuropathic ulcer?
Ulcers on the plantar aspect
Even wound margins
Loss of pain sensation
Deep ulcer
Calloused skin
May be infected
Palpable pulses and warm foot
A 75 year old woman with long standing hypertension has had progressive swelling of her legs over the last 3 months. She has consulted her GP because she has developed an ulcer on the anterior aspect of the right shin which weeps serous fluid profusely. What is the cause of the ulcer?
A. Arterial
B. Venous
C. Neuropathic
D. Rheumatoid Arthritis
B. Venous
A 62 year old diabetic woman shows you an ulcer on the bottom of her foot. It has a little stone lodged in it, which she hasn’t noticed. On neurological examination, she has no peripheral sensation of light touch up to her mid-foot. What is the cause of the ulcer?
A. Arterial
B. Venous
C. Neuropathic
D. Trauma
C. Neuropathic
A 78 year old obese woman presents with an ulcer on the top of her foot and one between her toes. They haven’t healed in two months. They are quite small, look punched out and yellow. She complains her feet are always cold and has a history of coronary artery disease.
A. Arterial
B. Venous
C. Neuropathic
D. Trauma
A. Arterial
A 45 year old lady presents with a 4 cm chronic ulcer on the medial aspect of the lower leg. She has a history of pain in the calf on walking. The skin around the ulcer is brown and heavily indurated.
A. Arterial
B. Venous
C. Neuropathic
D. Trauma
B. Venous
Define varicose veins
Subcutaneous, permanently dilated veins >3 mm (when standing) caused by VALVULAR INSUFFICIENCY
What are the risk factors of varicose veins?
Obesity
Pregnancy
OCP
Family history
What are the symptoms/presentation of varicose veins?
Visibly dilated veins
Leg aching, especially with prolonged standing
Swelling, itching
Bleeding
NOTE: inspect whilst standing
What are the examination findings of varicose veins?
- Veins feel tender/hard
- Tap test- tap VV distally & feel thrill over sapheno-femoral junction
- Bruits on auscultation
- Trendelenburg test
What is the endothelial management of varicose veins?
- RADIOFREQUENCY ABLATION catheter inserted into vein and heated–> destroys endothelium and ‘closes’ vein (similar outcome to surgery at 3mths)
- ENDOVENOUS LAZER ABLATION: similar but uses laser (similar outcomes to surgery at 2yrs)
- MICROINJECTION: liquid/foam used
Where is the most common site for an AAA?
90% occur below the renal arteries (infrarenal)
Mr Z, a 57-year-old lorry driver who takes crack cocaine at the weekends, arrives at A&E with a ‘really painful tearing feeling’ in his back. An early diastolic murmur is heard over the aortic area and a collapsing pulses is noted on examination.
Which murmur is most likely being described?
Aortic regurgitation
How can peripheral vascular disease be classified?
- Acute limb ischaemia (sudden decrease in limb perfusion)
- Intermittent claudication (pain on exertion)
- Critical limb ischaemia (pain at rest)
Signs of critical limb ischaemia + intermittent claudication
Most patients with PVD are asymptomatic
- Hair loss in feet/limbs
- parasthesia
- brittle, slow growing toenails
- ulcers
- absent femoral, popliteal or foot pulses
- atrophic skin
What may help with the pain in critical limb ischaemia?
Hanging legs over bed helps with pain (gravity)
Define acute limb ishcaemia
Sudden decrease in arterial blood flow to a limb that threatens its viability.
Vascular emergency –> extensive tissue necrosis –>limb amputation/death
Differentiate between acute limb ischaemia and critical limb ischaemia
ACUTE- thromboembolic event
- <2 week onset
- absent pulses
- sudden, unilateral calf tenderness at rest
- appearance = pale, marble-white
- cold, parasthesia, paralysis
- an emergency
CRITICAL- atherosclerotic event
- > 2 week onset
- weak/absent pulses
- gradual pain, at rest
- appearance = pink
- warm
- not an emergency
Describe the clinical test used to detect limb ischaemia
BEURGER’S TEST
- Lie patient flat on bed & lift up leg to 45°
- Limb developing pallor indicates arterial insufficiency
- <20°is Beurger’s angle and indicates severe limb ischaemia
- Patient then swings leg over the bed, reactive hyperaemia is seen
What is reactive hyperaemia?
Leg goes from pale –> red after elevation then lowering
Colour change occurs as a result of arteriolar dilatation, which is a response to increased anaerobic metabolic waste build up in the lower limbs.
What investigations do you do for PVD?
Full cardiovascular risk assessment:
- BP & HR
- Bloods (GBC, fasting glucose, lipids)
- ECG
Ankle-Brachial Pressure Index (ABPI)= GOLD STANDARD
Directly visualise site of stenosis:
- COLOUR DUPLEX ULTRASOUND
- MAGENTIC RESONANCE ANGIOGRAM
How can ankle-brachial pressure index score be used to diagnose PVD?
Normal range: 0.9 –> 1.2
<0.9 abnormal
<0.5 CLI
A triad of:
- Buttock claudication
- Impotence
- Absent / weak distal pulses
is suggestive of which condition?
Leriche Syndrome aka aortoiliac occlusive disease
What causes Leriche syndrome?
Narrowing of iliac arteries by atherosclerosis
Mr X speaks to his GP after noticing some hair loss on his feet and numbness in his toes. The GP finds Mr X’s ankle-brachial pressure index to be 0.7. What does result suggest?
Abnormal ABPI, but not yet critical limb ischaemia
CLI would be 0.5 or less
What are the surrounding signs of an arterial ulcer?
Hair loss, shiny & pale skin
Calf muscle wasting
Absent pulses
Night pain- worse supine & relieved by hanging legs off the bed
State 4 signs seen with venous ulcers
- Stasis eczema = retrograde flow of blood
- Lipodermatosclerosis = panniculitis
- Atrophie blanche
- Haemosiderin deposition- congested blood leaks out causing oedema + dark pigmentation
What is lipodermatosclerosis?
Type of panniculitis (inflammation of the layer of fat beneath the skin).
Causes pain, hardening of skin, redness, swelling & tapering above the ankles
(champagne bottle sign)
VENOUS ULCERS
What is atrophic blanche?
Areas of white, shiny, atrophic skin surrounded by small dilated capillaries and sometimes areas of hyperpigmentation
What is the gold standard investigation for both arterial and venous ulcers?
Duplex USS of lower limbs
What investigations would you do for ulcers?
Gold standard for both = duplex USS
ARTERIAL = same as for PVD
VENOUS = monitor surface area of ulcer = swab/biopsy if suspect infection/malignancy
What is a long term complication of venous ulcers that requires biopsy?
MARJOLIN’S ULCER
Squamous cell carcinoma that most commonly arise from areas of chronic inflammation or injury
Develop over many years
Management of venous ulcers
- Graded compression stockings
- Debridement + cleaning
- Abx if infected
- Moisturising cream
good prognosis if adhere to treatment
What must you ensure before providing venous ulcer patients with compression stockings?
DM, neuropathy & PVD
- may worsen ischaemia
Epidemiology of varicose veins
Age increasing incidence
Female (20-25% women suffer, 10-15% men)
Caucasian
State the primary and secondary causes of varicose veins
PRIMARY- idiopathic valvular incompetence = 98%
SECONDARY-
1. Venous outflow obstruction (ascites, pregnancy, ovarian cysts, pelvic malignancy)
2. DVT
3. AV malformations eg fistula
Describe the Trendelenburg test
- Patient lies supine and leg is lifted and the veins are emptied
- A tourniquet is placed above the knee
- When standing up, veins should refill in 30-35 seconds as blood returns from capillaries
-rapid filling on standing indicates deep veins valvular incompetence
- rapid filling on removal of tourniquet indicates superficial valvular incompetence
What are the investigations for varicose veins?
clinical diagnosis, gold standard/only test =
DOPPLER USS
- Localises the site of valve incompetence
- Can be used to exclude DVT
conservative management of varicose veins
- Compression stockings
- Lifestyle changes- weight loss, exercise, leg elevation
Surgery options varicose veins
- Stripping of the long saphenous vein
- Saphenofemoral ligation
- Avulsion of varicosities
Complications of varicose veins
- Venous ulcer
- Stasis eczema
- Lipodermatosclerosis
- Hemosiderin deposition
Complications of surgery/sclerotherapy (scarring, perineal nerve damage, phlebitis)
