Vascular

Question 1

Mx of peripheral artery disease?

Answer 1

Atorvastatin + clopidogrel

Question 2

What area of legs are effected more by intermittent claudication?

Answer 2

Distal extremity (calves) more common than proximal (thigh / buttock areas)

Question 3

Px of chronic limb ischaemia?

Answer 3

Chronic rest pain
- Worse at night due to lower BP and no gravity

Non-healing ulcers

Rubor, pallor on elevation and reduced cap refill

Absent foot pulses

Circulation so severely impaired -> imminent risk of limb loss

Question 4

6 P’s of acute limb ischaemia?

Answer 4

6 P’s
- Pain
- Pulseless
- Pallor
- Power loss (paralysis)
- Paraesthesia
- Perishing cold

Question 5

ABPI ratios

Answer 5

ABPI ratio:
- <0.5 = severe
- 0.5 – 0.8 = mild arterial disease
- 0.8 – 1.3 = normal
- >1.3 = arterial calcification

Question 6

What to examine for in peripheral artery disease?

Answer 6

• Ulcers (legs and feet)
• Differences in legs – temperature, muscle atrophy, skin changes
• Pulses – femoral, popliteal and foot
• Buerger’s test, capillary refill time

Question 7

Ix of peripheral artery disease?

Answer 7

1. Duplex ultrasound – speed and volume of blood flow
2. MRI angiography – contrast added to highlight arterial circulation
3. CT angiography

Question 8

Mx of intermittent claudication?

Answer 8

1. Exercise programme
   - Supervised or unsupervised
2. Angioplasty or stenting
3. Bypass surgery
4. Naftidrofuryl oxalate
   - If patient doesn’t want referred to surgery
   - Discontinue if no benefit after 3 months

Question 9

Mx of critical limb ischaemia?

Answer 9

Urgent referral to vascular MDT first

Analgesia (paracetamol + strong/weak opioids)

Options:
- Endovascular angioplasty and stenting
- Endarterectomy
- Bypass surgery
- Amputation

Question 10

Mx options of acute limb ischaemia?

Answer 10

Endovascular
- Thrombolysis (catheter applies thrombolysis directly into clot)
- Thrombectomy (catheter removes thrombus with mechanical device)

Surgical
- Thrombo-embolectomy
- Endarterectomy
- Bypass surgery
- Amputation

Question 11

What is minimum dilation for an AAA?

Answer 11

When dilatation of abdominal aorta diameter >3cm (1.5x normal size)

Question 12

At what age is screening available for AAA?

Answer 12

All men >65

Question 13

When to consider AAA repair?

Answer 13

o Symptomatic AAA
o >4cm and has grown by 1cm in one year
o >5.5cm

Question 14

Ruptured AAA px?

Answer 14

• Severe abdo pain which radiates to the back or groin
• Haemodynamically unstable
• Pulsatile and expansile mass
• Collapse
• Loss of consciousness

Question 15

What is aortic dissection?

Answer 15

Aortic dissection is when there is a break in intima layer, and this allows blood to enter between the intima and media layers

Question 16

Stanford classification of aortic dissection

Answer 16

Type A = affects ascending aorta (bad prognosis)

Type B = affects descending aorta (better prognosis)

Question 17

DeBakey classification of ascending aorta

Answer 17

Type 1 = begin in ascending aorta and extends to aortic arch / descending aorta
Type 2 = ascending aorta only
Type 3 = descending aorta distal to left subclavian

Question 18

Px of aortic dissection?

Answer 18

Sudden onset, severe, ripping / tearing chest pain
o Ascending aorta = anterior chest
o Aortic arch = neck
o Descending aorta = between scapulae
Differences in blood pressure between arms
Aortic regurgitation, coronary ischaemia,
cardiac tamponade
Diastolic murmur
Collapse

Question 19

Mx of aortic dissection?

Answer 19

Analgesia, O2 and IV access

BP and HR control to reduce aortic wall stress [B-blockers?]

Depends on type:
Type A: Surgery -> Replace aortic arch with graft (high mortality if untreated)
Type B:
-> Conservative – lower BP (IV Labetalol)
-> If rupture or complication -> Surgery – endovascular repair (TEVAR)

Question 20

Carotid artery stenosis diameter required for dx of severe stenosis?

Answer 20

Mild - <50%
Moderate 50-69%
Severe >70%

Moderate & severe -> assessment for carotid endarterectomy

Question 21

Ix for suspected stroke?

Answer 21

Non-enhanced CT

Question 22

Initial mx for suspected TIA or ischaemia stroke

Answer 22

Aspirin

Question 23

What is needed for a high rx diabetic foot?

Answer 23

Previous ulceration
Previous amputation
Renal replacement therapy
2 of:
- Neuropathy
- Callus / deformity
- Non-critical limb

Question 24

Antibiotics for diabetic foot sepsis?

Answer 24

Mild - oral flucloxacillin
Pen allergic -> Clarithromycin or doxycycline
Pen allergic + pregnant -> erithromycin

Moderate or severe:
* Flucloxacillin +/- gentamicin +/- metro
* Co-amoxiclav +/- gentamicin
* Co-trimoxazole +/- gentamicin +/- metro
* Ceftriaxone + metronidazole

Question 25

Antibiotic for MRSA?

Answer 25

Vancomycin

Question 26

What is charcot arthropathy?

Answer 26

This is progressive destruction of bones, soft tissues and joints in the ankle and feet due to peripheral neuropathy.

Question 27

Ix for charcot arthropathy?

Answer 27

1. X-ray – degenerative changes, loss of joint space, fragmentation (mimics OA)
2. MRI – abscess or soft tissue swelling?

Question 28

Mx for charcot arthropathy?

Answer 28

Removable offloading device (plaster cast)
- No bisphosphonates

Question 29

Px of varicose veins?

Answer 29

Tortuous dilated veins, skin discolouration, aching, itching
- Late – varicose eczema, ulceration, thrombophlebitis, bleeding

Question 30

Mx of varicose veins?

Answer 30

• Weight loss, avoid prolonged standing, increase exercise
• Compression stockings
• Venous ulceration -> four-layer bandaging
• Pregnant -> compression hosiery for symptom relief of leg swelling

Question 31

When to refer to vascular service with varicose veins?

Answer 31

• Symptomatic or skin changes or venous leg ulcer
• Or superficial vein thrombosis – hard, painful veins

Question 32

Surgical mx for varicose veins?

Answer 32

Mx if confirmed varicose veins + truncal reflux:
1. Endothermal ablation
2. Ultrasound guided foam sclerotherapy
3. Surgery

Question 33

Ix for varicose veins?

Answer 33

Duplex ultrasound to assess valve incompetence
- Extent of truncal reflux?

Question 34

Deep venous insufficiency Ix

Answer 34

Doppler US
- Foot pulses and ABPI – If bad, compression stocking could impair arterial flow

Question 35

Deep venous insufficiency mx

Answer 35

Conservative (compression stockings + elevate legs + analgesia)
- Surgical is an option but poor outcomes