Vascular Flashcards
Mx of peripheral artery disease?
Atorvastatin + clopidogrel
What area of legs are effected more by intermittent claudication?
Distal extremity (calves) more common than proximal (thigh / buttock areas)
Px of chronic limb ischaemia?
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
6 P’s of acute limb ischaemia?
6 P’s
- Pain
- Pulseless
- Pallor
- Power loss (paralysis)
- Paraesthesia
- Perishing cold
ABPI ratios
ABPI ratio:
- <0.5 = severe
- 0.5 – 0.8 = mild arterial disease
- 0.8 – 1.3 = normal
- >1.3 = arterial calcification
What to examine for in peripheral artery disease?
- Ulcers (legs and feet)
- Differences in legs – temperature, muscle atrophy, skin changes
- Pulses – femoral, popliteal and foot
- Buerger’s test, capillary refill time
Ix of peripheral artery disease?
- Duplex ultrasound – speed and volume of blood flow
- MRI angiography – contrast added to highlight arterial circulation
- CT angiography
Mx of intermittent claudication?
- Exercise programme
- Supervised or unsupervised - Angioplasty or stenting
- Bypass surgery
- Naftidrofuryl oxalate
- If patient doesn’t want referred to surgery
- Discontinue if no benefit after 3 months
Mx of critical limb ischaemia?
Urgent referral to vascular MDT first
Analgesia (paracetamol + strong/weak opioids)
Options:
- Endovascular angioplasty and stenting
- Endarterectomy
- Bypass surgery
- Amputation
Mx options of acute limb ischaemia?
Endovascular
- Thrombolysis (catheter applies thrombolysis directly into clot)
- Thrombectomy (catheter removes thrombus with mechanical device)
Surgical
- Thrombo-embolectomy
- Endarterectomy
- Bypass surgery
- Amputation
What is minimum dilation for an AAA?
When dilatation of abdominal aorta diameter >3cm (1.5x normal size)
At what age is screening available for AAA?
All men >65
When to consider AAA repair?
o Symptomatic AAA
o >4cm and has grown by 1cm in one year
o >5.5cm
Ruptured AAA px?
- Severe abdo pain which radiates to the back or groin
- Haemodynamically unstable
- Pulsatile and expansile mass
- Collapse
- Loss of consciousness
What is aortic dissection?
Aortic dissection is when there is a break in intima layer, and this allows blood to enter between the intima and media layers
Stanford classification of aortic dissection
Type A = affects ascending aorta (bad prognosis)
Type B = affects descending aorta (better prognosis)
DeBakey classification of ascending aorta
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
Px of aortic dissection?
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
Mx of aortic dissection?
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)
Carotid artery stenosis diameter required for dx of severe stenosis?
Mild - <50%
Moderate 50-69%
Severe >70%
Moderate & severe -> assessment for carotid endarterectomy
Ix for suspected stroke?
Non-enhanced CT
Initial mx for suspected TIA or ischaemia stroke
Aspirin
What is needed for a high rx diabetic foot?
Previous ulceration
Previous amputation
Renal replacement therapy
2 of:
- Neuropathy
- Callus / deformity
- Non-critical limb
Antibiotics for diabetic foot sepsis?
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
Antibiotic for MRSA?
Vancomycin
What is charcot arthropathy?
This is progressive destruction of bones, soft tissues and joints in the ankle and feet due to peripheral neuropathy.
Ix for charcot arthropathy?
- X-ray – degenerative changes, loss of joint space, fragmentation (mimics OA)
- MRI – abscess or soft tissue swelling?
Mx for charcot arthropathy?
Removable offloading device (plaster cast)
- No bisphosphonates
Px of varicose veins?
Tortuous dilated veins, skin discolouration, aching, itching
- Late – varicose eczema, ulceration, thrombophlebitis, bleeding
Mx of varicose veins?
- Weight loss, avoid prolonged standing, increase exercise
- Compression stockings
- Venous ulceration -> four-layer bandaging
- Pregnant -> compression hosiery for symptom relief of leg swelling
When to refer to vascular service with varicose veins?
- Symptomatic or skin changes or venous leg ulcer
- Or superficial vein thrombosis – hard, painful veins
Surgical mx for varicose veins?
Mx if confirmed varicose veins + truncal reflux:
1. Endothermal ablation
2. Ultrasound guided foam sclerotherapy
3. Surgery
Ix for varicose veins?
Duplex ultrasound to assess valve incompetence
- Extent of truncal reflux?
Deep venous insufficiency Ix
Doppler US
- Foot pulses and ABPI – If bad, compression stocking could impair arterial flow
Deep venous insufficiency mx
Conservative (compression stockings + elevate legs + analgesia)
- Surgical is an option but poor outcomes
