vascular Flashcards
fournier gangrene affects what fascia
deep fascia
Fournier’s gangrene is essentially necrotizing fasciitis of the perineum and it is a surgical emergency because it can cause rapid and uncontrollable necrosis of tissue and ultimately death by overwhelming sepsis if not treated promptly
most common site for peripheral arterial disease
femoral artery - producing pain in the calves on exertion
what are varicose veins
Varicose Veins are dilated and tortuous superficial veins, most often affecting the lower limb. They occur due to incompetence of the valves between the deep and superficial venous systems, resulting in retrograde flow and pooling of blood in the superficial venous system.
features of varicose veins
Visible superficial veins
Pain
Cramping or heaviness
Oedema
Venous ulcers may be present
Discolouration due to increased haemosiderin deposits
Haemorrhage
tx for varicose veins
Treatment not required unless bleeding, pain, ulceration, thrombophlebitis or significant psychological morbidity
Lifestyle modification
Reduce long periods of standing
Elevate lower limbs when possible
Support stockings
Weight loss
Walking
Radiofrequency ablation: destruction of the endothelium of the vein via high temperature catheter
Endovenous laser ablation: destruction of the vein using laser
Injection sclerotherapy: Injection of sclerosant substance at several points in the vein, leading to occlusion
Surgery: avulsion therapy or stripping of the vein
Chronic dull pain, discomfort, pruritus with skin changes (hemosiderin, oedema) suggest
chronic venous insuffiency
dilated tortuous veins are suggestive of varicose veins due to venous valve incompetence. As venous pressure rises, the veins become varicose and leak inflammatory substances into the interstitium. Duplex ultrasonography can pick up bidirectional blood flow in the superficial veins instead of unilateral blood flow from the superficial to the deep system.
diagnostic test for PAD
Computerised tomography angiography
varicose veins diagnostic test
Duplex ultrasonography
when do we use ABPI for PAD
ABPI is used to evaluate peripheral arterial disease which present as claudication pain and absent peripheral pulses. In a patient with chronic venous insufficiency, ABPI should be done to exclude PAD but it is not the diagnostic test for venous insufficiency.
lipodermatosclerosis
Lipodermatosclerosis refers to changes in the skin of the lower legs
superficial thrombophlebitis refers to thrombus formation in superficial venous vasculature most commonly in lower limb veins what is mx
Compression stockings
Dry gangrene is a complication
of criticlal limb ischaemia
Dry gangrene is a complication of critical limb ischaemia. The blood supply to the toe has become so poor that the lack of oxygen and nutrients has led to necrosis of the tissue. There is usually a clear delineation between the dead and living tissue. Dry gangrene is not infected
wet gangrene tx
debridement and amputuation and borad IV abx
what is buergers disease
Buerger’s disease is a non-atherosclerotic vasculitis caused by occlusion in small and medium-sized arteries. in men
how does buergers disease present
It typically presents as an acutely ischaemic limb, without a background of peripheral claudication.
what investigations would you do for burgers disease
Arterial Doppler will confirm the absence of peripheral pulses in the affected limb. Further imaging (such as with arterial duplex or CT/MR angiography) will show non-atherosclerotic occlusion. Martorell’s sign on arterial duplex describes the ‘corkscrew’-shaped collateral vessels characteristic of Buerger’s disease.
mx for buergers disease
Management is with smoking cessation ± vasoactive medication (such as nifedipine).
most likley cause of acute limb ischaemia
AF
The most likely aetiology for acute limb ischaemia is an embolus of cardiac origin, particularly in the absence of previous intermittent claudication due to atherosclerotic peripheral artery disease (PAD). The most likely explanation in this scenario is a cardiac thrombus in the myocardium due to AF, throwing off an embolus that has now lodged into the popliteal trifurcation of the right leg, producing ischaemic symptoms.
first line management in acute limb ischameia
IV heparin - slow clot propagation so it can be determind if embolic or thrombotic cause( inactivates the thrombin)
‘Inverted champagne bottle’ appearance (tapering of legs above the ankle)
venous ulcer commonly shin
arterial pressure points
PAD only MR angio if confrimed first test you can do is
ABPI
management of venous ulcer
compression bandaging - do ABPI first to avoid exacerbating PAD
what is wet gangrene
In wet gangrene the necrotic area is poorly demarcated from the surrounding tissue and patients are pyrexial/septic.
gold satndard would be magenic resonance angiogrpahy when do you do CT angio
MRA great for CKD as no chance of contrast
only if MRA CI
sx and rf for AAA
US of AAA
A 71-year-old man presents to the emergency department with an a painful left leg and is subsequently diagnosed with acute limb ischaemia.
Which of the following would point to an embolic rather than thrombotic cause for the patient’s presentation?
Onset over minutes
Acute limb ischaemia due to embolic obstruction tends to produce symptoms over minutes; patients can typically point out the precise time they started to develop symptoms. Thrombosis-induced acute limb ischaemia on the other hand develops over hours to days.
An ulcer with a rolled edge appearance should raise suspicion of
BCC
what is ABPI
what do diabetics have
It is a ratio of the highest ankle systolic blood pressure over the highest brachial blood pressure. A lower index suggests a narrowing of the lower limb blood vessels. Note: diabetic patients may have artificially high ABPI values as their arteries are not easily compressible due to calcification
double amputee potnetial with ischaemic limb do you offer below or above knee amputation
below as above would make less stable
carotid artery stenosis of 70-99%,
Patients should undergo carotid endarterectomy if there is carotid artery stenosis of 70-99%, with symptoms of an ischaemic event such as a Stroke or TIA in the corresponding vascular territory
as well as
Anti-platelet agents (first line is clopidogrel 75mg)
Cholesterol lowering therapy
Blood pressure control
Lifestyle advice
mx of intermittent claudication
supervised exercise programme - promotes collateral vessel formation
mx ischaemic legs
lifestyle
antiplatelettherapy
statin
diabetes
bp
pain relief iwth naftidofuryl oxalate - vasodialtor that can alleviate the pain
biggest RF for AAA
smoking
arterial ulcers located where
distal extremities and pressure points, bony promenince.
under 50% carotid stenosis what do you do
antiplatlet therapy
pain starts below the knee what artery occluded
Left femoro-popliteal artery
A 72-year-old man attends for follow-up after his visit complaining of exertional pain in the calves, relieved by rest. The GP suspects the patient has intermittent claudication and orders ankle–brachial pressure index (ABPI) investigations.
The ABPI comes back at 1.4 (normal 0.8–1). Subsequent imaging with Duplex ultrasound confirms the presence of significant anatomical stenoses bilaterally.
Which of the following conditions in the patient’s background is most likely to explain the misleading ABPI?
Diabetes mellitus
An ABPI of greater than 1.3 may suggest the presence of arterial calcification, usually due to diabetes mellitus or end-stage renal failure. In such patients, the ABPI is not a reliable indicator of peripheral artery disease and further investigations (such as toe–brachial pressure indices) are warranted.
further investigations such as toe-brachial pressure indices are needed
difference between chronic, acute and critical limb ischaemia
Acute limb ischaemia is a surgical emergency, caused by a sudden lack of blood flow to the limb. Cx thromboembolism. need RF. Symptoms are the 6Ps: Pain, Pulselessness, Pallor, Paraesthesia, Paralysis, Perishing with cold.
CT angiography is needed to confirm the diagnosis. Urgent surgical assessment is needed to determine the viability of the limb. If the limb is viable, revascularisation procedure (e.g. angioplasty) need to be performed within 4-6 hours of onset to save the limb.
Over this time, or if revascularisation fails, or the limb is deemed non-viable, amputation is the only option
Chronic limb ischaemia presents with cramping pain the lower limbs after walking a certain distance and is relieved by rest. Like with angina, it’s brought on by increased oxygen demand of the myocytes that cannot be met, the onset of the pain is predictable (with exercise) and symptoms are relieved by rest. Calf claudication is due to narrowing in the femoral vessels, hence the popliteal, dorsalis pedis and posterior tibial pulses are weaker
Critical limb ischaemia consists of a triad of ischaemic pain at rest (burning pain that is worse at night when the leg is elevated, and relieved by hanging the leg off the bed), arterial ulcers, and gangrene. Critical limb ischaemia is a worsening of chronic limb ischaemia to the point where the limb may receive permanent damage and has all the same risk factors as chronic limb ischaemia
CT angiography is needed to confirm the diagnosis of acute limb ischameia . Urgent surgical assessment is needed to determine the viability of the limb. If the limb is viable what happens revascularisation procedure (e.g. angioplasty) need to be performed within 4-6 hours of onset to save the limb.
if the limb is not viable what happens
revascularisation procedure (e.g. angioplasty) need to be performed within 4-6 hours of onset to save the limb.
and within how long
Over this time, or if revascularisation fails, or the limb is deemed non-viable, amputation is the only option
A 60 year old male complains of worsening cramping pain in his buttocks and legs. He used to be able to walk to the grocery store, but now has to stop intermittently due to pain. He also reports that he has difficulty getting erections these days. His past history is significant for hypertension and hyperlipidaemia.
Examination shows loss of hair and decreased temperature in the lower legs. The femoral pulses are not felt. The genital examination reveals no abnormalities.
Which of the following is the most likely diagnosis?
Aortoiliac artery stenosis
Claudication pain in the buttock and thigh, erectile dysfunction and diminished/absent femoral pulses are hallmark features of aortoiliac artery stenosis, also known as Leriche syndrome.
spinal stenosis sx
Spinal stenosis is caused by progressive narrowing of the spinal canal. It can manifest with cramping pain that typically involves the entire leg and would not cause absent limb pulses. The pain is usually relieved with bending forward, not with rest.
critical limb ischaemia what do patients tend to do
Critical limb ischaemia consists of a triad of ischaemic pain at rest (burning pain that is worse at night when the leg is elevated, and relieved by hanging the leg off the bed), arterial ulcers and gangrene
20 cigareetes a day for a year what pack year hisotry
1pack per year history
what is a saphena varix
A saphena varix is a dilation of the saphenous vein at the saphenofemoral junction (ie. the point where the saphenous vein drains into the femoral vein in the groin). This patient’s lump has several features in keeping with saphena varix: the classic location, bluish tinge, disappearance when lying down and positive cough impulse test. The past medical history of varicose veins also makes this more likely.
is diabetes protective against AAA
yes
chronic limb ischaemia tx
Refer for supervised exercise, clopidogrel 75mg once daily, atorvastatin 80mg
This is the correct answer. The patient presents with clinical features consistent with chronic leg ischaemia. Patients should be considered for 2 hours of supervised exercise per week for 3 months. Cardiovascular risk should be managed with smoking cessation, weight management, high dose statin therapy, antiplatelet therapy (with clopidogrel), and management of blood pressure and diabetes
common cause of acute limb ischaemia
AF
mesothelioma
what other places can it affect
cancer of the serosal services - pleura (lining of the lung) - can also affect pericadium and perineum
first line for superificial thrombophelbitis
NSAIDs. then stockings
PAD when is angio recommended
Percutaneous transluminal angioplasty is only indicated if conservative measures have failed and disease is severe enough to affect the patient’s quality of life, or if the disease is limb-threatening. Angioplasty is indicated with single-segment diseases which can be widened by a balloon
most common cause of aneurysm
artherosclerosis
what do you put between pleura servies with mesolethioma
talkam powder
asbestos related pleural disease
lesion associated with pleural effusion - exudate and blood stained - benign condtions but lead to thickening as an infalmmarty condtio
volume loss
pleural plaques - shows asbestos expsoure but no sx - paches of plaques due to calcfication of areas of pleura due to expsoure looks like fat worms as such
diffuse peural thickening - involves visceral pleura - around ribs, costophrenic angles results in restrictice disease
A 59 year old male comes to the emergency department with severe abdominal and lower back pain. He has a background of type 2 diabetes mellitus and hypertension. He is a lifelong smoker. Observations shows that his pulse rate is 120 beats per min, blood pressure 70/50 mmHg, SpO2 92% on air and temperature of 37.5 degrees Celsius. There are no airway noises and the chest sounds clear. Abdominal examination reveals an expansile and pulsatile mass. His calves are soft and non-tender.
What is the most appropriate initial management?
Fluid resuscitation to bring systolic blood pressure to 90mmHg
This patient’s presentation is typical for ruptured abdominal aortic aneurysms (severe abdominal and lower back pain, tachycardia, hypotension, expansile mass). Immediate fluid resuscitation with 0.9% normal saline to raise blood pressure to 90mmHg (permissive hypotension) is immediate first line treatment to keep vital organs perfused until definitive measures can be done.
get BP up first before procedure
Dilated pampiniform venous plexus
variocele
A 49 year old woman presents to the emergency department with sudden excruciating pain of the left arm associated with numbness while she was doing house chores this morning. There is no previous history of trauma to the arm. On further questioning, she has intermittent episodes of palpitations over the last few weeks.
Examination shows cyanosis to the level of the elbow and her left hand feels cold to touch. The radial and ulnar pulses are absent. She has active range of movement in the hand but the sensation is mildly reduced. Her right upper extremities are normal.
Following initial resuscitation with high flow oxygen, fluids and analgesia, what is the next best step of management?
Intravenous heparin bolus followed by continuous infusion
This patient has an acute ischaemic arm (acute pain, paraesthesia, pallor, cold) likely secondary to arterial embolism. She has minimal sensory loss without any motor deficit, putting her at category 2a- marginally threatened limb according to Rutherford criteria. For patients with category 2a and below, conservative management with prolonged course of heparin may be attempted first.
are people with asbestos related lung disease aviable for compensation
industrial injuries disablement benefit from departments of work and pensions for damages claim
