Vascular Flashcards
What is acute limb ischaemia?
Sudden hypoperfusion threatening limb viability < 2 weeks
What are the 6Ps of acute limb ischaemia?
Pain
Pallor
Pulselessness
Poikilothermia
Paralysis
Paraesthesia
Limb initially marble white -> mottles blue/pink = salvageable
Dark, non-blanching mottling = blistering and liquefactions = gangrene = non-salvageable
What are key investigations for acute limb ischaemia?
Doppler ultrasound
ABPI - if pulse present
CT angiogram - best if thrombotic cause
What suggests the cause of acute limb ischaemia is thrombotic over embolic?
Previous claudication with sudden deterioration
Develops within hours to days
Reduced or absent pulses elsewhere in the body
Incomplete ischaemia - presence of collaterals
Palpation of artery = hard, calcified
Widespread evidence of vascular disease
Bruits
What suggests the cause of acute limb ischaemia is embolic rather than thrombotic?
Sudden onset of painful leg < 24 hours
No history of claudication
Complete ischaemia - no collaterals
Evidence of emboli - MI, AF
No evidence of widespread vascular disease
Normal palpation of artery
What is the initial management of acute limb ischaemia?
Analgesia
Oxygen
IV fluids
IV heparin - bolus followed by continued infusion
How does compartment syndrome occur as a complication of revascularisation?
Reperfusion of ischaemic muscle → muscle oedema → swelling due to failure of cellular membrane function and capillary leakage → increase in volume leads to increase compartmental pressure → pressure rises = tissue perfusion decreases
How does reperfusion injury occur as a complication of revascularisation?
Products of cell death released when blood flow to ischaemic limb is restored - can result in rhabdomyolysis, cardiac dysrhythmia, acute kidney injury, ARDS, multi-organ failure and DIC.
Release of myoglobin from damaged muscle cells - reddish/brown urine - lead to AKI
What is the triad of Leriche Syndrome?
- Claudication of the buttocks and thighs
- Impotence erectile dysfunction - due to paralysis of the L1 nerve
- Loss of femoral pulses
At what % of stenosis is normally symptomatic?
> 70%
At which artery site is there occlusion for buttock and hip pain?
Aortoiliac artery
At which artery site is there occlusion for thigh pain?
Aortoiliac or common femoral artery
At which artery site is there occlusion for upper 2/3 of calf pain?
Superficial femoral artery
At which artery site is there occlusion for lower 2/3 of calf pain?
Popliteal artery
At which artery site is there occlusion for foot claudication?
Tibial/peroneal artery
What artery is most commonly affected first in lower limbs?
Superficial femoral artery
Why do symptoms of patients with PAD initially improve/stabilise before they deteriorate again?
Collateral vessels enlarge and develop when blood supply through main vessels are blocked. Ensure adequate blood supply which minimises symptoms.
Eventually collaterals become atherosclerosed and damaged = deterioration and worsening of symptoms
What are symptoms in PAD?
Intermittent claudication
Reduced skin temperature - cold limbs
Reduced hair and nail growth - shiny skin
Weak pulses and loss of sensation
Ischaemic rest pain
Reduced capillary refill
Non-healing ulcerations
Gangrene - dry or wet
What is ischaemic rest pain in PAD?
Associated with critical limb ischaemia
worse when patient is supine and better when hanging leg over bed
What are features of intermittent claudication in PAD?
-Exercise-induced muscle pain - Increased oxygen demand from exercise - unable to meet requirements = ischaemic pain - cramp/weakness
- Most commonly in the calf, thighs, buttocks
- Worse walking uphill or hurrying
- Normally specific, consistent reproducible pain at same distance = claudication distance
- Relieved by rest < 10 minutes
What is the Fontaine classification in PAD?
I - asymptomatic
IIa - mild claudication
IIb - moderate to severe - short distance claudication
III - ischaemic rest pain
IV - ulceration or gangrene
What are the ABPI measurements indicative of?
> 1.2 = Diabetes
0.9 - 1.2 = Normal
< 0.8 = PAD
< 0.5-0.8 - Moderate PAD
< 0.3 = Severe PAD
What is gold standard investigation in PAD?
MR angiography > CT angiography
(duplex ultrasound and ABPI first)
when needing to visualise for revascularisation
What is the conservative management in PAD?
Smoking cessation
Supervised exercise programme
Weight management
Diet
What is the medical management in PAD?
Anti-platelet - clopidogrel 75mg
Atorvastatin 80mg
Diabetic control
HTN control
Should get response within 6 months - 1 year to continue with medical management > surgical
What can medication can be used for pain relief in PAD when revascularisation options are not wanted?
Naftidrofuryl oxalate - vasodilator
Cilostazol
(also when exercise not effective)
What are endovasular revascularisation treatments for PAD?
Percutaneous transluminal angioplasty with balloon or stent
Atherectomy
What are the guidelines of stenosis for eligibility of surgical revasculrisation (bypass)
Aortoiliac stenosis > 10cm
Multifocal lesions
Lesions in common femoral artery
What are endovascular revascularisation treatments in acute limb ischaemia?
Thrombolysis - urokinase, alteplase - intra-arterial
Percutaneous transluminal angioplasty with balloon
Percutaneous mechanical thrombus extraction
What are the indications for endovasular revascularisation treatments in PAD?
Single, short segment uniform occlusions
Aortoiliac and femoropopliteal disease = < 10cm stenosis or if chronic/calcified stenosis <5cm
Also if no autologous vein for graft and life expectancy is less than 2 years
What are indications for surgical bypass in PAD and which vein is normally grafted?
Great saphenous vein
(prosthetic veins carry higher risk of infection)
Stenosis > 10cm
Large, extensive and multi-focal stenosis
and must be medically fit enough to handle surgery
What is the triad of symptoms of critical limb ischaemia?
- Ischaemic rest pain
- Gangrene
- Non-healing wounds/foot and leg ulcers
What are differentials for intermittent claudication?
Nerve root compression - sharp pain radiating down leg
Cauda equina syndrome
Hip arthritis
Spinal stenosis - relieved by flexing forward
Foot and ankle arthritis
Symptomatic Baker’s cyst
Venous obstruction
What is the difference between amputation and disarticulation?
amputation = removal of limb
disarticulation = removal of joint (more energy consumption)
Indications for amputation?
Gangrene - wet or dry
Uncontrolled sepsis of lower limb, necrotising fasciitis
Severe rest pain with no reconstruction option
Paralysis with contractures
Trauma
What are the 2 main complications of amputations?
Phantom limb pain
Wound breakdown - skin infections
Amputation levels:
Below knee - transtibial
Above knee - transfemoral
Above elbow - transhumeral
Congenital - transverse/longitudinal limb deficiency
Stump - residual limb
Difference between prosthesis and orthosis?
Prosthesis - artificial substitute or replacement of part of the body
Orthosis - device externally applied to body segment to improve
What are the K activity levels: K0-K4
K0 - Non ambulatory - bed bound
K1 - Limited to transfers or limited household ambulator
K2 - Unlimited household but limited community ambulator
K3 - Unlimited community ambulator
K4 - High energy activities - sports, work
Rehab timeline post amputation?
1 week - weight bearing on other limb between parallel bars
10 days - walk with pneumatic walking aid
3 weeks - trial of temporary prosthesis, final fitting of the artificial limb must await shaping and firming of the stump
-Once stump healed
- Elasticated compression stump socks fitted to shrink stump to an acceptable size for fitting for prosthesis
- Limb fitting usually delayed until >6/52 post-op to allow stump oedema to subside
What is Buerger’s Disease - Thromboangiitis obliterans?
Non-atherosclerotic, inflammatory vasculitis - segmental occlusions of small and medium sized arteries - typically in hands and feet
cigarette smoking - direct endothelial cell toxicity by tobacco + hereditary susceptibility
(Young males who smoke, Mediterranean and Middle Eastern origin)
What is the management of Buerger’s disease?
Smoking cessation
Nifedipine - vasodilate to improve blood flow
Escalate if turned into critical limb ischaemia
Presentation of Buerger’s disease?
Ischaemia of extremities - positive Allen test
Cold sensitivity in hands - raynauds
Severe pain, even at rest + night - neural involvement
Chronic ulceration of toes, feet, fingers - can lead to gangrene
Superficial thrombophlebitis
Wrist and ankle pulses usually absent - but brachial and popliteal pulses palpable
What is seen on arterial duplex and angiography in Buerger’s Disease?
Corkscrew collaterals are dilated vasa vasorum of the occluded main artery (Martorell’s sign)
Normal non-atherosclerotic proximal arteries and shows occluded distal small and medium-sized vessels
What is the guideline for aneurysm screening?
Single abdominal ultrasound for males 65+
< 3cm - discharged and no further action
3-4.4cm - rescan every 12 months
4.5-5.4cm - rescan every 3 months
> 5.5cm - 2 week referral to surgeon
What are the 3 separate criteria for 2 week referral to a vascular surgeon considering aneursyms?
If symptomatic
If grown > 1cm in a year
If > 5.5cm
What is the most common site for an AAA?
Between renal and inferior mesenteric arteries
Risk factors for AAA?
Atherosclerosis - mainly cause AAA
Hypertension - mostly associated with aneurysms of ascending aorta
Marfan Syndrome - defective synthesis of fibrillin
Ehlers-Danlos Syndrome - defective type III collagen synthesis
Vitamin C Deficiency - altered collagen cross-linking
Trauma
Infections - mycotic aneurysms - syphilis
Vasculitis
Congenital - berry aneurysms in circle of willis
What are the 2 main forms of an aneurysm?
Fusiform - symmetrical bulging on both walls of artery
Saccular - only one side of wall bulges outward (more likely to be false)
True aneurysm = dilation of all 3 tunica layers
What is a false aneurysm and how can it occur?
Defect in vascular wall - accumulation of blood within tunica media and adventitia layers
- risk of thrombosis
- common at radial, femoral, anastomotic site - where doctors make holes
How can syphilis cause an aneurysm?
Syphilis causes inflammation of vasa vasorum
Ischaemic injury of aortic media and aneurysmal dilation
Four pathophysiological ways infection can lead to mycotic aneurysms?
- Embolisation of septic thrombus, (usually as complication of IE = secondary mycotic aneurysm)
- Extension of an adjacent suppurative process
- Circulating organisms directly infecting the arterial wall
- Infection of prosthetic grafts = infected anastomotic aneurysms
Pathogenesis of vascular wall compromise leading to aneurysm formation?
- Poor quality of the vascular wall and connective tissue (Marfans, Ehlers-Danlos, Vitamin C deficiency)
- Altered balance of collagen degradation and synthesis is altered (Local inflammatory infiltrates → production of destructive proteolytic enzymes )
- Vascular wall is weakened through loss of smooth muscle cells (HTN or atherosclerosis)
What 4 ways can aneurysms cause symptoms?
- expansion - compression on adjacent structures
- rupture
- distal embolisation
- thrombosis
How does atherosclerosis cause aneurysms?
Atherosclerotic plaque in the intima compressed the underlying media → compromises nutrient and waste diffusion from the vascular lumen into the arterial wall → ischaemia - media undergoes degeneration and necrosis → arterial wall weakness and consequent thinning
What environmental changes can increase risk of rupture of an aneurysm?
Low atmospheric pressure
Colder weather
Symptoms in AAA
Pain - chest, belly, flanks, back, groin
Pulsatile abdominal mass
Blue toe syndrome - clot
Claudication
Acute limb ischaemia
Symptoms in ruptured AAA?
Severe, central abdominal pain radiating to back
Sudden cardiovascular collapse - shock, hypotension, tachycardia
Pulsatile abdominal mass
What are the anatomical requirements of an aneurysm for EVAR?
- Good iliac access - latent, diameter, toruosity
- Neck of aneurysm - infrarenal
- Aneurysm shape - cylindrical > conical/angulated
- Aneurysm size 15<30
What are patient factors when deciding open repair over EVAR for aneurysm repair?
If patient is medically fit enough to handle open surgery.
More invasive, risks and longer recovery
What are complications of EVAR?
Contrast and radiation toxicity
Wound haemotoma, infection, damage to access vessels
Endoleaks
Likely to need secondary intervention in the future
Rupture
What are the 5 types of endoleaks?
- Inadequate anastamoses - leak between attachement site
- Retroleak - aneurysm sac filling via branch vessel
- Leak through defect in graft fabric
- Graft wall porosity
- Endotension - not actual leak - sac expansion > 5mm
Acute initial management of ruptured AAA?
ABCDE
BP control - to reduce bleed (DO NOT give fluids, permissive hypotension at 80-100 systolic)
Pain control
Major haemorrhage protocol
- 2 units of packed red cells O negative
- 2 units FFP
- Cryoprecipitate
- Tranexamic acid
Immediate vascular review - take for CT
What are 4 mechanisms of physiological survival from ruptured AAA?
Rupture into retro-peritoneum which tamponades the leak
Intense vasoconstriction of nonessential circulatory beds
Patient develops intensely pro-thrombotic state
Blood pressure drops limiting blood loss - permissive hypotension
What are the driving restrictions for aneurysms in a normal car?
<6cm - continue as normal
6-6.4cm - must notify DVLA
>6.5cm - must stop driving
What are driving restrictions for bus/lorry drivers within aneurysms?
<5.5cm - must notify DVLA
>5.5cm - must stop driving
Management of small aneurysms?
Pharmacology
- Antiplatelet
- Statin
- Treatment of blood pressure
Smoking cessation
Surveillance
Management of large aneurysms?
Whilst waiting for 2 week referral to surgeons
No driving if > 6.5cm
No strenuous exercise
Keep BP low
Indications for surgery of popliteal aneurysm?
Asymptomatic
- Diameter > 2-3 cm
- Significant lining thrombus
Symptomatic
- Thrombosis - causing acute limb ischaemia
- Distal embolisation - chronic limb ischaemia or blue toe syndrome
- DVT - from compression of popliteal vein
What surgery is done in popliteal aneurysms?
Popliteal artery bypass graft with aneurysm exclusion
- Ligated above and below to exclude from circulation → femoro-popliteal bypass performed to restore blood flow to the foot
- Using long saphenous vein
Risks of popliteal aneurysms?
Distal embolisation and acute thrombosis
Can compress the popliteal vein and present as DVT
Complications of thoracic aortic aneurysms?
- Compress SVC - Superior vena cava syndrome
- Aortic valve dilation and regurgitation
- Compress recurrent laryngeal nerve and phrenic nerve - hoarseness, diaphragm paralysis, wheezing
What % of popliteal aneurysms are bilateral?
50%
What is a big risk factor for thoracic ascending aortic aneurysms?
Connective tissue disorders - Marfan’s, Ehler’s Danlos
What is an aortic dissection?
Rupute of the intima - allowing blood to leak through between intima and media to create a false lumen
What is type A and type B Stanford Classification of aortic dissections?
Type A - ascending aorta, proximal to left subclavian
Type B - distal to left subclavian, descending aorta
Which Stanford classification of an artery would you get a Radio-radial delay?
Type A
(and difference in BP between arms > 20)
Which Stanford classification of an artery would you get a Radio-femoral delay
Type A and B
What is a complication if the false lumen of an aortic dissection grows too big?
False lumen can narrow and occlude the true lumen of the artery - leading to organ ischaemia
What are 3 further complications from the spread of blood in an aortic dissection?
- Can extend along the aorta retrograde toward the heart - pericardial tamponade
- Rupture through adventitia - massive haemorrhage into mediastinum
- Pressure from false lumen creates a second tear in intima and blood reenters true lumen
What is the DeBakey Classification of aortic dissections?
Type I - originates in ascending aorta, propagates to at least the aortic arch and possibly beyond it distally
Type II - originates in and is confined to the ascending aorta
Type III - originates in descending aorta, rarely extends proximally but will extend distally
What can chest x-ray show in an aortic dissection?
widened mediastinum
Risk factors for aortic dissection?
Hypertension - MAIN
Connective tissue disease e.g. Marfan’s syndrome
Coarctation
Pregnancy
Valvular heart disease
Cocaine/amphetamine use
What can an ECG show in aortic dissection?
Ischaemia - ST elevation, if dissection extends to coronary arteries
What is the management of Type A aortic dissection?
Surgical management - open surgery
BP controlled to 100-120 systolic
What is the management of Type B aortic dissection?
Analgesia
Strict control of BP with IV labetalol
Nitroprusside
If complicated - TEVAR to cover entry tear
What are features and associated signs of an arterial ulcer?
Begin as minor wounds that fail to heal
Deep, punched out lesions
Painful
Deep green or back with no granulation tissue - dry
Over lateral side or bony prominences
Associated symptoms - shiny and col skin, local hair loss, reduced pulses, intermittent claudication
How does pooling of blood lead to venous ulcers?
Venous insufficiency → stasis of blood → increase venous pressure → tissue ischaemia → breakdown of tissues
How does venous insufficiency lead to venous ulcers?
Chronic Venous Insufficiency
- Reflux - due to valvular incompetence
- Outflow obstruction
- DVT
Common risk factors of venous ulcers?
- Venous hypertension
- Varicose veins
- Female
- Obesity
- Standing for prolonged periods of time
- Immobility
- Previous DVT
- Pregnant
Features and associated signs of venous ulcers?
- Shallow, Irregular borders
- Yellow, fibrinous exudate
- Mild pain
- Gait area, medial malleolus
Associated with oedema, venous stasis eczema, lipdermatosclerosis, haemosidren deposition
How do you treat venous ulcers?
Compression therapy/stockings - MUST exclude PAD - do ABPI
Leg elevation
Weight reduction
Emollients
Treatment of varicose veins
What is the referral guidelines for venous ulcers?
Refer to vascular specialist if venous leg ulcer not healed after 2 weeks of primary care
Surgery options - debridement, skin grafting, vein transplant
Features of a neuropathic ulcer?
Punched out appearance
Painless
Decreased sensation around area
Commonly over plantar surface of metatarsal head and plantar surface of hallux
Features of venous insufficiency?
- Phlebitis - inflammation in vein
- Thrombophlebitis - clot in vein
- Venous stasis
- Oedema
- Lipodermatosclerosis - upside champagne bottle sign
- Haemosiderin deposition - hyperpigmentation
- Bleeding
- Ulceration
What is the CEAP classification of varicose veins C0-C6?
C0 - No visible or palpable varicose veins
C1 - Telangectasia
C2 - Varicose veins
C3 - Swollen ankle (oedema)
C4 - Skin damage/changes
C5 - Healed venous leg ulcer
C6 - Venous leg ulcer
What are conservative managements of varicose veins?
- Leg elevation
- Weight loss
- Reduce long periods of standing
- Regular exercise, walking
- Manual Compression
- Compression Stocking
What are surgical intervention options for varicose veins?
Radio-frequency ablation - destruction of the endothelium of the vein via high RF
Injection sclerotherapy - injection of sclerosant substance at several points in the vein leading to occlusion
What are indications for surgical referral in vascular surgery?
- Significant pain and symptomatic varicose veins
- Skin changes secondary to chronic venous insufficiency
- Superficial thrombophlebitis
- Venous leg ulcer
What are varicose veins?
Abnormally dilated, tortuous veins > 2mm … normally superficial veins of upper and lower leg
Leads to incompetent venous valves - pressure changes in legs leads to structural defect of vein walls
What changes occur in the venous walls in varicose veins?
Retrograde flow and pooling of blood in the superficial venous system → increased venous pressure leads to…
Marked proliferation of collagen matrix and decreased elastin = distortion and disruption of muscle fibre layers
What is a varicocele and how does it occur?
Varicose veins of scrotal veins…
- Left testicular veins drain blood into left renal vein at 90 degree angle BUT Blood can back up and venous blood pools in testicle → Testicular vein enlarges and becomes tortuous
- Can be a result of compression of the gonadal vein from renal cell carcinoma
What is the presentation of a varicocele?
Looks like a bag of worms - Larger when standing and smaller when lying flat
Ache or heavy feeling within the scrotum
Causes testicular temp to rise - testicular atrophy and poor quality sperm + infertility
(can be treated if causing pain or infertility otherwise fine to leave)
What health condition is thought to be a protective against abdominal aortic aneurysms?
diabetes
?? due to metformin ??
Differentials for ruptured AAA?
- MI
- Dissections
- Perforated duodenal ulcer
- Acute pancreatitis
check amylase to rule out GI differentials
What blood test is helpful to rule out differentials in a ruptured AAA?
Amylase
(increased in pancreatitis)
Differentials for unilateral leg swelling?
- Lymphatic - filariasis, radiation, surgery, compression from tumour
- Trauma - bruise, sprain, tendon rupture
- Infection - cellulitis, erysipelas, osteomyelitis
- Gout
- Venous insufficiency
- DVT
- AV malformation
Differentials for bilateral leg swelling?
- Cardiac - CCF, pericarditis, pulmonary hypertension
- Renal - nephrotic syndrome
- Hepatic - cirrhosis, portal hypertension
- Venous - outflow obstruction
- Endocrine - myxoedema
- Allergic - angio-oedema
- Nutrition - hypoproteinaemia
- Drugs - CCB, steroids, NSAIDs
- Obesity - lipoedema
What is Virchow’s Triad?
- Abnormal vessel wall
- Endothelial cell damage promotes thrombus formation, usually at venous valves
- Abnormal blood flow - stasis
- Poor blood flow and stasis result in valvular damage and promote thrombus formation
- Abnormal coagulability
- Altered amounts of clotting factors - genetics, surgery, medications
What is a paradoxical embolus?
DVT that passes through PFO or cardiac defect to gain access to systemic circulation
What is a saddle embolus?
Occludes both pulmonary arteries
What is a positive Homan’s sign in DVT?
Homan’s sign - calf pain at dorsiflexion of the foot
What are features of Ilio-femoral DVT?
Cyanosed, white, cold, pulseless limb
What is the triad of symptoms in PE?
- Sudden onset SOB
- Pleuritic chest pain
- Haemoptysis
What are features of a massive PE
Shock - hypotension, cyanosis, signs of right heart strain - raised JVP, parasternal heave, loud P2
What are the guidelines of Well’s score for treatment and investigation in DVT?
> 2 = DVT likely → diagnostic imaging
<2 = DVT unlikely → d-dimer
What does a Well’s score of 2+ in DVT indicate and what should be done next?
Likely DVT
- Leg ultrasound within 4 hours
(If US cannot be done within 4 hours - take a D-dimer and give DOAC - if eventually US is negative = stop DOAC)
If US positive = give DOAC 3-6 months
What should be done if an ultrasound scan is negative in suspected DVT and d-dimer is positive?
Stop any DOACs that were started on the interim
Repeat ultrasound in 6-8 days
What does a Well’s Score of <1 indicate and what should be done?
DVT is unlikely
D-dimer should be done first
- If positive - then do an ultrasound within 4 hours
- If negative - consider alternative diagnosis
What are the time frames for DOAC treatment in VTE?
3 months if provoked
6 months if unprovoked
What intervention can be done in recurrent PE?
Inferior vena cava filter
What are ECG changes that can be seen from a pulmonary embolism?
S1Q3T3
large S wave in lead I, large Q wave in lead III, inverted T wave in lead III
rbbb, right axis deviation
sinus tachycardia
What does a Well’s score of 4+ mean in PE and what should be done?
PE likely
- Arrange CTPA
(if delay, give interim DOAC)
- If positive = diagnosed - continue with DOAC treatment
- If negative - consider leg US if DVT suspected
What does a Well’s score of <4 mean in PE and what should be done?
PE is unlikely
- Arrange d-dimer
- If positive - arrange CTPA (if delay - give DOAC)
- If negative - consider alternate diagnosis
What does a Well’s score of <4 mean in PE and what should be done?
PE is unlikely
- Arrange d-dimer
- If positive - arrange CTPA (if delay - give DOAC)
- If negative - consider alternate diagnosis
What modality of choice should be done in suspected PE for pregnant patients or in renal impairment or in iodine allergies?
V/Q scan
What is the PERC score in PE?
Pulmonary Embolism rule out Criteria
(used in patients already low probability)
if all are absent = PE probability < 2%
1. Age<50
2. HR > 100
3. Oxygen sats < 94%
4. Previous DVT, PE
5. Recent surgery or trauma in past 4 weeks
6. Haemoptysis
7. Unilateral leg swelling
8. Oestrogen use
What is the Well’s Score for PE?
Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins) - 3
An alternative diagnosis is less likely than PE - 3
Heart rate > 100 beats per minute - 1.5
Immobilisation for more than 3 days or surgery in the previous 4 weeks - 1.5
Previous DVT/PT - 1.5
Haemoptysis - 1
Malignancy (on treatment, treated in the last 6 months, or palliative) - 1
What is the Well’s Score for DVT?
Active cancer (treatment ongoing, within 6 months, or palliative) - 1
Paralysis, paresis or recent plaster immobilisation of the lower extremities - 1
Recently bedridden for 3 days or more or major surgery within 12 weeks requiring general or regional anaesthesia - 1
Localised tenderness along the distribution of the deep venous system - 1
Entire leg swollen - 1
Calf swelling at least 3 cm larger than asymptomatic side - 1
Pitting oedema confined to the symptomatic leg - 1
Collateral superficial veins (non-varicose) - 1
Previously documented DVT - 1
An alternative diagnosis is at least as likely as DVT: (-2)
what is the treatment for massive PE with circulatory failure / shock?
Thrombolysis
What is post-thrombotic syndrome?
Complication of DVT - increased pressure on vein walls damages valves
Features of post-thrombotic syndrome?
- Aching or cramping
- Feeling of heaviness in the limb
- Swelling
- Discolouration of the skin
- Hardening of the skin
- Varicose veins
- Venous ulcers
Management of Post-thrombotic syndrome?
- Leg elevations
- Compression stockings
- Regular exercise
- Weight loss
- NSAIDs
What are risk factors for post-thrombotic syndrome?
- DVT location: Risk of PTS is higher (two- to threefold) after proximal (especially with involvement of the iliac or common femoral vein) than distal (calf) DVT
- Previous ipsilateral DVT
- Preexisting primary venous insufficiency: up to twofold increased risk of PTS
- Elevated body mass index (BMI): obesity (BMI >30) more than doubles the risk of PTS
- Older age increases the risk of PTS; reported increased risk from 30% to threefold
- Inadequate level of anticoagulation for tx of DVT
What is superficial venous thrombophlebitis and what are common causes in upper and lower limbs?
Inflammation due to a blood clot in a superficial vein.
Lower leg - Varicose veins
Upper limb - IV catheters, infusions
How can DVTs cause superficial venous thrombophlebitis?
DVTs can push and compress on superficial veins - stasis in superficial vein leading to a clot and inflammation
What is the presentation of superficial venous thrombophlebitis?
- Gradual onset
- Redness following line of vein
- Warm and tender, pain
- Distal oedema
- Cyanosis
- Superficial vein dilation
- Swelling
What is the management in superficial venous thrombophlebitis?
- Warm compress
- Elevate legs
- Oral NSAIDs 8-12 days
- Compression stockings - if appropriate ABPI
- LWMH prophylactic dose 30 days
What is subclavian steal syndrome?
Occlusion of the subclavian artery proximal to the vertebral artery
- when the arm is used -> blood is stolen from the posterior circulation (retrograde flow via vertebral artery) = results in decrease in cerebral blood flow
(3x more common on left side)
When are patients with subclavian steal syndrome symptomatic?
Symptomatic mainly when arm is used…
- Dizziness
- Vertigo
- Diplopia
- Dysphagia, dysarthria
- Cortical blindness
- Collapse/Syncope
- Arm claudication - pain or paraesthesia
