Vascular Flashcards
Any acutely painful limb that is cold and pale should be treated as what until proven otherwise ?
Acute limb ischaemia
What is acute limb ischaemia classically associated with ?
Pain
Pallor
Pulselessness
Paraesthesia
Perishingly cold
Paralysis
What should be arranged if acute limb ischaemia is suspected ?
CT angiogram
Urgent vascular review
What are some risk factors for acute limb ischaemia ?
AF
HTN
Smoking
DM
Recent MI
Why is acute limb ischaemia a surgical emergency ?
Irreversible tissue damage occurs within 6 hours
What should be started immediately for acute limb ischaemia ?
IV heparin
What should be suspected if there is a sudden onset hot and swollen limb ?
DVT
Where is the pain felt in a DVT ?
Localised to the calf and is associated with calf tenderness and firmness.
What score is used to calculate the likelihood of a DVT ?
Well’s score
If the well’s DVT score is over 1 what investigation should be performed ?
USS Doppler scan
If a DVT is confirmed what is the initial treatment ?
Therapeutic doses of low molecular weight heparin before being swapped to a DOAC.
After initial treatment for a DVT how long should a patient be given a DOAC for ?
3 - 6 months
Other than a DVT what are some other causes of a hot and swollen leg ?
Cellulitis
MSK - related infections
What neurological causes should be assessed for in an acutely painful limb ?
Radiculopathies - typically associated with back pain that radiates to the affected area and is worse on movement.
Multiple sclerosis
Disc herniation
What is the definition of an ulcer ?
An abnormal break in the skin or mucous membrane - usually venous in origin.
Why do people who are less mobile get ulcers ?
They can be caused by prolonged or excessive pressure over a bony prominence leading to skin breakdown and eventual necrosis.
What is a venous ulcer ?
Caused by venous insufficiency
Shallow with irregular borders and a granulating base - normally over the medial malleolus
What are venous ulcers prone to ?
Infection and can present associated with cellulitis.
What is the pathophysiology of venous ulcers ?
Valvular incompetence or venous obstruction leads to impaired venous return with the resultant venous hypertension causing the trapping of WBC in capillaries and the formation of a fibrin cuff around the vessels hindering O2 transport.
There is a release of inflammatory mediators leading to resultant tissue injury, poor healing and necrosis.
What are the risk factors for venous ulcers ?
Increasing age
Pre-existing venous incompetence of history of VTE - varicose veins
Pregnancy
Obesity or physical inactivity
Severe leg injury or trauma
What are some symptoms of venous ulcers ?
Pain
Aching
Itching
Bursting sensation
What may be seen on examination in a venous ulcer ?
Varicose veins
Ankle or leg oedema
Varicose eczema
Haemosiderin skin staining
What investigations are performed for venous ulcers and why?
Usually diagnosis is clinical
Duplex USS
Ankle branchial pressure index - to assess if compression therapy will be suitable
Swab cultures - if infection is suspected
Where is the most common place for venous incompetence ?
Sapheno-femoral junction
Sapheno-popliteal junction
What is the conservative management for venous ulcers ?
Conservative - leg elevation and increased exercise, weight reduction, improved nutrition
What is the mainstay management for venous ulcers?
Abx if wound is infected
Multi component compression bandaging - changed 1-2 times a week ( ABPI must be over 0.6 before bandages are applied.
Emollients
If varicose veins are present when managing venous ulcers what should be performed ?
Endovenous techniques or open surgery to improve venous return to allow better healing of the venous ulcers.
What is an arterial ulcer ?
An ulcer caused by a reduction in arterial blood flow leading to decreased perfusion of the tissues and subsequent poor healing.
How do arterial ulcers appear ?
Small deep lesions with well-defined borders and a necrotic base. Commonly sen distally at sites of trauma and in pressure areas.
What are some risk factors for arterial ulcers ?
Smoking
DM
HTN
Hyperlipidaemia
Increasing age
Obesity
Family history
Physical inactivity
What are the symptoms of an arterial ulcer ?
Intermittent claudication
Critical limb ischaemia - pain at night
Painful and little to no healing
Cold limb
What signs are there for arterial ulcers and what is seen on examination ?
Thickened nails
Necrotic toes
Hair loss
Cold limb
Absent pulses
What investigations are performed for an arterial ulcer ?
Ankle brachial pressure index ( over 0.9 = normal, 0.9-0.8 = mild, 0.8-0.5 = moderate. Less than 0.5 is severe ).
Duplex USS
CT angiography and / or magnetic resonance angiogram
What is the management of critical limb ischaemia ( those with ulcers ) ?
Urgent vascular review
Conservative - lifestyle changes - smoking cessation, weight loss, increased exercise
Medical - statin therapy, Antiplatelet agent ( aspirin or Clopidogrel ), control BP and DM
Surgical - angioplasty or bypass grafting
What is a neuropathic ulcer ?
An ulcer that occurs as a result of peripheral neuropathy. This is due to loss of protective sensation which leads to repetitive stress and unnoticed injuries forming leading to painless ulcers.
What are some risk factors for neuropathic ulcers ?
DM
Vitamin B12 deficiency
Any foot deformity
Concurrent peripheral vascular disease
What are some clinical features of neuropathic ulcers ?
Numbness
Sharp or burning pain
Variable in size and depth
‘Punched out appearance’
Warm feet and good pulses
What investigations should be performed when suspecting a neuropathic ulcer ?
Blood glucose levels ( either random or HbA1c )
Serum B12 levels
ABPI +/- duplex scan
If signs of infection - swab
X-ray if signs of deep infection to assess for osteomyelitis
Assess the extent of the peripheral neuropathy which can be done using touch test or tuning fork
What is the management of a diabetic neuropathic ulcer ?
Refer to a diabetic foot clinic
Conservative - improve diet and exercise
Better diabetic control
Ensure regular chiropody
If signs of infection - ABx
Surgical debridement if ischaemic or necrotic tissue is present
What is the term used to describe the loss of the transverse arch of the foot ?
Rocker bottom sole
What is carotid artery disease ?
A build up of atherosclerotic plaque in one or both common and internal carotid arteries resulting in stenosis or occlusion.
What is the pathophysiology of carotid artery disease ?
A fatty streak forms accumulating a lipid core and formation of a fibrous cap. The turbulent flow at the bifurcation of the carotid artery pre-disposes to this process specifically at this region.
What are some risk factors for carotid artery disease ?
Age - over 65
Smoking
HTN
Hypercholesterolaemia
Obesity
DM
History of CVD
Family history of CVD
How can carotid artery disease present ?
Asymptomatic
However it may present as a focal neurological deficit - TIA or stroke
What can be heard on examination in carotid artery disease ?
Carotid bruit may be auscultated in the neck
Atherosclerosis is the most common for of carotid artery disease. What other pathologies are involved ?
Carotid dissection
Thrombotic occlusion of carotid artery
Vasculitis
What are the initial investigations when a patient is suspecting of having a stroke ?
Urgent non-contrast CT head scan - assess for evidence of infarction
Bloods - FBC, U&E’s, clotting screen, lipid profile, glucose
ECG - assess if AF
When a diagnosis of a stoke or TIA is made what further tests need to be performed ?
Screen the carotids - duplex USS
CT angiography
What is the acute management for a suspected stroke ?
High flow O2
Blood glucose optimisation
Swallowing screen
Ischaemic - IV Alteplase + 300 mg aspirin
Haemorrhagic - correction of any coagulopathy
Thrombectomy is indicated in patients with confirmed acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation on angiography.
What is the long term management of a stroke ?
Anti-platelet therapy long term - aspirin 300mg OD for 2 weeks then clopidogrel 75mg OD
Statin therapy - high dose atorvastatin
Aggressive control of HTN and DM
Smoking cessation
Weight loss and regular exercise
Referral to SALT
Physiotherapy and occupational therapy input is advised
How is a carotid endarterectomy performed ?
It is undertaken to prevent ischaemic stroke.
The procedure involves an incision along the medial aspect of the SCM muscle, dissection through the platysma and then along the border of the SCM. This reveals the internal jugular vein and carotid artery. Clamp the internal carotid, common then external carotid the artery is then dissected, slung and clamped where the artery becomes healthy again. The artery is then opened longitudinally and the plaque is excised.
What are some risks of a carotid endarterectomy ?
Intra-operative - haemorrhage, damage to surrounding structures
Early - pain, bleeding, infection, scarring, seroma, blood clots, stroke and MI
Late - re intervention however low risk
What referral should be made in a patient after an acute non-disabling stroke who has symptomatic carotid stenosis ?
Carotid endarterectomy
What are the complications of a stroke ?
Mortality
Long term dysphagia
Seizures
Ongoing spasticity
Bladder or bowel incontinence
Cognitive decline
What is an aneurysm ?
Defined as an abnormal dilation of a blood vessel by more than 50% of its normal diameter
What is the definition of an abdominal aortic aneurysm ?
A dilatation of the abdominal aorta greater than 3cm.
What are some risk factors for AAA’s ?
Smoking
HTN
Hyperlipidaemia
Family history
Male gender
Increasing age
What are some potential causes of AAA’s ?
Atherosclerosis
Trauma
Infection
Connective tissue disease - marfan’s disease, Ehler’s danlos syndrome
Inflammatory disease
What are the clinical features of an AAA ?
Can be asymptomatic and can be found incidentally or via screening
Abdominal pain
Back or loin pain
Distal embolisation producing limb ischaemia
What can be get on examination in an AAA ?
Pulsatile mass can be felt in the abdomen - above the umbilical level
What is the criteria for having screening for AAA ?
All men in their 65th year
What is used to screen for AAA ?
Abdominal USS
What are some differentials for AAA ?
Renal colic
Diverticulitis
IBD
IBS
GI haemorrhage
Appendicitis
Ovarian torsion
Splenic infarctions
What investigations are there for a suspected AAA ?
USS
Follow up CT scan with contrast is warranted when over 5.5 cm.
What is the management for an AAA less than 5.5cm ?
3cm-4.4cm - yearly USS
4.5cm-5.4cm - monthly USS
Smoking cessation
Improve BP control
Commence statin and aspirin therapy
Weight loss and increased exercise
At what level in the UK should the DVLA be notified about an AAA ?
Any AAA above 6.5cm disqualifies a person from driving
When should surgery be considered for an AAA ?
Larger than 5.5cm in diameter
It is expanding at more than 1cm per year
Symptomatic in a patient who is otherwise fit
Why is an AAA left to 6cm or more prior to repair if the patient is unfit ?
There is significant risk of mortality from an elective repair compared to the risk of mortality if not repaired.
What is the main treatment options for an AAA ?
Surgery
Open repair or endovascular repair
What are the main complications of AAA ?
Ruptures
Retroperitoneal leak
Embolisation
Aortoduodenal fistula
How does an AAA rupture present ?
Abdominal pain
Back pain
Syncope
Vomiting
Pulsatile abdominal mass
Abdominal tenderness
What is the classic triad of a ruptured AAA ?
Flank or back pain
Hypotension
Pulsatile abdominal mass
What is the management of a suspected AAA rupture ?
High flow O2
IV access x2
Urgent bloods - FBC, U&E’s, clotting
Any shock should be managed carefully
Transfer to vascular unit
If unstable - immediate surgery for an open repair
If stable - CT angiogram to determine if the aneurysm is suitable for endovascular repair
Why should shock be treated carefully in an AAA rupture ?
Raising the BP will dislodge any clot and may precipitate further bleeding therefore the aim is to keep the BP less than 100mmHg
What does the wall of an artery consist of ?
Tunica intima
Tunica media
Tunica adventitia
What is acute aortic syndrome ?
Disruption of these layers of the arterial wall and is split into 3 subgroups : aortic dissection, penetrating aortic ulcer and intramural haematoma.
What is an aortic dissection ?
A tear in the intimal layer of the aortic wall causing blood to flow between and splitting apart the tunica intima and media.
Which ways can aortic dissections progress ?
Distally and proximally in both directions from the point of origin.
Anterograde dissections propagate towards the iliac arteries and retrograde dissections propagate towards the aortic valve
What can retrograde aortic dissections cause ?
Can result in prolapses of the aortic valve causing bleeding into the pericardium and causing cardiac tamponade.
What is a penetrating aortic ulcer ?
An ulcer that penetrates the intima and progresses into the media of the artery. This can then progress into intramural haematoma, aortic dissection, perforation or aneurysm formation.
What are some systems used to classify aortic dissections ?
Stanford
DeBakey
What are the risk factors for aortic dissections ?
HTN
Atherosclerotic disease
Male
Connective tissue disorders
Bicuspid aortic valve
What is the characteristic presentation of an acute aortic syndrome ?
Tearing chest pain radiating through the back
Tachycardia
Hypotension
New aortic regurgitation murmur
End organ hypoperfusion - low urine output
What are some differentials for aortic dissection and how would you exclude these ?
MI - crushing and central chest pain with ECG changes showing ischaemia - raised troponin levels
PE - dyspnoea with prominent hypoxia, CTPA scan
Pericarditis - pleuritic chest pain, ECH shows diffuse ST elevation, pericardial rub on auscultation
MSK back pain - no systemic symptoms and tender on palpation
What investigations should be performed for a suspected aortic dissection ?
Baseline bloods - FBC, U&E’s LFT’s, troponin, coagulation
ECG
Imaging - CT angiogram, transoesophogeal ECHO
what is the management of aortic dissections ?
Urgent initial assessment -
Start high flow O2 and gain IV access x2
Fluid resus - cautiously
More serious - surgically - removal of ascending aorta Less serious - medically
Lifelong anti-hypertensives
What are the complications of aortic dissections ?
Aortic rupture
Aortic regurgitation
MI
Cardiac tamponade
Stroke
What is the definition of acute limb ischaemia ?
The sudden decrease in limb perfusion that threatens the viability of the limb. Complete or even partial occlusion of the arterial supply can lead to rapid ischaemia and poor functional outcomes within hours.
What are some causes of acute limb ischaemia ?
Embolisation
Thrombosis in situ
Trauma ( including compartment syndrome)
what are the clinical features of acute limb ischaemia ?
Pain
Pallor
Pulselessness
Paraesthesia
Perishingly cold
Paralysis
What are some investigations for acute limb ischaemia ?
Routine bloods including serum lactate, a thrombophilia screen and a group and save
ECG
Doppler USS followed by
CT angiography
What is the non-operative management of acute limb ischaemia ?
Prolonged course of heparin
Regular assessment - APTT ratio blood tests and clinical review
What is the surgical intervention for acute limb ischaemia ?
If embolic cause :
Embolectomy
Bypass surgery
If thrombotic cause :
Thrombolysis
Angioplasty
Bypass surgery
What does irreversible limb ischaemia require ?
Urgent amputation or a palliative approach
What is the long term management of acute limb ischaemia ?
Regular exercise
Smoking cessation
Weight loss
Anti-platelet agent - low dose aspirin or clopidogrel
Possibly anticoagulant - warfarin or DOAC
OT and physio
What are some complications of acute limb ischaemia ?
Reperfusion syndrome
Compartment syndrome
Possible AKI
What is chronic limb ischaemia ?
A form of peripheral arterial diseases that results in a symptomatic reduced blood supply to the limbs. Typically caused by atherosclerosis
What are some risk factors for chronic limb ischaemia ?
Smoking
DM
HTN
Hyperlipidaemia
Age
Family history
Obesity
What are the clinical features of chronic limb ischaemia ?
Intermittent claudication - as the disease progresses the pain becomes constant even at rest
Cold limb
Ulcers
Absent pulses
What are the stages of chronic limb ischaemia ?
Stage 1 - asymptomatic
Stage 2 - intermittent claudication
Stage 3 - ischaemic rest pain
Stage 4 - ulceration or gangrene or both
What is critical limb threatening ischaemia ?
An advanced form of chronic limb ischaemia and defined as :
- ischaemic rest pain greater than 2 weeks duration
- presence of ischaemic lesions or gangrene
- ABPI less than 0.5
What are some differentials for chronic limb ischaemia ?
Spinal stenosis
Acute limb ischaemia
What are some investigations should be performed when suspecting chronic limb ischaemia ?
ABPI
Doppler
CT angiography
BP, blood glucose, lipid profile and ECG
Thrombophilia screen
What is the medical management of chronic limb ischaemia ?
Smoking cessation, regular exercise and weight reduction
Statin therapy - atorvastatin 80mg
Anti-platelet therapy - Clopidogrel 75mg
Diabetic control
What is the surgical management of chronic limb ischaemia ?
Angioplasty
Bypass grafting
Amputations
What are some complications of chronic limb ischaemia ?
Sepsis
Acute on chronic ischaemia
Amputation
Reduced mobility
What is acute mesenteric ischaemia ?
The sudden decreases in the blood supply to the bowel resulting in bowel ischaemia and if not promptly treated death.
What are some causes of acute mesenteric ischaemia ?
Thrombus in situ
Embolism
Non-occlusive cause
Venous occlusion and congestion
What are some risk factors for acute mesenteric ischaemia ?
Smoking
Hyperlipidaemia
HTN
What are some clinical features of acute mesenteric ischaemia ?
Generalised abdominal pain - diffuse and constant
Nausea and vomiting
Non-specific tenderness
What are some differentials for mesenteric ischaemia ?
Peptic ulcer disease
Bowel perforation
Symptomatic AAA
What investigations should be performed when suspecting acute mesenteric ischaemia ?
ABG
Routine bloods - FBC, U&E’s, clotting, amylase ( to exclude pancreatitis ), group and save
Imaging - CT scan with contrast
What is the initial management of acute mesenteric ischaemia ?
Surgical emergency
Urgent resus
IV fluids + catheter inserted
Broad spectrum ABx
What definitive management is required for acute mesenteric ischaemia ?
Excision of necrotic or non-viable bowel
Revascularisation of the bowel - remove any thrombus
what are the complications of mesenteric ischaemia ?
Bowel necrosis and perforation
Mortality
Short gut syndrome
What is chronic mesenteric ischaemia ?
Reduced blood supply to the bowel which gradually deteriorates over time as a result of atherosclerosis in the coeliac trunk, SMA and / or IMA.
What is the pathophysiology of chronic mesenteric ischaemia ?
Gradual build up of atherosclerotic plaque within the mesenteric vessels narrowing the lumen imparting blood flow resulting in inadequate blood supply to the bowel. Collateral blood supply means that at least 2 of the coeliac, SMA or IMA must be affected for a patient to be symptomatic.
What are the risk factors for chronic mesenteric ischaemia ?
Smoking
HTN
DM
Hypercholesterolaemia
What are some clinical features of chronic mesenteric ischaemia ?
Postprandial pain - 10 mins to 4 hours after eating
Weight loss
Concurrent vascular co-morbidities - previous MI, stroke
Change in bowel habit
Nausea and vomiting
Generalised abdominal tenderness
Abdominal bruits
What investigations are performed when chronic mesenteric ischaemia is suspected ?
Bloods - FBC, U&E’s, LFT’s, magnesium and calcium
Lipid profile
CT angiography
What is the management for chronic mesenteric ischaemia ?
Modify risk factors - smoking cessation, commence statins and anti-platelets
Surgical - mesenteric angioplasty with stenting or open procedures - endartectomy or bypass
what are the complications of chronic mesenteric ischaemia ?
Bowel infarction or malabsorption
CVD
What are varicose veins ?
Tortuous dilated segments of veins associated with valvular incompetence.
What are the risk factors for varicose veins ?
Prolonged standing
Obesity
Pregnancy
Family history
What are the clinical features of varicose veins ?
Cosmetic issues
Aching or itching
What is the gold standard investigation for varicose veins ?
Duplex USS
What is the non-invasive treatment for varicose veins ?
Patient education - avoid prolonged standing, weight loss and increase exercise
Compression stockings
What criteria should be met for surgical treatment of varicose veins ?
Symptomatic
Lower limb changes
Superficial vein thrombosis
Venous leg ulcer
What are the surgical treatment options for varicose veins ?
Vein ligation, stripping and allusion
Foam sclerotherapy
Thermal ablation
What are some complications of untreated varicose veins ?
Worsen over time - skin changes, ulceration, thrombophlebitis or bleeding
What is deep vein insufficiency ?
A chronic disease that can result in significant morbidity. Commonly caused by DVT’s or valvular insufficiency and together with varicose veins it is part of the chronic venous insufficiency.
It is a failure of the venous system, characterised by valvular reflux, venous hypertension and obstruction.
What are the causes of deep venous insufficiency ?
Primary - underlying defect to the vein wall or valvular component ( includes congenital defects and connective tissue disorders.
Secondary - defects occur secondary to damage ( post thrombotic disease, post-phlebitis disease, venous outflow obstruction and trauma )
What are risk factors for deep venous insufficiency ?
Age
Female
Pregnancy
Previous DVT or phlebitis
Obesity
Smoking
Occupation - long periods of standing
Family history
What are some symptoms of deep venous insufficiency ?
Chronically swollen lower limb
Aching
Pruritic
Painful
Claudication
What can be seen on examination in deep venous insufficiency ?
Varicose eczema
Thrombophlebitis
Haemosiderin skin staining
Lipodermatosclerosis - champagne bottle shaped legs
Atrophied blanchie - localised white atophic regions surrounded by dilated capillaries
What are some investigations to perform when suspecting deep venous insufficiency ?
Doppler USS
Routine blood tests - FBC, U&E’s, LFT’s
ECHO
Foot pulses
ABPI
What is the management of deep venous insufficiency ?
Conservative - compression stockings, analgesia, leg elevation
Surgical ( less successful ) - valvuloplasty
What are the complications of deep venous insufficiency ?
Swelling
Recurrent cellulitis
Chronic pain
Ulceration
DVT
Varicose veins
What is hyperhidrosis ?
Sweating in excess of that required for regulation of body temperature
How is sweating controlled ?
It is controlled by the autonomic nervous system.
Increased sympathetic stimulation from thoracolumbar autonomic fibres stimulate the eccrine sweat glands to increase sweat production.
What are some causes of hyperhidrosis ?
Pregnancy
Anxiety
Infections
Malignancy
Endocrine disorders - hyperthyroidism
Medications
In a peripheral vascular examination what is assessed for in general inspection ?
Missing limbs or digits
Scars
Mobility aids
Medications
In a peripheral vascular examination what is assessed for in inspection of the upper limbs ?
Peripheral cyanosis
Peripheral pallor
Tar staining
Xanthomata
Gangrene
What is abnormal when assessing temperature and capillary refill time in a peripheral vascular exam ?
Cool and pale limbs indicate poor arterial perfusion
CRT longer than 2 seconds suggests poor peripheral perfusion
What is radio-radial delay and what could this indicate ?
A loss of synchronicity between the radial pulse on each arm.
Causes - subclavian artery stenosis, aortic dissection
What does a carotid bruit suggest ?
Underlying carotid stenosis
Radiating cardiac murmur - aortic stenosis
In a peripheral vascular examination what is assessed for in abdomen ?
Inspect - any obvious pulsation in the midline of the epigastrium
Palpation - superior to the umbilicus ( any pulsatile mass )
Auscultate - over the aorta, renal arteries to assess for bruits
In a peripheral vascular examination what is assessed for in inspection in the lower limbs ?
Peripheral cyanosis
Peripheral pallor
Ischaemic rubour - dusky redness of the legs
Venous ulcers
Arterial ulcers
Gangrene
Missing digits
Scars
What pulses are felt for in a peripheral vascular exam ?
Femoral pulse
Popliteal pulse
Posterior tibial
Dorsalis pedis
If pulses aren’t palpable what can be used to assess blood flow ?
A Doppler
Where is the femoral pulse felt ?
Mid-inguinal point which is located half way between the ASIS and pubic symphysis
What does a femoral bruit suggest ?
Femoral or iliac stenosis
How is the popliteal pulse palpated ?
Ask patient to lie supine and relax their leg
Flex their knee 30 degrees. Place your thumbs on the tibial tuberosity and place your fingers into the popliteal fossa.
In a peripheral vascular examination what is assessed in the gross peripheral sensation assessment ?
Ask patient to close their eyes and touch their sternum ask them to say yes when they feel it.
Then assess on the legs distal to proximal comparing each side as you go.
What does the bergers test assess for ?
Adequacy of the arterial supply to the leg
How is the Berger’s test performed ?
Place patient supine and stand at the bottom of the bed and raise both of the patients legs to 45 degrees for 1-2 minutes.
Observe the colour
Sit the patient up anal ask them to hang their legs down over the side of the bed
What further assessments and investigations are performed after a peripheral vascular exam ?
BP
Cardiovascular exam
Ankle-brachial pressure index measurement
Upper and lower limb neurological exam
