Vascular Flashcards
whats peripheral arterial disease
narrowing of arteries that supply the limbs and peripheries so reducing the blood supply to these areas
usually refers to the lower limbs that results in claudication symtpoms
what is included in peripheral arterial disease
intermittent claudication
critical liumb ischemia= end stage of peripheral arterial disease
acute limb ischmia = like an mi where clot stuck and ishcmeia acutely
whats intermittent claudication and s and s
symotom of ichemia in a limb
athleroscleoriss in the limb and so not enough blood supply to the limb on exertion
occurs on exertion and relived by rest
crampy achy pain
calf, buttocks, thighs
whats critical limb ischemia
end stage of peripheral arterial disease
have inadequate blood supply to limb to allow it to function normally even at rest
pain at rest- burning pain worse at nigh (no gravity to help)
ulcers that dont heal
gangrene
6ps:
pain
pallor
perishingly cold
pulsless parlysis
paraestheisa
have sign risk of loosing a limb
what acute limb ischemia
due to peripheral arterial disease
have a rapid onset of ischemia in a limb
typically due to a thombus - clot - blocking the arterial supplying distal lumb
like a thrombus blocking a coronary artery causing MI
whats atheleroscleorisis and the end results of athelroscleorisis
fatty depsits in arterial walls
medium- large arteries
get hardening and stiffening of blood vessel
casued by chroninc inflammatio and acitvation of immune system and depisots of lipids casuing a fibrous atherloscelrotic plaque
plaques cause:
stiffenng => ht, strain on heart
stenoiss => reduced blood flow- angina
plaque rupture=> thrombus block distal vessel= acs
resutls in
angina
MI
TIA
stroke
peripheral arterial disease
chronic mesenteric ischemia
risk factors atherloscleorisis
non modifiable= male, age, fam hist
modifiable=
obestiy
smoking
alcohol
sedentary-no exercise
diet- high fats low veg
stress
poor sleep
medical co morbitis increase risk of getting athelroscletisis if not managed well
hypertesnion
CKD
inflammatory conditions =RA
diabtetes
atypical antipsycotic medication
pt has claducation in thigh/buttock
male impotence
absent femoral pulse
leriche syndrome =
occulsion of dital arota/proximal common iliac artery
signs of periheral arterial disease
look for risk factors (atherloesclorisis risk factors cus this casues peripheral arterial disease) :
tar staining
xanthomata
cvd:
missing limb/digit already
midline sternomty - cabg
scar on calf- cabg
wakenss- stroke
signs of PAD:
weak peirpheral pulses - use hand hel[ doppler to asess properly
hair loss
cyanosisi
pallor
ulcers
dependent rubor - deep red limb whe. below body
poor wound healing
muscle wasting
gangrene
low skin temp
prlonged capillary refil time
changes in beurgers test
decreased snesation
whats beurgers test
Buerger’s test is used to assess for peripheral arterial disease in the leg. There are two parts to the test.
The first part involves the patient lying on their back (supine). Lift the patient’s legs to an angle of 45 degrees at the hip. Hold them there for 1-2 minutes, looking for pallor. Pallor indicates the arterial supply is not adequate to overcome gravity, suggesting peripheral arterial disease. Buerger’s angle refers to the angle at which the leg is pale due to inadequate blood supply. For example, a Buerger’s angle of 30 degrees means that the legs go pale when lifted to 30 degrees.
The second part involves sitting the patient up with their legs hanging over the side of the bed. Blood will flow back into the legs assisted by gravity. In a healthy patient, the legs will remain a normal pink colour. In a patient with peripheral arterial disease, they will go:
Blue initially, as the ischaemic tissue deoxygenates the blood
Dark red after a short time, due to vasodilation in response to the waste products of anaerobic respiration
The dark red colour is referred to as rubor.
peropheral arterial disease can get leg ulcers due to skin and tossue not having adequate blood suplly to heal opropelry
how differntiate between venous and arterial leg ulcers
arterial:
smaller
deeper
well defined
punched out apperance
distally- toes, dorsum foot
reduced bleeding
painful - more
pale = decreased blood to it
pain worse at night- horozontally
oain worse on elevation and improve when lower leg
venous;
larger
more superficial
occur after a minory injury to leg
irregular and sloping bprder
gaiter area of leg
less painful
occur with other signs of chronic venous insufficiency : haemosiderin staining, venous ezcema, lipodermatoslcerosis (inverted champagne bottle legs)
more likly to bleed
pain relieved on elevation and worse lowering elg
when do arterial ulcers occur
ishcemia 2dry to inadequate blood supply
when do venous ulcers occur
impaired drainage and pooling of blood in legs
deep
painful
quite small
ulcer
type?
arterial
investigations an do for peripheral arterial disease
ankle brachail pressure index
duplex US
angiogrpahy- contrast involved
how do you do ankle brachial pressure index and values mean
measure ankle systolic BP
brachial systolic bp using dopple probe
ankle/brachial systolic BP = ratio
eg. 80/100=0.8
0.9-1.3 normal
0.6-0.9= mild pAD
0.3-0.6=mod - severe PAD
less 0.3= severe PAD- critical limb ischemia
above 1.3= calcification- hard to compress bv- in diabtetics
management of intermitent claudication
modify risk facotrs -
lifestyle changes
exercise training - w;aking till hurt the rest
meds:
atorvastatin 80mg
clopidogrel 75mg OD(aspirin if clopiudogrel CI)
naftiodrofuryl oxalate- 5HT R antagonist= peripheral vasodialtor
surgical:
endarvascualr angioplasty and stening
endarectomy = remove plaque
bypass surgery
magament critical limb ischemia
urgent referal vascualr team
analgesia
urgent revascualrisation:
endovascualr angiop;asty and steniting
endarterectomy
bypass
amputation
management acute limb ischemia
urgernt referal oncall vascualr team
enovacualr thrombolyisis
endovacualr thromectomy
surgical thromectomy
endaertectomy
bypass
amputation
VTE
dvt and PE
dvt can embolise and cause PE
if atrial septal defect can go into ssytemic and have stroke
risk fctors DVT
stagnation of blood and hypercoagualbility:
immobility
recernt surgery
pregnacy
long haul flight
oestrogen- COCP, HRT
maligancy
polycythaemia
thrombophilia
SLE
what thrombophilias increase risk of VTE
antiphospholid sydnrome
factor V leiden
antithrombin deficiency
protien C or S deficiency
hyperchromocystiameia
prothrombin gene variant
actuvcated protein c resitance
what vte prophylaxis is there
all pt in hosp asses for need
LMWH = enoxaparin
ci= active bleeding, already o anticoagulation
anti-embolic compression stockings
ci= SIGNIFICANT PERIPHERAL ARTERIAL DISEASE
DVT PRESENTATION
unilatral
calf weliing- more 3cm diff is sign= measure 10cm below tibila rubersotiy
dilated superfical veins
tenderness
oedema
colour changes t leg
investigations for vte
inital
diagnostic
wells score
inital= D dimer
diagnostic for dvt= doppler US (if negative and psotive d dimer and wells score re do in 6-8 days)
diagnotic for pe= CTPA (if contrast allergy/renal impairement do VQ scan)
when can d dimer be rasied
sensitive but not specific for vte
also raised in:
PE
DVT
pregancy
heart failure
maligancy
pneumonia
surgery
management inital fir dvt/pe
is susepcted confirmed inital start immediate anticoagulation:
DOAC= apixaban/ rivaroxaban
if dvt in ileofemoral and less tha14 days can maybe do catherter directed thrombolysis
loing term management for dvt/pe
first line for most (including cancer) = DOAC= apixaban, rivaroxaban, edoxaban/ dabigatran
pregnacy first line= LMWH= enoxaparin
antiphospholipid syndrome first line is warfarin- INR aim 2-3
duration=
reversible casue 3months
cancer 3-6 months
uknown casues/ not reversible/ recurrent vte= more than 3 monhts (usulally 6)
then review them all
can use IVC filter if anticoagualtion CI
if unprovocked VTE what can you do for managment after anticoagulation
test for antiphosphlipid syndrome- antbpdies
if forst degree relative has thrombophilia test [t for herediatary thrombophilias
whats varicose veins
distended superficial veins measuring more tha 3mm in diameter
usually in legs
whats dialted bv in skin that are 1-3mm in diameter
reticular veins
whats dilated veins in skin that are less than 1mm in diameter
telangiectasia / thread veins/ spider veins
how do varicose veins develop
incompetnet valves
blood drains down towards gravity and pools in veins and feet
perforating veins connect deep and superficial veins
these valves in these veins become incompetnant and so blood flowd backwards from deep vein into superficial veins and so get dilitation and egorgement
whats signs of chronic venous innufficiecy
skin changes- brown= haemosiderin staining = due to blood pooling in the dital veins, the pressure in veins causes the blood to leak a bit and the hb in the tissues gets broken down to haemosiderin and the haemosiderin gets deposited aorund the shins
venous eczema = the blood pools in dital veins that causes inglammation and so skin becomes dry and inflammed
lipodermatoscleorisis =
skin and soft tissue becomes fibrotic and tight so legs become narrowed and hard
risk facotrs of varicose veins
obesity
long periods standing - ask re occupation
pregnancy
female
fam hist
DVT- damage the valves
increased age
presentation of varicose veins
engorged and dilated superficial veins
can be asymptomatic
heavy dragging feeling
itching
burning
aching
oedema
muscle. cramps
restless leg
may also have signs of chronic venous insufficniecny - skin colour changes and ulcers
investigations for varicose veins
tap test
cough test= thrill at SFT then dilated at SFJ and means saphenous varix
trendelburg test
perthes test
duplex US - SEE EXTENT OF VARIOCSE VEINS SEE FLOW AND VOLUME
Tap test – apply pressure to the saphenofemoral junction (SFJ) and tap the distal varicose vein, feeling for a thrill at the SFJ. A thrill suggests incompetent valves between the varicose vein and the SFJ.
Cough test – apply pressure to the SFJ and ask the patient to cough, feeling for thrills at the SFJ. A thrill suggests a dilated vein at the SFJ (called saphenous varix).
Trendelenburg’s test – with the patient lying down, lift the affected leg to drain the veins completely. Then apply a tourniquet to the thigh and stand the patient up. The tourniquet should prevent the varicose veins from reappearing if it is placed distally to the incompetent valve. If the varicose veins appear, the incompetent valve is below the level of the tourniquet. Repeat the test with the tourniquet at different levels to assess the location of the incompetent valves.
Perthes test – apply a tourniquet to the thigh and ask the patient to pump their calf muscles by performing heel raises whilst standing. If the superficial veins disappear, the deep veins are functioning. Increased dilation of the superficial veins indicates a problem in the deep veins, such as deep vein thrombosis.
managmenet of varicose veins
pregnancy normally go back to normal after delviery
weight loss
physically active
rasie legs when can
compression stockings- once excluded arterial disease using ankle brachial pressure index
endothermal ablation - catheter in and use radiofrequency ablation
sclerotherpay- irritaitng foam injected to casue vein to close
stripping
complciations of treatment of varicose veins
dvt
prlonged/ heavy bleeding after trauma
chronic venous insufficney symptoms
superficial thrombophelbititd = thormbosis and inflammation in superficial veins
what eed check before givng patient compression stockings
dont have peripheral arterial disease = check measuring ankle brachial pressure index
0.9-1.3 normal
whats chronic venous insufficiency
blood doesnt efficiently drain from legs to heart
usually result of damage of valves in the veins
asocaited with varicose veins
what can damage the valves in the veins of legs causing chronic venous insufficiency
dvt
obesity
prolonged stadning
immobility
increased age
presentation of chronic venous insufficency
skin changes in gaiter area:
haemosiderin staining - red/brown discolouration (poolsing blood leaks into tissue hb broken down to haemosidering and deposited in tissues)
lipodermatosclerosis=> harfdening and tigheting of skin and tissue => inverted champagne bottle appearance (chronic infallamtion casues fibrosis of the subcutaenous tissue (infalm of subcutaneous tissue is called panniculitis) )
venous eczema= dry, itchy, scaly, flaky, red, cracked skin (due to chroninc inflammation due to blood pooling)
atrophie blanche = pathes smooth white scar tissue often surrounded by areas of hyperpigemntation
chronic venous insufficency can lead to what
cellulits
pain
poor healing after injury
skin ulcers
managment of chronic venous insufficney
skin healthy:
regular emolients = double base, diprobase, cetraben, oliatum
topical steroids for venous eczema flares
v potent topical steroids for lipodermatoscleorisis flares
monitor and avoid damage
improve venous drainage:
loose weight
active
raise legs when can
compression stockings = once ruled out arterial disease using ankle brachial pressure index
manage complications :
antibiotics for cellulits - when look at patients legs and look like chronic venous insufficeny dont think defo cellulits as bilateral cellulitis is rare and abx wont help chronic venous insufficency so make sure it is actually they also have an ifection- cellulitis
anaglesia for pain
wound care for ulceration
why do arterial ulcers occur
insufficeint blood supply to skin due to periheral arterial disease
why do venous ulcers occur
due to pooling of blood and waste products
secondary to venous insufficency
type of ulcers
diabetic foot ulcers
arterial
venous
pressure
why do diabetic fppt ulcers occur
loos sensation = diabetic neuropahty= dont feel foot as well so less likely relasie injuried it/ tight fitting shoes
large nad small bv are damaged so impairs blood supply for wound healing
high blood glcuose, high immune system, autonomic neuropahty=> ulceration and poor wound healing
complication of diabetic foot ulcers
osteomyeloitis
why do pressure ulcers occur and how to prevent them
pt with reduce mobility- prlonged pressure on certain area
skin breaks down due to:
decreased blood supply and locaslised ischemia
decreased lymph drainagae
abdmoal change to shape of tissues
prevetn:
risk asses= waterflow score
regular turns
special inflating matress
regular ski checks
protective dressings and creasm
investigfations for leg ulcers
ankle bracial pressure index= do for arterial and venous as need excluse not arterial when treating = assesing for arterial disease
bloods= inflammation, co morbidits- hba1c(diabaeted), albumin (malnutirtion)
swabs- infection
skin biospy- suspect other eg. skin cancer
management arterial ulcers
urgent referal to vascualr
consider surgical revascualrisation
same as periheral arterial disease - meds, lifestule etc.
not using compression or debridment
managment for venous ulcers
may refer to:
vascualr if mixed
tissue viability clinics if not healing. complex
dermatology suspect other
pain cliic
diabetic ulcer services
district nurses/ tissue viability nurses: clean wound. debridement(remove dead tissue0 dressing
compression- once exclude not arterial using ABPI
pentoxifylline orally - not licensed
abx
anaglesia - nsaids make it worse
what medication ca make venous ulcers worse
NSAIDs
whats lymohoedema
chronic condition
caused bu impaired lymphatic draiange of area
lymph system drains excess fkuid and so if impaired get swoellen with protein rich fluid
taking blood/cannula/ bp/ injection on pt with lymphoedema need think what
prone to infection on area of lymphoeema so dont do injection/cannulation/bloods/bp on this area
whats primary lymphoeodema
rare, genti consition
usuallt present before 30s
faulty development of lymph system
whats seondary lymphoedema
anothe conditions that affects the lymph system
eg. breast cancer have removal of axially nodes leads to pt developing lymphoedema in the arm
whats a differential for lymphodema and signs of it
lipodema = abmnorla build up of fat tissue in the limbs- often legs
women more
feet are spared (unline lymphoedema)
pain
psyco distress
swollen right leg
foot spared
lipoedema
swollen left leg
what can casues be
lymphoedema
something blocking blood vessels so blood cant drain out eg. lymoh tumour
investigfations for lymphoedema
stemmers sign = 2nd toe or mid finger - pinch the skin and if lift and tent negative. if cant lift and tent skin the postive and suggestive of lymphoedmea
limb volume calcuations- water displacement
circumferntial
perometry
bioelectric impedance spectrometry - electric current passed
lymphoscintography= nuclear med scan- see structure of lymphatics
stemmers sign postive
sugegstive of what
lymohedema
managment of lymphoedema
specialist
manual lymohatic drainage- massage
weight loss
exercises
compression bandages
lymphaticovenular anastamosisis- connect lymph and nearby veins so can drain via veibs
abx if celluitis develops
cbt / anti depresants
pt been recent to africa
swollen left leg
akin thickened
elephatiasis
what lymphatic filariasis
infectious disease
caused by parastic worms spread by mosquitos
worms live in lyphatics and damage it => severe lymphoedema
asscociated with thickening and fibrosis of skin= elephantiasis
whats an abdominal aortic aneurysm
dilation of abdominal aorta more than 3cm
risk facotros of AAA
men
increase age
smoking
hypertension
hyperlipidameia
cvd
fam hist
what age and who can have screeing for aaa
what scan is it
all men 65 can have US scan to screen for asymptomatic AAA
women over 70 who have riskfacotrs- cvd, copd, hypertension, hyperlipidameia, fam hist, smoking
presntaion of AAA
most are asymptomatic
seen on screening/ investigatios for other things- ct, abdo xray, us
non specific abdo pain
pulsatile and expansile mass in abdo on palpation
investigations for AAA
intial US
detail in pic and to help for elective surgery - ct angiogram
classiication of aaa
under 3cm normal
3-4.4 cm = small aneursym
4.5-5.4cm= medium aneursy
5.5 above = large aneurysm
management of aaa
if aorta diameteter over 3cm - refer to vasuclar
if aorta over 5.5 cm need urgent referal to vascualr
decrease risk of progression of aaa by:
stop smoking
healthy diet and exercise
optomise rx of ht, diabetes, hyperlipidaemia
follow up scan to monitor:
yearly if small- 3cm-4.4cm
3 monthly if med size 4.5-5.4cm
elective repair - do for:
all over 5.5cm diameter
symtpoamtic
diameter grow more than 1cm per year
repiar via grafting - lapartomy or by endovascualr aneurysm repiar via stent into the femoral a
when do pt need iinvolve dvla they have an aaa
anyeusrm over 6cm then inform dvla
stop driving if aneurysm over 6.5cm
stricter if drive heavy vehicle
when to do elecetive repiar of aaa
symtpomatic
over 5.5.cm diameter
grows diameter more than1cm/year
presentaion of ruptured aaa
severe abdo pain- can radiate to back/groin
haemodynamically unstable - low bp, high hr
pulsatile and exapnsile mass in abdo on palpation
collapse
loss consiousness
treat ruptured aaa
mortalilty 80%
surgical emergency
if haemodynamically ustbale straight to thetatre (not even imaging)
if haemodynamically stable can do ct angiogram to diagnose/exlcude ruptured aaa
permissive hypotension- allow a lower than normal bp when giving fluid resus as thoght as increasing bp can increase blood loss
pt has severe abdo pain
radiates to groin
they then collapse
what could it be
ruputured aaa
whats aortic dissection
tear of inner layer of aorta
blood enters between intima and media creating false lumen
type A aortic dissection
start in asecinding aorta
before brachiaocephalic artery
typeB aortic dissection
start in descinding aorta
after left subclavian artery
type 1 aortic dissection
begin in ascending aorta and involves at least the arch of aorta if not whole of it
type 2 aortic dissection
beigns in asceinding aorta and is isolated to the asceidning aorta
type 3a aortic dissection
begins in descending aorta
onoly involves section above diaphragm
type 3b aortic dissection
begins in descending aorta and involes the aorta belo the diaphrgam
risk facrtors aortic dissection
same peripheral arterial disease
male
increase age
hypertension!= big one - sudden increase in bp(trigger) can cause dissection eg. weight lifting/ cocaine use
amoking
poor diet
low activity
high cholesterol
bicuspid aortic valve
coarctation of aorta
aortic valve repalcement
cabg
marfans syndrome
ehlers danlos syndrome = both are connective tissue disorders
diagnose aortic dissection
inital use ct angiogram - relativel quick
in ed can use bedisde us - quick and easy
ecg and cxr to exclude other casues - but can have mi and aortic dissection
mri angiogram- more detail but takes longer
pt has stemi on ecg but suspect aortic dissection
what need think
can have them both occur
can have mi and also aortic dissection so need be careful cus if got aortic dissection and treat the mi with thrombolysis that casues progression of dissection worse
presentation of aortic dissection
suden onset, tearing/ripping severe chest pain
can have no chest pain
chest pain and abdominal pain together
back pain- descinding aorta
chest pain - ascending aorta
pain may migrate
hypertension
diffin arm bp= more 20mmhg sign
radial pulse defecit = once is decreased/absent/ doesnt match apex beat
diastolic murmur
focal nuerological defecit-paraestheisa/ weaknes
syncope
hypotension as progresses
managemnt of aortic dissection
surgical emergency
need control bp and heart rate as want to decrease stress on aortic walls= Bblockers
type A= open surgery and graft
type B = thoracic endovascualr aortic reapia- TEVAR- and stent graft inserted- may need open if complex
complications of aortic dissection
mi
stroke
paraplegia- sensation/motor in legs
cardiac tamponade
death
aortic valve regurgitation
man 60
ht
presents with sudden onset tearing chest pain
aortic dissection
carotid arterty stenosis
narrowing of carotid arteires
casue of carotid stenosis
usually secondary to athleroscleorsis
whats the risk of carotid arteru stensois
plaque can break off- embolus and go to brain and casue embolic stroke
risk facvtors carotid artery stneosis
same as peripheral arterial disease ad athlerosclerosis
increase age
male
smoke
ht
poor diet
high cholesterol
decreased pysical activity
patients who have a tia/ stroke will be investigated for carotid artery stneosis how
carotid us
classification of caarotid artery stenosis
mild= less than 50% redcution in diameter
moderate= 50-69% reduction in daimeter
severe= 70% or more reduction in diameter
presentation of carotid artery stenosis
usually asymptoamtic
usually found after stroke/tia
may hear carotid bruit =whooshing over stenosis during systole
investigfations carotid artery stensois
carotid us - inital
ct /mri angiogram to see better detail beofre surgery
managemnt of carotid artery stenosis
conservcative:
stop smoking
better healthy diet and exercise
manage comorbidities-diabetes, ht
antiplatelets- aspirin, clopidogrel, ticagrelor
lipid lowering= atrovastatin
surgical:
carotid endarterectomy - first line
angioplassty and stening - into femoral artery and balloon and stent
whats the complciations of carotid endaerterectomy
stroke
damage nerve: permenat or tmeporary:
facial nerve= facial weakenss- often marginal mandibular nerve= lower lip drooping
glossopharyngeal nereve=> diff swallowing
recurrent laryngeal nerve=> hoarse voice
hypoglossal nerve=> unilateral tongue paralysis
if pt has carotid artery stneois what other illness think may have
v likely have arterial disease and athlerosclerosis elsewhere in body => at risk of cornary artery disease and MI
whats buerger disease
inflammatory condition that casues thrombus formation in small and medium bv in distal arterial system = hands and feet
antoher name for buerger disease
thromboangittis olbiterans
diagnostic criteria for buerger disease
under 50
no other ahtleroscletorric risk factors other than smoking
presentation of buerger disease
typically men 25-35
painful
blue discolouration of fingertips and tips of toes
pain worse at night
mag progress to ulcers, gangrene and amputation
whats buerger disease very strongly asscoaited with
smoking
what investigations for diangosis do for buerger idsease
mainly clinical diagnosis
can do angiogram- show corkscrew collaterals - new bv that have grown to bypass affected ones
management of buerger disease
main component= stop smoking!!! - completley stop- not enough to reduce or nicotine patches
can give iv iloprost = prostacylin analouge that dialtes bv
risk factros for buerger disease
men
strong association with smoking
