vascular Flashcards
types of skin ulcers
venous
arterial
diabetic foot
pressure
why do you get arterial ulcers
insufficient BS to the skin due to PAD
why do you get venous ulcers
pooling of blood + waste products in the skin secondary to venous insufficiency
Waterlow Score
risk assessment tool for estimating an individual patient’s risk of developing a pressure ulcer
typical arterial ulcers
occur distally (toes/foot dorsum)
PAD - absent pulses, pallor, intermittent claudication
smaller
deeper
well defined borders
punched out appearance
pale colour due to poor BS
less likely to bleed
painful
pain worse at night (lying down)
pain worse on elevating + improved by lowing leg (as gravity helps circulation)
typically venous ulcers
occur in gaiter area (top of foot + bottom of calf muscle)
chronic venous changes - hyperpigmentation, venous eczema, lipodermatosclerosis
often occur after minor leg injury
larger
more superficial
irreg, gently sloping border
more likely to bleed
less painful
pain relieved by elevation + worse on lowering leg
ix for arterial + venous ulcers
Ankle-brachial pressure index (ABPI) - to assess poor arterial flow
blood tests - FBC, CRP, co-morbidities
charcoal swabs if infection suspected
skin biopsy if skin cancer suspected - +2 wk wait
mx arterial ulcers
urgent referral to vascular to consider surgical revascularisation
referral for venous ulcers
refer to:
vascular surgery is suspect mixed venous + arterial
tissue viability / specialist leg ulcer clinic if complex or non-healing
derm if skin cancer
pain clinics
diabetic ulcer services
tx venous ulcers
input from district nurses or tissue viability nurses
cleaning wound, debridement, dressing
COMPRESSION BANDAGING therapy
(stockings are for after they have healed)
pentoxifylline to improve healing (peripheral vasodilator)
abx if infect
analgesia (avoid NSAIDs)
neuropathic ulcer presentation
tingling and numbness over area
on bony prominences + peripheries
deep, calloused + punched out
in poorly controlled diabetic px
Venous thromboembolism (VTE)
blood clot developing in the circulation, secondary to blood stagnation or hypercoagulable states. When a thrombus develops in a deep vein, it is called a deep vein thrombosis (DVT).
RFs VTE
Immobility
Recent surgery
Long haul travel
Pregnancy
Hormone therapy with oestrogen
Malignancy
Polycythaemia
Systemic lupus erythematosus
Thrombophilia
examples of thrombophilias
conditions that predispose patients to develop blood clot
Antiphospholipid syndrome !!
Factor V Leiden
Antithrombin deficiency
Protein C or S deficiency
Hyperhomocysteinaemia
Prothombin gene variant
Activated protein C resistance
VTE prophylaxis
LMWH - enoxaparin
unless CI (active bleeding/existing anticoag)
Anti-embolic compression stockings are also used (CI in PAD)
presentation DVT
unilateral :
Calf or leg swelling
- the calf circumference is measured 10cm below the tibial tuberosity. >3cm is significant.
Dilated superficial veins
Tenderness to the calf (particularly over the site of the deep veins)
Oedema
Colour changes to the leg
Consider a pulmonary embolism (e.g., shortness of breath and chest pain)
dx DVT
Wells score, if:
Likely: perform a leg vein ultrasound
Unlikely: perform a d-dimer, and if positive, perform a leg vein ultrasound
Repeat -ve US scans after 6-8 days if the px has a +ve D-dimer and the Wells score suggests a DVT is likely.
conditions that can cause raised d-dimer
Pneumonia
Malignancy
Heart failure
Surgery
Pregnancy
mx DVT
apixaban or rivaroxaban is the initial anticoagulant
LMWH is main alternative
started asap is suspected + delay in scanning
consider catheter-directed thrombolysis in patients with a symptomatic iliofemoral DVT
long term anticoags DVT
DOAC, warfarin or LMWH.
3 months with a reversible cause (then review)
3-6 months in active cancer (then review)
Long-term for unprovoked VTE, recurrent VTE or an irreversible underlying cause (e.g., thrombophilia)
Inferior vena cava filter if already on anticoag / unsuitable for it
features of acute limb ischaemia
Pain
Pallor
Pulseless
Paralysis
Paraesthesia
Perishing cold
initial ix for acute limb-threatening ischaemia
handheld arterial Doppler examination
If Doppler signals are present, an ankle-brachial pressure index (ABI) should also be obtained
what is peripheral arterial disease (PAD)
narrowing of the arteries supplying the limbs and periphery, reducing the BS
usually refers to the lower limbs -> sx of claudication
what is intermittent claudication
sx of ischaemia in a limb occurring during exertion and relieved by rest
crampy achy pain in the calf, thigh or buttock muscles associated with muscle fatigue when walking beyond a certain intensity.
what is critical limb ischaemia
end-stage of peripheral arterial disease, where there is an inadequate supply of blood to a limb to allow it to function normally at rest = signif risk of losing limb
critical limb ischaemia features
pain at rest - worse at night when the leg is raised, as gravity no longer helps pull blood into the foot
non-healing ulcers
gangrene
what is acute limb ischaemia
rapid onset of ischaemia in a limb
-due to a thrombus blocking the arterial supply of a distal limb
what is gangrene
death of the tissue, specifically due to an inadequate blood supply
what is atherosclerosis
affects the medium and large arteries
caused by chronic inflammation + activation of the immune system in the artery wall
Lipids are deposited in the artery wall -> dev of fibrous atheromatous plaques
- stiffening -> HTN + heart strain
- stenosis -> reduced BF
- plaque rupture -> thrombus
Non-modifiable risk factors atherosclerosis
Older age
Family history
Male
modifiable risk factors atherosclerosis
Smoking
Alcohol consumption
Poor diet (high in sugar and trans-fat and low in fruit, vegetables and omega 3s)
Low exercise / sedentary lifestyle
Obesity
Poor sleep
Stress
Medical Co-Morbidities increasing atherosclerosis risk
Diabetes
Hypertension
Chronic kidney disease
Inflammatory conditions such as rheumatoid arthritis
Atypical antipsychotic medications
end results of atherosclerosis
Angina
Myocardial infarction
Transient ischaemic attack
Stroke
Peripheral arterial disease
Chronic mesenteric ischaemia
what is leriche syndrome
Occlusion in the distal aorta or proximal common iliac artery
triad of leriche syndrome
Thigh/buttock claudication
Absent femoral pulses
Male impotence
signs of CVD
RFs:
Tar staining on the fingers
Xanthomata (yellow cholesterol deposits on the skin)
Signs:
Missing limbs or digits after previous amputations
Midline sternotomy scar (previous CABG)
A scar on the inner calf for saphenous vein harvesting (previous CABG)
Focal weakness suggestive of a previous stroke
signs of arterial disease
Skin pallor
Cyanosis
Dependent rubor (a deep red colour when the limb is lower than the rest of the body)
Muscle wasting
Hair loss
Ulcers
Poor wound healing
Gangrene (breakdown of skin and a dark red/black change in colouration)
what is buerger’s test
used to assess for peripheral arterial disease in the leg
- px supine, raise feet to 45º for 1-2 minutes
- pallor? - which angle
- hang legs down again - blue -> dark red?
mx intermittent Claudication
lifestyle changes
exercise training
medical
- Atorvastatin 80mg
- Clopidogrel 75mg OD (aspirin if clop unsuitable)
- Naftidrofuryl oxalate (5-HT2 receptor antagonist that acts as a peripheral vasodilator)
surgical
- Endovascular angioplasty and stenting
- Endarterectomy – cutting the vessel open and removing the atheromatous plaque
- Bypass surgery – using a graft to bypass the blockage
Mx of Critical Limb Ischaemia
urgent referral to the vascular team
analgesia
Urgent revascularisation can be achieved by:
Endovascular angioplasty and stenting
Endarterectomy
Bypass surgery
Amputation of the limb if it is not possible to restore the blood supply
mx acute limb ischaemia
urgent referral to vascular team
what is chronic venous insufficiency
occurs when blood does not efficiently drain from the legs back to the heart
Usually a result of damage to the valves inside the veins
The damage may occur with age, immobility, obesity, prolonged standing or after a DVT
Often associated with varicose vein
what is venous hypertension
occurs when the pressure inside the veins in the lower extremities increases due to weakened vein valves
blood pools in veins of legs
where are venous ulcers most common
gaiter area - below the knee and above the ankle
what is venous eczema
dry, itchy, flaky, scaly, red, cracked skin caused by a chronic inflammatory response
what is lipodermatosclerosis
hardening and tightening of the skin and tissue beneath the skin
- i.e. subcutaneous fibrosis = panniculitis
->“inverted champagne bottle” appearance
what is atrophie blanche
patches of smooth, porcelain-white scar tissue on the skin, often surrounded by hyperpigmentation
risks of carotid endarterectomy
(incision in the neck, opening the carotid artery and scraping out the plaque)
stroke (around 2%)
injury of nearby nerves:
- Facial nerve injury causes facial weakness
- Glossopharyngeal nerve injury causes swallowing difficulties
- Recurrent laryngeal nerve (a branch of the vagus nerve) injury causes a hoarse voice
- Hypoglossal nerve injury causes unilateral tongue paralysis
what is virchow’s triad
blood stasis
hyper-coagulability
endothelial damage/ vessel wall injury
