Vascular Flashcards
Define intermittent claudication
-> Symptom 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.
Define acute limb ischaemia
- Rapid onset of ischaemia in a limb.
- Either due to thrombus or embolus (secondary to AF)
Define critical limb ischaemia and 3 features
- End-stage of peripheral arterial disease
- Features include 1 or more of :
- Rest pain in foot for >2 wks (pain worse at night, hang it out of bed to ease)
- Ulceration
- Gangrene
Presentation of acute limb ischaemia
6 P’s
- Pain
- Pallor
- Pulseless
- Paralysis
- Paraesthesia (abnormal sensation or “pins and needles”)
- Perishing with cold
What is Leriche syndrome
- Occurs with occlusion in the distal aorta or proximal common iliac artery
- Triad of : Thigh/buttock claudication, absent femoral pulses
and male impotence
Signs of arterial disease on examination
- 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
what test can be done to assess for peripheral arterial disease
-> Buerger’s Test
Investigations for peripheral arterial disease
-> Ankle-brachial pressure index (ABPI)
-> Duplex ultrasound – 1st line
-> Angiography (CT or MRI) – using contrast to highlight the arterial circulation
Stepwise management of intermittent claudication
- Lifestyle changes - stop smoking
- Exercise training
- Medical treatments : atorvostatin, clopidogrel, naftidofuryl oxalate
- Surgical options
what should all patients with PAD be started on ?
- Atorvastatin 80mg
- Clopidogrel
Initial management of acute limb-threatening ischaemia
- Analgesia
- IV unfractionated heparin
- Vascular review
Management of critical limb ischaemia
Urgent revascularisation with :
- Endovascular angioplasty and stenting
- Endarterectomy
- Bypass surgery
- Amputation of the limb if it is not possible to restore the blood supply
Management of acute limb ischaemia
- Endovascular thrombolysis
- Endovascular thrombectomy
- Surgical thrombectomy
- Bypass surgery
- Endarterectomy
- Amputation
Stepwise diagnosis of DVT
- D dimer
- Doppler USS
- CTPA (if PE concerns)
How long is anticoagulation continued for in a DVT
- 3mnths if provoked
- 6 mnths in unprovoked
- 3-6 months in active cancer
Define varicose veins, reticular veins and telangiectasia
- Varicose veins : distended superficial veins >3mm.
- Reticukar veins : dilated blood vessels in skin 1-3mm.
- Telangiectasia : dilated blood vessels in the skin <1mm.
Signs of chronic venous insufficiency
- Brown discolouration to lower legs (haemosiderin)
- Venous eczema
- Lipodermatosclerosis (champagne bottle legs)
Special tests for varicose veins
- Tap test : pressure on SFJ and tap vein, feel trill at SFJ
- Cough test : trill when applying to pressure on SFJ and pt coughs
- Trendelenberg’s test
- Perthes test
Management of varicose veines
- Weight loss, staying active, elevating leg and graduated compression stockings
- Surgical : endothermal ablation, foam sclerotherapy, surgical stripping
RF for varicose veins
- Increasing age
- Female
- Pregnancy
- Obesity
what is chronic venous insufffiency ?
- When blood does not efficiently drain from the legs back to the heart
- Blood pools in the vein causing venous hypertension
what does chronic venous insufficiency result in ?
- Haemosiderin staining (red/brown discolouration of the skin)
- Venous eczema
- Lipodermatosclerosis : hardening and tightening of skin and rissue beneat the skin
- Atrophie blanche : patches of smooth, porcelain-white scar tissue
4 common types of skin ulcers
Venous ulcers
Arterial ulcers
Diabetic foot ulcers
Pressure ulcers
Causes of aterial and venous ulcers
- Arterial ulcers : insufficient blood supply to the skin due to peripheral arterial disease.
- Venous ulcers : due to the pooling of blood and waste products in the skin secondary to venous insufficiency.
Features of arterial ulcers
- Occur distally (toes and heels)
- Associated with PAD : absent pulses, pallor and intermittent claudication
- Smaller and deeper than venous ulcers
- Well defined borders
- Have a “punched-out” appearance
- Pale colour due to poor blood supply
Are less likely to bleed - Painful !
- Pain worse at night (when lying horizontally)
- Pain is worse on elevating and improved by lowering the leg (gravity helps the circulation)-
Features of venous ulcers
- Proximal to medial malleolus
- Associated with chronic venous changes : hyperpigmentation, venous eczema and lipodermatosclerosis
- Occur after a minor injury to the leg
- Larger and more superficial than arterial ulcers
- Irregular, gently sloping border
- More likely to bleed
- Less painful than arterial ulcers
- Have pain relieved by elevation and worse on lowering the leg
Management of arterial ulcers
- Same as PAD : urgent vascular referral
Management of venous ulcers
- Cleaning the wound
- Debridement
- Dressing the wound
- Compression therapy
Defintion and types of lymphoedema
- Impaired lymphatic drainage
- Primary : rare genetic condition, presents befpre 30
- Secondary : a separate condition affects lymphatic drainage (e.g. after breast cancer surgery due to removal of axillary lymph nodes)
Important differential of lymphoedema
- Lipoedema
- This is abnormal build-up of fat
- Spares the feet, ulike in lymphoedema
In what ways can lymphoedema be assessed
- Negative Stemmer’s sign
- Assessing limb volume
- Bioelectric impedance spectrometry to measure volume of fluid in the limb
- Lymphoscintigraphy : to assess structure of lymphatic system
Non surgical management of lymphoedema
-> Massage techniques to manually drain the lymphatic system
-> Compression bandages
-> Specific lymphoedema exercises to improve lymph drainage
-> Weight loss if overweight
-> Good skin care
Surgical management of lymphoedema
Lymphaticovenular anastomosis
what is lymphatic filariasis
- Disease caused by parasitic worms spread by mosquitos causing severe lymphoedema
How is the severity of carotid artery stenosis classified
- Mild – less than 50% reduction in diameter
- Moderate – 50 to 69% reduction in diameter
- Severe – 70% or more reduction in diameter
What may be heard on examination in carotid artery stenosis
Carotid bruit
Diagnosis of carotid artery stenosis
Carotid Ultrasound
Surgical interventions for carotid artery stenosis
- Carotid endarterectomy
- Angioplasty and stenting
Injuries caused by carotid endarterectomy
-> Facial nerve injury causes facial weakness (often the marginal mandibular branch causing drooping of the lower lip)
-> 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 Buerger disease (thromboangiitis obliterans)
- Inflammatory condition causing thrombus formation in distal arterial system (hands and feet)
What are the notable features of buerger disease
- <50 (usually men 25-35)
- NOT having RF for atherosclerosis (other than smoking = strong association)
How does Buerger disease present
- Painful, blue discolouration to the fingertips or tips of toes
- Pain is worse at night
Typical finding on angiograms in buerger’s disease
Corkscrew collaterals = new collateral vessels form to bypass affected arteries
Management of buergers disease
- Stop smoking
- IV iloprost (prostacyclin analogue to dilate blood vessels)
Age of screening for AAA
Males aged 65
AAA screening outcomes
- <3cm = normal
- 3-4.4 = small = rescan 12mnths
- 4.5 - 5.4 = rescan every 3 mnths
- > 5cm = 2wk vascular referral
When will AAA be referred 2wk
- > =5.5cm
- Symptomatic
- Growth of >1cm a year
Management of AAA
Elective endovascular repair (EVAR)
Diagnosis of varicose veins
Venous duplex USS = retrograde venous flow.
First line investigation for PAD
DUplex USS
Interpretation of ABPI in PAD
Looks at SBP in ankle compared to that in arm
> 1.3 - calcification of artery (e.g. DM)
1 : normal
0.6-0.9 : claudication (mild PAD)
0.3-0.6 : rest pain (mod-severe)
<0.3 : impending (critical)
Define superficial thrombophelbitis
Inflammation of a superficial vein associated with a thrombus. Usually long saphenous vein of the leg
when should be measure when suspected superficial thrombophelbitis ?
ABPI to exclude PAD
USS to exlcude DVT
Management of superficial thrombophebitis
- Topical NSAIDS if mild, oral if more severe
- Compression stockings.
Presentation of neuropathic ulcers
- Over plantar surface of metarsal head and plantar surface of hallux
- Common in diabetics
Intermittent claudication affecting the buttock, what vessel
Iliac stenosis
Surgical options for intermittent claudication
- Endovascular angioplasty anfd stenting
- Endarterectomy
- Bypass surgery
