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Vascular Flashcards

1
Q

Risk Factors for DVT?

A

immobility
recent sx
long haul travel
pregnancy
hormone therapy with oestrogen (COCP or HRT)
malignancy
polycythaemia
SLE
thrombophilia

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2
Q

Examples of thrombophilias?

A

antiphospholipid syndrome
Factor V Leiden
antithrombin deficiency
Protein C or S deficiency
hyperhomocysteinaemia
prothrombin gene variant
activated protein C resistance

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3
Q

Contraindication for compression stockings?

A

Peripheral Arterial Disease

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4
Q

Presentation of DVT?

A

unilateral calf swelling
dilated superficial veins
calf tenderness
oedema
red, hot calf

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5
Q

How to examine for calf swelling in suspected DVT?

A

measure the circumference of the calf 10cm below the tibial tuberosity

> 3cm difference between calves is significant

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6
Q

Components of Wells Score?

A

clinical signs of DVT
tachycardia
recent sx or immobilisation
prev PE or DVT
haemoptysis
malignancy
alt diagnosis less likely than PE

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7
Q

Diagnosis of DVT?

A

d-dimer is non-specific but good rule out test if negative
Doppler US
CTPA if susp of PE

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8
Q

When to repeat negative Doppler US if suspected DVT?

A

repeat after 6-8 days if positive D-dimer and Wells score suggests DVT likely

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9
Q

Initial management of DVT?

A

anticoagulation with apixaban or rivaroxaban
consider catheter-directed thrombolysis in patients with iliofemoral DVT

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10
Q

Long-term management of DVT?

A

DOACs first-line
warfarin (antiphospholipid syndrome)
LMWH (pregnancy)

3 months if ‘provoked’ reversible cause
6 months if ‘unprovoked’ or irreversible cause
3-6 months in active cancer

IVC filter can be used

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11
Q

Virchow’s Triad contributing to thrombosis?

A

stasis of blood flow
endothelial injury
hypercoagulability

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12
Q

Complications of DVT?

A

PE
stroke (if septal defect)
chronic venous insufficiency
venous gangrene

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13
Q

Indications for IVC filter?

A

recurrent PEs despite treatment
contraindication to anticoagulation
if anticoagulation can not be used in major sx

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14
Q

Risks of placing IVC filter?

A

air embolism
arrhythmia
pneumothorax
haemothorax
IVC obstruction
bleeding

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15
Q

What is intermittent claudication?

A

muscular crampy pain brought on by exercise and relieved by rest
caused by increased demand for oxygen during exercise in the context of a reduced blood supply

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16
Q

What is critical limb ischaemia?

A

end-stage of PAD, where there is not enough blood supply for the limb to function normally at rest
typically worse at night
some relief by hanging over the edge of the bed

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17
Q

What is acute limb ischaemia?

A

rapid onset of ischaemia in a limb
due to a thrombus blocking artery

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18
Q

RFs for PAD?

A

Non-modifiable:
age
FHx
male
Modifiable:
smoking
alcohol
diet
obesity
sedentary lifestyle
poor sleep
stress
HTN
cholesterol
DM
prev stroke/MI

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19
Q

6 P’s of acute limb ischaemia?

A

pain
pallor
pulseless
perishing cold
paraesthesia
paralysis

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20
Q

What is Leriche Syndrome?

A

occurs with occlusion in the distal aorta or proximal common iliac artery

triad of:
thigh/buttock claudication
absent femoral pulses
erectile dysfunction

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21
Q

Signs of PAD on examination?

A

skin pallor
cyanosis
dependent rubor
muscle wasting
hair loss
ulcers
gangrene
poor wound healing
reduced temp
reduced sensation
positive Buerger’s test
prolonged cap refill time

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22
Q

What is Buerger’s test?

A

legs up 1 or 2 mins
pallor
hang over side of bed
blue then dark red in PAD
pink in normal

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23
Q

Features of arterial ulcers?

A

caused by ischaemia secondary to a reduced blood supply
smaller
deeper
well-defined borders
‘punched-out’ appearance
occur peripherally (toes, heels)
have reduced bleeding
painful

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24
Q

Investigations in PAD?

A

Hx and exam
ABPI
Duplex US
angiography (CT/MRI)

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25
DDx for PAD?
spinal stenosis osteoarthritis nerve root entrapment e.g., sciatica trauma
26
Interpretation of ABPI results?
0.9-1.2 - normal 0.6-0.9 - mild PAD 0.3-0.6 - moderate PAD <0.3 - critical ischaemia >1.2 - calcified arteries (DM, CKD)
27
Management of intermittent claudication?
conservative (lifestyle changes, smoking cessation) medical (atorvastatin 80mg, clopidogrel 75mg, optimise medical treatment of co-morbidities) surgical (endovascular angioplasty and stenting, endartectomy, bypass sx)
28
Management of critical limb ischaemia?
endovascular angioplasty and stenting endartectomy bypass sx amputation if limb is unsalvageable
29
Management of acute limb ischaemia?
UFH infusion ASAP endovascular thrombolysis endovascular thrombectomy surgical thrombectomy endartectomy bypass sx amputation if limb is unsalvageable
30
Complications of reperfusion in PAD?
reperfusion injury rhabdomyolysis compartment syndrome
31
Causes of acute limb ischaemia?
thrombosis (acute-on-chronic) embolic (AFib, AAA, post-MI) trauma (compartment syndrome)
32
When does irreversible tissue damage occur in acute limb ischaemia?
>6hrs of onset
33
What are varicose veins?
tortuous dilated segments of veins associated with valvular incompetence between the deep and superficial veins
34
Risk Factors for varicose veins?
prolonged standing obesity FHx pregnancy female incr. age DVT
35
Clinical presentation of varicose veins?
heavy or dragging sensation aching itching burning oedema muscle cramps restless leg signs and symptoms of chronic venous insufficiency
36
Special Tests for varicose veins?
Tap test Cough test Trendelenburg's test Perthe's test
37
Management of varicose veins?
conservative (weight loss, elevation) medical (compression stockings, moisturiser) surgical (endothermal ablation, sclerotherapy, stripping)
38
Complications of varicose veins?
prolonged and heavy bleeding post-trauma superficial thrombophlebitis DVT skin changes and ulcers (chronic venous insufficiency)
39
Indications for sx intervention in varicose veins?
symptomatic lower limb skin changes venous ulcers superficial thrombophlebitis
40
Gold standard investigation for varicose veins?
Duplex US
41
What is Buerger Disease?
aka thromboangiitis obliterans inflammatory condition that causes thrombus formation in small and medium arteries affects the peripheries
42
Presentation of Buerger Disease?
painful, blue discolouration to fingers and toes pain worse at night may progress to gangrene corkscrew collaterals are typical finding on angiograms
43
RFs for Buerger's Disease?
smoking!!! male gender 25-35yrs
44
Management of Buerger's Disease?
complete cessation of smoking (cutting down or nicotine replacement not enough) IV iloprost
45
Features of chronic venous insufficiency?
haemosiderin deposition venous eczema lipodermatosclerosis atrophie blanche venous ulcers
46
Management of chronic venous insufficiency?
moisturisers, topical steroids weight loss, elevation, compression stockings antibiotics for infections analgesia for pain wound care for ulcers
47
Complications of chronic venous insufficiency?
recurrent cellulitis chronic pain ulceration DVT secondary lymphoedema varocise veins Marjolin's ulcer
48
Types of skin ulcers?
Arterial ulcers Venous ulcers Pressure ulcers Diabetic foot ulcers
49
Features of venous ulcers?
occur in the gaiter area associated with chronic venous insufficiency changes occur after a minor injury larger more superficial irregular, gently sloping borders more likely to bleed less painful pain relieved by elevation and worsened by lowering
50
Where is the gaiter area?
mid calf to just below medial malleolus
51
Investigations of ulcers?
ABPI Bloods for infection Charcoal swab (cellulitis) Skin biopsy (SCC)
52
Management of arterial ulcers?
treatment of underlying arterial disease no place for debridement or compression
53
Management of venous ulcers?
cleaning, debriding and dressing of wound compression therapy (ABPI first) pentoxifylline orally antibiotics for infection analgesia (avoid NSAIDs)
54
Definition of ulcer?
abnormal breaks in the skin surface or mucous membranes
55
Causes of lymphoedema?
primary (rare, <30) secondary (e.g., post axillary clearance in breast ca)
56
What is Stemmer's sign?
ability to pinch the skin at base of fingers or toes if positive -> lymphoedema?
57
Lymphoedema vs Lipoedema?
Lipoedema spares the feet
58
Management of lymphoedema?
manual lymphatic drainage compression bandages exercises to improve drainage weight loss if overweight lymphaticovenular anastomosis if other treatments fail ***avoid taking blood, inserting cannula or giving injections in lymphoedema limb
59
What is an AAA?
dilatation of the aorta with a diameter >3cm often asymptomatic
60
RFs for AAA?
male incr. age smoking HTN hyperlipidaemia FHx CVD CT disease
61
Definition of an aneurysm?
abnormal dilatation of a blood vessel by >50% of its normal diameter
62
Presentation of AAA?
usually asymptomatic, picked up incidentally or during screening non-specific abdo or back pain pulsatile, expansile mass
63
Diagnosis of AAA?
US CT
64
Management of AAA?
treat reversible RFs surveillance (3-4.4cm yearly, 4.5-5.2cm 3 monthly) elective repair (symptomatic, >5.5cm, growing >1cm per year)
65
Options for Sx repair of AAA?
open repair via laparotomy EVAR (femoral)
66
Presentation of ruptured AAA?
severe abdo pain (may radiate to back) hypotension, tachycardia pulsatile, expansile mass collapse LOC
67
Management of ruptured AAA?
permissive hypotension surgical emergency
68
What is an aortic dissection?
tearing of the intima of the aorta so that blood flows between the intima and the media, creating a false lumen
69
Types of aortic dissection?
Type A - ascending aorta, before brachiocephalic artery Type B - descending aorta, after left subclavian artery
70
RFs for aortic dissection?
hypertension bicuspid aortic valve coarctation of the aorta aortic valve replacement CABG Marfans Ehlers-Danlos PAD RFs
71
Presentation of aortic dissection?
severe, sudden onset 'ripping' or 'tearing' chest pain HTN difference in blood pressure between arms radio-radial delay diastolic murmur chest and abdo pain collapse hypotension late sign
72
Diagnosis of aortic dissection?
ECG CXR CT angiogram MR angiogram
73
Mx of aortic dissection?
surgical emergency analgesia beta blockers (BP) Type A - open surgery Type B - conservative or TEVAR
74
Complications of aortic dissection?
MI stroke paraplegia cardiac tamponade aortic regurgitation death
75
Classification of carotid artery stenosis?
mild (<50%) moderate (50-69%) severe (>70%)
76
Presentation of carotid artery stenosis?
usually asymptomatic diagnosed after TIA or stroke carotid bruit
77
Diagnosis of carotid artery stenosis?
US CT/MR angiogram
78
Mx of carotid artery stenosis?
modify risk factors antiplatelets + statins surgery: carotid endartectomy angioplasty and stenting
79
Complications of carotid endartectomy?
stroke facial nerve damage hypoglossal nerve damage glossopharyngeal nerve damage recurrent laryngeal nerve damage
80
Symptoms of unruptured AAA?
back pain acute limb ischaemia secondary to embolus from aneurysm sac buttock claudication/Leriche syndrome GI bleed secondary to aorto-enteric fistula
81
Complications of AAA repair?
Early: death haemorrhage MI arrhythmias heart failure bowel ischaemia abdominal compartment syndrome atelectasis, ARDs endoleak renal dysfunction limb ischaemia Late: graft infection graft limb occlusion aortoenteric fistula endoleak
82
Rutherford-Fontaine Classification of Limb Ischaemia?
I - asymptomatic IIa - intermittent claudication >200m IIb - intermittent claudication <200m III - rest pain IV - tissue loss (gangrene, ulcers, necrosis)
83
DDx for PAD?
spinal stenosis osteoarthritis nerve root entrapment (sciatica) trauma
84
Differentiating spinal stenosis from PAD?
PAD improves on rest, independent of posture spinal stenosis improves with sitting down PAD worse going up a hill, spinal stenosis worse going down
85
Compartments of the lower limb?
anterior lateral deep posterior superficial posterior
86
What is Trendelenburg's test for varicose veins?
used to find what level the valve defect is raise affected leg so that blood drains out apply tourniquet around the thigh and get patient to stand if the varicose veins do not refill, the level of the defect is above the tourniquet, if they do, it's below repeat until they don't refill
87
Anatomical landmark for dorsalis pedis pulse?
lateral to the extensor hallucis tendon within 1cm of the navicular bone
88
Anatomical landmark for posterior tibial pulse?
immediately posterior to the medial malleolus
89
Anatomical landmark for the popliteal pulse?
in the popliteal fossa, between the heads of gastrocnemius muscles
90
Anatomical location for the femoral pulse?
below the inguinal ligament midway between the ASIS and the pubic tubercle

Surgery (10 decks)

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