Vascular Flashcards
Method to monitor heparin infusion
Activated Partial Prothromboplastin TIme (aPTT)
Goal: maintain range of 1.5-2.5 times the patient’s aPTT baseline value
Measured 6 hourly initially, then 24 hourly once at therapeutic range
Father with history of AAA at 60
Management
20% higher lifetime risk of developing AAA
Ultrasound screening for men and women > 50 years old with family history of AAA
CTA only if AAA present and if surgery needed; not the ideal test.
Which sign of ALI requires immediate surgical treatment?
Key diagnosis of complete ischaemia warranting urgent surgery:
Paralysis
- unable to wiggle toe or fingers
Mortality rate of ruptured AAA
~80%
Urgent surgical repair of AAA when > 5.5cm
50% of PAD patients are asymptomatic; only 10-15% have symptoms.
What is the most common symptoms?
How to diagnose?
Management
Intermittent Claudication (IC)
- Symptomatic pts have worse prognosis.
Diagnosis
1. History, clinical examination
2. Initial diagnostic tool: ankle-brachial index (ABI) measurement
No need for US Doppler/CTA if no endovascular or open surgery planned.
DSA - gold standard for imaging peripheral arteries, but rarely used cause invasive.
Management
- First: smoking cessation if there is
- Surgery
What is helpful as a DVT prophylaxis for a hospitalised patient?
Enoxaparin (Clexane)
- Subcutaneous injection 40mg OD
- Found to prevent VTE without causing serious bleeding complications.
- In patients with renal failure, reduce dose to 20mgOD
Management for newly diagnosed peripheral artery disease
- Antiplatelet medication (aspirin or Clopidogrel) ONLY IF there is risk of CVS disease
- Anticholesterol medication even in the absence of dyslipidaemia
- Antihypertensive (ramipril or any other ACEI or ARBs)
- Supervised exercise program
Pulmonary Embolism or DVT in a Pregnant Woman
Diagnosis
V/Q scan for PE (after confirming CXR is normal)
US Doppler for DVT
ALI by femoral artery occlusion by an embolus
SSX
Management
Pain, pallor, paraesthesia, pulselessness, paralysis, perishing cold
Emergency embolectomy under LA/GA after giving IV Heparin
- reversible within 4 hours
- irreversible after 6 hours
[If CLI, arterial bypass is helpful; Amputation only if presence of irreversible changes]
Non-healing DFU in the presence of PVD
Management
- Conservative management
- If fail —> REVASCULARISATION with angioplasty and endovascular stunting
- most appropriate to restore blood supply - Reduce cardiovascular events: antiHTN + antiplatelet
- If infection, antibiotics
AAA
Initial imaging
When to refer?
Physical examination —> ultrasound
Refer to vascular surgeons when AAA > 5cm
[CTA with contrast for evaluation and if planning elective repair]
4.5 AAA on aortic US
Management?
Repeat US in 12 months
Recommendations:
3 - 3.9cm: every 24 months
4 - 4.5cm: every 12 months
4.6 - 5.0cm: every 6 months
> 5.0cm: every 3 months
When to refer CLI patient to vascular surgeon?
- Rest pain
- Ischaemic ulceration
- Gangrene
- Claudication symptoms – limiting life and work, no improvements with conservative management after 6 months
Revascularisation required to prevent limb loss.
- endovascular angioplasty or stenting
- open surgical reconstruction by bypass or endarterectomy
Internal carotid artery 90% stenosed
Management?
Carotid endarterectomy
- can reduce stroke!!!
Start aspirin after endarterectomy.
Reperfusion Injury
Features?
- Acute renal failure
- Increased CK levels
- Hyperkalaemia
- Myoglobinaemia
- Metabolic acidosis
These metabolic complications can cause death
Varicose Veins
- dilated superficial veins
CEAP Classification is used for grading severity of venous disease
When to refer to Vascular Team?
Guidelines: above CEAP 3 only refer to vascular team.
Oedema = CEAP 3 can manage in GP as treatment is often conservative
- compressive therapy
- diet/smoking cessation etc.
Venous Duplex Ultrasound*
ABI > 0.6 and palpable pulses usually means compressive therapy
