Vascular Flashcards
What is the first line and gold standard for investigating an AAA?
FIrst Line - Abdo US as a screening tool and for follow-up
Gold standard - CT Angiogram for pre-operative planning
What is the management for AAA?
4.5-5.4cm = 3 monthly monitoring via Abdo US
>5.5cm = Referral to Vascular service within two weeks
Open repair or Endovascular Aneurysm Repair (EVAR)
What is the interpretation of the APBI?
Less than 0.5 suggests severe arterial disease.
Compression treatment is contraindicated.
Refer the person urgently for specialist vascular assessment.
Greater than 0.5 to less than 0.8 suggests the presence of arterial disease or mixed arterial/venous disease.
Compression should generally be avoided. However, reduced compression can be used under specialist advice and with strict supervision.
Refer the person for specialist vascular assessment.
Between 0.8 and 1.3 suggests no evidence of significant arterial disease.
Compression may be safely applied in most people.
Greater than 1.3 may suggest the presence of arterial calcification, such as in some people with diabetes, rheumatoid arthritis, systemic vasculitis, atherosclerotic disease, and advanced chronic renal failure.
For values above 1.5, the vessels are likely to be incompressible, and the result cannot be relied on to guide clinical decisions.
What is the treatment for Acute Limb Ischaemia?
For thrombotic causes, management strategies include:
Angiography for incomplete ischaemia. This helps map the occlusion site and plan for intervention. Potential endovascular procedures include angioplasty, thrombectomy, or intra-arterial thrombolysis.
Urgent bypass surgery for complete ischaemia.
For embolic causes:
Urgent surgical embolectomy and if that fails on the table thrombolysis
What is the management of aneurysms?
Observation and Risk Factor Modification: Small, asymptomatic aneurysms may be managed conservatively with close monitoring and aggressive risk factor management. This includes lifestyle changes such as smoking cessation, control of hypertension, maintaining a healthy weight, regular exercise, and a low-sodium diet.
Medical Therapy: Medications such as antihypertensives and statins may be used to reduce the risk of aneurysm expansion and rupture. Anticoagulant or antiplatelet drugs might be prescribed to reduce the risk of thrombosis in specific circumstances.
Surgery: Larger or symptomatic aneurysms, or those that are rapidly increasing in size, are generally managed surgically. The specific surgical approach depends on the location and characteristics of the aneurysm but could include endovascular repair (such as stent placement) or open surgical repair.
Postoperative Care and Surveillance: Following surgical repair, patients require regular surveillance to monitor for complications or the development of new aneurysms. This typically involves imaging studies at regular intervals, with the timing and modality dependent on the specifics of the initial aneurysm and the type of surgical repair.
What are characteristic for arterial ulcers?
Risk Factors of PAD ( Smoking, HTN, DMT2, CAD , hypercholesterolemia )
Symptoms of PAD
Hair loss and shiny appearance of the skin
Location over a bony prominence
Deep and well-delineated appearance
Develop over long period of time
Painful
What is the management of venous ulcers?
Compression ( Bandage or Stocking)
Topical or systemic antibiotics (if there is evidence of infection)
Who is AAA screening for?
Men over 65
What is superficial thrombophlebitis?
Superficial thrombophlebitis is a condition in which a blood clot forms in a vein near the surface of the skin, causing inflammation and tenderness.
What is the criteria for Carotid Endarterectomy for Carotid artery stenosis?
Carotid artery stenosis of 70-99%, with symptoms of an ischemic event such as a stroke or TIA in the corresponding vascular territory.
In the context of TIA or stroke >50% occlusion is indication for the surgery
What is Amaurosis Fugax?
Temporary blockage of blood flow to the retinal arteries ( TIA )
Typically caused by carotid artery stenosis
What is the gold standard for diagnosing Varicose Veins?
Duplex ultrasound
What skin change is seen in Chronic Venous Insuffienency?
Lipodermatosclerosis
Haemosiderin Staning
What are the investigations for suspected Peripheral Arterial Disease?
ABPI
Duplex US
What is Chronic Limb ischaemia and what’s the difference between that and Critical Limb Ischaemia?
Triad of ischaemic pain at rest for more than 2 weeks (burning pain that is worse at night when the leg is elevated, and relieved by hanging the leg off the bed), arterial ulcers and gangrene.
Critical limb ischaemia is a worsening of chronic limb ischaemia to the point where the limb may receive permanent damage and has all the same risk factors as chronic limb ischaemia
Why are patients with Diabetes APBI artificially higher than what would be expected in PAD?
Their arteries are not easily compressible due to calcification
What are the indications for referral with Varicose veins?
Bleeding
Pain
Superficial thrombophlebitis
Ulceration
“severe impact on the quality of life”
What location of a varicose vein is indicative of Long Saphenous Vein Insufficiency?
From the dorsum of the big toe and travels above the medial malleolus and the medial aspect of the thigh before inserting into the femoral vein
What location of a varicose vein is indicative of Short Saphenous Vein Insufficiency?
Originates at the lateral malleolus and winds around to the back of the calf before piercing the fascia at the popliteal fossa.
What is the initial lifestyle management for intermittent claudication?
This mainly revolves around risk factor modification including advice on smoking cessation, weight management and referral to supervised exercise programme
Supervised exercise programme for 3 months ( improves blood supply of collateral vessels)
What is the first line management for chronic limb ischaemia?
Refer for supervised exercise, clopidogrel 75mg once daily, atorvastatin 80mg
Cardiovascular risk should be managed with smoking cessation, weight management
Management of HTN of DMT2
What is the criteria for referral for surgical repair of an AAA?
Patient is symptomatic
Patient is asymptomatic with a AAA >5.5cm
Patient is asymptomatic with a AAA >4.0cm and has grown by >1cm in 1 year
What is the first line imaging for assessing carotid artery stenosis?
Duplex US
What are the risk factors associated with Variscose veins?
Obesity
Family history
Pregnancy
Previous leg injury
Prolonged standing
What implies an acute on chronic picture of Acute Limb Ischaemia?
Progressive pain over days , usually due to an atheroma
What is a Paradoxical embolus?
A paradoxical embolus is rare but common exam favourite. A paradoxical embolus involves a venous thromboembolism such as a DVT which travels via the inferior vena cava to the right atrium and crosses an atrial septal defect to enter the left heart circulation.
When would you refer a patient for EVAR for their AAA if it was smaller than 5.5cm?
If they are symptomatic, as there is a high risk of rupture
What medications should all patients with PAD be on?
Aspirin 80mg
Clopidogrel 75mg
What will a venous duplex US scan show if a patient has varicose veins/ chronic venous insufficiency ?
Retrograde venous flow
What are neuropathic ulcers typically caused by?
Diabetes
Peripheral Neuropathy
Spinal Cord Disease
What is the immediate management of Acute Limb Ischaemia?
Analgesia
IV heparin
A vascular review
Which nerve may be damaged during a carotid endarterectomy?
Hypoglossal nerve
It presents as ipsilateral tongue deviation
How do you remember the Hepatitis B tests?
HbA → antigen means has an infection right now
Anti-HbS → S for safe i.e. vaccinated ( surface antigen from vaccine)
Anti-HbC → C for caught the infection previously ( core antigen from actual infection)
How does a patient’s presentation help you distinguish between if a hernia is incarcerated or strangulated?
Incarcerated - irreducible and PAINLESS
Strangulated - irreducible and PAINFUL due to ischaemia of bowel
What type of cancer is Achalasia a risk factor for?
SCC of oesophagus
How do you differentiate between Familial Adenomatous Polyposis and Lynch Syndrome?
FAP - lots of polyps
Lymph syndrome - poorly differentiated mucinous tumours, few polyps
How can you work out the use of monoclonal antibodies from their names?
The names of monoclonal antibodies often hold clues as to what they do as there is a system for suffixes:
-mab means monoclonal antibody
-xu- or -zu- means the source (chimaeric vs humanised)
The bit before tells us the target: tu for cancers, li for immune system, ci for circulatory
e.g Transtuzumab (tu - cancer, HER2 positive breast cancer)
e.g Inflixumab ( li - immune system e.g complex Crohn’s or Rheumatoid Arthritis)
