vascular

Question 1

discuss acute ischaemic limb

Answer 1

sudden decreace in perfusion threatenining viability of the limb.

caused by
embolisation
thrombosis
trauma

S+S: 6P’s
pallour, pain, pulselessness, parasthesia, paralysis, perishingly cold.

categorised as level 1-3

1- still pretty viable- no sensory or motor loss

2a- salvagable if treat soon- somt toe sensory loss, arterial doppler gone

2b- salvegable if done NOW- more sensory loss, some motor loss, no art doppler

3- fucked.

Ix: bloods- lactate for extent of ischaemia

doppler ultrasound
CT angio

Rx: 6 hours will lead to irreversable damage

heparin as soon as practical.

1-2a- conservative- heprain + hope it improved- surg if it doesnt.

2b- embolectomy, thrombolysis (local), bypass,

3- amputate.

once revasced- look for compartment syndrome, and K levels as cells release dead contents.

chronically- prob need some antiplatelet.

Question 2

aortic dissection

Answer 2

a acute onset tearing/ stabbing chest, or back pain. - although can be chronic also.

typical patient is male and in 50s.

other S+S: heart failure, mesenteric/ limb ischaemia, pulse deficit.

RF: connective tissue- marfans/ EDS, hypertension, atherosclerosis, smoking.

type A is ascending aorta.
type b is descending aorta.

Ix: ECG- ST depression, ECHO, CXR, TROP.

Rx: resus as needed

once confirmed, give medical therapy to have heart rate 60bpm
BP 100-120

if aortic regurg is excluded- can give B blockers.

type A- emergency surgery.
type B- complicated- TEVAR surgery
uncomplicated- watch and hope.

most people with type A either die or get surgery quick.

Question 3

carotid artery disease

Answer 3

narrowing of the lumen of the carotid artery

atherosclerosis is the most common cause.

10-15% of all ischaemic strokes are associated with carotid art stenosis.

S+S: commonly asymptomatic.
can have- carotid bruit, TIA, stroke.

Rf: age, smoking, CVS disease

Ix: doppler USS- looks as blood velocities- if inc it is then cateorgerised.

generally categorised as mild (<50%), moderate (50% to 69%), high-grade (70% to 99%)

CT head and neck can also help.

Rx: asymptomatic- aspirin
2’ clopidogrel

asymptomatic and 60% or greater- carotid endartectomy.

if high risk for surgery- stent.

symptomatic- carotid endarterectomy if the ipsilateral carotid stenosis is ≥50%

stent if high risk and less than 65.

all symptomatic pts should recieve high intensity statin therapy.

Question 4

gangrene

Answer 4

complication of necrosis- decay of body tissues resulting from ischaemia, infection or trauma.

infectious (wet)- nec fash + gas gangrene

ischaemia (dry)- arterial/ venous occlusion.

S+S: pain, diminished pulses, crepitus (gas) oedema/ swelling.

RF: Diabetes, atherosclerosis, smoking, drug and alcohol abuse, malignancy, contaminated wounds.

Ix: bloods- leukocytosis
low sodium
cultures

imaging as appropriate.

important to distinguish between the two- one requires surgery immediately- biopsy of the fascia is the only way to tell.

Rx: limb sepsis- amputation in 2 stage process.
level 3 ischaemia- amputation.
aggressive debridement and treatment with ABX

Ischaemic- heparin bolus + continuous infusion.
revascularisation as appropriate.

Question 5

peripheral vascular disease

Answer 5

most commonly caused by atherosclerosis.

mostly asymptomatic.

RF: smoking, hyperlipidaemia, DM, HTN, age, inactivity.

erectile dysfunction can be an early sign. intermittent claudication, diminished pulses, buttock pain when walking.

Ix: ABPI- if less than 0.9 it is indicative of disease.

Rx: aggressive risk factor alteration
manage BP- less than 130
lipids <2.59
hba1c <7

structured exercise program.

aspirin
or
clopidogrel

consider for revascularisation.

Question 6

varicose veins

Answer 6

tortuous dilation of veins– valvular incompetence.

the valves permit flow from deep to superficial systems—> venous hypertension and distension as a result.

98% of varicose veins are primary idiopathic varicose veins

can be due to DVT

risk of varicose veins inc by 1.9% in men and 2.6% in women each year.

RF: prolonged standing, obesity, pregnancy, family history.

usually present due to cosmetic issues., can cause ache, itching, – can ulcer or bleed.

often varicosities occur in the great or short saphenous veins.

Ix: gold standard- duplex ultrasound

Rx: avoid prolonged standing, wt loss, inc exercise

compression stockings (check ABPI)
any ulceration- needs compression therapy.

surgery- if symptoms, skin changes, thrombosis, ulcer.

thermal ablation- fibroses + closes the vein.
foam sclerotherapy- scleroses the vein.
vein ligation- stripping and avulsion.

50% reoccurrence at 10 years.