Vascular Flashcards
DVT?
thrombus in deep veins of calf / hip
DVT RFx?
- immobility
- recent surgery
- long haul flight
- pregnancy
- cOCP, combined HRT
- tamoxifen, olanzapine
- malignancy
- polycythaemia
- SLE
- thrombophilias
- sickle cell
- hyperviscosity syndrome
VTE prophylaxis
- assess risk
- LMWH - enoxaparin - CI if bleeding / anticoagulated
- Anti-embolic compression stockings - CI in PAD
DVT Px?
- unilateral calf / leg swelling
- pain
- dilated superficial veins
- tender
- oedema
- colour changes
- ask about SOB, pleuritic CP
what are the criteria for the DVT Wells Score?
- Active cancer 1
- Paralysis / immobilisation of lower limbs 1
- Bedridden for 3+ days, or major surgery within 12wks 1
- Localised tenderness 1
- Entire leg swollen 1
- Calf swelling >3cm than other side 1
- Unilateral pitting oedema 1
- Dilated superficial veins 1
- Previous DVT 1
- Alternative dx likely -2
If 1 or less points - DVT unlikely, 2 or more - DVT likely
If DVT likely (2 or more) on Wells?
USS <4hrs
- positive -> DVT Mx
- negative -> D dimer - if positive, stop interim anticoagulants, rpt US 1wk (negative - DVT unlikely)
If US not available <4hrs, D-dimer, start interim DOAC / LMWH, USS <24hrs
IF DVT unlikely (1 or less) on Wells?
D-dimer
- positive -> USS <4hrs, or start anticoagulation and scan <24hrs
- negative - DVT unlikely
DVT Mx?
- Apixaban / rivaroxaban - 1st line / active cancer
- LMWH, followed by dabigatran / edoxaban / warfarin
- renal impairment - LMWH, heparin / warfarin
- APl syndrome - LMWH, warfarin
- ORBIT score
- ?Catheter-directed thrombolysis
- IVC filter
Provoked VTE
- 3mo tx (3-6mo if active cancer)
Unprovoked VTE
- 6mo tx
- APl ABs, Ix for thrombophilias
Peripheral artery disease (PAD)
- narrowing of artery - atherosclerosis / thrombus
Intermittent claudication
- cramping, relieved by rest
Critical limb ischaemia
- claudication at rest, eg nocturnal
Acute limb ischaemia
- sudden decrease in limb ischaemia
Atherosclerosis RFs
- older, FHx, male
- smoking, alcohol, poor diet, low exercise, obesity, poor sleep, stress
- DM, HTN, CKD, RA, atypical antipsychotics
PAD Px?
Intermittent claudication
- aching / burning in legs after walking
- relieved by rest
- not at rest
Critical limb ischaemia
- rest pain
- worse at night
- hang foot off bed to relieve pain
- ulcers, gangrene
PAD Ix?
Pulses, Buerger’s
- FBC…
- ABPI - PAD 0.5-0.9, critical <0.5
- Doppler US
- MR / CT angiography
PAD MX?
- exercise, stop smoking
Medical
- atorvastatin 80mg
- clopidogrel
- Tx comorbidities
- consider naftidrofuryl oxalate
Surgical
- angioplasty +/- stent
- surgical bypass
- endarterectomy
- amputation
acute limb ischaemia - + factors that might suggest thrombus versus embolus?
sudden decrease in arterial perfusion to limb
factors suggesting thrombus
- pre-existing claudication
- reduced pulses in other limb
- vascular disease, eg MI, stroke, TIA
Embolus
- sudden onset pain
- no hx claudication
- embolus source, eg AF, recent MI
- no PAD
- proximal aneurysm, eg abdo / poplitea
Acute limb ischaemia Px
- pale
- Pulseless
- Painful
- Paralysed
- Paraesthesia
- Perishingly cold
Acute limb ischaemia Ix
- US doppler
- CT angio
Acute limb ischaemia Mx
- unfractionated heparin
- IV opioids - analgesia
Vascular mx
- endovascular thrombolysis
- endovascular thrombectomy
- surgical embolectomy / thrombectomy
- angioplasty
- bypass surgery
- amputation
Varicose veins
- dilated, tortuous, superficial veins, commonly found in legs
- incompetent valves
- often in great / small saphenous veins in legs
Varicose veins RFs
- older
- female
- pregnancy
- obesity
- FHx
- prolonged sitting / standing
- Hx of DVT
Varicose veins Px
- varicose veins
- aching, throbbing
- itching
- swelling
- heaviness
varicose vein complications?
- skin changes - varicose eczema, haemosiderin, lipodermatosclerosis, atrophie blanche
- bleeding
- superficial thrombophlebitis
- venous ulceration
- DVT
Varicose veins Ix
- tap test
- cough test
- Trendelenburg test
- Perthes test
- venous duplex US
Varicose veins Mx
- elevate leg, wt loss, exercise
- graduated compression stockings