Vascular Flashcards
Abdominal aortic aneurysm features
- Pulsatile abdominal mass
- Abdominal or back pain = suggests rapid expansion or impending rupture
- Signs of rupture = severe pain, hypotension, shock
- Compression symptoms if very large = early satiety, N&V
Abdominal aortic aneurysm investigations
- USS = investigation of choice for screening/monitoring
- CT angiography = used preoperatively for surgical planning
When are Abdominal aortic aneurysms first screened for, and how often are they monitored?
A single abdo US is offered to all men at age 65, follow up screening depends on the size of the aneurysm:
- 3 - 4.4cm = yearly repeat US
- 4.5 - 5.4 = repeat US every 3 months
- > 5.5 = surgical intervention
Abdominal aortic aneurysm management
Surgery = open repair or endovascular aneurysm repair (EVAR)
This is offered to all pt w/ AAA’s > 5.5 cm, or those with rapidly expansion
Rapid expansion = growing > 5mm in 6 month, or > 10mm over a year
Define Acute limb ischaemia
Severe, symptomatic hypoperfusion of a limb that has been occurring for less that 2 weeks
In reality, surgical intervention is ideally w/in 4-6 hours of presentation
What are the causes of Acute limb ischaemia?
- Thrombosis = atherosclerotic plaque rupture
- Embolism = AF
- Vasospasm = Raynaud’s
- External vascular compromise = trauma, compartment syndrome
Acute limb ischaemia features
6 P’s:
- Pulseless
- Painful
- Pale
- Paralysis
- Perishingly cold
- Paraesthesia
How is Acute limb ischaemia stratified?
Using the Rutherford criteria:
- Stage I = viable limb, arterial signal can be picked up on Doppler
- Stage IIa = mild sensory deficit, no motor deficit
- Stage IIb = severe sensory deficit (more than just toes), mild motor deficit, rest pain - needs immediate treatment whilst limb is still salvageable
- Stage III = severe sensory and motor deficit (non-viable limb)
Acute limb ischaemia management
Thrombotic causes:
- Angiography (stages I-IIa)
- Urgent bypass surgery (stage IIb)
Embolic causes:
- Immediate embolectomy
- If that fails, on-table thrombolysis
If limb is non-viable (stage III) = amputation - keep them nil by mouth and give IV heparin
Define Aneurysm
A localised dilation or expansion of a segment of a blood vessel to more than 50% of its usual diameter
Arterial ulcer features
- Occur distally (heel or toe tips)
- Small and deep
- Punched out margins
- Don’t bleed or ooze
- Painful, elevated by hanging foot off the bed
Venous ulcer features
- Occur in the gaiter area
- Large and shallow
- Sloping edges
- Bleed and ooze
- Painful when leg elevated
- Associated w/ chronic venous changes
What are the features if chronic venous insufficiency
- Haemosiderin deposition = dark patches on the skin
- Lipodermatosclerosis = hardening of the skin
- Atrophie blanche = painful papules which ulcerate and then leave white scars
- Ulcers
Define Buerger’s disease
A non-atherosclerotic vasculitis characterised by the occlusion of small and medium-sized arteries
Strongly linked to smoking
Buerger’s disease features
- Typically presents as acute limb ischaemia w/out a background of peripheral claudication
- Raynaud’s
- Ulcers on fingers and toes often associated w/ gangrene
- Superficial thrombophlebitis
Buerger’s disease investigations
- Arterial Doppler = diminished pulses distal to the occlusion
- Arterial Duplex = Martorell’s sign (corkscrew-shaped collateral vessels)
- CT angiography
Buerger’s disease management
- Smoking cessation
- Vasoactive medication to improve blood flow (nifedipine, iloprost, prostaglandin E1)
- Management of critical limb ischaemia
Carotid artery stenosis management
Conservative (don’t meet surgical criteria):
- Clopidogrel 75mg
- Statins
- BP control
- Smoking cessation
Surgical:
- For pts w/ stenosis of 70 - 99% and symptoms of a stroke or TIA in the corresponding vascular territory
- Surgery = carotid endarterectomy
Define Peripheral arterial disease
Substantial narrowing of the arteries distal to the aortic arch
Peripheral arterial disease features
- Intermittent claudication’s
- Pale, cold leg
- Hair loss
- Ulcers
- Poor wound healing
- Weak/absent peripheral pulses
Peripheral arterial disease investigations
CV assessment = FBC, BP, BM, lipids, ECG
ABPI is diagnostic:
- 0.9 - 1.2 = normal
- 0.8 - 0.9 = mild disease
- 0.5 - 0.8 = moderate disease
- <0.5 = severe disease
Imaging:
- Duplex
- MR arteriogram = in pts who are candidates for revascularisation
- CT arteriogram = in the rest of pts
Define Critical limb ischaemia
Severe peripheral arterial disease with:
- Rest pain
- Tissue loss (ulcers)
- Ankle artery pressure < 50mmHg
Peripheral arterial disease management
Conservative:
- Modify RF
- Smoking cessation
- Refer to supervised exercise program
Medical:
- Clopidogrel 75mg daily
- Atorvastatin 80mg
- Optimise glycaemic control
- Manage HTN
- Analgesia = naftidrofuryl oxalate (vasodilator) can be prescribed if supervised exercise is ineffective, and pt doesn’t want surgery
Surgical:
- Endovascular revascularisation
- Surgical bypass (for larger, extensive stenosis)
- Pts w/ intermittent claudication not resolved by RF modification or exercise should be referred
- Anyone w/ critical limb ischaemia should be urgently referred
Define Superficial thrombophlebitis
The formation of a blood clot in the superficial venous vasculature, often associated w/ inflammation of the vessel walls
Superficial thrombophlebitis features
- Localising pain along the course of the vein
- Itching
- Erythema
- Tenderness and warmth over affected vein
- Palpable, firm, cord-like vein
What causes Superficial thrombophlebitis?
- Varicose veins
- Hormonal contraception
- Pregnancy
- Obesity
- Smoking
- Malignancies
Superficial thrombophlebitis investigations
- Doppler
- D-dimer
Superficial thrombophlebitis management
Compression stockings + NSAIDs
Varicoceles features
- Aching or heavy feeling in the scrotum
- Visibly enlarged or twisting veins in the scrotum
- Testicular atrophy
- Unable to get above the swelling
- Impaired fertility
Varicoceles investigations
- Examination = esp during Valsalva
- Doppler = will show enlarged veins and retrograde blood flow
Varicoceles management
- Watchful waiting = for asymptomatic w/ no fertility issues
- Embolization = blocking the blood flow to the enlarged veins
- Surgery
Define Varicose veins
Dilated and tortuous superficial veins
Develop due to the incompetence of the valves between the deep and superficial venous system, resulting in retrograde flow and pooling of the blood in the superior system
Varicose veins management
Treatment is not required unless symptoms like bleeding, pain, ulceration, thrombophlebitis occur
Conservative:
- Reduction in long periods of standing
- Elevation of LL
- Compression stockings
- WL
- Regular walking to promote venous return
Invasive:
- Radiofrequency ablations = destruction of the vein endothelium using a high-temp catheter
- Endovenous laser ablations
- Injection sclerotherapy = occludes the veins
- Surgery = avulsion therapy or stripping
Define Gangrene
Tissue destruction and necrosis
Can be:
- Wet = due to infections
- Dry = due to ischaemia
What are the causes of Wet Gangrene?
- Necrotising fasciitis
- Gas gangrene = clostridium
- Gangrenous cellulitis
Gangrene features
Wet:
- Poorly demarcated areas of necrosis
- Fever and sepsis
Dry:
- Well demarcated areas of necrosis
- Auto-amputation
Gangrene investigations
Wet:
- FBC, CRP, blood cultures, lactic acid
- XR, US, CT to assess extent of damage
- Tissue biopsy to confirm causative organism
Dry:
- Rule out wet gangrene
- Doppler US or angiography to locate blockage
Gangrene management
Wet:
- Surgical debridement or amputation
- Broad-spectrum IV abx
Dry:
- Surgical debridement or amputation
