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Finals > Vascular > Flashcards

Vascular Flashcards

1
Q

what is peripheral arterial disease?

A

narrowing of the arteries supplying the limbs and periphery, reducing the blood supply to these areas. results in claudication

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2
Q

what is intermittent claudication?

A

symptom of ischaemia in a limb, occurring during exertion and relieved by rest

  • crampy
  • aching in calf, thigh, buttock
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3
Q

what is critical limb ischaemia

A
  • end-stage of peripheral arterial disease
  • inadequate blood supply to limb at rest
  • burning pain worse at night
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4
Q

what is acute limb ischaemia

A
  • rapid onset of ischaemia in a limb
  • due to a thrombus blocking arterial supply
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5
Q

what is atherosclerosis

A

atheromas (fatty deposit) and sclerosis (hardening of BVs)

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6
Q

what do atheromatous plaques cause

A
  • stiffening of artery walls –> hypertension and strain on the heart
  • stenosis –>reduced blood flow
  • plaque rupture –> thrombus and ischaemia
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7
Q

modifiable risk factors for atherosclerosis

A
  • smoking
  • obesity
  • poor diet
  • low exercise
  • smoking
  • stress
  • poor sleep
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8
Q

non-modifiable risk factors for atherosclerosis

A
  • older age
  • FH
  • male
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9
Q

co-morbidities that increase the risk of atherosclerosis

A
  • diabetes
  • hypertension
  • CKD
  • RA
  • atypical antipsychotics
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10
Q

what is the end result of atherosclerosis

A
  • angina
  • myocardial infarction
  • TIA
  • stroke
  • peripheral arterial disease
  • chronic mesenteric ischaemia
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11
Q

what are the features of acute limb ischaemia

A

6Ps
1. Pale
2. Pulseless
3. Pallor
4. Perishingly cold
5. Paralysis
6. Paraesthesia (pins and needles)

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12
Q

What is Leriche syndrome

A

occlusion in the distal aorta or proximal common iliac artery

triad:
1. thigh/buttock claudication
2. absent femoral pulses
3. male impotence

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13
Q

signs of leriche syndrome

A

tar staining
xanthomata

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14
Q

signs of CVD

A
  • missing limbs/digits due to amputations
  • midline sternotomy scar
  • scar on inner calf due to CABG
  • focal weakness (stroke)
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15
Q

signs of arterial disease

A
  • skin pallor
  • cyanosis
  • rubor
  • muscle wasting
  • hair loss
  • ulcers
  • poor wound healing
  • gangrene
  • poor temperature
  • reduced sensation
  • prolonged capillary time
  • changes during Buerger’s
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16
Q

Cause of arterial ulcers

A

caused by ischaemia secondary due to inadequate blood supply

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17
Q

Indications of an arterial ulcer

A
  • smaller
  • deeper
  • well defines borders
  • punched out appearance
  • peripherally (toes)
  • reduced bleeding
  • painful
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18
Q

Cause of venous ulcers

A

impaired drainage and pooling of blood in the legs

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19
Q

Indications of a venous ulcer

A
  • after minor injury to the leg
  • larger
  • superficial
  • irregular borders
  • affect gaiter area of leg
  • less painful
  • other signs of venous insufficiency (haemosiderin staining and venous eczema)
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20
Q

investigations for peripheral arterial disease

A
  • ABPI
  • duplex USS
  • angiography
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21
Q

what is ankle brachial pressure index

A

ratio of systolic BP in the ankle compared to systolic BP in the arm

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22
Q

what do the results of an ABPI show?

A
  • 0.9 – 1.3 normal
  • 0.6 – 0.9 mild peripheral arterial disease
  • 0.3 – 0.6 moderate to severe peripheral arterial disease
  • < 0.3 severe disease to critical ischaemic
  • > 1.3 calcification of arteries (diabetics)
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23
Q

Mx of intermittent caludication

A
  • lifestyle
  • exercise training

Medication
- atorvastatin 80mg
- Clopidogrel 75mg (aspirin if unsuitable)
- Naftidrofuryl oxalate (5-HT2 receptor antagonist that acts as a peripheral vasodilator)

Surgical
- Endovascular angioplasty and stenting
- Endarterectomy: cutting the vessel open and removing the atheromatous plaque
- Bypass surgery: using a graft to bypass the blockage

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24
Q

management of critical limb ischaemia

A
  • urgent referral to vascular
  • analgesia

Urgent revascularisation by:
- Endovascular angioplasty and stenting
- Endarterectomy
- Bypass surgery
- Amputation of the limb if it is not possible to restore the blood supply

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25
Q

Mx of acute limb ischaemia

A
  • urgent referral to vascular
  • Endovascular thrombolysis: inserting a catheter through the arterial system to apply thrombolysis directly into the clot
  • Endovascular thrombectomy: inserting a catheter and removing the thrombus by aspiration or mechanical devices
  • Surgical thrombectomy: cutting open the vessel and removing the thrombus
  • Endarterectomy
  • Bypass surgery
  • Amputation of the limb if unable to restore the blood supply
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26
Q

what is DVT

A

thrombus in the venous circulation

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27
Q

causes of DVT

A

stagnation of blood and hypercoagulable states

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28
Q

where can thrombus emoblise (travel) to?

A

pulmonary arteries

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29
Q

RFs for DVT of PE

A
  • immobility
  • long haul flight
  • recent surgery
  • pregnancy
  • COCP
  • malignancy
  • polycythaemia
  • SLE
  • thrombophilia
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30
Q

what are thrombophilias

A

conditions that predispose pts to developing blood clots

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31
Q

name thrombophilic conditions

A
  • antiphospholipid syndrome
  • Factor V Leiden
  • Antithrombin deficiency
  • Protein C or S deficiency
  • Hyperhomocysteinaemia
  • Prothombin gene variant
  • Activated protein C resistance
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32
Q

what is VTE prophylaxis

A

LMWH
TED stockings

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33
Q

Presentation fo DVT

A
  • unilateral
  • calf/leg swelling
  • dilated superficial veins
  • calf tenderness
  • oedema
  • leg colour changes
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34
Q

system to identify PE/DVT

A

Wells score

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35
Q

How to diagnose DVT/PE

A
  • D dimer
  • doppler USS
  • CTPA or VQ scan
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36
Q

Initial mx of DVT

A

DOAC (apixaban)
- consider cather directed thrombolysis in iliofemoral DVT

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37
Q

long term mx of DVT

A

DOAC, warfarin or LMWH

Usually DOAC- no monitoring
Warfarin- need to check INR. for patients with antiphospholipid syndrome

LMWH- pregnancy

anticoagulate 3 months if identifiable cause
6 months if unidentifiable cause
3-6 months in active cancer

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38
Q

what is an IVC filter

A

device in IVC to filter blood and catch clots
used in recurrent PEs or unsuitable for anticoagulation

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39
Q

what are varicose veins

A

distended superficial veins >3mm diameter

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40
Q

what are reticular veins

A

dilated blood vessels in the skin measuring less than 1-3mm in diameter

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41
Q

what is telagniectasia

A

dilated blood vessels in the skin measuring less than 1mm in diameter. They are also known as spider veins or thread veins

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42
Q

what is haemosiderin

A

Hb in leaking blood is broken down. Gives brown discolouration

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43
Q

what is venous eczema

A

Pooling of blood in the distal tissues results in inflammation. The skin becomes dry, itchy, flaky, scaly, red, cracked skin

44
Q

what is lipodermatosclerosis?

A

skin and soft tissues become fibrotic and tight, causing the lower legs to become narrow and hard. Narrowing causes legs to have inverted champagne bottle appearance

45
Q

RFs for varicose veins

A
  • Increasing age
  • FH
  • Female
  • Pregnancy
  • Obesity
  • Prolonged standing
  • Deep vein thrombosis (causing damage to the valves)
46
Q

presentation of varicose veins

A
  • engorged and dilated superficial leg veins
  • can be asymptomatic
  • Heavy or dragging sensation in the legs
  • Aching
  • Itching
  • Burning
  • Oedema
  • Muscle cramps
  • Restless legs
47
Q

tests for varicose veins

A
  • tap test
  • cough test
  • trendelenburg’s test
  • perthes test
  • duplex USS
48
Q

Mx of varicose veins

A
  • weight loss
  • exercise
  • elevate leg
  • compression stockings

Surgery
- Endothermal ablation: inserting a catheter into the vein to apply radiofrequency ablation
- Sclerotherapy: inject the vein with an irritant foam that causes closure of the vein
- Stripping: veins are ligated and pulled out of the leg

49
Q

complications of varicose veins

A
  • prolonged and heavy bleeding after trauma
  • Superficial thrombophlebitis (thrombosis and inflammation in the superficial veins)
  • DVT
  • All the issues of chronic venous insufficiency (e.g., skin changes and ulcers)
50
Q

what is chronic venous insufficiency

A

when blood does not efficiently drain from elgs back to the heart.
Usually due to valve damage

51
Q

What does pooling of blood in the veins of the leg cause

A

venous hypertension

52
Q

what is haemosiderin staining

A

red/brown discolouration caused by haemoglobin leaking into the skin.

53
Q

what is atrophie blanche

A

patches of smooth, porcelain-white scar tissue on the skin, often surrounded by hyperpigmentation

54
Q

what can chronic venous insufficiency lead to?

A
  • Cellulitis
  • Poor healing after injury
  • Skin ulcers
  • Pain
55
Q

Mx of chronic venous insufficiency

A
  • Keeping the skin healthy (emollients, topical steroids)
  • Improving venous drainage to the legs ( weight loss, elevate legs, TEDs)
  • Managing complications (abx, analgesia, wound care)
56
Q

what are the common types of skin ulcers?

A
  • Venous ulcers
  • Arterial ulcers
  • Diabetic foot ulcers
  • Pressure ulcers
57
Q

Complication of diabetic foot ulcers

A

osteomyelitis

58
Q

what risk assessment tool is used for estimating an individual patient’s risk of developing a pressure ulcer

A

waterlow score

59
Q

Ix for ulcers

A
  • ABPI
  • blood tests
  • charcoal swabs
  • skin biopsy
60
Q

Mx of arterial ulcer

A

same as peripheral arterial disease
- urgent referral to consider surgery

61
Q

Mx of venous ulcers

A
  • refer
  • tissue viability/ulcer clinic
  • derm if cancer suspected
  • pain clinic
  • clean, debride, dress
  • compression
  • prentoxifylline can improve healing
  • abx for infection
  • analgesia (no NSAIDs)
62
Q

what is lymphoedema

A

impaired lymphatic drainage of an area

63
Q

what is primary lymphoedema

A

genetic
presents <30yrs
faulty dvlpt of lymphatic system

64
Q

what is secondary lymphoedema

A

due to separate condition e.g. breast cancer surgery remmoving axillary LNs

65
Q

what is lipoedema

A

abnormal build-up of fat tissue in the limbs, often the legs.
Feet are spared unlike in lymphoedema
F > M
pain

66
Q

how to assess lymphoedema

A
  • Stemmer’s sign: pinch bottom of second toe. if makes ‘tent’ = -ve, if unable = +ve suggestive of lymphoedema
  • measure limb volume
  • bioelectric impedance spectrometry
  • lymphoscintigraphy
67
Q

Mx of lymphoedema

A
  • massage
  • compression bandages
  • specific exercises
  • weight loss
  • good skin care
  • Lymphaticovenular anastomosis
  • abx if cellulitis
  • CBT
68
Q

what is lymphatic filariasis

A
  • infectious disease caused by parasitic worms spread by mosquitos
  • cause severe lymphoedema
  • thickening and fibrosis of skin and tissues (elephantiasis)
69
Q

what is abdominal aortic aneurysm

A

dilation of abdominal aorta diameter >3cm

70
Q

what is the mortality of AAA?

A

80%
often presents when it ruptures

71
Q

RFs for AAA?

A
  • M > F
  • Increased age
  • Smoking
  • Hypertension
  • FH
  • Existing cardiovascular disease
72
Q

Screening for AAA

A

all men at 65 offered USS
if >3cm refer to vascular, urgent if >5.5cm

73
Q

Presentation of AAA

A

most asymptomatic
- non-specific abdo pain
- pulsatile expansile mass in abdo
- incidental on AXR/USS/CT

74
Q

diagnosis of AAA

A

USS- initial
CT angiogram- better

75
Q

classification of AAA

A

dependent on size:
- Normal: < 3cm
- Small aneurysm: 3 – 4.4cm
- Medium aneurysm: 4.5 – 5.4cm
- Large aneurysm: > 5.5cm

76
Q

Mx of AAA

A

treat reversible RFs:
- stop smoking
- diet and exercise
- optimise co-morbidities

Surveillance
- yearly for 3 - 4.4cm
- 3 monthly for 4.5-5.4cm

Elective repair if symptomatic, growing >1cm each year or >5.5cm

77
Q

surgical mx options for AAA

A

insert artifical graft into affected aorta by:
- Open repair via a laparotomy
- Endovascular aneurysm repair (EVAR) using a stent inserted via the femoral arteries

78
Q

DVLA advice if you have AAA

A
  • Inform if aneurysm > 6cm
  • Stop driving if > 6.5cm
  • Stricter rules apply to drivers of heavy vehicles
79
Q

presentation of ruptured AAA

A
  • Severe abdominal pain that may radiate to the back or groin
  • Haemodynamic instability
  • Pulsatile and expansile mass in the abdomen
  • Collapse
  • Loss of consciousness
80
Q

Mx of ruptured AAA

A
  • surgical emergency
  • want lower BP than normal in fluid resuscitation to prevent blood loss
  • CT angio if haemodynamically stable
81
Q

what is aortic dissection

A

break or tear forms in the inner layer of the aorta, allowing blood to flow between the layers of the wall of the aorta

82
Q

what are the layers of the aorta?

A

intima, media and adventitia
in dissection blood is between intima and media

83
Q

how to classify aortic dissection?

A

Stanford system OR
DeBakey system

84
Q

where does aortic dissection normally affect?

A
  • ascending aorta and aortic arch but can affect any part of the aorta
  • right lateral area of the ascending aorta is the most common site of a tear of the intima layer, as this is under the most stress from blood exiting the heart
85
Q

what is the Stanford system?

A
  • A: ascending aorta before brachiocephalic artery
  • B: descending aorta after the left subclavian artery
86
Q

What is the DeBakey system?

A
  • Type I: begins in the ascending aorta and involves at least the aortic arch, if not the whole aorta
  • Type II: only ascending aorta
  • Type IIIa: begins in the descending aorta and involves only the section above the diaphragm
  • Type IIIb: begins in the descending aorta and involves the aorta below the diaphragm
87
Q

RFs for aortic dissection

A

HYPERTENSION
+ same as peripheral arterial disease
- age
- Male
- smoking
- hypertension
- poor diet
- raised cholesterol

88
Q

conditions/procedures that increase risk of dissection

A
  • Bicuspid aortic valve
  • Coarctation of the aorta
  • Aortic valve replacement
  • Coronary artery bypass graft (CABG)
89
Q

Conditions that affect connective tissue that can increase risk of dissection

A
  • Ehlers Danlos syndrome
  • Marfan’s syndrome
90
Q

Presentation of aortic dissection

A
  • sudden onset, severe, “ripping” or “tearing” chest pain
  • hypertension
  • difference in BP in arms
  • radial pulse deficit
  • diastolic murmnur
  • chest + abdo pain
  • syncope
  • hypotension as dissection progresses
91
Q

how to diagnose aortic dissection?

A
  • ECG and CXR to exclude other causes
  • CT angiogram
  • MR angiogram
92
Q

Mx of aortic dissection

A
  • analgesia
  • beta blocker to control HR/BP

Surgical emergency
- type A: open surgery midline sternotomy, artificial graft
- type B: TEVAR with a catheter

93
Q

complications of aortic dissection

A
  • MI
  • Stroke
  • Paraplegia (motor or sensory impairment in the legs)
  • Cardiac tamponade
  • Aortic valve regurgitation
  • Death
94
Q

what is carotid artery stenosis

A

narrowing of the carotid arteries in the neck, usually secondary to atherosclerosis

95
Q

risk of carotid artery stenosis?

A

plaque breaking away and becoming an embolus, travelling to the brain and causing an embolic stroke.

96
Q

RF for carotid artery stenosis?

A
  • age
  • male sex
  • smoking
  • hypertension
  • poor diet
  • reduced physical activity
  • raised cholesterol
97
Q

classification of carotid artery stenosis

A
  • Mild: < 50% reduction in diameter
  • Moderate: 50 to 69% reduction in diameter
  • Severe: 70% or more reduction in diameter
98
Q

presentation of carotid artery stenosis

A
  • usually asymptomatic and diagnosed after TIA or stroke
  • carotid bruit
99
Q

diagnosis of carotid artery stenosis?

A
  • carotid USS
  • CT/MRI angiogram
100
Q

Mx of carotid artery stenosis

A
  • healthy diet, exercise, stop smoking etc.
  • antiplatelets (aspirin, clopi)
  • lipi lowering meds (atorvastatin)

surgery
- Carotid endarterectomy (scrape out plaque)
- Angioplasty and stenting

101
Q

complication of endarterectomy in carotid artery stenosis

A

stroke

102
Q

nerves that can be effected in endarterectomy in carotid artery stenosis

A
  • facial (weakness)
  • glossopharyngeal (swallowing issues)
  • recurrent laryngeal (hoarse voice)
  • hypoglossal (unilateral tongue paralysis)
103
Q

what is buerger disease

A
  • known as thromboangiitis obliterans
  • inflammatory condition that causes thrombus formation in the small and medium-sized blood vessels in the distal arterial system (affecting the hands and feet)
104
Q

demographic of Buerger disease

A

25-35yrs
smoking

105
Q

Presentation of buerger disease

A
  • painful, blue discolouration to the fingertips or tips of the toes
  • pain is often worse at night.
  • This may progress to ulcers, gangrene and amputation
  • Corkscrew collaterals on angiogram (new vesel formation)
106
Q

Mx of Buerger disease

A
  • stop smoking (MAIN)
  • IV iloprost (dilates BVs)

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