Vascular Flashcards
what is peripheral arterial disease?
narrowing of the arteries supplying the limbs and periphery, reducing the blood supply to these areas. results in claudication
what is intermittent claudication?
symptom of ischaemia in a limb, occurring during exertion and relieved by rest
- crampy
- aching in calf, thigh, buttock
what is critical limb ischaemia
- end-stage of peripheral arterial disease
- inadequate blood supply to limb at rest
- burning pain worse at night
what is acute limb ischaemia
- rapid onset of ischaemia in a limb
- due to a thrombus blocking arterial supply
what is atherosclerosis
atheromas (fatty deposit) and sclerosis (hardening of BVs)
what do atheromatous plaques cause
- stiffening of artery walls –> hypertension and strain on the heart
- stenosis –>reduced blood flow
- plaque rupture –> thrombus and ischaemia
modifiable risk factors for atherosclerosis
- smoking
- obesity
- poor diet
- low exercise
- smoking
- stress
- poor sleep
non-modifiable risk factors for atherosclerosis
- older age
- FH
- male
co-morbidities that increase the risk of atherosclerosis
- diabetes
- hypertension
- CKD
- RA
- atypical antipsychotics
what is the end result of atherosclerosis
- angina
- myocardial infarction
- TIA
- stroke
- peripheral arterial disease
- chronic mesenteric ischaemia
what are the features of acute limb ischaemia
6Ps
1. Pale
2. Pulseless
3. Pallor
4. Perishingly cold
5. Paralysis
6. Paraesthesia (pins and needles)
What is Leriche syndrome
occlusion in the distal aorta or proximal common iliac artery
triad:
1. thigh/buttock claudication
2. absent femoral pulses
3. male impotence
signs of leriche syndrome
tar staining
xanthomata
signs of CVD
- missing limbs/digits due to amputations
- midline sternotomy scar
- scar on inner calf due to CABG
- focal weakness (stroke)
signs of arterial disease
- skin pallor
- cyanosis
- rubor
- muscle wasting
- hair loss
- ulcers
- poor wound healing
- gangrene
- poor temperature
- reduced sensation
- prolonged capillary time
- changes during Buerger’s
Cause of arterial ulcers
caused by ischaemia secondary due to inadequate blood supply
Indications of an arterial ulcer
- smaller
- deeper
- well defines borders
- punched out appearance
- peripherally (toes)
- reduced bleeding
- painful
Cause of venous ulcers
impaired drainage and pooling of blood in the legs
Indications of a venous ulcer
- 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)
investigations for peripheral arterial disease
- ABPI
- duplex USS
- angiography
what is ankle brachial pressure index
ratio of systolic BP in the ankle compared to systolic BP in the arm
what do the results of an ABPI show?
- 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)
Mx of intermittent caludication
- 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
management of critical limb ischaemia
- 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
Mx of acute limb ischaemia
- 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
what is DVT
thrombus in the venous circulation
causes of DVT
stagnation of blood and hypercoagulable states
where can thrombus emoblise (travel) to?
pulmonary arteries
RFs for DVT of PE
- immobility
- long haul flight
- recent surgery
- pregnancy
- COCP
- malignancy
- polycythaemia
- SLE
- thrombophilia
what are thrombophilias
conditions that predispose pts to developing blood clots
name thrombophilic conditions
- antiphospholipid syndrome
- Factor V Leiden
- Antithrombin deficiency
- Protein C or S deficiency
- Hyperhomocysteinaemia
- Prothombin gene variant
- Activated protein C resistance
what is VTE prophylaxis
LMWH
TED stockings
Presentation fo DVT
- unilateral
- calf/leg swelling
- dilated superficial veins
- calf tenderness
- oedema
- leg colour changes
system to identify PE/DVT
Wells score
How to diagnose DVT/PE
- D dimer
- doppler USS
- CTPA or VQ scan
Initial mx of DVT
DOAC (apixaban)
- consider cather directed thrombolysis in iliofemoral DVT
long term mx of DVT
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
what is an IVC filter
device in IVC to filter blood and catch clots
used in recurrent PEs or unsuitable for anticoagulation
what are varicose veins
distended superficial veins >3mm diameter
what are reticular veins
dilated blood vessels in the skin measuring less than 1-3mm in diameter
what is telagniectasia
dilated blood vessels in the skin measuring less than 1mm in diameter. They are also known as spider veins or thread veins
what is haemosiderin
Hb in leaking blood is broken down. Gives brown discolouration
what is venous eczema
Pooling of blood in the distal tissues results in inflammation. The skin becomes dry, itchy, flaky, scaly, red, cracked skin
what is lipodermatosclerosis?
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
- thick waxy feel, due to haemosiderin deposition
RFs for varicose veins
- Increasing age
- FH
- Female
- Pregnancy
- Obesity
- Prolonged standing
- Deep vein thrombosis (causing damage to the valves)
presentation of varicose veins
- engorged and dilated superficial leg veins
- can be asymptomatic
- Heavy or dragging sensation in the legs
- Aching
- Itching
- Burning
- Oedema
- Muscle cramps
- Restless legs
tests for varicose veins
- tap test
- cough test
- trendelenburg’s test
- perthes test
- duplex USS
Mx of varicose veins
- 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
complications of varicose veins
- 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)
Mx of superficial thrombophlebitis
NSAIDs e.g. naproxen
unless >10cm or at a junction then would need anticoagulation
what is chronic venous insufficiency
when blood does not efficiently drain from elgs back to the heart.
Usually due to valve damage
What does pooling of blood in the veins of the leg cause
venous hypertension
what is haemosiderin staining
red/brown discolouration caused by haemoglobin leaking into the skin.
what is atrophie blanche
patches of smooth, porcelain-white scar tissue on the skin, often surrounded by hyperpigmentation
what can chronic venous insufficiency lead to?
- Cellulitis
- Poor healing after injury
- Skin ulcers
- Pain
Mx of chronic venous insufficiency
- Keeping the skin healthy (emollients, topical steroids)
- Improving venous drainage to the legs ( weight loss, elevate legs, TEDs)
- Managing complications (abx, analgesia, wound care)
what are the common types of skin ulcers?
- Venous ulcers
- Arterial ulcers
- Diabetic foot ulcers
- Pressure ulcers
Complication of diabetic foot ulcers
osteomyelitis
what risk assessment tool is used for estimating an individual patient’s risk of developing a pressure ulcer
waterlow score
Ix for ulcers
- ABPI
- blood tests
- charcoal swabs
- skin biopsy
Mx of arterial ulcer
same as peripheral arterial disease
- urgent referral to consider surgery
Mx of venous ulcers
- 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)
what is lymphoedema
impaired lymphatic drainage of an area
what is primary lymphoedema
genetic
presents <30yrs
faulty dvlpt of lymphatic system
what is secondary lymphoedema
due to separate condition e.g. breast cancer surgery remmoving axillary LNs
what is lipoedema
abnormal build-up of fat tissue in the limbs, often the legs.
Feet are spared unlike in lymphoedema
F > M
pain
how to assess lymphoedema
- 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
Mx of lymphoedema
- massage
- compression bandages
- specific exercises
- weight loss
- good skin care
- Lymphaticovenular anastomosis
- abx if cellulitis
- CBT
what is lymphatic filariasis
- infectious disease caused by parasitic worms spread by mosquitos
- cause severe lymphoedema
- thickening and fibrosis of skin and tissues (elephantiasis)
what is abdominal aortic aneurysm
dilation of abdominal aorta diameter >3cm
what is the mortality of AAA?
80%
often presents when it ruptures
RFs for AAA?
- M > F
- Increased age
- Smoking
- Hypertension
- FH
- Existing cardiovascular disease
Screening for AAA
all men at 65 offered USS
if >3cm refer to vascular, urgent if >5.5cm
Presentation of AAA
most asymptomatic
- non-specific abdo pain
- pulsatile expansile mass in abdo
- incidental on AXR/USS/CT
diagnosis of AAA
USS- initial
CT angiogram- better
classification of AAA
dependent on size:
- Normal: < 3cm
- Small aneurysm: 3 – 4.4cm
- Medium aneurysm: 4.5 – 5.4cm
- Large aneurysm: > 5.5cm
Mx of AAA
treat reversible RFs:
- stop smoking
- diet and exercise
- optimise co-morbidities
Surveillance USS
- yearly for 3 - 4.4cm
- 3 monthly for 4.5-5.4cm
Elective repair if symptomatic, growing >1cm each year or >5.5cm
surgical mx options for AAA
insert artifical graft into affected aorta by:
- Open repair via a laparotomy
- Endovascular aneurysm repair (EVAR) using a stent inserted via the femoral arteries
DVLA advice if you have AAA
- Inform if aneurysm > 6cm
- Stop driving if > 6.5cm
- Stricter rules apply to drivers of heavy vehicles
presentation of ruptured AAA
- Severe abdominal pain that may radiate to the back or groin
- Haemodynamic instability
- Pulsatile and expansile mass in the abdomen
- Collapse
- Loss of consciousness
Mx of ruptured AAA
- surgical emergency
- want lower BP than normal in fluid resuscitation to prevent blood loss
- CT angio if haemodynamically stable
what is aortic dissection
break or tear forms in the inner layer of the aorta, allowing blood to flow between the layers of the wall of the aorta
what are the layers of the aorta?
intima, media and adventitia
in dissection blood is between intima and media
how to classify aortic dissection?
Stanford system OR
DeBakey system
where does aortic dissection normally affect?
- 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
what is the Stanford system?
- A: ascending aorta before brachiocephalic artery
- B: descending aorta after the left subclavian artery
What is the DeBakey system?
- 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
RFs for aortic dissection
HYPERTENSION
+ same as peripheral arterial disease
- age
- Male
- smoking
- hypertension
- poor diet
- raised cholesterol
conditions/procedures that increase risk of dissection
- Bicuspid aortic valve
- Coarctation of the aorta
- Aortic valve replacement
- Coronary artery bypass graft (CABG)
Conditions that affect connective tissue that can increase risk of dissection
- Ehlers Danlos syndrome
- Marfan’s syndrome
Presentation of aortic dissection
- 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
how to diagnose aortic dissection?
- ECG and CXR to exclude other causes
- CT angiogram
- MR angiogram
Mx of aortic dissection
- analgesia
- beta blocker to control HR/BP
Surgical emergency
- type A: open surgery midline sternotomy, artificial graft
- type B: TEVAR with a catheter
complications of aortic dissection
- MI
- Stroke
- Paraplegia (motor or sensory impairment in the legs)
- Cardiac tamponade
- Aortic valve regurgitation
- Death
what is carotid artery stenosis
narrowing of the carotid arteries in the neck, usually secondary to atherosclerosis
risk of carotid artery stenosis?
plaque breaking away and becoming an embolus, travelling to the brain and causing an embolic stroke.
RF for carotid artery stenosis?
- age
- male sex
- smoking
- hypertension
- poor diet
- reduced physical activity
- raised cholesterol
classification of carotid artery stenosis
- Mild: < 50% reduction in diameter
- Moderate: 50 to 69% reduction in diameter
- Severe: 70% or more reduction in diameter
presentation of carotid artery stenosis
- usually asymptomatic and diagnosed after TIA or stroke
- carotid bruit
diagnosis of carotid artery stenosis?
- carotid USS
- CT/MRI angiogram
Mx of carotid artery stenosis
- healthy diet, exercise, stop smoking etc.
- antiplatelets (aspirin, clopi)
- lipi lowering meds (atorvastatin)
surgery
- Carotid endarterectomy (scrape out plaque)
- Angioplasty and stenting
complication of endarterectomy in carotid artery stenosis
stroke
nerves that can be effected in endarterectomy in carotid artery stenosis
- facial (weakness)
- glossopharyngeal (swallowing issues)
- recurrent laryngeal (hoarse voice)
- hypoglossal (unilateral tongue paralysis)
what is buerger disease
- 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)
demographic of Buerger disease
25-35yrs
smoking
Presentation of buerger disease
- 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)
Mx of Buerger disease
- stop smoking (MAIN)
- IV iloprost (dilates BVs)
INR thresholds
- 5-8, no bleeding = Withhold few doses, reduce maintenance. Restart when INR <5.
- 5–8, minor bleeding = Stop warfarin. Vit K slow IV. Restart when INR <5.
- > 8, no bleed/minor bleed Stop warfarin. Vitamin K (oral/IV) no bleeding/if risk factors for
bleeding or minor bleeding. Check INR daily. - Major bleeding = Stop warfarin. Give prothrombin complex concentrate. If
unavailable, give FFP. Also give vitamin K IV.
