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F24 > Vascular > Flashcards

Vascular Flashcards

1
Q

What is a aortic disection

A

Aortic dissection is when there is a tear in the inner ( intimal) most layer of the aorta leading to creation of a false lumen
Caused by tear, atherosclerosis rupture or intralumonal
Bleeding

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2
Q

What is classification of aortic disection

A

Stanford type A and B
A: ascending +_ descending requiring urgent surgery
B: descending only post left subclavian artery medical conservative management

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3
Q

Risk factors for aortic dissection

A

HTN
Connective tissue disorder: ehlos Danlos/ Marfans
Structural abnormalities: bicuspid aortic valve
Coarction of aorta
Known aneurysm
Cocaine use
Recent aortic instrumentation iatrogenic
Infections: syphilis
Vasculitis

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4
Q

Examination feature of dissection

A

Pulse deficit
Systolic BP deficit
Focal neurological deficit
Murmur of aortic insufficiency
Hypotension/ shock
Pericardial tamponade - becks triad

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5
Q

What is more common aortic dissection or aneurysm rupture

A

Aortic dissection is 2-3x more common

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6
Q

What percentage of aortic dissection die pre hospital

A

20%

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7
Q

Investigation in aortic dissection what do they show

A

ECG: sinus rhythm, inferior ischaemia, non Specific changes, LVH 40%
Trop elevated
EUC renal artery involvement
D dimer low risk patients
Limited echo initial flap
Ct angio intimal flap and false lumen

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8
Q

Management of aortic dissection

A

HR < 60
SBP < 120 in right arm
Pain

Beta blocker first - esmolol 500mcg/kg bolus over 1 min
40mg bolus 20mg/ min
or metoprolol 15 mg total bolus - 5mg/hr

Vasodilator: GTN/ hydrazine

Pain fentanyl

Cross match 6 units blood

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9
Q

Complications of aortic dissection

A

Haemodynamic collapse
Aortic regurgitation
AMI
Tamponade
Haemothorax
End organ ischaemia
Stroke - carotid involvement
Branch involvement: renal/ mesentery

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10
Q

Risk stratification rule for aortic dissection

A

Aortic dissection detection risk score
Low risk 0/1: d dimer can assist need for further imagine
>1 ct angiogram

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11
Q

CXR signs aortic dissection

A

Mediastinal widening > 8cm at aortic arch
Aortic contour >0.5 cm from edge of calcification
Double aortic knob >5cm
Irregular aortic knob
Pleural effusion L>R
Tracheal shift
Left apical csp
Deviated ng tube

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12
Q

Risk factors AAA

A

Male
Age>60
Smoking
HTN
Genetic

Atherosclerosis
Primary connective tissue
Arteritis
Traumatic
Mycotic

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13
Q

Definition of AAA

A

Permanent dilation of all three layers of the vessel >3cm in diameter or >50% increase from baseline

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14
Q

Types of shape of AAA

A

Fusiform: true entire circumference dilation of vessel
Saccular: lateral out pouch can be false
False: deficient in 1 layer pseudaneurysm

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15
Q

Where do most AAA occur

A

Infrarenal

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16
Q

Normal infrarenal diameter in >50 year

A

Men: 1.7cm
Women 1.5cm

> 3 cm aneurysm

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17
Q

Emergency presentation of AAA

A

Incidental finding asymptomatic
Symptomatic or painful due to inflammation
Contained retroperitoneal rupture
Uncontained free rupture
Distal embolism

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18
Q

Causes of AAA

A

Atherosclerotic injury
Primary connective tissue degeneration
Inflammation with arteritis
Traumatic injury
Mycotic injury
Aortic dissection related

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19
Q

Complication of AAA

A

Death
Major haemorrhage
Aortic branch involvement - renal, spinal pancreatic
Distal embolism
Rhabdo

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20
Q

Classic triad AAA rupture

A

Pain severe and back pain
Signs of shock Pericardial tampon
Puslatile mass in abdomin

Elderly back pain, radiation to legs, chronic severe back pain

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21
Q

Rupture AAA management

A

A-C
2x IVC
SBP> 90 permissive hypotension maintain perfusion
Cross match 6 units
Bloods
Analgesia
Vascular to theatre

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22
Q

Indication for repair of AAA

A

Male >5.5
Female >5.0
Rapid growth >1cm/ year
Symptomatic AAA

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23
Q

Repair options AAA

A

Open repair - ruptures
Endovascular stent grafting less invasive and lower mortality

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24
Q

Ruptured AAA mortality

A

50%

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25
Q

AAA and risk of rupture

A

3.0-3.9: 0%
4.0-4.9: 1%
5.0-5.9: 10%
6.0-6.9 10-20%
>7: 30-50%

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26
Q

Risk factors for rupture AAA

A

Aneurysm >5.5cm
Rate of expansion >0.5cm/ year
Smokers
Untreated hypertension

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27
Q

Shapes of AAA

A

Fusiform: all three layers including the whole diameter
Saccular: only part is dilated - not all three layers
False: collection of blood in lumen

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28
Q

Sensitivity and specificity in CT angio for aortic dissection
What see

A

Sensitivity 95 %
Specificity 95%
Intimal flap
Entry point and ischaemia

29
Q

Most common 3 symptoms in aortic dissection

A

Chest pain 75%
Back pain 50%
Abdominal pain 30%

No chest pain 25%

30
Q

What correlates to poor outcome in aortic disection

A

Delay in diagnosis
Increase age
Stroke
Tamponade
ECG changes

31
Q

PE perc score

A

Age >50
Hr > 100
Spo2 < 95
Immobilisation 3 days surgery 3m
Hormone replacement
Precious PE/DVT
Signs of DVT
Haemoptysis

Any positive can’t rule out

32
Q

Wells score PE

What’s is 2 tier vs 3 tier model

A

Signs and symptoms DVT +3
PE most likely diagnosed +3
Previous VTE +1.5
Immobilisation 3 days surgery 3 m +1.5
Hr >100 +1.5
Haemoptysis + 1
Malignancy +1

3 tier
0-1 low
2-6 mod
>6 high

2 tier
0-4 low
>4 high

33
Q

Wells score DVT

A
  1. Bedridden > 3 days or major surgery within 12 weeks
  2. Calf swelling >3cm compared to other side
  3. Collateral superficial veins present
  4. Entire leg swollen
  5. Localised tenderness to deep vein system
  6. Active cancer
  7. Pitting oedema to symptomatic leg
  8. Paralysis or recent cast immobilisation
  9. Previous DVt
  10. Alternative diagnoses as likely -2

All + 1 except last one

0- low risk
1-2 mod
>2 high

34
Q

PESI score

A

Pe severity score for risk stratification op vs inpatient
Add up score total

Age - pts/ year
Male +10
History
Cancer +30
HF + 10
Chronic lung disease +10
Examination
AMS +60
SBP <100 + 30
Hr >110 + 20
SPO2 < 90 +20
Temp <36 +20

Total score
V Low < 65
Low 65-85
Mod 86-105
High 106-125
V high >125

<65 mortality <2%

35
Q

Risk factors for PE

A

Recent major trauma
Recent major surgery
Recent immobility
Recent LL fracture
Hypercoagulable stage
Pregnancy
Active malignancy
Hormone replacement
Previous VTE
>80 years ago
Obesity

36
Q

ECG finding in PE

A

Sinus tachycardia
Incomplete RBBB
Rad
S1q3t3
R v strain R in avr, twi V1-4, II, III
Non specific St changes
Atrial tachycardia
Ventricular

37
Q

Echo finding in PE

A

RV>LV 0.9
Reduced taper
D. Sign
McConnell signs
Dilated IVC

38
Q

CXR
% abnormal

A

70-85% CXR abnormal in PE

Hampton humps - peripheral wedge infarction 20%
Pleural effusion 35%
Watermark sign regional
Origaemia
Knuckle sign
Palla sign - enlarged right descending pulmonary artery
Chang sign - dilated right descending pulmonary srtery
Elevated hemidiaphragm

39
Q

% patient with PE will have DVT

40
Q

% with a DVT will have a pe

41
Q

Massive PE
Submissive
Non massive
Definitions

A

Massive PE is an acute PE with haemodynamic instability
-SBP <90 for > 15 mins or requiring vasopressor support/ cardiac arrest

Submissive PE : acute PE with evidence of right heart strain: imaging, trop, ecg, bnp

Non massive nil haemodynamic compromised or signs above

42
Q

Mortality of massive PE

43
Q

Imaging for PE

A

CTPA
V/Q
Bilateral Doppler us
Echo/ toe

44
Q

CTPA contraindications

A

Nephropathy, renal disease
Contrast allergy
Pregnancy

45
Q

Surgical options for PE management

A

Mechanical thrombectomy
IVC filter
ECMO

46
Q

Contraindications to thrombolysis
Absolute

A

Previous ICH
Stroke in 3m
Av malformation
CNS neoplasm
Recent brain or spinal surgery
Active bleeding or bleeding diathesis
Suspected aortic dissection
Recent closed head injury fracture

47
Q

Relative contraindications to thrombolysis

A

Age >75
Current anti coagulation
Pregnancy
Non compressive vascular punctured
Traumatic cpr
Recent internal bleeding 2-4 weeks
History uncontrolled hypertension
Remote ischaemic stroke >3m
Major surgery 3 weeks

48
Q

Mortality submissive PE

49
Q

Dose of thrombolysis for PE

A

Patients >65kg
Bolus 10mg then 90 mg over 2 hours

<65kg 1.5mg/kg
10Mg bolus rest over % 2 hours

Streptokinase / tenectaplase alternatives

50
Q

Treatment of massive PE

A

Thrombolysis: alteplase 10mg 90 mg over 2 hours

Heparin 1000units/ hr infusion - aptt

Then anticoagulations

51
Q

Cardiac arrest PE

A

50 mg alteplase bolus

52
Q

Risk of bleeding score

A

HASBLED
H hypertension >160
A abnormal LFT/ EUCs cr >200, bili x2
S stroke
B bleeding history
L labels INR
E elderly >65
Drugs/ alcohol us

53
Q

DVT complications

A

PE: untreated 15-25% risk
Post thrombotic syndrome - 60% pain swelling venous hypertension
Recurrent DVT

54
Q

Risk factor DVT

A

Immobilisation
Surgery
Trauma
Procoagulant disorders
Age
Previous VTE
Smoking
Malignancy
Pregnancy
Hormone replacement
Composites

55
Q

Risk factors in pregnancy for PE

A

Age >35
Weight >80kg
Parity >4
Varicose veins
Prolonged hospital stay
C section
Labour >12 hours
Excessive blood loss
Assisted birth
Dehydration
Pre eclampsia

56
Q

Investigation bloods for PE/ DVT

A

FBC,
Coags
EUCs
Antiphospholipid: Lupus anticoagulant, anti cardiolipin, ab B2 glycoprotein ab
Age <46 factor V leidon, prothrombin gene mutation, protein C/s antithrombin III

57
Q

Treatment VTE
Non cancer
Cancer

A

Non cancer
1st DOAC
2nd warfarin

Cancer
1st LMWH
2nd warfarin

Rivaroxaban 15mg bd for 3 weeks - 20mg po od
Dabigatran IV heparin first - 150mg od bd
Apixaban: 10mg po bd for 7 days
5mg po bd 6m
Warfarin 5mg inr 2-3
Clexane 1mg/kg bd or 1.5mg/kg od

Pregnancy: LMWH

58
Q

Causes of axillary vein thrombosis

A

Primary: effort induced spontaneous post strenuous effort arms e.g crick or, tennis

Secondary: iatrogenic: picc line insertion/ CVC, mastectomy, radiation
IVDU
Thoracic inlet obstruction - lymphoma
Prothrombotic malignancy
Venous stasis

59
Q

Ileofemoral DVT
2 appearances 1 bad 1 ok

A

Phlegmasia cerla do lens
Circulatory compromise - entire leg swelling mottled cyanotic pain - gangrene

Phlegmasia Alba do lens: white less severe

60
Q

What DVT superficial do we treat

A

Those 1cm of deep venous system
1 cm from saphenofemoral
1cm from sapheno popliteal
Those high risk factors
>5cm high risk

Or others observe and repeat 2 weeks us

61
Q

Acute limb ischaemia 6ps

A

Pulseless
Palor
Paraesthesia
Paralysis
Poikolothermia
Pain

62
Q

Causes of acute limb ischaemia

A

Thrombosis: 60% acute thrombotic occlusion stenosis atheroscleroris
Embolus 30%: cardiac - AF, atherosclerosis
Trauma: penetrating
Dissection: aorta
Mass lesion
Vasculitis
Spasm of vessel

63
Q

Complications of ischaemic limb

A

Rhabdomyolysis
Hyperkalaemia
Myoglobinaeia
Infection - nec fasc and acute renal failure

64
Q

Management of acute limb ischaemia

A

Resuscitation analgesia
Rhabdo- high K/ renal - aim UO >
Vascular consultation early
Heparinisation 5000 units bolus infusion
Revascularisation
Options IV thrombolysis
Embolectomy
Emergency bypass grafting
OT
Amputation
ABX if infected

65
Q

History of acute limb ischaemia

A

Cardiac - af
Heart valves etc
Rf: PVD, smoking HTN, diabetes, cholesterol
Hx of intermittent claudication
Time of onset

66
Q

Ankle brachial index
Normal
Ischaemia

A

1-1.4 normal
0.5-0.8 critical arterial disease
<0.5 severe

67
Q

How to measure ankle brachial pressure index

A

Doppler
Ankle SBP when goes measured at DP and PT x3 highest reading kept
Some done same side at brachial highest
Divided by each other r

68
Q

Bergers disease
Name and cause
Treatment

A

Thromboangitis obliterans
Non atherosclerotic segmental inflammatory disease
Small medium vessels arteries and veins
Stop smoking
Medical management nifediipine iloptasdt
Surgical debridement/ amputation

F24 (22 decks)

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