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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
AAA and risk of rupture
3.0-3.9: 0% 4.0-4.9: 1% 5.0-5.9: 10% 6.0-6.9 10-20% >7: 30-50%
26
Risk factors for rupture AAA
Aneurysm >5.5cm Rate of expansion >0.5cm/ year Smokers Untreated hypertension
27
Shapes of AAA
Fusiform: all three layers including the whole diameter Saccular: only part is dilated - not all three layers False: collection of blood in lumen
28
Sensitivity and specificity in CT angio for aortic dissection What see
Sensitivity 95 % Specificity 95% Intimal flap Entry point and ischaemia
29
Most common 3 symptoms in aortic dissection
Chest pain 75% Back pain 50% Abdominal pain 30% No chest pain 25%
30
What correlates to poor outcome in aortic disection
Delay in diagnosis Increase age Stroke Tamponade ECG changes
31
PE perc score
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
Wells score PE What’s is 2 tier vs 3 tier model
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
Wells score DVT
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
PESI score
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
Risk factors for PE
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
ECG finding in PE
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
Echo finding in PE
RV>LV 0.9 Reduced taper D. Sign McConnell signs Dilated IVC
38
CXR % abnormal
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
% patient with PE will have DVT
70%
40
% with a DVT will have a pe
45%
41
Massive PE Submissive Non massive Definitions
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
Mortality of massive PE
15%
43
Imaging for PE
CTPA V/Q Bilateral Doppler us Echo/ toe
44
CTPA contraindications
Nephropathy, renal disease Contrast allergy Pregnancy
45
Surgical options for PE management
Mechanical thrombectomy IVC filter ECMO
46
Contraindications to thrombolysis Absolute
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
Relative contraindications to thrombolysis
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
Mortality submissive PE
2-5%
49
Dose of thrombolysis for PE
Patients >65kg Bolus 10mg then 90 mg over 2 hours <65kg 1.5mg/kg 10Mg bolus rest over % 2 hours Streptokinase / tenectaplase alternatives
50
Treatment of massive PE
Thrombolysis: alteplase 10mg 90 mg over 2 hours Heparin 1000units/ hr infusion - aptt Then anticoagulations
51
Cardiac arrest PE
50 mg alteplase bolus
52
Risk of bleeding score
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
DVT complications
PE: untreated 15-25% risk Post thrombotic syndrome - 60% pain swelling venous hypertension Recurrent DVT
54
Risk factor DVT
Immobilisation Surgery Trauma Procoagulant disorders Age Previous VTE Smoking Malignancy Pregnancy Hormone replacement Composites
55
Risk factors in pregnancy for PE
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
Investigation bloods for PE/ DVT
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
Treatment VTE Non cancer Cancer
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
Causes of axillary vein thrombosis
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
Ileofemoral DVT 2 appearances 1 bad 1 ok
Phlegmasia cerla do lens Circulatory compromise - entire leg swelling mottled cyanotic pain - gangrene Phlegmasia Alba do lens: white less severe
60
What DVT superficial do we treat
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
Acute limb ischaemia 6ps
Pulseless Palor Paraesthesia Paralysis Poikolothermia Pain
62
Causes of acute limb ischaemia
Thrombosis: 60% acute thrombotic occlusion stenosis atheroscleroris Embolus 30%: cardiac - AF, atherosclerosis Trauma: penetrating Dissection: aorta Mass lesion Vasculitis Spasm of vessel
63
Complications of ischaemic limb
Rhabdomyolysis Hyperkalaemia Myoglobinaeia Infection - nec fasc and acute renal failure
64
Management of acute limb ischaemia
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
History of acute limb ischaemia
Cardiac - af Heart valves etc Rf: PVD, smoking HTN, diabetes, cholesterol Hx of intermittent claudication Time of onset
66
Ankle brachial index Normal Ischaemia
1-1.4 normal 0.5-0.8 critical arterial disease <0.5 severe
67
How to measure ankle brachial pressure index
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
Bergers disease Name and cause Treatment
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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