VASCULAR Flashcards
Describe intermittent claudication:
Symptom of ischaemia in a limb.
Brought on by exertion, relieved with rest. Cramping, aching pain in calves, also buttocks and thighs.
Muscle fatigue when walking past a certain intensity.
Risk factors to ask about in a vascular history, non-mod, mod and medical:
Non-mod = age, male, FHx
Mod = smoker! alcohol, poor diet, sedentary, obesity, poor sleep, stress
Medical = DM, HTN, hyperlipidaemia, CKD, RA
What is Leriche syndrome?
occlusion of the distal aorta or proximal common iliac artery
Triad:
Male impotence
Femoral pulse absent
Thigh / buttock claudication
Which ABPI measurement would suggest severe and limb-threatening ischaemia?
<0.5
Colour changes in legs in the second part of Buerger’s test and what they mean:
Blue initially as all the oxygen in the blood is used up by the ischaemic tissue
Then dark red / rubor as the accumulation of waste products from anaerobic respiration
What does a high ABPI indicate the possibility of?
Calcification of the arteries, esp in diabetes
Management of intermittent claudication (non-pharmacological):
Lifestyle = stop smoking, weight loss, staying active
Medical = optimising medical conditions e.g. maybe using drugs
Exercise training!
First line assessments / investigations in intermittent claudication:
Pulses - femoral, popliteal, posterior tibialis, dorsalis pedis
ABPI
Duplex US FIRST LINE imaging
(MRA prior to any intervention)
Pharmacological management in peripheral arterial disease:
STATIN 80mg / high intensity for lipid reduction
Clopidogrel
Naftiurofutyl oxalate used if poor quality of life, is a peripheral vasodilator
Endovascular vs open surgical techniques and indications in peripheral arterial disease:
Surgery indicated in severe / critical limb ischaemia
Endovascular - percutaneous angioplasty +/- stent
<10cm, aorto-iliac disease and high risk patients
Open - bypass with autologous vein or prosthetic material, or endarterectomy
>10cm, multifocal disease, common femoral artery lesions or purely infrapopliteal disease
Features of critical limb ischaemia compared to intermittent claudication:
Rest pain in foot >2 weeks
Ulceration
Gangrene
^ any 1 of the above
Patients who have had a TIA or a stroke are investigated for carotid artery stenosis. What investigation is used, and describe the classification of the severity.
US of carotid arteries
<50% reduction = mild
50-69% reduction = moderate
>70% = severe
Carotid artery stenosis is usually asymptomatic and most patients are diagnosed after a TIA or a stroke. A bruit may be heard on examination; which phase of the cardiac cycle is it heart during?
systole
First line treatment for patients requiring surgical intervention for carotid artery stenosis, and the main risk:
Carotid endarterectomy (unless total occlusion)
2% risk of stroke
Which nerves can be damaged during carotid endarterectomy and what symptoms may be precipitated:
Facial - marginal mandibular branch = drooping of bottom lip
RLN - hoarse voice (branch of vagus)
Glossopharyngeal - swallowing difficulties
Hypoglossal - unilateral tongue paralysis
Describe the development of varicose veins.
Vein valves become incompetent and this precipitates backflow and pooling of blood.
Deep and superficial veins are connected by perforators - the valve incompetence in these means there is back flow from deep into superficial, causing dilation and engorgement of superficial veins.
Common complaints of varicose veins are cosmetic, aching, throbbing and itching. What are some further complications / skin changes?
Bleeding
Superficial thrombophlebitis
DVT
Skin changes = venous eczema, hyperpigmentation, lipodermatosclerosis, atrophie blanche
Investigation in varicose veins:
Venous duplex US demonstrating retrograde blood flow
Conservative management options for varicose veins:
Elevate feet when resting to reduce pooling
Weight loss
Stay active
Graduated compression stockings, after ABPI has been done
Pathophysiology of hyperpigmentation, venous eczema and lipodermatosclerosis:
Vessels leak blood, Hb is broken down into haemosiderin = causes brown pigementation of skin
Venous eczema is caused by inflamamtion caused by pooling, dry and inflamed skin
Fibrotic and tight soft tissues occur at the lower legs , narrow and hard
Risk factors for varicose veins:
Age
FHx
Female
Pregnancy, as uterus compresses the pelvic veins
Obesity
Prolonged standing
DVT
Special tests in varicose veins (4):
Tap test: pressure at the saphenofemoral junction, tap the vein and should feel a thrill if valves are incompetent.
Cough test: same as tap test , if this is positive it indicates saphena varix
Trendelenburg test:
Perthe’s test:
DUPLEX US
4 complications of varicose veins:
Heavy and prolonged bleeding after trauma
DVT
Superficial thrombophlebitis
Chronic venous insufficiency
Reasons for referral to secondary care for varicose veins:
Significant impact on life due to pain / discomfort / swelling
Superficial thrombophlebitis
Skin changes e.g. venous
Previous bleeding
Active or healed venous leg ulcer
Which vein is most likely affected in superficial thrombophlebitis?
great / long saphenous vein
Superficial thrombophlebitis is usually an inflammatory aetiology rather than infective, but it can progress to septic thrombophlebitis rarely. What is a more likely progression if the superficial thrombophlebitis remains untreated?
3-4% progress to DVT
20% of people presenting with superficial thrombophlebitis have an underlying DVT
Risk is associated with length e.g. >5cm = higher risk of DVT
Investigation and management of a superficial thrombophlebitis:
Doppler US to exclude DVT
Consideration of LMWH for 30 days
Oral / topical NSAIDs
Moist warm towel to area
Keep elevated when resting
Carry on exercising
Graduated compression stockings
When would therapeutic anticoagulation be considered in superficial thrombophlebitis?
<3cm from the saphenofemoral junction
Which score risk stratifies patients with chronic limb ischaemia, and what does it predict?
WIfI score (0-3 on each category):
Wound - presence of ulcer / gangrene / how extensive
Ischaemia - using toe pressures, >60 to <30
Foot Infection - mild - sepsis
Those most likely to benefit from revascularisation
Possible surgical management of varicose veins:
Endothermal ablation
Foam sclerotherapy - irritation = inflammation = closure of vein
