Vascular Flashcards
What are the two main complications of aneurysms?
- Can rupture –> internal bleeding (typical of AAAs)
- Can from laminated thrombus in aneurysm sac which can embolise or thrombose –> limb loss (typical of popliteal aneurysms)
How does a patient with a AAA typically present?
Usually asymptomatic, most picked up as incidental findings
UNLESS impending rupture: hypotension + abdo pain radiating to the back
BUT can also atypically present with LIF or loin pain
How are aneurysms evaluated? (3)
- US (observation, population screening, diagnosis)
- X-ray - can see calcification
- CT
How are aneurysms managed? (2)
Dependent on size
- Small - observation with regular US
- Surgical repair if greater than 5cm in diameter or growth rate of more than 0.5cm over 1 year (endovascular vs open surgical repair)
What are the two types of true aneurysms?
- Fusiform - bulges out on all sides
2. Saccular - bulges out on one side
What is a false aneurysm?
when there is a breach in the vessel wall such that blood leaks through the wall but is contained by the adventitia or surrounding perivascular soft tissue
Define claudication
Pain with exertion that is relieved by short rest (no postural changes necessary) and is reproducible (i.e. same distance to elicit pain, same location pain, same amount of rest to relieve pain)
What is Buerger’s test?
Prolonged pallor with elevation and rubor on dependency
How does acute arterial occlusion/insufficiency differ from that of chronic in terms of aetiology?
Acute - due to acute occlusion/rupture of a peripheral artery
Chronic - predominantly due to atherosclerosis and primarily affecting lower extremities
How do the clinical features of spinal claudication differ to that of arterial claudication?
Neurogenic claudication: due to spinal stenosis or radiculopathy; pain very similar but relieved by longer rest and postural changes
What investigations are warranted if you suspect peripheral vascular disease? (2)
- ABI - divide ankle systolic pressure by arm BP (less than 0.95 indicative of PVD, varying levels)
- CTA or MRA - gold-standard but invasive - require nephrotoxic contrast and better for larger arteries
What are the ABI value cut-offs for varying stages of PVD?
Greater than 0.95 = normal/no ischaemia 0.85-0.94 Mild 0.50-0.84 Moderate 0.26-0.49 severe Less than 0.25 consider limb salvage
If greater than 1.2 suspect wall calcification (in patients with diabetes) i.e. not compressible by BP cuff
How is peripheral vascular disease classified?
Fontaine classification
Stage 1: asymptomatic
Stage 2: intermittent claudication (with activity)
Stage 3: rest pain or nocturnal pain
Stage 4: necrosis/gangrene
How is PVD managed?
Refer to vascular team
- Conservative - risk factor modification (e.g. statins for dyslipidaemia, antiplatelet therapy, diabetes control, hypertension management, smoking cessation)
- Surgery if severe e.g. rest pain,night pain or gangrene
- stenting/angioplasty, bypass, amputation (if severe +++++)
What are the 6 Ps of acute arterial insufficiency? Which of these is the most worrying?
Pain Pallor Paraesthesia Perishingly cold Pulselessness Paralysis - impending gangrene
List 3 broad causes of acute arterial occlusion/insufficiency.
- Embolus - cardiac (AF, endocarditis etc.), venous (intra cardiac shunt) etc.
- Thrombus - haematological disorders, atherosclerotic etc.
- Trauma
What are the indications of surgical management of chronic PVD?
Rest pain, night pain, pain interferes with lifestyle, gangrene
Describe the pathophysiology behind venous ulcers
Venous insufficiency - failure of normal mechanisms returning venous blood from lower limbs causing venous hypertension and impaired tissue perfusion and nutrition of skin and subcutaneous tissue - poor wound healing = ulcer
Describe the location of arterial vs venous ulcers
Arterial ulcers - bony prominences e.g. Above lateral malleolus or over MTP joints
Venous ulcers - pretibial, 1/3 lower leg, medial side I.e. ‘Gaiter region’
Describe the appearance of arterial vs venous ulcers
Arterial - deep pale base ‘punched out’ with well-defined edges and necrotic tissue
Venous - uneven edges with base of granulation tissue and is surrounded by eczematous and/or pigmented skin
List 6 features of a leg affected by arterial ulcers
Minimal/no hair Cool Thin/dry and shiny skin Thickened toe nails May have neuropathy Diminished or nil pulses
List 6 features of a leg affected by venous ulcers
Ruddy pigmentation and venous eczema - lipodermatosclerosis Usually warm leg Hair present Evidence of healed ulcers Varicose veins Normal pulses
Compare sensation in arterial vs venous ulcers
Arterial ulcers are very painful and the pain is reduced by lowering leg
Venous ulcers tend not to be as painful, but pain is eased by raising leg
What is a Marjorin’s ulcer and when is it suspected?
Associated with malignant change usually SCC
Suspected in any long-standing ulcer or one with an atypical appearance or that fails to heal despite adequate management
