Vascular

Question 1

Cause of Peripheral Vascular Disease

Answer 1

Obstruction of the large arteries in the peripheries

Obstruction can arrise as a result of :

1. atherosclerosis
2. thromboembolic disease
3. inflammatory stenosis

Question 2

NAME THAT ARTERY

Answer 2

…

Question 3

Paraphernalia of peripheral vascular disease

Answer 3

Oxygen, GTN spray, Cigarettes, Walking aids, amputation, prothesis

Question 4

Signs in the Hands of peripheral vascular Exam

Answer 4

• Skin Changes:
  
  • Tar Staining
  • Tendon Palmar Xanthoma (Hypercholestolaemia)
  • Purple Discolouration on Fingertips (Atherothromboembolism)
• Muscle Wasting
  
  • Small Muscles (Thoracic Outlet Syndrome)
• Temperature

Question 5

Normal difference in blood pressure between arms

Answer 5

<15mmHg

Question 6

VENOUS SCARS/ ARTERIAL SCARS

Answer 6

….

Question 7

Arterial Disease Skin Changes

Answer 7

• Discolouration
  
  • Erythema
  • Pallor
  • Brown Haemosiderin Deposits
  • Purple or Black from Haemostasis
• Venous Guttering
• Trophic Changes
  
  • Absence of Hair
  • Shiny Skin
  • Gangrene
• Ulcers

Question 8

Name of the test for peripheral artery disease

Answer 8

Buerger’s Test

Question 9

What happens in positive Buergers Test

Answer 9

Reactive Hyperaemia!

In normal person the leg goes pink when hang feet off couch.

In PAD they turn a bluish color from deoxygenated blood and then red from reactive hyperaemia from post- hypoxic vasodilation.

This can take up to 2 minutes in severe PAD

Question 10

Classification of PAD by Buergers angle

Answer 10

Some discrepency in exact definition but:

Severe Ischaemia: Buerger’s Angle <50^o

Critical Ischaemia: Buerger’s Angle <20-25^o

Question 11

Anatomical Location of the Femoral Artery

Answer 11

MID-INGUINAL POINT

Halfway between ASIS and Pubic Symphisis

Question 12

Anatomical Location of the Popliteal Artery

Answer 12

Lower margin of the Popliteal Fossa between the two heads of the gastrocnemius muscle

Question 13

Anitomical location of the Dorsalis Pedis Pulse

Answer 13

Lateral to extensor hallucis longus tendon

Question 14

Pulses to feel in peripheral Vascular Examination

Answer 14

1. Radial
   
   • Radial Radial Delay
   • Radio-Femoral Delay
2. Brachial
3. Carotid
4. Subclavian
5. Abdominal Aorta
6. Femoral
7. Popliteal
8. Posterior Tibial
9. Dorsalis Pedis

Question 15

What special tests do you do in the vascular Exam?

Answer 15

Buerger’s Test

Ankle Brachial Pressure Index (ABPI)-on both sides!

Question 16

Describe the Ankle Brachial Pressure Index

Answer 16

ABPI examines for a fall in BP in the arteries supplying the legs which occurs as a result of occlusive arterial disease in the lower limbs.

ABPI= P_leg/ P_arm

1. Sphygmomanometer proximal to ankle joint.
2. Place doppler proble on posterior tibial pulse and inflate the cuff until the noice from doppler disappears
3. Deflate cuff until doppler signal reappears.
4. Can repeat on dorsalis pedis
5. Highest reading is used
6. Repeat on both arms with brachial artery.
7. Use the highest systolic reading

Question 17

What would you do to investigate this PVD patient?

Answer 17

Simple bedside tests that I would like to do include:

1. Checking the pt’s BM
2. A 12 lead echocardiogram for evidence of coexisting heart disease as the patient is likely to be an arteriopath.

I would like to do some bloodtests including:

1. FBC to check for anaemia or polycythaemia
2. U&Es to check the patients renal function-this is particularly important if there is a view to doing contrast studies later, particularly if the patient is diabetic as you can get contrast induced nephopathy.
3. Serum Cholesterol for hypercholesterolaemia to address risk factor modification.
4. Clotting for the presence of a coagulopathy.
5. G&S incase the patient undergoes operative management
6. ESR to screen for vasculitides and a specialist antinuclear antibody screen for selective patients

Imaging that I would like to request would include:

1. CXR to look for coexisting cardiorespiratory disease and do a preoperative assessment
2. Specialist Imaging that I would use to assess the extent of disease and help plan operative management would include
   
   1. a duplex scan to look for the degree of stenosis and
   2. a spiral CT to reconstruct 3D images of vessels non invasively.
   3. In some patients I would do a digital subtraction angiogram (DSA) to demonstrate the level of blockage, runoff and the presence of a collateral blood supply.

Question 18

What is DSA?

Answer 18

Digital Subtraction Angiography

Computer software subtracts bone and soft tissue from image.

Arterial supply is demonstrated in high resolution and it uses less contrast material

Question 19

Can you estimate the extent of stenosis from a hand held doppler probe?

Answer 19

Yes, the doppler probe detects arterial pulsation as an audible signal.

Normal vesels: Triphasic waveform

Mild Stenosis: Biphasic waveform

Severe Stenosis: Monophasic waveform

Question 20

What is the treatment for Lower limb occlusive arterial disease?

Answer 20

Requires MDT approach

In general management can be divided into conservative, medical or surgical.

Conservative and Medical management focus around modifying risk factors

Conservative

• Stop Smoking
• Treat obesity with Diet
• If Diabetes: Liase with diabetic nurse for diabetic control
• Referal to podiatrist for foot care
• Dedicated exercise program in those with intermittant claudication to encourage collateral supply build up

Medical

• Aspirin (75mg)
• Treat HTN
• Treat Hypercholestrolaemia
• Treat Diabetes

_Surgical _

• Endovascular techniques with stents and grafting
• Reconstructive Surgery resulting in a bypass of the occlusion: This can be
  
  • Anatomical (e.g fem-pop)
  • Extra-Anatomical (e.g axillo-femoral)
• Amputation

Other operative measurs such as endarterectomy, where the atheromatous plaque is cored out, is commonly used in surgery for carotid artery stenosis.

Sympathectomies can be useful in those with chronic, intractable pain.

Question 21

What are the benefits of Below knee amputation above an above knee amputaiton

Answer 21

BKA is prefered as

1. Pts typically demonstrate better mobility- less likely to be wheelchair bound–> increased chance of successful rehabiliation and better QOL
2. Preserve Limb Length
3. Reduced energy required to mobalise
4. Studies have shown the life expectancy for those with AKA is poorer than BKA
5. AKA are more likely to develop critical limb ischaemia in the other leg

Question 22

Reasons for Amputation

Answer 22

1. Dead (e.g PVD)
2. Dangerous (e.g Infection)
3. Debilitating (e.g Trauma)

Question 23

What level does the aorta bifurcate?

Answer 23

L4

Question 24

What is an aneurysm?

Answer 24

A Pathological, localised, permanant dilation of an artery, involving all 3 layers of its wall to 1.5 times its normal diameter.

Question 25

What are the potential complications of Abdominal Aortic Aneurysm?

Answer 25

1. Rupture, dissection, thrombosis and embolisation from the thombosis leading to trash foot.
2. Fistula formation into adjacent organs such as the colon (esp the duodenum) or the vena cava

Question 26

what is a fistula?

Answer 26

An abnormal connection between two epithelial surfaces lined by granulation tissue

Question 27

What factors would make you consider elective operative treatment of an aneurysm?

Answer 27

This depends on whether the patient is symptomatic or not.

In patients that are asymptomatic the Uk small aneurysm trial recommends repair when its diameter is >5.5cm or it is expanding at a rate of >1cm a year

If the patient is smptomatic then they should have their aneurysm repaired.

Question 28

AAA Screening Programe

Answer 28

Screening Criteria: Modified Wilson’s Criteria

Men are invited at 65- if negative then ruled out of AAA screening for rest of life

USS of abdomen