Vascular Flashcards
Define TIA
Acute loss of focal cerebral function with symptoms lasting for less than 24 hours
No apparent cause other than vascular origin
What % of strokes are caused by ischaemia?
80%
What are the potential pathologies of the carotid artery?
Carotid thromboembolism
Small vessel disease
Cardiac embolism
Haematological
What are the features of a stroke of carotid origin?
Hemisensory or hemimotor deficit
Monolateral blindness
Higher cortical dysfunction e.g. Expressive dysphasia, visuospatial neglect
What are the features of a vertebrobasilar stroke?
Hemisensory or hemimotor deficit Bilateral motor/sensory Bilateral blindness Dysarthria Veering to one side Ataxia/unsteadiness Homonymous hemianopia
What features indicate that the patient has not had a TIA?
Isolated diplopia
Isolated vertigo
Isolated dizziness
(pre)syncope
What grade of carotid stenosis requires surgical intervention?
High-grade: over 70%
What are the aspects of optimal medical management for carotid artery disease?
Anti platelet Blood pressure Statin therapy Diabetic management Angina Lifestyle advice
Describe carotid endarterectomy
Carotid artery cut at its bifurcation
Temporary shunt inserted to avoid the surgical site
Plaque removed
Artery sutured
What nerves may be damaged during carotid endarterectomy?
Vagus CNX
Hypoglossal CNXII
Ansa (part of cervical plexus)
What are the potential risks of carotid endarterectomy?
Stroke (3%)
Nerve damage - especially hypoglossal (3%)
When is surgery used for asymptomatic carotid disease?
70-99% stenosis
Otherwise fit males
What are the potential benefits of carotid angioplasty rather than endarterectomy?
Less invasive
No neck incision
No risk of cranial nerve injury
Define aneurysm
A permanent localised dilatation of an artery
More than 50% of the normal diameter of the artery
Define ectasia
Localised area of enlargement in the artery but less than 1.5x
What is a true aneurysm?
All 3 layers of the arterial wall involved
What is a false aneurysm?
Leakage of blood out of an artery into a cavity surrounded by connective tissue, that is expansile and Pulsatile
Where is the most common site for an abdominal aortic aneurysm?
Infra-renal AA
What is the normal diameter of the male abdominal aorta?
1.5 - 2 cm
Define an infra-renal AAA
Diameter > 3 cm
What % of elderly males have an AAA?
5%
At what rate do AAAs commonly expand?
10% per year
What factors influence rupture of AAAs?
Blood pressure
Smoking
What is the most common presentation of an AAA?
Majority are asymptomatic
How does a ruptured AAA present?
Triad:
Abdominal pain (epigastric radiating to back, sudden onset)
Pulsatile mass
Hypovolaemic shock - leading to collapse
What are the indications for repair of am AAA?
Symptomatic, rapidly expanding, or ruptured
Asymptomatic > 5.5 cm
What is the mortality from ruptured AAAs?
Overall 75%
50% make it to hospital, and 50% of these die
What are the complications of open repair of an AAA?
Haemorrhage Cardiac events Respiratory complications Renal failure Embolism/thrombosis of distal arterial tree Colonic ischaemia Death
What are the complications of endovascular repair of an AAA?
Graft migration
Fracture of supporting wires
Endoleak
Endotension
Define stroke
Acute loss of focal cerebral function, with symptoms lasting longer than 24 hours
No apparent cause other than a vascular origin
How can popliteal aneurysms present?
Asymptomatic Claudication Embolisation Occlusion Rupture
How do you examine for a popliteal aneurysm?
Get patient to relax leg and bend to 45degrees
How do you treat popliteal aneurysms?
Hunterian ligation of popliteal aneurysm and bypass surgery
Endovascular stenting
What is the normal range for ABPI?
0.9 - 1.3
What is the underlying pathology of intermittent claudication?
Atheroma
What are the non-modifiable risk factors for PVD?
Age
Male gender
Family history
What are the modifiable risk factors for PVD?
Smoking Hypertension High LDLs High cholesterol Sedentary lifestyle Diabetes mellitus
What is intermittent claudication?
Pain in the muscles of the lower limb elicited by walking/exercise
What are the characteristics of intermittent claudication pain?
Always in the muscles, most commonly calf but sometimes thigh or buttock
Cramp-like pain
Always relieved by rest
Worse going uphill
What causes pain in PVD?
Muscle O2 requirement/availability mismatch
Leads to muscle ischaemia
Muscles have to metabolise anaerobically, producing lactate and substance P - cause pain
What are the differential diagnoses of intermittent claudication?
Spinal stenosis
Lower limb arthritis
Musculoligamentous strain
How does arthritis pain differ from intermittent claudication?
Arthritic pain worse going downhill and in the first few steps
Where are the majority of atheromatous plaques located in PVD?
Superficial femoral artery
What is Leriche’s syndrome?
Bilateral buttock claudication + erectile failure
Common/internal iliac or distal aorta affected
Where do you feel for the common femoral pulse?
Mid-inguinal point
Where do you feel for the posterior tibial pulse?
Behind medial malleolus
Where do you feel for the dorsalis pedis pulse?
Pull toe up - lateral to flexor hallucis longus tendon
What is the conservative management of PVD?
Stop smoking
Correct risk factors
Exercise
What are the surgical options for intermittent claudication?
Angioplasty
Surgical bypass: fempop
Why is smoking such a powerful risk factor for PVD?
Atherogenic
Increases lipids
Reduces HDLs
Increases platelet adhesion and fibrinogen levels
How does exercise rehabilitation help PVD?
Optimises collateral blood distribution
Improves capillary perfusion
What % of patients with intermittent claudication require surgery?
2%
What are the features of critical limb ischaemia?
Rest pain
Ulceration/gangrene of leg
What is sunset foot?
Foot is paradoxically red on examination in critical limb ischaemia
What is Buergers test?
When you lift an ischaemic foot it goes white, showing arterial stenosis
How is critical limb ischaemia managed?
Optimise medical management
Will need angioplasty or bypass surgery to salvage leg
May need amputation if in a lot of pain and revascularisation not possible
What is the course of the long saphenous vein?
Begins at medial malleolus
Travels up medial calf
Wiggles round knee then goes straight up the thigh
Joins femoral vein at saphenous opening
Where is the saphenous opening?
1 inch medial and lower than femoral pulse
What are the superficial veins in the lower limb?
Superficial saphenous vein
Long saphenous vein
What are the deep veins in the lower limb?
Deep femoral (thigh) Popliteal (calf)
Define varicose veins
Tortuous, twisted or lengthened veins
What are the different types of varicose veins?
Trunk
Reticular
Telangiectasia
What factors aggravate varicose veins?
Obesity
Occupation
Pregnancy
What type of varicose veins lead to surgery?
Trunk
Define Telangiectasia
Tiny blood vessels swollen so they become visible
What is Virchow’s triad?
Stasis
Viscosity
Direct damage to vessel
How are varicose veins classified?
0 - 6 depending on degree of signs and symptoms
What class of varicose veins need treatment?
5 or 6
What are class 5 varicose veins?
Ulcer present
What are class 6 varicose veins?
Had ulcer but either with treatment/conservative management it resolved
What are the symptoms of varicose veins?
Heaviness
Tension
Aching
Itching
What are the potential complications of varicose veins?
Haemorrhage
Thrombophlebitis
Complications from venous hypertension…Oedema, skin pigmentation, varicose eczema, atrophie blanhe, lipodermatosclerosis, venous ulceration
What is lipodermatosclerosis?
Skin becomes thick and yellowish
What are the potential causes of varicose veins?
DVT
Pelvic tumours
AV fistulae
How do you examine varicose veins?
Not distribution of veins with patient standing - long or short saphenous involved?
Tap test
Note whether there are any skin changes
Hand-held Doppler to detect incompetent veins
What is the treatment for varicose veins?
Reassurance Compression hosiery Surgery Injection sclerotherapy Endovenous laser obliteration of long saphenous vein
What does varicose veins surgery involve?
Tiny cut made below knee Cannula put into LSV Ablate LSV (burn it) using a laser Means blood returns via the deep venous system which is still competent, rather than the incompetent superficial system
What proportion of leg ulcers are venous?
80-85%
What are the indications than an ulcer is due to arterial pathology?
Pale, pulseless, pain, paraesthesia, cold
Muscle wasting
Low ABPI
Gangrene
Medical history and RFs for arterial disease
Sites of high external compression eg metatarsal I and heel
Where are arterial ulcers commonly found?
Sites of high external compression eg metatarsal I and heel
Where are venous ulcers commonly found?
Gaiter area - between knee and ankle
What are the associated features of venous ulceration?
Varicose eczema Lipodermatosclerosis Oedema Erythema Itching Haemosiderin staining Telangiectasia Induration (hardening) Phlebitis
What are the causes of leg ulcers?
Arterial pathology - atheroclerosis or AV malformation
Vasculitis
Neuropathic
Haematological
Traumatic eg burns, cold injury, radiation
Neoplastic
What is the pathophysiology of venous ulceration?
Calf muscle pump failure means veins can’t drain blood back to the heart leading to venous hypertension
What are the causes of calf muscle pump failure?
Failure of calf muscle contraction eg immobility, obesity
Outflow tract obstruction
Deep vein incompetence
Volume overload
What must you check before using compression bandages for varicose veins?
ABPI > 0.8 safe for 4-layer bandaging
> 0.5 safe for 3-layer bandaging
How do you prevent ulcers recurring?
Keep mobile Surgery to correct superficial venous reflux (varicose veins) Below knee class 2 compression hosiery
What is ischaemic rest pain?
Pain in skin due to ischaemic nerve endings
Usually at night as there are no effects of gravity and cardiac output is lower when asleep
What artery is stenosis to cause calf pain?
Superficial femoral
What artery is stenosis to cause thigh or buttock pain?
Aorto-iliac stenosis or occlusion
What do ulceration and gangrene occur?
Insufficient blood to maintain tissue viability
What are the trophic changes found with ulceration?
Loss of hair
Shiny skin
Muscle wasting
Thickened toenails
What causes misleading ABPI results?
Diabetes causing calcified vessels
What are the indications for varicose vein surgery?
Haemorrhage
Venous skin changes
Superficial thrombophlebitis
Aching legs
What proportion of claudicants progress to amputation?
Stop smoking limb loss at 5y 0%
Continue smoking 10% at 5y
What are the clinical features of acute limb ischaemia?
6Ps: Pain Pallor Pulseless Paraesthesia Perishingly cold Paralysis
What are the underlying mechanisms for a diabetic foot?
Neuropathy
Ischaemia
Infection
What is the law of Laplace?
The bigger the diameter of an aneurysm, the faster it grows
What are the secondary causes of lymphoedema?
Malignant obstruction
Surgery
Radiotherapy
What are the clinical features of lymphoedema?
Painless swelling
Associated with recurrent infection
