Vascular Flashcards
Sources of cardiac embolism
- atrial and ventricular
- paradoxical
- endocarditis
- cardiac tumour
Arterial sources of emboli
- artheroembolism
- aortic mural thrombus
3 causes of thrombi
- atherosclerosis
- hypercoagulable states
- bypass graft occlusion
When does irreversible limb necrosis start?
After 6-8 hours
How to classify acute limb ischaemia
Rutherford classification
Investigation of choice for acute limb ischaemia
CT angiography
Investigations for acute limb ischaemia
- U/S
- CTA
- MRA
- Echo
- Transfemoral arteriography
Possible management modalities of acute limb ischaemia
- anticoag alone
- operative intervention
- endovascular intervention
- mechanical thrombectomy
- thrombolysis
Definition of an aneurysm
A focal permanent dilatation of an artery greater than 1.5 times that artery’s normal diameter
Definition of Ectasia
A focal dilatation of an artery greater than the normal diameter of that artery, but less than 1.5 times the normal diameter
Definition of arteriomegaly
The entire arterial segment is diffusely dilated
Definition of aneurysmosis
Multiple aneurysms with intervening normal arterial segments
Complications of aneurysms
- rupture
- thrombotic occlusion
- thrombo-embolism
- pressure-related problems
- spontaneous fistulisation
Causes of aneurysms
- degenerative
- infective
- CTD
- trauma
- inflammatory
- post-dissection
- post-stenotic
- congenital
Ways to classify arterial aneurysms
- anatomical location
- aneurysm type (T/F)
- morphology
- size
- etiology
- clinical presentation
Types of AAA
- infra-renal
- juxta-renal
- para-renal
- supra-renal
- thoracoabdominal
Risk factors for AAA
- uncontrolled HPT
- hyperchol.
- smoking
- chlamydia pneumonia
Symptoms of AAA
- abdo/back pain
- compression (vomiting, constipation, flank pain, venous disease)
First line investigation for AAA
Duplex doppler
Who to screen for AAA
- caucasian males >65 yo
- peripheral aneurysms
- throacic aortic aneurysms
- family history
Symptoms of a ruptured AAA
- sudden onset acute backpain
- shock
- pulsatile abdo mass
Where is Cullen’s sign found?
Umbilicus
Where is Grey-Turner sign found?
Flanks
What is Hardman risk index for?
To predict who to intervene for with AAA
- >3 = 100% mortality
Causes of Thoraco-abdominal aneurysms
- degen
- Takayasu’s
- intimo-medial mucoid degen
- HIV-related aneurysm
- mycotic aneurysm
- TB aortitis with aneurysm
Common peripheral aneurysms
- popliteal
- femoral
Uncommon peripheral aneurysms
- subclavian
- extra-cranial carotid
- mesenteric
- renal artery
Deformities associated with diabetic motor neuropathy
- pes cavus
- hammer toes
Natural history of Charcot’s osteoarthropathy
- ligamentous failure
- subluxation and dislocation
- swollen and red
What is a normal ABI?
0.9-1.1
Foot deformities of diabetic foot
- skin cracks, fissures, calluses
- claw/hammer toes
- Rocker bottom feet
- Pes cavus
- Hallux valgus/rigidis
- Charcot’s foot
- fixed flexion deformity of PIPJ
How to classify treatment of diabetic foot
Wagner classification (Grade 0-5)
How to classify follow-up for diabetic foot
Foot-at-risk classification (Category 0-3)
Acute indications for referral for diabetic foot
- callus formation
- ulceration
- ischaemic changes
- acute local sepsis
- non-healing trauma
Chronic indications for referral for diabetic foot
- recurrence
- worsening deformity
- worsening neuropathy
- worsening sugar control
- ischaemic symptoms
Risk factors for venous thromboembolism
- age
- obesity
- varicose veins
- family history
- thrombophilia
- majory surgery/immobility
- acute illness/sepsis
Complications of venous thromboembolism
- PE
- pulmonary HPT
- post-thrombotic syndrome
Signs of a DVT
- phlegmasia alba dolens
- phlegmasia cerulea dolens
- Homan’s sign
What is homan’s sign?
Calf pain at dorsiflexion of the foot
How to know if it is likely a DVT
Well’s score >2
D-dimer (neg excludes)
Duplex US
Features of DVT on Duplex US
- venous compressability
- intraluminal echoes
- venous flow
- filling defects
Methods of prophylaxis for DVT
General
- hydration
- early mobilization
Mechanical
- elastic compression stockings
- intermittent pneumatic stockings
Pharmacological
- Unfractionated heparin
- LMWH
- oral Vit K antagonists
Clinical categorisation of PAD
- aorto-iliac
- femero-popliteal
- tibio-peroneal
Types of claudication
- intermittent
- spinal
- venous
- atypical
Stratification of PAD
- Fontaine
- Rutherford
Pharmacotherapy for PAD
Cilostazol (phosphodiesterase type 3 inhibitor)
Nafidrofuryl- hydroxytaptamine type 2 inhibitor
Classification for chronic venous disease
CEAP
- clinical signs
- etiology
- anatomy
- pathophysiology
Risk factors for chronic venous disease
- increasing age
- pregnancy
- family history
- obesity
- prolonged standing
- caucasian race
- poor dietary fibre
Clinical classification of chronic venous disease
0 = no signs 1 = telangiectasia, reticular veins, malleolar flare 2 = varicose veins 3 = oedema without skin changes 4 = skin changes (pig, eczema, lipodermato) 5 = skin changes with healed ulceration 6 = skin changes with active ulceration
Causes of venous hypertension
Reflux (90%) - superficial - deep Obstruction (10%) - iliofemoral - superficial femoral
Cause of venous insufficiency
- varicose veins
- DVT
- external pressure
- inborn valve def
- prolonged muscle inactivity
- muscle dysfunction/paralysis
- skeletal poblems
Symptoms of venous insufficiency
- aching
- throbbing
- leg fatigue/ heaviness
- swelling
- worse at night
Complications of venous insuff
- thrombophlebitis and rupture
- oedema - ulceration
Where does the GSV run?
- medial calf and thigh
Where does the SSV run?
- posterolateral calf
Where does the pelvic vein run?
- upper medial thigh and labia
Investigation of chronic venous disease
- Duplex doppler
- CT venography for complicated cases
Treatment of chronic venous disease
- compression
- sclerotherapy
- surgery
Definition of a venous ulcer
A full thickness defect of the skin, present for >30 days that fails to heal spontaneously and is sustained by chronic venous disease
How to treat venous ulcer
Compression!
Clinical presentation of ischaemic ulcers
- over bony prominences
- very painful at rest, relieved by gravity
- punched out
- surrounding skin changes
- delayed cap refill
Presentation of neuropathic ulcers
- deep punched out over pressure points
- usually painless
- Charcot’s foot
Describe Martorell ulcer
Very painful ulcer of lower leg associated with poorly controlled hypertension
Investigation of venous ulcers
- duplex doppler
- ambulatory venous pressure
- plethysmography
Why do people with upper limb ischaemia present later?
- good collaterals in the neck and less muscle mass
Etiology of upper limb ischaemia
- embolic (90%)
- thrombosis
- trauma
- iatrogenic (invasive procedures)
- Takayasu’s
- aortic dissection
- hypercoagulable states
Management of upper limb ischaemia
- anticoag (unfrac, heparin)
- analgesia
- refer to vascular
- embolectomy
- thrombolysis (if acute on chronic)
How to manage embolisation after an intra-arterial injection
- irrigate with heparin-saline solution
- inject vasodilator (nitroglycerine)
- heparin
- low mol weight dextran + dexamethasone
Explain subclavian steal syndrome
retrograde blood flow in the vertebral artery due to proximal stenosis/occlusion of the subclavian artery
- leads to vertebrobasilar insufficiency
Etiology of chronic upper limb ischaemia (large vessel)
- atherosclerosis
- aneurysms
- arteritis
- arterial thoracic outlet compression syndrome
Clinical findings in chronic upper limb ischaemia
- unilat Raynauds
- BP difference between arms
- palpable cervical rib
- palpable subclavian artery
- bruit of subclavian artery
Management of chronic upper limb ischaemia
- risk factor modification
- anti-platelet therapy
- percutaneous transluminal angioplasty + stent
- bypass surgery
Causes of upper limb ischaemia (small vessel)
- vasospasm (Raynauds)
- CTD
- Beurger’s disease
- occupational injury
- vasculitis
- misc
Principles of treating digital ulcers
- conservative debridement
- retain as much tissue as possible
- avoid damaging blood supply
- appropriate wound cover
- treat vasospasic conditions
- appropriate Ab
- protection against further injury
Management of Raynauds
- general (warmth, gloves)
- drugs (nifedipine 5mg tds)
- sympathectomy
Causes of secondary hypertension
- endocrine disorders
- renal parenchymal disorders
- renovascular disorders
Causes of renovascular hypertension
- RAS
- coarctation of the aorta
- middle aortic syndrome
Features suggesting secondary hypertension
- early onset (<30)
- late onset
- severe HPT
- malignant HPT
- HPT needing multi-drug Rx
- medically refractory
- epigastric bruits
- grade 3/4 HPT retinopathy
- flash pulm oedema
- refractory angina
- stigmata of endocrine d/o
Endocrine screen for hypertension
- 9am serum cortisol
- 24 hour urinary cortisol
- serum aldo
- plasma renin assays
- 24hr urinary metaneph/catchol
- plasma catechol
- thryoid tests
- parathyroid tests
- serum Ca and Phos
Imaging for secondary hypertesion
- CT (abdo, brain, chest)
- US of thyroid
- radio-isotope scans
- Duplex of kidneys
- MAG 3 renogram
- Captopril renogram
- Vascular (CTA, MRA, DSA)
Pathophysiology of renovascular hypertension
- activation of the RAAS system
Ang II actions
- acts on ATII receptors - vasoconstriction
- aldosterone release - fluid retention
Anatomical classification of RAS
- ostial
- parostial
- truncal
- accessory
- segmental
- mixed
- renal artery occlusion
Pathological classification of RAS
Atherosclerotic Non-atherosclerotic - FMD - Takayasu's - renal artery dissection - RA aneurysms - trauma - radiation-induced
Treatment of RAS
- medical (ACE-I)
- percutaneous transluminal renal angioplasty + stenting
- surgical revasc
- nephrectomy (if unilat)
Requirements for a nephrectomy for RAS
- 1 kidney <8cm
- single kidney GFR <10
What is FMD?
A degenerative condition of branchless vessels
- occurs in young women
Types of FMD
- medial
- adventitial
- intimal
Dx of FMD on DSA
- normal aorta
- string of beads
- mid and distal 1/3 of the renal artery
Gold standard treatment of FMD
- transluminal balloon angioplasty
What is Takayas’s disease
Non-specific large vessel vasculitis
Findings of Takayasu’s disease on CTA
- thick walled aorta
- aortic occlusion
- RAS
Gold stardard treatment of Takayasu’s
Surgical revasc
Where does coarctation of the aorta usually occur
At the ligamentum arteriosum
Diagnosis of coartcation
- ECG (LVH)
- Chest XRAY (post. inf. rib notching)
- CTA/MRA/DSA
- TOE
Classification of coarctation
- post-ductal
- pre-ductal
- interrupted
Surgical management of coarctation
- patch angioplasty
- interpositional bypass graft
- resection and re-anastomosis
Interventional management of coarctation
- balloon angioplasty
- aortic stent
- aortic stent grafting
What is mid-aortic syndrome
Acquired vascular condition - narrowing of the aorta
Disorders associated with mid-aortic syndrome
- Takayasu’s
- atherosclerosis
- cong. hypoplasia
- Von Recklinghausen’s disease
- FMD
- tuberculous aortitits
Clinical features of mid-aortic syndrome
- upper limb HPT
- radio-femoral delay
- inter-scap/ abdo bruits
- lower extremity claudication
Etiology of acute mesenteric ischaemia
- arterial embolism
- arterial thromboembolism
- venous thrombosis
- non-occlusive mesenteric ischaemia
- rare (aortic dissec, vasculitis)
Natural history of intestine in mesenteric ischaemia
- changes in villi
- mucosa sloughs off
- transmural necrosis
- perforation
- sepsis
- death
Presentation of acute Mesenteric ischaemia
- severe abdo pain (sudden, colicky)
- N+V
- Hx of arrythmias/MI
- atherosclerotic disease
Abdo XRAY findings in acute mesenteric ischaemia
- dilated small bowel
- wall oedema
- gas in wall
Management of acute mesenteric ischaemia
Resus and anticoag
Surgical
- exploratory lap
- resection
- revasc
Endovasc
- aspiration thrombectomy
- thrombolysis
- angioplasty + stenting
Associations with mesenteric vein thrombosis
- thrombophilia
- portal HPT
- intra-abdo malignancies
- pancreatitis
- preg
Causes of non-occlusive mesenteric ischaemia
- severe systemic illness
- usually in ICU on inotropes
Presentation of chronic mesenteric ischaemia
Mesenteric angina (post-prandial, peri-umbilical, recurrent)
- LOW + food fear
- N + V
Management of chronic mesentery ischaemia
Endovasc
- balloon angioplasty and stenting
Surgery
- re-implantation techniwue
- endarterectomy
- bypass
Amaurosis Fugax
Temporary retinal artery ischaemia
How to predict likelihood of secondary ischaemic event
ABCD2 stroke risk score
- age
- BP
- clinical features
- duration
- diabetes
Surgery for carotid artery stenosis
Carotid endarterectomy (local/GA)
Complications of endovasc. carotid angioplasty and stenign
- ipsilat ischaemic stroke
- labile BP
- ACS
- death
- local Hg
- nerve injuries
What does the verebrobasilar system supply?
- occipital cortex
- cerebellum
- thalamus
- brain stem
Presentation of vertebrobasilar insufficiency
- vertigo
- visual disturbance
- drop attacks
- numbness/tingling
Surgical management of vertebrobasilar insufficiency
- endarterectomy
- bypass grafting/ direct arterial transposition
