Differentiate arterial / venous ulcers in regards to: 1. History 2. Progression 3. Ulcer features (site/appearance/pain) 4. Oedema 5. Skin appearance

Arterial: 1. PMH IHD/IC / HTN / DM 2. Small but rapid 3. Lat mall / toes / heels – punched out – v painful 4. No oedema 5. Shiny/hairless / cool/pale / atrophic nails Venous 1. PMH DVT/VVV / Obese 2. Slow but large 3. Med mall / gaiter – shallow / sloughy – painless 4. Oedema common 5. Venous insufficiency / red+warm

Vascular Flashcards by Emmy Beever

List the differential causes of arterial aneurysms (7)

V: artherosclerotic
Infective: mycotic endocarditis, tertiary syphilis
Trauma
C/D: berry, ehlers-danlos, marfans

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What are the indications for surgery on AAA (3)

What rupture RFs may allow this earlier (4)

> 6cm
Expanding >1cm/yr
Symptomatic

Female
HTN
Smoker
FH rupture

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What is the main procedure done for AAAs?
What special considerations must be made?
Commonest complication

EVAR (endovascular arterial repair)

Need thorough pre-op (cardiac/resp/RENAL problems)
EVAR: Contrast nephrotoxic
Open: prolonged renal ischaemia

Common comp: endoleak

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What are some complications of popliteal aneurysms (3)

Acute limb ischaemia (rupture/thrombosis/emboli)
Chronic ischaemia (gradual occlusion)
DVT (if inc/ pop vv’s)

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What Ix and management are done for popliteal aneurysms

USS + Angiogram (pre-op assess distal aa tree)

Distal popliteal aa bypass graft
Intravascular thrombolysis/embolectomy

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Outline the Fontaine classification of peripheral arterial disease

Asymp
IC
Ischaemic rest pain (critical)
Ulceration/gangrene

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What is normal ABPI

What are the diff ABPI thresholds for arterial disease (3)

Normal: 0.8–1.2

<0.8 = arterial disease
<0.4 = critical
>1.2 = DM arterial calcification/stiff

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What are the causes of peripheral arterial disease (3)

Artherosclerosis
Fibromuscular dysplasia (non-inflamm thickening)
Buerger’s

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What is Buerger’s disease

What are the RFs (4)

Thromboangiitis obliterans = acute inflamm / thrombosis

Male
Young (20-40)
SMOKING***
Middle/Far East

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What ABPI are conservative measures taken for IC/Rest pain

Describe these measures (6)

ABPI >0.6 = conservative

Lifestyle: Lose wt/ STOP SMOKING
Shoe heel
Foot care (avoid minor trauma)
Control HTN
Control DM
Clopidogrel/atorvastatin

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What are the indications for surgical intervention of IC/Rest pain (3)

ABPI <0.6
Highly symptomatic (loss of func)
Conservative ineffective

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List some life/limb threatening causes in an acutely painful limb (7)

Acute ischaemia
Compartment syndrome
Spinal cord compression
Septic arthritis
Gangrene
Nec Fasc
Sickle cell crisis

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What are the diff surgical options for arterial limb disease (4)

Percutaneous transluminal angioplasty (balloon/stent)
Bypass reconstruction
Sympathectomy
Amputation

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What features appear in diabetic neuropathy of the foot (7)

Dry skin
Corns
Bunions
Callus
Ulcers
Bad toenails
Deformity

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How does peripheral neuropathy of lower limb present
With
Without presence of arterial disease

With arterial:
Severe ischaemia yet painless
Ulceration / rapid gangrene

W/o arterial:
Stabbing pain
Red/warm
Strong pulses
Not relieved lifting over bed/off floor

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Whats the diff b/wn dry + wet gangrene?

Dry = bact not prolif
Wet = bact prolif (emergency)

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What Ix are done for ?Ao Dissection

ECG – mimicks MI
CXR – widened mediastinum (not sensitive)
CT – Dx

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How is aortic dissection managed

A–E
Analgesia
Urgent cardiothoracic advice
ITU control SBP to 100 (IV esmolol)
Type A: surgery if fit
Type B: medically unless comps

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List possible complications of aortic dissection (1+6)

Cardiac tamponade (retrograde spread)
Distal arterial blockage:
Coronary – MI
Brachiocephalic – unequal arm pulses / stroke sx
L carotid / L subclav – same
Renal – haematuria/anuria/AKI
SMA/IMA – acute mesenteric ischaemia
Iliac – acute lower limb ischaemia

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Outline the management of venous leg ulcers

Assess for:
Arterial (ABPI/Doppler)
Infection

Uncomplicated:
Washing + Compression bandaging (2 or 4-layer)
Leg elevation

Infected:
Swab + Dress
Abx (fluclox)

Long-term: compression stockings
Lifestyle / avoid prolonged standing
DM control

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List 5 diff types of lower leg ulcers

Arterial
Venous
Neuropathic
Marjolin's (SCC)
Pyoderma gangrenosum

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Differentiate arterial / venous ulcers in regards to:

History
Progression
Ulcer features (site/appearance/pain)
Oedema
Skin appearance

Arterial:

PMH IHD/IC / HTN / DM
Small but rapid
Lat mall / toes / heels – punched out – v painful
No oedema
Shiny/hairless / cool/pale / atrophic nails

Venous

PMH DVT/VVV / Obese
Slow but large
Med mall / gaiter – shallow / sloughy – painless
Oedema common
Venous insufficiency / red+warm

List 5 diff types of lower leg ulcers

Arterial
Venous
Neuropathic
Marjolin's (SCC)
Pyoderma gangrenosum

List the features of small bowel ischaemia (4)

Post-prandial pain (gut claudication)
PR bleed
Malabsorption
Wt loss (eating painful)

List the features of large bowel ischaemia (3)

L sided abdo pain Bloody diarrhoea Peritonitis / sepsis (tachycardia / WCC / pyrexial) ± shock

In acute arterial occlusion of limb (thrombi/emboli) What are the features of a threatened limb (4) Features of a non-viable limb (2)

Paralysis Paraesthesia Pain passively moving limb Pain squeezing calf Non-blanching stain (purple/mottled)

In acute arterial occlusion of limb (thrombi/emboli) What are the features of a threatened limb (4) Features of a non-viable limb (2)

Paralysis Paraesthesia Pain passively moving limb Pain squeezing calf Non-blanching stain (purple/mottled) Rigid muscles

Differentiate b/wn thrombosis / embolus presentations of acute arterial occlusion of limb 1. Onset 2. Hx 3. Source 4. Pulses

Thrombosis 1. Gradual onset, less severe (collaterals) 2. H/o arterial disease 3. No obvious source 4. Long-standing weak bilateral pulses Embolus 1. Sudden onset severe (lack collaterals) 2. No H/o arterial disease (IC/MI/CVA) 3. Obvious source (AAA/AF) 4. Unilateral absent pulse, contralat normal, prev normal

Outline the management of acute limb ischaemia (6)

A–E resus IV heparin Assess limb Urgent CT angio Surgery (embolectomy/thrombolysis/bypass/amputation) Post-op monitoring (reperfusion/compartment)

List the causes of an AV fistula (3)

Penetrating trauma (commonest) Neighbouring aneurysm erosion Iatrogenic (haemodialysis)

What are the features of a (non-iatrogenic) AV fistula (5)

``` Pain / heaviness Oedema Prominent vv's Audible murmur / palpable thrill S/o CCF (severe) ```

What Ix may be done if suspecting a non-iatro AV fistula (4) | How are they treated?

VBG (distal – O2 sats) Coag Duplex USS Contrast CT

What Ix/management for: Chronic small bowel ischaemia Chronic large bowel ischaemia

Small bowel: angiography / angioplasty ``` Large: Contrast enema / AXR (thumb printing) MR angiography** Conservative – fluid/abx Stenting (for severe) ```

Causes of secondary VVVs (4)

Prev DVT Compression (pelvic tumour / preg) Av fistula Severe tricuspid incompetence

Symptoms of VVV/Deep VV insuffs

``` Leg tiredness/aching Nocturnal cramps Itching Oedema Haemosiderin (gaiter) Atrophie blanche Lipodermatosclerosis Ulceration ```

What Ix can be done into VVV/insufficiency (3)

Doppler (SFJ/SPJ reflux) Duplex Venography

What are the indications for managing VVVs? (4)

Symptomatic Grossly dilated Deep vv insufficiency (e.g. skin changes) Incompetent perforator valves

What are the management options for VVVs (5)

Lifestyle (avoid prolonged standing / exercise / lose wt) Compression stockings (for minor/unfit/preg) Endothermal ablation (USS laser + thrombose) Sclerotherapy (foam injected + compression = fibrose) Surgery (vv stripping / ligate incompetent perforators)

What are the complications of VVVs?

Haemorrhage (from minor trauma) | Phlebitis (spontaneously/post-sclero)

List some other causes for a raised D-dimer in DVT? (4)

Pregnancy Post-op Malignancy Infection

What are the components of a DVT Well's score (9)

``` Malignancy (active/<6m) Calf swelling >3cm than other Prominent superficial vvs (non-varicose) Pitting oedema (> in affected leg) Swelling of entire leg Localised pain along deep vv distrib Immob (paralysis/cast) Bed rest >3d / Major Surgery (<12wks) PMH DVT/PE ``` Alternative Dx just as probable (subtract 2 points)

How is a proven DVT managed? + how long these Tx for?

``` Start together: LMWH: stop when INR = 2–3 Warfarin: • Lifelong if recurrent/thrombophilia • 6m if no obv cause • 3m if post-op ```

What are the indications for an IVC filter in a DVT?

If PE despite anticoag | If bleeding from anticoag

List the DDx causes for Reynaud's sydrome | Cold Temp Makes Cold Digits

CTDs (sys sclerosis / SLE/ sjorgen's / polayarteritis) Trauma (occupational) (vibration / chem) Macrovascular (arthero / buerger's / thoracic outlet) Cancer / cancer drugs Drugs (B-blockers / OCP)

What features in Reynaud's may suggest a 2º cause? (4)

Dilated nail fold capillaries Young child / >30 Asymm distrib Male

What Ix may be done into Reynauds?

Only do if suspect 2º ``` FBC (polycythaemia / malig) ESR UEs (renal / dehyd) Urine dip (GN) ANA (if suspect CTD) ```

What are the causes of 1º/2º lymphoedema?

1º – Milroy's (lymphatic defc) | 2º – Filaria infection/Recurrent cellulitis // Malig/Post-op

What is the main DDx feature of lymphoedema vs normal oedema

Lymphoedema = non-pitting

How is lymphoedema managed (4)

Elevation Compression stockings Physical massage Long-term Abx (for recurrent cellulitis)

What Ix can be done into a non-iatro AV fistula? | How would it be managed?

VBG (distal to AVF) Coag (coagulopathies due to turbulent flow) Duplex USS Contrast CT Surgical Rx / Interventional radiology

List the life/limb threatening DDx of leg pain

``` 4 physiological: • acute ischaemia • compartment syndrome • spinal cord compression • sickle ``` 3 infective: • gangrene • nec fasc • septic arthritis

Causes of thoracic outlet obstruction (3)

Cervical rib Healed clavicular # Excess mm development

DDx to thoracic outlet obstrn

Cervical Myelopathy