Vascular Flashcards
List the differential causes of arterial aneurysms (7)
V: artherosclerotic
Infective: mycotic endocarditis, tertiary syphilis
Trauma
C/D: berry, ehlers-danlos, marfans
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
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
What are some complications of popliteal aneurysms (3)
Acute limb ischaemia (rupture/thrombosis/emboli)
Chronic ischaemia (gradual occlusion)
DVT (if inc/ pop vv’s)
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
Outline the Fontaine classification of peripheral arterial disease
- Asymp
- IC
- Ischaemic rest pain (critical)
- Ulceration/gangrene
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
What are the causes of peripheral arterial disease (3)
Artherosclerosis
Fibromuscular dysplasia (non-inflamm thickening)
Buerger’s
What is Buerger’s disease
What are the RFs (4)
Thromboangiitis obliterans = acute inflamm / thrombosis
Male
Young (20-40)
SMOKING***
Middle/Far East
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
What are the indications for surgical intervention of IC/Rest pain (3)
ABPI <0.6
Highly symptomatic (loss of func)
Conservative ineffective
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
What are the diff surgical options for arterial limb disease (4)
Percutaneous transluminal angioplasty (balloon/stent)
Bypass reconstruction
Sympathectomy
Amputation
What features appear in diabetic neuropathy of the foot (7)
Dry skin Corns Bunions Callus Ulcers Bad toenails Deformity
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
Whats the diff b/wn dry + wet gangrene?
Dry = bact not prolif Wet = bact prolif (emergency)
What Ix are done for ?Ao Dissection
ECG – mimicks MI
CXR – widened mediastinum (not sensitive)
CT – Dx
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
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
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
List 5 diff types of lower leg ulcers
Arterial Venous Neuropathic Marjolin's (SCC) Pyoderma gangrenosum
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
- Onset
- Hx
- Source
- Pulses
Thrombosis
- Gradual onset, less severe (collaterals)
- H/o arterial disease
- No obvious source
- Long-standing weak bilateral pulses
Embolus
- Sudden onset severe (lack collaterals)
- No H/o arterial disease (IC/MI/CVA)
- Obvious source (AAA/AF)
- 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
