Vascular Flashcards
Post-phlebitic limb: chronic venous insuficiency
Examination
(Inspection, palpation, completion, special test)
Inspection
- Venous Infufficiency (HAS LEGS)
- Haemosiderosis; damages capillaries leak blood -> read brown patches
- Atrophie blanch
- Swelling, ankle (chronic v insuff/DVT/HF)
- Lipodermatosclerosis; inflammation of subcutaneous fat-> woody hard skin
- Eczema, venous
- Gaiter ulcers
- Stars, venous
- Varicose veins: Superficial venous dilation and tortuosity.
- Present as collaterals bypassing the obstruction
Palpation: pitting oedema
Completion
- Perthe’s test;
- Tests for deep venous occlusion
- High tourniquet around pts. leg + walking for 5min
- Deep obstruction → swelling and pain
- Abdominal exam + PR
- Pelvic exam in women
Post-phlebitic limb: chronic venous insuficiency
History
Hx
- Previous DVT; Orthopaedic surgery/Complicated obstetric
- Venous Claudication: “Bursting” pain in the leg after exercise, Relieved by rest and elevation of limb (cf. arterial)
Post-phlebitic limb: chronic venous insuficiency
causes
Reflux following DVT: 90%
Obstruction following DVT: 10%
Post-phlebitic limb: chronic venous insuficiency
venous gangerne
(What? 3 phase)
- Rare complication of DVT in the iliofemoral segment
- 3 phases
- Phlegmasia alba dolens: white leg
- Phlegmasia cerulea dolens: blue leg
- Gangrene 2O to acute ischaemia
Post-phlebitic limb: chronic venous insuficiency
Lipodermatosclerosis (viva)
Lipodermatosclerosis
- Panniculitis
- Venous HTN → extravasation of fibrin and red cells
- Poor tissue oxygenation → ulceration and fat necrosis
- Inverted champagne bottle appearance
- Chronic inflam → fibrosis → distal shrinkage
- Venous obstruction → proximal leg swelling
Post-phlebitic limb: chronic venous insuficiency
Ix of Deep Venous Disease
Ix of Deep Venous Disease
- Duplex: reflux and occlusion
- Venography
- Ascending: patency and perforator incompetence
- Descending: reflux
- Ambulatory venous pressures
Post-phlebitic limb: chronic venous insuficiency
Surgical options (reflu/obstruction)
Surgical Options
Reflux
- Trahere Transplantation
- Transplant segment of axillary vein c¯ valve into deep venous system of leg
- Wrap c¯ PTFE cuff
- Kistner Operation
- Valvuloplasty of damaged valves
Obstruction
- Palma operation
- Use contralateral GSV and anastomose to femoral vein to bypass iliofemoral obstruction
Venous
Examination
(inspect, palpate, ausculation, other)
Inspect;
- Scars; esp in groin creases
- skin colour changes
- Venous Infufficiency (HAS LEGS)
- Haemosiderosis; damages capillaries leak blood -> read brown patches
- Atrophie blanch
- Swelling, ankle (chronic v insuff/DVT/HF)
- Lipodermatosclerosis; inflammation of subcutaneous fat-> woody hard skin
- Eczema, venous
- Gaiter ulcers
- Stars, venous
- Varicose veins: Superficial venous dilation and tortuosity
- Distribution;
- medial and above the knee; great saphenous
- Posterior and below the knee; short saphenous
- Few varicosities and prominent skin changes; calf perforators
- Distribution;
- ?Inverted champagne bottle leg
Palpate
- Pitting oedema; if present establish how far oedema extends; also check JVP if oedema is found
- Palpate varicosities
- Tenderness/hardness: thrombophlebitis
- Induration: thrombosis
- Saphena varix @ SFJ
- Two finger breaths below and lateral to pubic tubercle
- Bluish tinge, disappears on lying flat
- May have cough impulse (Cruveihier’s Sign)
- Calf tenderness (DVT)
Percussion (wave of varicosities; tap distally and feel impulse proximally (normal) and tap proximally and feel impulse distally (incompetent valves))
- Tap test (Chevrier’s Test)
- Tap proximally and feel for impulse distally
- Distal pulses: PTA, DPA
Auscultation ; bruit over varicosity; AVM
Other
- Trendelenburg (/tourniquet) test if varicosities present; determines the position of venous regurgitation of varicosities in leg.
- Elevate limb to 15* and note rate of venous emptying
- Position patient supine, Lift pt leg as high as comfortable and milk leg to empty the veins. While elevated place tourniquet/press thumb over saphenofemoral junction (2-3cm below and 2-3cm lateral to pubic tubercle) ask pt to stand while pressure is maintained.
- Controlled: incompetence above tourniquet. Release tourniquet to confirm filling
- Uncontrolled: incompetence below tourniquet e.g. SPJ or calf perforators. Repeat test with tourniquet just below knee
- Examine the abdomen and perform a PR
- Pelvis examination in females
- Pulses (arterial)
- Doppler; Place probe @ SFJ/SPJ and squeeze calf. Normally hear only half second whoosh when pressure released. Long whoosh suggests valve incompetence.
Varicose veins
presentation
presentation: Abnormal, Tortuous, dilated veins of the superficial venous system. clearly in the distribution of the LSV in the medial side of the thigh and calve. These can be primary: which 99% are, which replies a failure of the valves and reflux down the superficial venous system. They can be secondary; as a result of blockage in the deep viens and increased pressure on the venous system higher up.
Varicose veins
symptoms and complications
Symptoms:
- Cosmetic defect
- Pain, cramping, heaviness
- Tingling
- Bleeding: may be severe
- Swelling
Complications;
- Swelling and oedema
- Thrombophlebitis
- Bleeding
- Varicose eczema
- Haemosidering deposition-> lipodermatosclerosis (woody, champagne bottle)-> venous ulceration
Varicose veins Investigations
Duplex US
- Indications
- Previous Hx of DVT
- Signs of chronic venous insufficiencyl Suggests deep venous disease for which the varicosity may be the collateral.
- Recurrent varicose veins
- Difficulty in deciding whether GSV or SSV is incompetent
Preparation for Surgery
- FBC, U+E, clotting, G+S
- CXR
- ECG
Varicose veins classifications
CEAP Classification, Classification of Chronic Venous Disease
- Clinical signs (1-6 + sympto or asympto)
- Etiology
- Anatomy
- Pathophysiology
Varicose veins management
Conservative
- Lose wt. and regular exercise
- Avoid prolonged standing
- Class II graduated Compression Stockings; 18-24mmHg
- Skin care: emollients
Minimally Invasive Therapies (Indications; Small below knee varicosities not involving GSV or SSV)
- Techniques
- Local or GA
- Injection sclerotherapy: 1% Na tetradecyl sulphate
- Endovenous laser or radiofrequency ablation
- Post-Operatively
- Compression bandage for 24hrs
- Compression stockings for 1mo
Surgery (Indications; SFJ incompetence//Major perforator incompetence// Symptomatic: ulceration, skin changes, pain)
- Procedures
- Trendelenberg: saphenofemoral ligation
- SSV ligation: in the popliteal fossa
- LSV stripping: no longer performed due to potential for saphenous nerve damage.
- Multiple Avulsions
- Cockett’s Operation: perforator ligation
- SEPS: Subfascial Endoscopic Perforator Surgery
- Post-op
- Bandage tightly and elevate for 24h
- D/C c¯ compression stockings and told to walk daily.
- Complications:
- Early
- Haematoma: esp. groin
- Wound sepsis
- Nerve damage: e.g. long saphenous
- Late
- Superficial thrombophlebitis
- DVT
- Recurrence: 10% @ 5yrs
Varicose veins
pathophysiology
- One-way flow from sup → deep maintained by valves
- Valve failure → ↑ pressure in sup veins → varicosity
- Fibrous tissue invades tunica intima and media, breaking up the SM
- Prevents maintenance of vascular tone → dilatation
- 3 main sites where valve incompetence occurs
- SFJ: 3cm below and 3cm lateral to pubic tubercle
- SPJ: popliteal fossa
- Perforators: draining GSV
- Chronic venous insufficiency is distinct and results from incompetency in the deep system itself.
- May co-exist c¯ varicose veins
Varicose veins
causes
- Primary / Idiopathic: 95%
- Prolonged standing
- Pregnancy
- Obesity
- OCP
- Secondary: 5%
- Valve destruction: DVT, thrombophlebitis
- Obstruction: pelvic mass, DVT
- AVM
- Syndromes
- Klippel-Trenaunay-Weber
- Abnormality of the deep venous system
- Varicose veins
- Port wine stain
- Bony and soft tissue hypertrophy of the limbs
- Parkes-Weber Syndrome
- Multiple AVMs c¯ limb hypertrophy
- AVMs can → high-output HF
- Klippel-Trenaunay-Weber
Lymphoedema
Examination
(inspect, palpate, complete)
Inspection
- Gross leg swelling
- Bilateral or unilateral
- Thick, indurated skin
- Lichenification
- Yellow nail discoloration
Palpation
- Initially: pitting
- Later: non-pitting
- Palpate for inguinal nodes
Completion
- Exclude RHF: ↑ JVP, Hepatomegaly
- Take a Hx: esp. re hereditary conditions
Lymphoedema
vival
DDiagnosis; bilateral and unilateral limb swelling
Bilateral
- ↑ Venous Pressure
- RHF
- Venous insufficiency
- Drugs: e.g. nifedipine
- ↓ Oncotic Pressure
- Nephrotic syndrome
- Hepatic failure
- Protein losing enteropathy
- Lymphoedema
- Myxoedema; Hyper- / hypo-thyroidism
Unilateral
- Venous insufficiency
- DVT
- Infection or inflammation
- Lymphoedema
Lymphodema
define
Pimary and secondary causes
Define: Collection of interstitial fluid due to blockage or absence of lymphatics.
Primary; Congenital absence of lymphatics. May or may not be familial. Presentation:
- Congenital: evident from birth.
- Praecox: after birth but < 35yrs
- Tarda>35 yrs
- Milroy’s Syndrome: 2% of primary lymphoedema. Familial AD subtype of congenital lymphoedema F>M
Secondary: FIIT
- Fibrosis: e.g. post-radiotherapy
- Infiltration
- Ca: prostate, lymphoma
- Filariasis: Wuchereria bancrofti
- Infection: TB
- Trauma: block dissection of lymphatics
Lymphoedema
Viva; Management
(conservative, physio, surgical)
Conservative
- Skin care
- Grade 3 compression stockings
- Treat or prevent cellulitis
Physio
- Raise leg as much as possible
Surgical
- Debulking operation
- Bypass procedures
Peripheral Ulcer Examination
Inspect, palpate, complete
Inspection: BEDS
- 3s: Site, Size, Shape
- Base:
- Granulation tissue
- Slough
- Floor: bone, tendon, fascia
- Edge:
- Sloping: healing – usually venous
- Punched-out: ischaemic or neuropathic
- Undermined: pressure necrosis or TB
- Rolled: BCC
- Everted: SCC
- Discharge: Serous, Purulent, Sanguinous
- Surroundings: Cellulitis, Excoriations, Sensate, LNs
Palpation
- Limb pulses
- Sensation around the ulcer
Completion
- Examine contralateral side
- Distal neurovascular examination
- ABPI: must be >0.8 for compression bandaging
Causes of PEripheral ulcer
Causes;
Venous: 75% + Arterial: 2% + Mixed arteriovenous: 15% + Neuropathic
Other: Pressure, Vasculitis: e.g. PAN, Malignancy: SCC, Marjolin’s, Systemic: pyoderma gangrenosum
Venous ulcer
Findings on Examination
(inspect/palpate)
Inspection Site: medial malleolus, Size: variable, can be v. large, Base: Shallow and Pink granulation tissue, Edge: sloping edge, Discharge: seropurulent Surroundings: Signs of chronic venous insufficiency: HAS LEGS and Varicose veins
Palpation Painless, Warm surroundings, Sensate
Venous ulcer
viva causes
Valvular disease Varicose veins Deep vein reflux: e.g. post DVT Outflow obstruction (Often post DVT) Muscle pump failure Stroke Neuromuscular disease
Venous ulcer
Investigations
ABPI if possible
Duplex ultrasonography
Biopsy may be necessary: esp. if persistent ulcer
Look for malignant change: Marjolin’s ulcer
Venous Ulcer mangagement
(general, compression, other)
Refer to leg ulcer community clinic
General Measures
- Optimise risk factors: nutrition, smoking
- Analgesia
- Bed rest + elevate leg
4 layer compression bandaging if ABPI >0.8
- Construction
- Non-adherent dressing + wool bandage
- Crepe bandage
- Blue line bandage: light compression
- Cohesive compression bandage
- Change bandages 1-2 x/wk
- Once healed use grade 2 compression stockings for life
Other Options
- Pentoxyfylline PO: ↑ microcirculatory blood flow
- Desloughing c¯ larval therapy
- Topical antiseptics: Manuka honey
- Surgical: split-thickness skin grafts
Ischaemic Ulcer
Examination
Inspection/palpation
Inspection
- Site; Tips of and between toes, Base of 1st and 5th metatarsals, Heel
- Size: mm-cm
- Base; Deep: may be down to bone, May be slough but no granulation tissue
- Edge: punched-out
- Surroundings; Pale, Trophic changes
Palpation; Painful, Cold surroundings, Sensate, Reduced or absent distal pulses
Causes of Ischaemic ulcer
(large/small)
Large Vessel; Atherosclerosis, Thombangiitis obliterans (Buerger’s Disease)
Small Vessel; DM, PAN, RA
MAnagement of ischaemic ulcer
Analgesia, RF modification, medical
Analgesia:
- Can be extremely painful-> Combination of drugs administered regularly
- Based on the analgesic ladder: titrate to pain
- Paracetamol + NSAIDs
- Weak opioids: e.g. codeine
- Strong opioids: e.g. morphine
Risk Factor Modification; Stop smoking + Control DM and HTN + Optimise lipids
Medical
- Avoid drugs which may worsen symptoms: e.g. β-B
- Low-dose aspirin
- IV prostaglandins
- Chemical lumbar sympathectomy: Chemical ablation of L1-L4 paravertebral ganglia, Inhibit sympathetic-mediated vasoconstriction, Relief of pain, Often unsuccessful in DM: neuropathy
Neuropathic Ulcer Examination
Inspection, extras, palpation, completion
Inspection
- Site: pressure areas: Tips of and between toes, Base of 1st and 5th metatarsals, Heel
- Size: variable
- Shape: corresponds to shape of pressure point
- Base: may be deep c¯ bone exposure
- Edge: punched-out
- Surroundings; Skin looks normal, Charcot’s joints, May be signs of PVD if co-existent arterial disease
Extras
- Blood sugar testing marks on fingers
- Insulin injection marks on the abdomen
Palpation;
- Normal temperature
- Normal peripheral pulses
- Absent sensation around ulcer
- Absent ankle jerks
Completion
- Full peripheral vascular exam
- Cranial and peripheral neuro exam
NEuropathic ulcer causes
Any cause of peripheral neuropathy
DM Alcohol B12 CRF Drugs: e.g. isoniazid, vincristine Every vasculitis
Pathophysiology of neuropathic ulcer (sensory, motor, autonomic)
Sensory neuropathy: distal limb damage not felt by pt.
Motor neuropathy: wasting of intrinsic foot muscles and an altered foot shape e.g. Claw toes + prominent metatarsal heads
Autonomic neuropathy: ↓ sweating → cracked, dry foot
Thoracic Outlet Obstruction Examination
Inspection, palpation
Inspection
- Arm: ↓ venous outflow
- Oedema: pitting
- Cyanosis
- Pallor
- Hand: ↓ arterial inflow
- Raynaud’s
- Patchy gangrene
- Fingertip necrosis
- Hand and Arm: neurological complications
- Complete claw hand
- T1 sensory loss
- Radicular pain
Palpation
- Palpate for cervical rib above the supraclavicular fossa
- Disappearance of radial pulse on abduction and external rotation of arm
Differential of Thoracic Outlet Obstruction
- Arterial: Raynaud’s
- Venous: axillary vein thrombosis or trauma
- Neurological: cervical spondylosis, Pancoast’s tumour
Ix of TOS
- X-Ray: cervical rib
- Duplex in abduction
- Arteriograms of subclavian artery may show kinking
- Nerve conduction studies
Aetiology of thoracic outlet syndrome
- Congenital: cervical rib
- Acquired: clavicle #, pathological enlargement of 1st rib
Management of thoracic outlet syndrome
?first rib/cervical rib excision
Raynaud’s Phenomenon
Examination ( Key Questions, inspection, palpation, completion)
Key Questions
- What is the main problem you have c¯ your hands?
- When do symptoms occur?
- Is it precipitated by any specific weather conditions?
- Can you describe the colour changes your fingers go through?
Inspection
- Usually bilateral
- Dry, red skin
- Brittle nails
- Ulceration or gangrene on the pulps
Palpation; Normal radial pulse
Completion; Ask about symptoms and look for signs of secondary causes of Raynaud’s phenomenon
Raynaud’s phenomenon
definition, pathogenesis, 2ndary causes
Definitions
Phenomenon: characteristic cold-induced changes assoc. c¯ vasospasm
Disease: primary Raynaud’s phenomenon occurring in isolation
Syndrome: secondary Raynaud’s phenomenon assoc. ¯c other disease
Colour Changes (Cold- or emotion-induced) = White → Blue → Crimson
Pathogenesis; Overactive α sympathetic receptors Or, fixed obstruction in vessel wall
Secondary Causes: BADCAT Blood: polycythaemia, cryoglobulinemia, cold agglutinin Arterial: atherosclerosis, thrombangiitis obliterans Drugs: β-B, OCP, ergotamine Cervical rib: → thoracic outlet obstruction Autoimmune: SLE, RA, SS Trauma: vibration injury
Raynaud’s syndrome
Management
(conservative, medical, surgical)
Mx
- Conservative; wear gloves and avoid cold + Stop smoking
- Medical; CCBs: e.g. nifedipine + IV prostacyclin
- Surgical ; Cervical sympathectomy + amputate gangrenous digits
Gangrene
Examination (Inspection , palpatation)
Inspection
Wet; Putrefaction + Ill-defined, spreading edge
Dry; Dry and shrunken + Well demarcated + Features of PVD
Palpation = Temperature + Distal pulses
Differentiate Intermittent Claudication vs. Spinal Claudication
Chronic limb ischaemia classification
Upper Limb
Inspection, palpation, auscultation, completion
Lower Limb
inspection, palpation, auscultation,buergers,completion
LL superficial venous drainage anatomy
Lower limb deep and superficial venous anatomy
Present
presentation: Abnormal, Tortuous, dilated veins of the superficial venous system. clearly in the distribution of the LSV in the medial side of the thigh and calve. These can be primary: which 99% are, which replies a failure of the valves and reflux down the superficial venous system. They can be secondary; as a result of blockage in the deep viens and increased pressure on the venous system higher up.
palpate graft across pubic symphysis (reinforcement rings?) ?bilateral femoral pulses distal to the graft=working
LEFT: Long saphenous vein harvest; (+ stenotomy scar=CABG), arteria graft in the leg (+ scar over femoral artery=Femer-O-popliteal bypass/distal) pulse over scar=in situ graft // RIGHT: PTFE prosthetic material, scar at access site/terminal site. Access popliteal artery from medial above the knee or below the knee (NOT THE BACK)
extra anatomically tunnelling (fem-anterior tivia)
arterial supply of the upper limb (anatomy)
Thoracic aorta anatomy
External iliac artery anatomy (coeliac trunk to ext iliac)
Lower limb arterial supply anatomy
position of anterior tibial pulse
transmetatarsal amputation
- Charcot joints; painless but hugely deformed joint abnormality
raynaud’s phenomenon
Venous malformations:
- Bluish
- Often raised
- Painful sometimes
- By far the most common
- Not pulsatile
- No Bruit
- No signal with hand held Doppler
- No cardiac compromise
Arteriovenous malformations; like a fistula
- Rare
- Pulsatile dilated veins
- Bruit
- Obvious signal on hand held Doppler
- May be overgrowth of limb (or steal and no growth)
- May be significant shunt and Cardiac failure; high output cardiac failure due to shunt
lymphoedema
- PRIMARY
- SECONDARY
- COMMONEST WORLDWIDE IS FILARIASIS
- COMMONEST IN UK IS IATROGENIC
- CANCER
- OTHER INFECTIOUS CAUSES
