Vascular Flashcards
Chronic Limb Ischaemia
5% males >50 have intermittent claudication
Definition - ankle artery pressure <50 (toe <30mmHg)
- and either persistent rest requiring analgesia for 2+ weeks
- or ulceration gangrene
Chronic Limb Ischaemia Cause
Atherosclerosis - typical ASx until 50% stenosis
Vasculitis + fibromuscular dysplasia > v rare causes
Atherosclerosis
- Endothelial injury: haemodynamic, HTN, ↑ lipids
- Chronic inflammation
Lipid-laden foam cells produce GFs, cytokines,
ROS and MMPs
→ lymphocyte and SMC recruitment - SM proliferation: conversion of fatty streak to
atherosclerotic plaque
NB. Arteriosclerosis = general arterial hardening
Atherosclerosis = arterial hardening specifically due to
atheroma
Atheroma
Fibrous cap: SM cells, lymphocytes, collagen
Necrotic centre: cell debris, cholesterol, Ca, foam cells
Chronic Limb Ischaemia RF + ass vasc disease
Modifiable Smoking BP DM control Hyperlipidaemia ↓ exercise
Non-Modifiable FH and PMH Male ↑ age Genetic
Ass Vasc Disease IHD: 90% Carotid stenosis:15% AAA Renovascular disease DM microvascular disease
Chronic Limb Ischaemia Presentation
Intermittent Claudication
Cramping pain after walking a fixed distance
Pain rapidly relieved by rest
Calf pain = superficial femoral disease (commonest)
Buttock pain = iliac disease (internal or common)
Chronic limb ischaemia presentation
Critical Limb Ischaemia
Critical Limb Ischaemia - Fontaine 3 or 4
Rest pain Especially @ night Usually felt in the foot Pt. hangs foot out of bed Due to ↓ CO and loss of gravity help
Ulceration
Gangrene
Chronic Limb Ischaemia
Presentation
Leriche’s Syndrome - Aortoiliac Occlusive Disease
Atherosclerotic occlusion of abdominal aorta and iliacs
Triad
Buttock claudication and wasting
Erectile dysfunction
Absent femoral pulses
Chronic Limb Ischaemia
Presentation
Buerger’s Disease
Thromboangiitis Obligerans
Young, male, heavy smoker
Acute inflammation and thrombosis of arteries and
veins in the hands and feet → ulceration and gangrene
Chronic Limb Ischaemia Signs
Pulses: pulses and ↑ CRT (norm ≤2sec) Ulcers: painful, punched-out, on pressure points Nail dystrophy / Onycholysis Skin: cold, white, atrophy, absent hair Venous guttering Muscle atrophy
↓ Buerger’s Angle
≥90: normal
20-30: ischaemia
<20: severe ischaemia
+ve Buerger’s Sign
Reactive hyperaemia due to accumulation of
deoxygenated blood in dilated capillaries
Clinical Classification of Chronic limb ischaemia
Fontaine
- Asympto (subclinical)
- Intermittent claudication
a. >200m
b. <200m - Ischaemic rest pain
- Ulceration / gangrene
Rutherford
- Mild claudication
- Moderate claudication
- Severe claudication
- Ischaemic rest pain
- Minor tissue loss
- Major tissue loss
Chronic Limb Ischaemia Ix
Doppler Waveforms
Normal: triphasic
Mild stenosis: biphasic
Severe stenosis: monophasic
ABPI (another card)
Walk test
- walk on treadmill at certain speed + incline to establish maximum claudication distance
- ABPI measured before and after 20% drop is sign
Bloods FBC + U+E: anaemia, renovascular disease Lipids + glucose ESR: arteritis G+S: possible procedure
Imaging: assess site, extent and distal run-off
- Colour duplex US
- CT / MR angiogram: gadolinium contrast
- Digital subtraction angiography
Invasive :. not commonly used for Dx only.
Used when performing therapeutic angioplasty
or stenting
Other
ECG: ischaemia
ABPI in CLIschaemia
Clinical Fontaine ABPI
Calcification: CRF, DM >1.4
Normal ≥1
Asymptomatic Fontaine 1 0.8-0.9
Claudication Fontaine 2 0.6-0.8
Rest pain Fontaine 3 0.3-0.6
Ulceration and gangrene Fontaine 4 <0.3
NB. Falsely high results may be obtained in DM / CRF due
to calcification of vessels: mediasclerosis
Use toe pressure with small cuff: <30mmHg
Chronic limb ischaemia conservative Mx
Most pt can be managed like this ^exercise (exercise program) Stop amoking Wt loss Foot Care
Prog: 1/3 improve, 1/3 stay the same, 1/3 deteriorate
Chronic Limb Ischaemia Medical Mx
Risk factors: BP, lipids, DM
β-B don’t worsen intermittent claudication but use w caution in CLI
Antiplatelets: aspirin / clopidogrel
Analgesia: may need opiates
(Parenteral prostanoids ↓ pain in pts. unfit for surgery)
Endovascular Mx of Chronic Limb Ischaemia
Percutaneous Transluminal Angioplasty ± stenting
Good for short stenosis in big vessels: e.g. iliacs, SFA
Lower risk for pt.: performed under LA as day case
Improved inflow → ↓ pain but restoration of foot pulses is required for Rx of ulceration / gangrene.
Surgical Reconstruction of Chronic Limb Ischaemia
Indication
Pre-op
Practicalities
Indicated > V short claudication distance (<100m)
- Sx greatly affecting pt QUAL
- Development of rest pain
Pre-op - need good optimisation of cardioresp co-morbidities
Practicalities - need good proximal supply + distal run-off
> saphenous vein grafts preferred below IL
> more distal grafts have ^ rates of thrombosis
Surgical Reconstruction of Chronic Limb Ischaemia
Classification
+ altenratives
Classification
- anatomical - fem-pop, fem-distal, aortobifemoral
- extra-anatomical - axillofem/-bifem, fem-fem crossover
Other
- endarterectomy - core out atheromatous plaque
- sympathectomy - cheimcal EtOH injeuction) or surgical
> caution in DM w neuroapthy
- amputation
Chronic limb ischaemia Prognosis
1yr after onset of CLI
50% alive w/o amputation
25% will have had major amputation
25% dead (usually MI or stroke)
Following amputation Perioperative mortality BK: 5-10% AK: 15-20% 1/3 → complete autonomy 1/3 → partial autonomy 1/3 → dead
Acute Limb Ischaemia
Acute <14d
Acute on chronic - worsening Sx + signs <14d
Chronic - ischaemia stable >14d
Severity
Incomplete - limb not threatened
Complete - limb thretened (loss of limb unless intervention w/i 6 hours
Irreversible - requires amputation
Causes of Acute Limb Ischaemia
Thrombosis in situ (60%)
A previously stenosed vessel w plaque rupture
Usually incomplete ischaemia
Embolism (30%) 80% from LA in AF Valve disease Iatrogenic from angioplasty / surgery Cholesterol in long bone # Paradoxical (venous via PFO) Typically lodge at femoral bifurcation Often complete ischaemia
Graft / stent occlusion
Trauma
Aortic dissection
Acute Limb Ischaemia Presentation
Painful Perishingly cold Pulseless Pale Paralysis Paraesthesia
Thrombosis (Acute limb ischaemia)
Onset - hrs/days
Severity - less severe - collaterals
Claudication - present
Contralateral pulses - absent
Dx - angiography
Rx - thrombolysis, bypass surgery
Embolus (acute limb ischaemia)
Onset - sudden Severity - Profound ischaemia Embolic source - AF oft Claudiction - Absent Contralateral pulse - present
Dx - clinical
Rx - embolectomy + warfarin
Acute Limb Ischaemia Ix
Blood
FBC, U+E, INR, G+S
CK
ECG
Imaging
CXR
Duplex doppler
Acute Limb Ischaemia
General Mx
Discuss w senior as time is crucial.
NBM
Rehydration: IV fluids
Analgesia: morphine + metoclopramide
Abx: e.g augmentin if signs of infection
Unfractionated heparin IVI: prevent extension
Complete occlusion?
Yes: urgent surgery: embolectomy or bypass
No: angiogram + observe for deterioration
Angiography Not if complete occlusion - introduces delay: straight to theatre. If incomplete occlusion, pre-op angio will guide any distal bypass.
Acute Limb Ischaemia Embolus Mx
Embolectomy
Under LA or GA
Wire fed through embolus
Fogarty catheter fed over the top
Balloon inflated and catheter withdrawn, removing the embolism.
Send embolism for histo (exclude atrial myxoma)
Adequacy confirmed by on-table angiography
- Thrombolysis
Consider if embolectomy unsuccessful
E.g. local injection of TPA - Other options
Emergency reconstruction
Amputation
Post-embolectomy
Anticoagulate: heparin IVI → warfarin
ID embolic source: ECG, echo, US aorta, fem and pop
Complications >Reperfusion injury Local swelling → compartment syndrome Acidosis and arrhythmia 2ndary to ↑K ARDS GI oedema → endotoxic shock >Chronic pain syndromes
Acute Limb Ischaeima
Thrombosis M
Emergency reconstruction if complete occlusion
Angiography + angioplasty
Thrombolysis
Amputation
Carotid Artery Disease
Define Stroke
Define TIA
Stroke: sudden neurological deficit of vascular origin
lasting >24h
TIA: sudden neurological deficit of vascular origin
lasting <24h (usually lasts <1h) w complete recovery
Carotid Artery Disease
Pathogenesis
Presentation
Ix
Pathogenesis
Turbulent flow → ↓ shear stress @ carotid bifurcation
promoting atherosclerosis and plaque formation.
Plaque rupture → complete occlusion or distal emboli
Cause 15-25% of CVA/TIA
Presentation
Bruit
CVA/TIA
Ix
Duplex carotid Doppler
MRA
Carotid Artery Disease Mx
Conservative - aspirin/clopidogrel, control RF
Surgical Endarterectomy (unblock) Symptomatic (ECST, NASCET) ≥70% (5% stroke risk per yr) ≥50% if low risk (<3%, typically <75yrs) Perform w/i 2wks of presentation
Asymptomatic (ACAS, ACST)
≥60% benefit if low risk
Complications of Endarterectomy
Stroke or death 3%
HTN 60%
Haematoma
MI
Nerve Injury
- hypoglossal - ipsilateral tongue deviation
- great auricular - numb ear lobe
- recurrent laryngeal - hoarse voice, bovine cough
Carotid Artery Disease
Mx Stenting
less invasive than endarterecrtomy
Less invasive: ↓ hospital stay, ↓ infection, ↓ CN injury
There is concern over ↑ stroke risk, esp. pts. >70yrs
Meta-analysis shows no sig difference in mortality vs.
CEA @ 120d
Younger pts. have best risk / benefit ratio
Aneurysm
Abnormal Dilatation of blood Vessel >50% of its normal diameter (across all layers)
Aneurysm Classification
True Aneurysm
Dilatation of a blood vessel involving all layers of
the wall and is >50% of its normal diameter
Two different morphologies
> Fusiform: e.g AAA
> Saccular: e.g Berry aneurysm
Aneurysm Classification
False Aneurysm
Collection of blood around a vessel wall that
communicates c¯ the vessel lumen.
Usually iatrogenic: puncture, cannulation
Aneurysm Classification
Dissection
Vessel dilatation caused by blood splaying apart
the media to form a channel w/i the vessel wall.
Aneurysm Causes
Congenital
ADPKD → Berry aneurysms
Marfan’s, Ehlers-Danlos
Acquired Atherosclerosis Trauma: e.g. penetrating trauma Inflammatory: Takayasu’s aortitis, HSP Infection >Mycotic: SBE >Tertiary syphilis (esp. thoracic)
Aneurysm Complications
Rupture Thrombosis Distal Embolization Pressure - DVT, oesophagus, nutcracker syndrome Fistula (IVC, intestine)
Popliteal aneurysm
Less common than AAA
50% pt w PA also have AAA
Presents - v easy palpable popliteal pulse
> 50% bilateral
> rupture rare
> thrombosis + distal embolism main complication
- causes acute limb ischaemia
Mx
Acute - embolectomy or fem-distal bypass
Stable - elective grafting + tie off vessel
Abdominal Aortic Aneurysm
Dilatation of abdominal aorta to 3+cm
90% infrarenal, 30% involve iliac arteries
Present usually ASx (incidental) May > back pain or umbilical pain radiating to groin Acute limb ischaemia Blue toe syndrome (distal embolisation Acute Rupture
AAA Exam + Ix
Examination
Expansile mass just above the umbilicus
Bruits may be heard
Tenderness + shock suggests rupture
Ix
AXR: calcification may be seen
Abdo US: screening and monitoring
CT / MRI: gold-standard
Angiography
Won’t show true extent of aneurysm due to endoluminal thrombus.
Useful to delineate relationship of renal arteries
AAA Conservative Mx
Conservative - Manage CV RF esp BP - Trial suggest AAA <5.5cm in maximum diameter can be monitored by US (/CT) <4cm: yearly monitoring 4-5.5cm: 6 monthly monitoring
Screening - UK M offered one time screen at 65
AAA Surgical Mx
Aim to treat aneurysm before it ruptures.
Elective mortality: 5%
Emergency mortality: 50%
Operate when risk of rupture > risk of surgery
Indications Symptomatic (back pain = imminent rupture) Diameter >5.5cm Rapidly expanding: >1cm/yr Causing complications: e.g. emboli
Open or EVAR (endovasc aneurysm repair)
EVAR has ↓ perioperative mortality
No ↓ mortality by 5yrs due to fatal endograft failures.
EVAR not better than medical Rx in unfit pts.
Thoracic Aortic Dissection
Blood splays apart laminar planes to form channel w/i aortic wall
Atherosclerosis and HTN cause 90%
Minority caused by connective tissue disorder
Marfan’s, Ehlers Danlos
Vitamin C deficiency
Thoracic Aortic Dissection Presentation
Sudden onset, tearing chest pain
Radiates through to the back
Tachycardia and hypertension (primary + sympathetic)
Distal Propagation > sequential occlusion of branches Left hemiplegia Unequal arm pulses and BP Paraplegia (anterior spinal A.) Anuria
Proximal propagation
Aortic regurgitation
Tamponade
Rupture into pericardial, pleural or peritoneal cavities - commonest cause of death
Stanford Classification
Thoracic Aortic Dissection
Type A: Proximal 70% Involves ascending aorta ± descending Higher mortality due to probable cardiac involvement Usually require surgery
Type B: Distal
30%
Involves descending aorta only: distal to L SC artery
Usually best managed conservatively
Thoracic Aortic Dissection Ix
ECG - exclude MI
TTE/TOE - haemodynamically unstable pts
CT MRI - if stable
Thoracic Aortic Dissection Mx
Resuscitate
Investigate
Bloods: x-match 10u, FBC, U+E, clotting, amylase
ECG: 20% show ischaemia due to involvement of the
coronary ostia
Imaging
CXR
CT/MRI: not if haemodynamically unstable
TOE: can be used if haemodynamically unstable
Treat Analgesia ↓SBP (systolic) Labetalol or esmolol (short t½) Keep SBP 100-110mmHg
Type A: open repair
Acute operative mortality: <25%
Type B: conservative initially
Surgery if persistent pain or complications
Consider TEVAR if uncomplicated
Gangrene
Death of tissue from poor vascular supply
Gangrene classification + presentation
Wet - tissue death + infection
Dry - tissue death only
Pregangrene - Tissue on brink of gangrene
Presents
black tissues +/- slough
May suppuration sepsis
Gas Gangrene
Clostridium perfringes myositis
RF- DM, trauma, malignancy
Presentation Toxaemia Haemolytic jaundice Oedema Crepitus from surgical emphysema Bubbly brown pus
Rx
Debridement (may need amputation)
Benzylpenicillin + metronidazole
Hyperbaric O2
Synergistic Gangrene
Aerobes and anaerobes
Fournier’s - perineum
Meleney’s - post op ulceration
Gangrene Mx
Mx - take cultures
- debridement (include amputation)
Benpen +/- clindamycin
Varicose Veins
Tortuous, dilated veins of the superficial venous system
One-way flow from sup → deep maintained by valves
Valve failure → ↑ pressure in sup veins → varicosity
3 main sites where valve incompetence occurs:
SFJ: 3cm below and 3cm lateral to pubic tubercle
SPJ: popliteal fossa
Perforators: draining GSV
3 medial calf perforators (Cockett’s)
1 medial thigh perforator (Hunter’s)
Varicose Vein Causes
Primary Idiopathic (congenitally weak valves) Prolonged standing Pregnancy Obesity OCP FH Congenital valve absence (v. rare)
Secondary Valve destruction → reflux: DVT, thrombophlebitis Obstruction: DVT, foetus, pelvic mass Constipation AVM Overactive pumps (e.g. cyclists) Klippel-Trenaunay PWS, varicose veins, limb hypertrophy
Varicose Veins Sx and Signs
Sx Cosmetic defect Pain, cramping, heaviness Tingling Bleeding: may be severe Swelling
Signs
Ulcers: medial malleolus / gaiter area
Oedema
Thrombophlebitis
Skin changes Venous stars Haemosiderin deposition Venous eczema Lipodermatosclerosis (paniculitis) Atrophie blanche
Varicose Veins Ix + Referral Criteria
Ix Duplex ultrasonography Anatomy Presence of incompetence Caused by obstruction or reflux
Surgery: FBC, U+E, clotting, G+S, CXR, ECG
Referral Criteria Bleeding Pain Ulceration Superficial thrombophlebitis Severe impact on QoL
Varicose Veins CEAP classification
Chronic venous disease
Clinical signs (1-6 + sympto or asympto)
Etiology
Anatomy
Pathophysiology
Varicose Veins Conservative Mx
Treat contributing factors (wt loss, relieve constipation)
education - avoid prolonged standing, regular walks
Class II Graduated compression stockings
(18-24mmHg)
- Sx relief + slows progression
Skin care - maintain hydration w emollients
- treat ulcers rapidly
Varicose Veins Minimally Invasive therapy
Indication - small below knee not involving Great Saphenous Vein or Small Saphenous Vein
Techniques - LA, GA
- Injection sclerotherapy - 1% Na teradecyl sulphate
- endovenous laser or radiofrequency
Post-op
- compression bandage for 24h
- compression stockings for 1mo
Varicose Veins Surgical Mx
Indications
SFJ incompetence
Major perforator incompetence
Symptomatic: ulceration, skin changes, pain
Procedures
Trendelenberg: saphenofemoral ligation
Small SV ligation: in the popliteal fossa
LSV stripping: no longer performed due to potential for saphenous nerve damage.
Multiple avulsions
Perforator ligation: Cockett’s operation
Subfascial endoscopic perforator surgery (SEPS)
Post-op
- bandage tightly
- elevate 24h
- discharged w compression stockings + instructed to walk daily
Varicose Vein surgical complications
Haematoma (esp. groin) Wound sepsis Damage to cutaneous nerve (e.g. long saphenous) Superficial thrombophlebitis DVT Recurrence: may approach 50%
Leg Ulcers
Interruption of continuity of epithelial surface
Causes
- venous (commonest)
- arterial - large or small vessel
- neuropathic (EtOH, DM)
- traumatic (pressure)
- systemic - pyoderma gangrenosum etc
- neoplastic - SCC
Venous Leg Ulcers
75%
Painless, sloping, shallow ulcers
Usually on medial melleolus (gaiter area)
Assw haemosiderin deposition + lipodermatosclerosis
RF - venous insufficiency, varicosities, DVT, obesity
Arterial leg ulcers
2% Hx of vasculopathy + RF Painful deep punched out lesions Occur at pressure points > heal > tips of and between toes > metatarsal (esp 5th) Other signs of chronic leg ischaemia
Neuropathic leg ulcers
painless w insensate surrounding skin
warm foot w good pulses
Leg ucler complications
Oesteomyelitis
Dev SCC in ulcer (Marjolin’s ulcer)
Leg Ulcer Ix
ABPI if poss
Duplex ultrasonography
Biopsy may be neessary (look for malignancy
Mx of Venous leg ulcers
refer leg ulcer community clinic
Focus on preention (graduated compression stockings, venous surgery)
Optimise RF -nutrition, smoking
Specific Rx - analgesia - bed rest + elevate leg - 4 layer graded bandage (if ABPI >0.8) - Pentoxyfylline PO > microcirculatory blood flow > improves healing rates
Other options (no proven benefit)
- desloughing (larval therapy, hydrogel)
- topical antiseptics - iodine, manuka honey
- split thickness skin grafting may be considered
Bilateral Leg Swelling Differential
↑ Venous Pressure
RHF
Venous insufficiency
Drugs: e.g. nifedipine
↓ Oncotic Pressure
Nephrotic syndrome
Hepatic failure
Protein losing enteropathy
Lymphoedema
Myxoedema
Hyper- / hypo-thyroidism
Unilateral Leg Swelling Differentials
Venous insufficiency
DVT
Infection/inflammation
Lymphoedema
Lymphoedema definition + primary
Collection of interstitial fluid due to blockage or absence of lymphatics
Primary
- congen absence of lymphatics
- presents - congen from birth, praecox (after birth <35y), tarda (>35y)
Milroy’s Syndrome
- famillial AD subtype of congenital lymphoedema
- F>M
Secondary Lymphoedema
FIIT
Fibrosis (post radio etc)
Infiltration
Ca: prostate, lymphoma
Filariasis: Wuchereria bancrofti
Infection - TB
Trauma - block dissection of lymphatics
Lymphoedema Ix + Mx
Ix
Doppler US
Lymphoscintigraphy
CT / MRI
Mx Conservative Skin care Compression stocking Physio Treat or prevent comorbid infections
Surgical: debulking operation
