Vascular Flashcards
What mainly causes peripheral arterial disease? What are some less common causes?
Atherosclerosis causing stenosis of the arteries
Others:
- Vasculitis
- Trauma
- Thromboangiitis obliterans (Buerger’s disease)
What causes acute limb ischaemia?
Thrombosis usually at the site of stenosis
What is the chief feature of peripheral arterial disease?
Intermittent claudication exacerbated by walking, relieved by rest
Calf = femoral artery Buttock = iliac artery
What are some features of critical limb ischaemia?
- Ulceration
- Gangrene
- Foot pain at rest e.g. burning pain at night relieved by hanging legs over side of bed
What is Leriche’s syndrome?
Embolus at the aortic bifurcation
- Absent femoral pulse
- Claudication/wasting of buttock
- Pale cold leg
- Impotence
Who is most at risk of thomboangiitis obliterans (Buerger’s disease)?
Young heavy smokers
What classification is used for peripheral arterial disease?
Fontaine classification
- Asymptomatic
- Intermittent claudication
- Ischaemic rest pain
- Ulceration/gangrene
What are the signs on examination of peripheral arterial disease?
6 Ps Pallor Pulseless Painful Paralysed Paraesthesia Perishingly cold
Buerger’s test - leg goes pale when raised (if less than 20 degree angle, it is severe ischaemia)
What test is done for peripheral vascular disease? Describe how you would do this
ABPI
- Position patient at 45 degrees
- Allow patient 20 mins rest before procedure
- Record brachial pulse in each arm and take highest
- Record dorsalis pedis pulse then record posterior tibial pulse and take highest of the 2
- Repeat on other leg
ABPI = Highest of ankle BP / highest of arm BP
What ABPI ratios indicate what?
1.0 - 1.2 = normal
<0.9 = peripheral arterial disease
<0.5 = critical limb ischaemia
What can cause falsely high results in ABPI?
Incompressible calcified arteries
What is the drug treatment for peripheral vascular disease?
1st line - Clopidogrel
2nd line - naftidrofuryl oxalate (peripheral vasodilator)
What is the surgical management of peripheral arterial disease?
- Percutaneous transluminal angioplasty - balloon inflated in narrowed segment
- Surgical revascularisation - bypass graft
- Amputation - can prevent death from sepsis and gangrene
- Embolectomy - if acute limb ischaemia
Define aneurysm; true aneurysm; false aneurysm
Aneurysm = an artery with a dilatation
>50% of its original diameter
True aneurysm = dilatations that involve all layers of the arterial wall
False/pseudoaneurysm = collection of blood in outer layer only (adventitia) after trauma
What are the main risk factors for AAA?
- Severe atherosclerotic damage to aortic wall
- Family history - there is genetic component to the degeneration of elastic lamellae + smooth muscle
- Smoking
- Hypertension
- Connective tissue disorders
(AAAs are less common in diabetics)
What size of aorta defines an AAA?
Normal diameter = 2cm
AAA = 3cm
Surgery if >5.5cm
How might an AAA present?
Unruptured:
- Usually asymptomatic
- May cause abdominal/back pain
Ruptured:
- Sudden onset of tearing epigastric pain in abdomen that radiates to back, groin, iliac fossa, testicles
- Shock/collapse
What is the screening programme for AAA?
All males > 65 years are invited for ultrasound screening
What is the emergency management of an AAA?
Do ECG Take bloods - amylase, crossmatch, Hb Catheterise Give fluids to treat shock but keep BP<100 systolic Surgery
What are varicose veins?
Long, tortuous + dilated veins of the superficial venous system
What is the pathology behind varicose veins?
Normally, blood from superficial veins pass into deep veins via perforator veins and at the saphenofemoral + saphenopopliteal junctions
Valves prevent blood from passing from deep to superficial veins - if they become incompetent, there is venous hypertension + dilatation of superficial veins
What are the risk factors for developing varicose veins?
- Prolonged standing
- Obesity
- Pregnancy
- Family history
- Contraceptive pill
What are some secondary causes of varicose veins?
Obstruction - DVT, foetus, tumour
AV malformations
Overactive muscle pumps e.g. cyclists
Congenital valve absence
What signs might you see on examination of varicose veins?
- Oedema
- Eczema
- Ulcers
- Atrophie blanche - scar at site of healed ulcer
- Lipodermatosclerosis - skin hardness from fibrosis due to chronic inflammation + fat necrosis
- Fluid thrills felt at level of valve on tapping
What veins are affected if medial, below knee and calf variscosities?
Medial = long saphenous
Below knee = short saphenous
Calf = perforators
What test assesses the veins in the leg? Describe how you would do it
Trendelenburg’s test
- Lift patient’s leg as high as comfortable to empty the veins
- Whilst their leg is elevated, place torniquet over saphenofemoral junction
- Ask patient to stand
- Rapid filling of varicosities with torniquet suggests incompetent perforator veins below levels of SFJ
How can you educate a patient about managing their varicose veins?
- Avoid prolonged standing
- Elevate legs when possible
- Wear compression stockings
- Lose weight
- Regular walks because calf muscles aid venous return
What endovascular treatments can be done for varicose veins?
Radiofrequency ablation - catheter inserted into vein and heated to ‘close’ the vein
Injection sclerotherapy - foam injected to damage endothelium of veins and occlude them
Surgery - stripping of veins
Where are arterial ulcers most common?
- At tips of toes or between toes
- Over phalangeal heads
- Above lateral malleolus
What does an arterial ulcer look like?
Ulcer
- Punched out lesion
- Well defined edges
- Black/necrotic tissue
- No exudate
What does the leg around an arterial ulcer look like?
Leg
- Hair loss
- Cool, pale
- Thin, dry, shiny skin
- Thickened toe nails
Describe the pain of an arterial ulcer
Pain
- Burning pain
- Exacerbated by exercise and lying down
- Relieved by rest and hanging foot out of bed
Where are venous ulcers most common?
- Lower 1/3rd of leg
- Pre-tibial area
- Anterior to medial malleolus
What are the main causes of venous ulcers?
DVT
Obesity
Calf muscle pump deficits
Valvular incompetence in superficial perforating veins
What does a venous ulcer look like?
- Uneven edges
- Ruddy granulation tissue
- No dead tissue
- Exudate
What does the leg around a venous ulcer look like?
- Red/brown pigmentation = haemosiderin
- Evidence of past healed ulcers
- Venous eczema
- Tortuous superficial veins
- Warm
- Hair is still on legs
Describe the pain of a venous ulcer
- Moderate to no pain at all
- Pain is eased by raising the leg
Where are neuropathic ulcers usually seen?
- On sole of feet
- Under the heel
What usually causes a neuropathic ulcer?
Diabetic with peripheral neuropathy
What does a neuropathic ulcer look like?
- Even margins
- Deep
- Cellulitis
- Not much exudate
What is the rest of the leg like in neuropathic ulcers?
- Diminished sensation in foot
- Warm foot
