Vascular Flashcards
218 Varicose Veins. Q1. What two significant venous abnormalities are visible on this picture? Q2. How should this patient be investigated? Q3. What are the complications if the venous hypertension goes untreated. Q4 What is the mainstay of threatment for this condition.
Q1. Dilation, tortuous veins, telangectasias, chronic venous insufficiency (oedema, skin changes e.g. lipodermatosclerosis, venous ulcers)
Q2. Duplex USS, contrast venography
Q3. Chronic venous insufficiency, haemorrhage, venous ulceration, lipodermatosclerosis, haemosiderin deposition
Q4. Treatment
- Conservative = elevation, exercise, compression stockings, ulcer wound management
- Vein ablation = sclerotherapy, laser
- Surgical = excision/venous stripping
279 What are the usual indications, in an otherwise fit person, for considering them for repair of an abdominal aortic aneurysm?
1) RUPTURE = surgical emergency (true mortality up to 85%, >50% die before reaching hospital)
2) Symptomatic = back/abdo pain or tenderness, distal embolisation, fever = assume imminent rupture
3) Asymptomatic
- AAA >5.5cm (male) or >5cm (female)
- Rapid growth (>1cm/year or >7mm/6mo)
- AAA associated with peripheral arterial aneurysm or peripheral arterial disease
280 What are the features of a patient who presents with a rupturing Abdominal Aortic Aneurysm?
Symptoms:
- Sudden onset severe epigastric ± back/loin pain
- Sudden collapse (usually with transient hypotension)
- History of asymptomatic AAA
Signs:
- Unexplained rapid onset hypotension, severe pain, sweating
- Pulsatile abdominal mass (present in up to 62% of patients)
- Lower extremity ischaemia (combined with abdo/back/flank pain)
- Flank ecchymosis
Risk factors for rupture:
- AAA >5.5 (male) or 5 (female)
- Female
- Smoking
- Greater aortic expansion (0.5cm/year)
- Hypertension
Other rare features:
- Heart failure due to rupture into venous structures (e.g. IVC) forming an AV fistula
- Sudden groin pain/hernia (due to sudden increased intra-abdominal pressure)
- Upper GI bleeding due to aortoduodenal fistula
Pain patterns:
- Proximal (near renal arteries) = severe back/flank pain
- Distal (near iliac bifurcation) = low abdo/pelvic pain ± radiation to groin/thighs
- Posterior = severe focal pain, often attributed to another cause (leads to retroperitoneal haematoma)
- Anterior = abdo pain with rapid progression and profound haemodynamic instability (may be briefly contained)
281 A 68 year old man presents to ED with a 1 hour history of pain in the left side of his abdomen and mid back. It started suddenly, has not moved, and is getting worse. It is the worst pain he has experienced. He has a history of stable angina, managed with beta blockers and nitrates. On examination, he is pale, sweaty, has a pulse of 110bpm, blood pressure of 100/65mmHg, normal chest and cardiac exam. Abdominal exam reveals a tender mass in the epigastrium, which is pulsatile and expansile, peripheral pulses and neuro exam are normal. What is the diagnosis? What investigations and treatments are needed?
Diagnosis is RUPTURED AAA until proven otherwise = surgical emergency
Ddx: aortic dissection, renal colic, coronary ischaemia, pancreatitis
Investgations: FAST scan, CT with IV contrast (assess need)
Initial approach:
1) Notify senior ED staff + request immediate senior surgical consult
Remainder of resus may be done while transporting to theatre
2) 2 x IV access, cross-match blood, order FFP + platelets, high flow O2, analgesia, catheterise
3) Allow permissive hypotension (systolic 70-80 or MAP = 65)
NB: If NFR or ineligible for surgery, then only option is to palliate
Operative management:
- Anaesthesia - not started until patient is fully prepared and draped if the patient is unstable
- Antibiotic prophylaxis
1) EVAR
- Most effective for ruptured AAA
- Insertion of stent graft using guide-wire and fluoroscopy guidance, followed by contralateral iliac stent
2) Open repair
- Transperitoneal or retroperitoneal approach
- Primary repair or conversion from failed EVAR
282 What are the treatment options for an otherwise fit 75 year old man who has been found to have a 6cm AAA (abdominal aortic aneurysm) on routine screening?
AAAs can be managed either conservatively or surgically. Due to the size of his aneurysm (>5.5cm), he has a high risk of rupture (10-22% per year) and should be managed surgically.
The procedures available are an endovascular aneurysm repair or an open repair.
283 What are the common complications of endovascular (stent) repairs of abdominal aortic aneurysms?
1) Endoleak = persistent flow of blood into the aneurysm sac after graft placement
I = Insufficient seal (a = suprarenal, b = iliac) 2 = Flow in2 and out of patent branch vessel 3 = Contralateral graft has come FREE 4 = Graft is PORous V = Very poorly understood mechanism
2) Access site complications
- Infection
- Haematoma
- Distal embolisation
- Dissection
3) Systemic complications
- Cardiopulmonary (e.g. MI)
- IV contrast-induced nephropathy or allergy
- Ischaemia (renal, intestinal, spinal, pelvic, extremity)
4) Other complications
- Conversion to open repair (mortality rate = 10-13%)
- Abdominal compartment syndrome (organ dysfunction due to intra-abdominal hypertension)
- Post-implantation syndrome (acute flu-like inflammatory syndrome characterised by fever, leucocytosis, elevated CRP, and perigraft air during first 7-10 days post-EVAR)
284 What are the main indications for Carotid endarterectomy (CEA, Carotid surgery)?
- *Symptomatic patients** (i.e. stroke/TIA/amaurosis fugax) in last 3-6 months)
- Men: stenosis >50%
- Women: stenosis >70%
- *Asymptomatic patients**
- Stenosis >80%
- The efficacy in 60-79% stenosis is debated
- *Contraindications**
- Life expectancy < 5 years
- Symptomatic stenosis < 50%
- Asymptomatic complete carotic occlusion
- Prior ipsilateral endoarterectomy
- Perioperative risk 6%+ in symptomatic patients and 3%+ if asymptomatic
- History of neck surgery/irratiation
285 A 71 year old man presented to the ED with weakness and numbness in his left arm. These symptoms started suddenly 2 hours ago. His vision was not affected, and the numbness and weakness is getting better. He has no other symptoms, What is the likely diagnosis? What investigations are needed?
Likely diagnosis = TIA
Investigations:
ABCD2 assessment - prognostic
Laboratory - FBC, UEC, fasting lipids, ESR/CRP, glucose
ECG
Imaging - CT/MRI
If carotic symptoms, carotid artery duplex ultrasound
286 A 71 year old man presents to the ED with weakness and numbness in his left arm. These symptoms started suddenly 2 hours ago. His vision was not affected, and the numbness and weakness is getting better. He has no other symptoms, he is a lifelong smoker. Physical exam is normal, other than the numbness. What is the likely diagnosis? What are the risk factors for this disease?
Likely diagnosis = TIA
Risk factors:
- AF and CHF
- Carotid stenosis
- Smoking
- Hypertension
- Diabetes mellitus
- Alcohol abuse
- Advanced age
Minor risk factors: patent foramen ovale (paradoxical embolism), hyperlipidemia, inactivity, obesity, hypercoagulability
287 A 65 year old man presents to the emergency department with an 8 hour history of severe, generalised abdominal pain. Earlier in the day he passed fresh blood in his stool, there is no previous episodes of blood PR. His medical history included AF, Diabetes mellitus and hypertension. He is a long term smoker. He is restless with pain. His pulse is 110 irregularly irregular. His BP is 90/50mmHg. His temperature is 37.5C. Abdominal examination shows acute pain but a soft, non-rigid abdomen. Rectal exam shows fresh blood mixed into normal stools. His venous blood tests show a normal Hb, slightly raised white cell count (neutrophilia), a moderately raised CRP at 40, a near normal amylase and the rest are normal. His arterial blood gases show a pH of 7.29, lactate of 9.4 and base deficit of - 6.5, and a PaCO2 of 3.5. What does the arterial blood gas show? What is the most likely diagnosis?
ABG interpretation:
- Metabolic acidosis (low pH, base deficit) with lactic acidosis
- Low PaCO2 indicates partial respiratory alkalosis (compensation)
Most likely diagnosis = acute intestinal ischaemia
- Abdominal pain disproportionate to examination
- Blood in stool
- Risk factors for arterial disease (AF, DM, HT, smoking)
- High lactate indicates ischaemia
Ddx: infectious colitis, UC, Crohn’s, diverticular bleed, gastroenteritis, large/small bowel obstruction, acute pancreatitis
288 A 65 year old man presents to the emergency department with an 8 hour history of severe, generalised abdominal pain. Earlier in the day he passed fresh blood in his stool, there is no previous episodes of blood PR. His medical history included AF, Diabetes mellitus and hypertension. He is a long term smoker. He is restless with pain. His pulse is 110 irregularly irregular. His BP is 90/50mmHg. His temperature is 37.5C. Abdominal examination shows acute pain but a soft, non-rigid abdomen. Rectal exam shows fresh blood mixed into normal stools. His venous blood tests show a normal Hb, slightly raised white cell count (neutrophilia), a moderatley raised CRP at 40, a near normal amylase and the rest are normal. His aterial blood gases show a pH of 7.29, lactate of 9.4 and base deficit of - 6.5, and a PaCO2 of 3.5. What does the arterial blood gas show? What is the most likely diagnosis? How should he be managed?
ABG interpretation:
- Metabolic acidosis (low pH, base deficit) with lactic acidosis
- Low PaCO2 indicates partial respiratory alkalosis (compensation)
Most likely diagnosis = acute intestinal ischaemia
- Abdominal pain disproportionate to examination
- Blood in stool
- Risk factors for arterial disease (AF, DM, HT, smoking)
- High lactate indicates ischaemia
Investigation:
- Bloods: FBC (anaemia, leukocytosis), UEC (renal perfusion)
- ABG: (done)
- ECG: cardiogenic source of ischaemia or possible embolus
- Erect CXR: rule out perforation
- AXR: rule out obstruction or perforation
- Mesenteric duplex USS (useful for proximal obstructions only, ED/consult setting only)
- Mesenteric angiography (definitive test)
Management:
- Primary survey (ABC resus, supplemental O2, fluids, inotropic support, IV access)
- NBM
- NGT decompression
- Empirical antibiotics with enteric coverage (due to risk of bacterial translocation)
- Urgent angiography ± CT angiogram
- Urgent vascular surgery consult for exploratory laparoscopy/otomy with embolectomy ± resection of non-viable intestine
289 You are the ED intern on duty. You are asked to see and treat a 75 yoa man who has presented with sudden onset of pain in his right leg. What are you going to do?
Working diagnosis: limb ischaemia
1) Monitor vitals
2) Thorough history
- SOCRATES - incl. relief by lowering leg (arterial) or elevating leg (venous)
- PMH: symptoms suggestive of MI, aortic dissection, embolism elsewhere; recent/past surgery
- Risk factors for PVD: smoking, DM, hyperlipidaemia, hx CAD or CVA
Differentiate between acute and chronic limb ischaemia:
- Acute = 6 Ps (Pain, Pulseless, Pale, Perishingly cold, Paraesthesia, Paralysis), immediate onset
- Chronic = gradual, claudication pain (distance, duration, progression), rest/night pain, skin changes incl. ulcers, bilateral
3) Examination
- Vascular: 6 Ps, comparison of pulses, palpable aneurysms (popliteal, AAA), radiofemoral delay
- Cardiovascular exam
- ECG (for recent MI or AF as embolus source)
4) Investigations
- Bloods: FBC, UEC, group and save, LFTs, coags
- ABI (normal = 0.9-1.2, <0.9 = peripheral vascular disease, <0.4 = critical limb ischaemia)
- Duplex USS
- CT angiography (gold standard)
5) Grade the ischaemia
- Acute: viable, marginally-threatened, immediately-threatened, irreversible/non-viable
- Chronic: Rutherford’s grades (0 = asymptomatic, 1/2/3 = mild/moderate/severe claudication, 4 = rest pain/critical limb ischaemia, 5 = minor tissue loss e.g. non-healing ulcer or focal gangrene, 6 = major tissue loss, no longer viable)
290 You are the ED intern on duty. You have seen 75yoa man with a painful left leg of sudden onset. He has a cardiac history (AF and hypertension) and he smoked for 60 years. On examination he has a left cold leg from mid thigh downwards with no palpable pulses below the femoral pulse. His right leg is normal. What is the likely diagnosis, what may have caused it and what are you going to do?
Acute limb ischaemia, likely from an emboli 2o AF, or an atherosclerotic plaque
Causes of acute limb ischaemia
- *1) Embolisation** = cardiac until proven otherwise
- Cardiac sources incl. AF, valvular vegetation
- Non-cardiac sources incl. atheroembolism, aneurysm, paradoxical embolism
- *2) Thrombosis** of native artery (or bypass graft)
- Atherosclerosis
- Popliteal aneurysm (only aneurysm where risk is of thrombosis rather than rupture)
3) Trauma (blunt, penetrating, IVDU)
What to do:
1) Vascular consult
2) Clinical examination, arterial and venous Doppler, digital subtraction angiography
3) Heparin infusion
4) If viable - revascularisation - embolectomy, thrombolysis, bypass (thrombosed popliteal aneurysm only)
If non-viable - amputation
291 You are the ED intern on duty. You have seen 75yoa man with a painful left leg of sudden onset. He has a cardiac history (AF and hypertension) and he smoked for 60 years. On examination he has a left cold leg from mid thigh downwards with no palpable pulses below the femoral pulse. His right leg is normal. What are the clinical signs that you will assess to determine whether the leg is salvagable, or that it is beyond help and needs amputation?
292 A 54 year old insulin diabetic presents to the ED complaining of increasing pain in her right foot that has been developing over 1 week. It is worse at night, partially relieved by hanging her foot over the side of the bed. Her right great toe has become swollen, red in parts and discoloured in others. She is febrile (37.7C), pulse 86 regular, BP 130/80mmHg, blood glucose 13.2mmol/L. Femoral pulses are present bilaterally, but no distal pulses can be felt below this, the right great toe is erythematous with a large fluctuant swelling at the base. What does this clinical appearance suggest? What investigations are needed? What treatment is needed?
Clinical appearance suggests peripheral vascular disease with critical limb ischaemia and possible abscess/wet gangrene at the base of the right great toe
Symptoms of critical limb ischaemia:
P ain
O edema
U lceration
C olour changes
H yperesthesia
Investigations:
1) Bloods: FBC, UEC, LFTs, coags, HbA1c, BSL
2) ABI <0.4
3) Duplex USS (arterial and venous)
Management:
1) Vascular surgery referral
2) Pain relief + ulcer management
3) Pharmacologic - statin, beta blocker, antiplatelet
4) Revascularisation
