Vascular Flashcards
A 69 year old man with a background of hypertension complained of flank pain all day at work. He then has sudden onset abdominal pain that radiates to his back and groin. He arrives in an ambulance unconscious. The doctor notes Grey Turner’s and Cullen’s signs. What is the most likely diagnosis? A Renal colic B Myocardial Ischaemia C Ruptured AAA D Pancreatitis
C Ruptured AAA
A 65 year old gentleman is coming in for screening for a AAA following a letter received in the post. What modality would be used as a screening tool?
A Abdominal Ultrasound
B Abdominal CT
C Abdominal X-ray
D Doppler Ultrasound
A Abdominal Ultrasound
The same gentleman, 3 years later with a known AAA (last measured 5.2 cm) comes in complaining of severe abdominal pain. What investigation would you use to assess if it has ruptured?
A Abdominal Ultrasound
B Abdominal CT
C Abdominal X-ray
D Doppler Ultrasound
B Abdominal CT
A 70 year old gentleman with known hypertension presents to A&E with tearing chest pain, radiating to the back. His CXR shows a widened mediastinum. What is the most likely diagnosis?
A Aortic Dissection
B STEMI
C Teitze’s Syndrome
D Costochondritis
A Aortic dissection
Which of the following examination findings is not consistent with an aortic dissection?
A BP 100/40
B Ejection systolic murmur
C Collapsing pulse
D Radio-radio delay
B Ejection systolic murmur
What are the risk factors of an AAA
- Hypertension
- Smoking
- Hypercholesterolemia
- Male (although F have an increased rupture risk)
- Connective tissue disorders such as Marfans, Ethlers-Danlos
What are the features of a ruptured abdominal aortic aneurysm
- severe abdominal pain, radiating to the back/groin
- Bleeding can result in hypovolaemic shock (low BP/ high HR) which can result in collapse
- Retroperitoneal bleeding may result in Grey Turner’s or Cullen’s sign
The severe abdominal pain, radiating to the back/groin is often confused with what other pathology
renal colic
What is the AAA screening programme
It invites male >65 yrs for an ultrasound
What is a: small medium large aneurysm
small: 3-4.4 cm
medium (4.5-5.4 cm)
Large (>5.5cm)
After the initial ultrasound, a patient is found to have a small (3-4.4cm) abdominal aneurysm, what happens next
Follow up scan in 1 year
Also consider conservative management: smoking, exercise, weight loss
AND
medical management: statins, aspirin, BP management
After the initial ultrasound, a patient is found to have a small (3-4.4cm) abdominal aneurysm, what happens next
Follow up scan in 1 year
If a patient had a small or medium abdominal aortic aneurysm, other than follow up ultrasounds, what else can be done
Also consider conservative management: smoking, exercise, weight loss
AND
medical management: statins, aspirin, BP management
After the initial ultrasound, a patient is found to have a medium (4.5-5.4cm) abdominal aneurysm, what happens next
follow up scan in 3 months
After the initial ultrasound, a patient is found to have a large (>5.5cm) abdominal aneurysm, what happens next
Surgical management: 1. open aortic surgery young patients, longer recovery time 2. endovascular repair less peri-operative mortality but higher chance of further procedures
What AAA qualify for surgery
- large (>5.5cm) aneurysms
2. aneurysms growing >1cm per year
If there is a suspected AAA rupture/leak what is the best investigation to do
Abdominal CT
Define aortic dissection
A tear in the tunica intima resulting in blood accumulation between the inner and outer tunica media (creating a false lumen)
How are aortic dissections classified
Stanford classification
Type A: tear in the ascending aorta
Type B: tear in the descending aorta (after the left subclavian branch)
What are the risk factors for aortic dissection
- Hypertension
- Atherosclerosis
- Connective tissue disorders such as Marfan’s, Ethler’s Danlos
What are the risk factors for aortic dissection
- Hypertension
- Atherosclerosis
- Connective tissue disorders such as Marfan’s, Ethler’s Danlos
- iatrogenic: angiography/angioplasty
- Congenital: coarctation of aorta (narrowing)
- Cocaine
What are the clinical features of aortic dissection
Chest pain S: central O: sudden C: tearing R: to the back A: depends on the position of the tear - carotid: blackouts, hemiparesis - coronary: MI, angina - renal: AKI - coeliac trunk
What features would you find on examination of a patient with aortic dissection
- tachycardia
- BP >20 mmHG discrepancy between arms
- radio-radial delay
- wide pulse pressure
- murmur on back below scapulae
What are the signs of aortic insufficiency
- collapsing pulse
2. EDM (early diastolic mummer)
What are the investigations for an aortic dissection
- ECG
ST depression (ischaemia) in acute dissection - CXR
widened mediastinum + visible aortic notch - cardiac enzymes (trops)
usually negative - CT angiography
visualisation of dissection and intimal flap
What are the investigations for an aortic dissection
- ECG
ST depression (ischaemia) in acute dissection - CXR
widened mediastinum + visible aortic notch - cardiac enzymes (trops)
usually negative - CT angiography
visualisation of dissection and intimal flap
if CT is unavailable in acute setting, transoesophageal echo is very sensitive
Define peripheral arterial disease
Narrowing of arteries other than those supplying the brain/heart. Most commonly seen in the legs
What in intermittent claudication
- cramping muscular pain in the calf, high or buttocks precipitated by exercise and relieved by rest
- reproducible claudication distance
M>50 yrs alongside CVD
A 65 year old lady with known CVD presents to the GP with pain in her legs. She finds the pain comes on when she is walking to the shops, but is relieved by rest. She has a 40 pack year smoking history. What is the most likely diagnosis?
Acute limb ischaemia
Deep vein thrombosis
Varicose veins
Peripheral arterial disease
Peripheral arterial disease
A 60 year old male with known atrial fibrillation presents to A&E with a sudden onset of a painful, cold leg. The doctor is unable to feel peripheral pulses, and upon examination notes a loss of sensation and paralysis. A venous doppler is inaudible. What is the definitive management?
Embolectomy
Watch and wait
Angioplasty
Amputation
Amputation
A 69 year old heavy smoker complains of pain in his leg when he walks to the bus stop. On examination of his leg, you see shiny skin, patchy hair, weak pulses and brittle toenails. What would be the first line investigation?
Angiography
Doppler Ultrasound
Magnetic Resonance Angiography
ABPI
ABPI
What is the triad for Leriche’s syndrome
- Bilateral claudication
- erectile dysfunction
- reduced femoral pulse
What is critical limb ischaemia
- Advanced stages of peripheral limb ischaemia
Triad:
a) rest pain (burning pain at rest, alleviated by standing)
b) arterial ulcers
c) Gangrene
Prognosis of peripheral arterial disease
Intermittent claudication
- 80% of improvement
- 5% intervention
- 1% amputation
- 15% dead within 5 years
Critical Limb ischaemia
- 90% major intervention
- 25% major amputation
- 50% dead within 5 years
What are the investigations of claudications
ABPI (ankle brachial pressure index)
when the blood pressure in the ankles is lower than the brachial pressure
if suspected PAD but normal ABPI - exercise testing ABPI conducted
What are the investigations of claudications
- ABPI (ankle brachial pressure index)
when the blood pressure in the ankles is lower than the brachial pressure
if suspected PAD but normal ABPI - exercise testing ABPI conducted - Doppler Ultrasound
measures blood flow through arteries/veins. Poor visualisation below the knee - Magnetic Resonance Angiography
GOLD STANDARD for demonstrating anatomy
however contrasting agents may be nephrotoxic
How can the ABPI (ankle brachial pressure index) be used to diagnose PAD
> 0.95: Normal
0.5-0.95: Claudication
0.3-0.5: Rest pain
<0.3: critical ischamia
Why might the ABPI produce a false negatives
vessel calcification makes arteries more difficult to compress
Define Acute Limb ischamia
Sudden lack of blood flow to the limb - often caused by embolus or thrombus (surgical emergency)
Thrombus: due to PAD (leading to vessel blockage)
Embolus: cardiac origin
What are the clinical features of limb ischaemia
6 Ps Pain pallor pulselessness perishingly cold parasthaesia paralysis
What is the classification of acte limb ischaemia
Viable: no neurological signs + audible doppler at ankle
Threatened: sensory loss, tense calf, no audible doppler
Dead: complete neurological deficit, fixed mottling
Define deep vein thrombosis
Formation of a clot (thrombus) in the deep vein most commonly in the pelvis or leg
What are the cause of deep vein thrombosis
Virchow’s triad:
venous stasis,
vessel wall injury
blood hypercoagulability
What are the risk factors for deep vein thrombosis
Acquired
- age
- pregnancy
- trauma
- surgery
- cancer
- oestrogen
Inherited
- antithrombin deficiency
- protein c/s deficiency
- anti-phospholipid syndrome
What are the clinical features of deep vein thrombosis
50% asymptomatic
leg swelling
calf tenderness
erythema
A 38 year old lady presents with swelling in her leg, and associated calf tenderness. She has been taking the OCP for several years. What is the best management for this patient?
Warfarin + LMWH Warfarin Aspirin LMWH + Aspirin LMWH
Warfarin + LMWH
A 72 year old gentleman is complaining of pain in his right leg. He is 8 days post operative for a tibia/fibula fracture repair. What is the minimum amount of time the patient must be anticoagulated for?
3 months
6 months
1 year
Lifelong
3 months
A 32 year old woman on the OCP complains of pain in her calf for one day. She does not have any chest pain or shortness of breath. The nurse tells you that the A&E doctors assessed the patient, who scored 2 although she cannot remember the name of the score. What is the most appropriate initial investigation?
D-Dimer
MRA
Leg Vein USS
ABPI
Leg vein USS
How can the two-level DVT Well’s Score used to classify DVT risk
> 2 point = DVT likely
- leg vein USS
- if -ve perform D-dimer
- if D-dimer +ve repeat USS 6-8 days later
<2 points = DVT unlikely
- D-dimer
- if +ve perform leg vein USS
Why shouldn’t you do a D-dimer on a pregnant woman
high false positive rate
What is the management for deep vein thrombosis
LMWH for at least 5 days
Warfarin
What is the management for deep vein thrombosis
LMWH for at least 5 days
Warfarin for at least 3 months
(best long term anticoagulant)
Inferior vena cava filters (temporary measure)
Thromolytic therapy but there’s a high risk of bleeding
Thrombectomy
What are measures to prevent DVT
stop OCP 4 week pre surgury
Compression stockings
LMWH for high risk patients
Define arterial ulcers
Also known as ischaemic ulcers caused by lack of blood flow commonly cause due to PAD
What are the clinical presentations of arterial ulcers
- in between toes/lateral aspect of foot and ankle
- punched out appearance - well defined
- very painful
- evidence of gangrene/necrosis
- minimal exudate
- surrounding skin - cold, shiny hairless
Define venous ulcer
ulcers due to inappropriate valvular function
Explain the pathophysiology of venous ulcers
Valvular incompetence leads to venouse hypertension: blood and protein leaks into the extravascular space
- leakage of fibrinogen and fibrin build up results in reduced oxygen delivery
- accumulation of leukocytes leads to release of proteolytic enzymes and ROS
What are the clinical presentation of venous ulcers
- Found in the ‘gaiter’ region
- Shallow, irregular, sloping edges
- usually painless (some pain on walking)
- ‘wet’ - heavy exudate
- Surrounding skin - oedematous, lipodermatosclerosis, haemosiderin
A 75 year old woman with long standing hypertension has had progressive swelling of her legs over the last 3 months. She has consulted her GP because she has developed an ulcer on the anterior aspect of the right shin which weeps serous fluid profusely. What is the cause of the ulcer?
Arterial
Venous
Neuropathic
Rheumatoid Arthritis
Venous
A 62 year old diabetic woman shows you an ulcer on the bottom of her foot. It has a little stone lodged in it, which she hasn’t noticed. On neurological examination, she has no peripheral sensation of light touch up to her mid-foot. What is the cause of the ulcer?
Arterial
Venous
Neuropathic
Rheumatoid Arthritis
Neuropathic
A 78 year old obese woman presents with an ulcer on the top of her foot and one between her toes. They haven’t healed in two months. They are quite small, look punched out and yellow. She complains her feet are always cold and has a history of coronary artery disease.
Arterial
Venous
Neuropathic
Trauma
Arterial
A 45 year old lady presents with a 4 cm chronic ulcer on the medial aspect of the lower leg. She has a history of pain in the calf on walking. The skin around the ulcer is brown and heavily indurated.
Arterial
Venous
Neuropathic
Trauma
Venous
Define varicose veins
varicose veins are long, tortuous and dilated vein of the superficial venous system due to valvular insufficiency
What are the risk factors for varicose veins
obesity
pregnancy
OCP
Fx
What are the clinical features of varicose vain
Pain Unsightly legs Cramps Tingling/heaviness Restless
What are the clinical features of varicose vain
Pain Unsightly legs Cramps Tingling/heaviness Restless legs
What can be found on physical examination of a patient with varicose veins
oedema exema ulcers phlebitits Atrophie Blanche Lipodermatosclerosis
What is the management of varicose veins
- Endothermal ablation
- US guided foam sclerotherapy
- surgery
