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MedEd Lectures > Vascular > Flashcards

Vascular Flashcards

1
Q 
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
A

C Ruptured AAA

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2
Q

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

A Abdominal Ultrasound

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3
Q

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

A

B Abdominal CT

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4
Q

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

A Aortic dissection

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5
Q

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

A

B Ejection systolic murmur

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6
Q

What are the risk factors of an AAA

A
  1. Hypertension
  2. Smoking
  3. Hypercholesterolemia
  4. Male (although F have an increased rupture risk)
  5. Connective tissue disorders such as Marfans, Ethlers-Danlos
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7
Q

What are the features of a ruptured abdominal aortic aneurysm

A
  1. severe abdominal pain, radiating to the back/groin
  2. Bleeding can result in hypovolaemic shock (low BP/ high HR) which can result in collapse
  3. Retroperitoneal bleeding may result in Grey Turner’s or Cullen’s sign
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8
Q

The severe abdominal pain, radiating to the back/groin is often confused with what other pathology

A

renal colic

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9
Q

What is the AAA screening programme

A

It invites male >65 yrs for an ultrasound

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10
Q 
What is a:
small 
medium 
large 
aneurysm
A

small: 3-4.4 cm
medium (4.5-5.4 cm)
Large (>5.5cm)

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11
Q

After the initial ultrasound, a patient is found to have a small (3-4.4cm) abdominal aneurysm, what happens next

A

Follow up scan in 1 year

Also consider conservative management: smoking, exercise, weight loss
AND
medical management: statins, aspirin, BP management

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12
Q

After the initial ultrasound, a patient is found to have a small (3-4.4cm) abdominal aneurysm, what happens next

A

Follow up scan in 1 year

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13
Q

If a patient had a small or medium abdominal aortic aneurysm, other than follow up ultrasounds, what else can be done

A

Also consider conservative management: smoking, exercise, weight loss
AND
medical management: statins, aspirin, BP management

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14
Q

After the initial ultrasound, a patient is found to have a medium (4.5-5.4cm) abdominal aneurysm, what happens next

A

follow up scan in 3 months

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15
Q

After the initial ultrasound, a patient is found to have a large (>5.5cm) abdominal aneurysm, what happens next

A 
Surgical management:
1. open aortic surgery
young patients, longer recovery time 
2. endovascular repair 
less peri-operative mortality 
but higher chance of further procedures
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16
Q

What AAA qualify for surgery

A
  1. large (>5.5cm) aneurysms

2. aneurysms growing >1cm per year

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17
Q

If there is a suspected AAA rupture/leak what is the best investigation to do

A

Abdominal CT

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18
Q

Define aortic dissection

A

A tear in the tunica intima resulting in blood accumulation between the inner and outer tunica media (creating a false lumen)

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19
Q

How are aortic dissections classified

A

Stanford classification
Type A: tear in the ascending aorta
Type B: tear in the descending aorta (after the left subclavian branch)

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20
Q

What are the risk factors for aortic dissection

A
  1. Hypertension
  2. Atherosclerosis
  3. Connective tissue disorders such as Marfan’s, Ethler’s Danlos
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21
Q

What are the risk factors for aortic dissection

A
  1. Hypertension
  2. Atherosclerosis
  3. Connective tissue disorders such as Marfan’s, Ethler’s Danlos
  4. iatrogenic: angiography/angioplasty
  5. Congenital: coarctation of aorta (narrowing)
  6. Cocaine
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22
Q

What are the clinical features of aortic dissection

A 
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
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23
Q

What features would you find on examination of a patient with aortic dissection

A
  1. tachycardia
  2. BP >20 mmHG discrepancy between arms
  3. radio-radial delay
  4. wide pulse pressure
  5. murmur on back below scapulae
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24
Q

What are the signs of aortic insufficiency

A
  1. collapsing pulse

2. EDM (early diastolic mummer)

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25
Q

What are the investigations for an aortic dissection

A
  1. ECG
    ST depression (ischaemia) in acute dissection
  2. CXR
    widened mediastinum + visible aortic notch
  3. cardiac enzymes (trops)
    usually negative
  4. CT angiography
    visualisation of dissection and intimal flap
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26
Q

What are the investigations for an aortic dissection

A
  1. ECG
    ST depression (ischaemia) in acute dissection
  2. CXR
    widened mediastinum + visible aortic notch
  3. cardiac enzymes (trops)
    usually negative
  4. CT angiography
    visualisation of dissection and intimal flap
    if CT is unavailable in acute setting, transoesophageal echo is very sensitive
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27
Q

Define peripheral arterial disease

A

Narrowing of arteries other than those supplying the brain/heart. Most commonly seen in the legs

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28
Q

What in intermittent claudication

A
  1. cramping muscular pain in the calf, high or buttocks precipitated by exercise and relieved by rest
  2. reproducible claudication distance
    M>50 yrs alongside CVD
29
Q

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

A

Peripheral arterial disease

30
Q

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

A

Amputation

31
Q

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

A

ABPI

32
Q

What is the triad for Leriche’s syndrome

A
  1. Bilateral claudication
  2. erectile dysfunction
  3. reduced femoral pulse
33
Q

What is critical limb ischaemia

A
  1. Advanced stages of peripheral limb ischaemia
    Triad:
    a) rest pain (burning pain at rest, alleviated by standing)
    b) arterial ulcers
    c) Gangrene
34
Q

Prognosis of peripheral arterial disease

A

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
35
Q

What are the investigations of claudications

A

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

36
Q

What are the investigations of claudications

A
  1. 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
  2. Doppler Ultrasound
    measures blood flow through arteries/veins. Poor visualisation below the knee
  3. Magnetic Resonance Angiography
    GOLD STANDARD for demonstrating anatomy
    however contrasting agents may be nephrotoxic
37
Q

How can the ABPI (ankle brachial pressure index) be used to diagnose PAD

A

> 0.95: Normal
0.5-0.95: Claudication
0.3-0.5: Rest pain
<0.3: critical ischamia

38
Q

Why might the ABPI produce a false negatives

A

vessel calcification makes arteries more difficult to compress

39
Q

Define Acute Limb ischamia

A

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

40
Q

What are the clinical features of limb ischaemia

A 
6 Ps
Pain 
pallor 
pulselessness 
perishingly cold 
parasthaesia 
paralysis
41
Q

What is the classification of acte limb ischaemia

A

Viable: no neurological signs + audible doppler at ankle
Threatened: sensory loss, tense calf, no audible doppler
Dead: complete neurological deficit, fixed mottling

42
Q

Define deep vein thrombosis

A

Formation of a clot (thrombus) in the deep vein most commonly in the pelvis or leg

43
Q

What are the cause of deep vein thrombosis

A

Virchow’s triad:
venous stasis,
vessel wall injury
blood hypercoagulability

44
Q

What are the risk factors for deep vein thrombosis

A

Acquired

  1. age
  2. pregnancy
  3. trauma
  4. surgery
  5. cancer
  6. oestrogen

Inherited

  1. antithrombin deficiency
  2. protein c/s deficiency
  3. anti-phospholipid syndrome
45
Q

What are the clinical features of deep vein thrombosis

A

50% asymptomatic
leg swelling
calf tenderness
erythema

46
Q

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
A

Warfarin + LMWH

47
Q

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

A

3 months

48
Q

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

A

Leg vein USS

49
Q

How can the two-level DVT Well’s Score used to classify DVT risk

A

> 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
50
Q

Why shouldn’t you do a D-dimer on a pregnant woman

A

high false positive rate

51
Q

What is the management for deep vein thrombosis

A

LMWH for at least 5 days

Warfarin

52
Q

What is the management for deep vein thrombosis

A

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

53
Q

What are measures to prevent DVT

A

stop OCP 4 week pre surgury
Compression stockings
LMWH for high risk patients

54
Q

Define arterial ulcers

A

Also known as ischaemic ulcers caused by lack of blood flow commonly cause due to PAD

55
Q

What are the clinical presentations of arterial ulcers

A
  1. in between toes/lateral aspect of foot and ankle
  2. punched out appearance - well defined
  3. very painful
  4. evidence of gangrene/necrosis
  5. minimal exudate
  6. surrounding skin - cold, shiny hairless
56
Q

Define venous ulcer

A

ulcers due to inappropriate valvular function

57
Q

Explain the pathophysiology of venous ulcers

A

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
58
Q

What are the clinical presentation of venous ulcers

A
  1. Found in the ‘gaiter’ region
  2. Shallow, irregular, sloping edges
  3. usually painless (some pain on walking)
  4. ‘wet’ - heavy exudate
  5. Surrounding skin - oedematous, lipodermatosclerosis, haemosiderin
59
Q

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

A

Venous

60
Q

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

A

Neuropathic

61
Q

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

A

Arterial

62
Q

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

A

Venous

63
Q

Define varicose veins

A

varicose veins are long, tortuous and dilated vein of the superficial venous system due to valvular insufficiency

64
Q

What are the risk factors for varicose veins

A

obesity
pregnancy
OCP
Fx

65
Q

What are the clinical features of varicose vain

A 
Pain 
Unsightly legs 
Cramps
Tingling/heaviness 
Restless
66
Q

What are the clinical features of varicose vain

A 
Pain 
Unsightly legs 
Cramps
Tingling/heaviness 
Restless legs
67
Q

What can be found on physical examination of a patient with varicose veins

A 
oedema 
exema 
ulcers 
phlebitits 
Atrophie Blanche 
Lipodermatosclerosis
68
Q

What is the management of varicose veins

A
  1. Endothermal ablation
  2. US guided foam sclerotherapy
  3. surgery

MedEd Lectures (15 decks)

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