Vascular Flashcards
1
Q
- What are the usual indications, in an otherwise fit person, for considering them for repair of an abdominal aortic aneurysm?
A
- Leaking or ruptured aneurysms
- Symptomatic aneursyms – pain, obstruction or embolism
- Expanding aneurysms - >0.5cm/year
- Size >5.5cm diameter or saccular
2
Q
- What are the features of a patient who presents with a rupturing abdominal aortic aneurysm?
A
Typical presentation:
- Sudden onset of severe abdominal pain, radiating to the back
- Haemodynamic collapse – hypotension and tachycardia
- Pulsatile abdominal mass
Unusual presentation
- Transient lower limb paralysis (lumbar nerve compression)
- RUQ pain
- Groin pain
- Testicular pain
- Testicular ecchymosis
- Iliofemoral venous thrombosis
- Grey turner and cullens sign
- Acute limb ischaemia from embolism
3
Q
- A 68 year old man presents to ED with a 1 hour history of pain in the left side of his abdomen and midback. It started suddenly, has not moved, and is getting worse. It is the worst pain he has ever experienced. He has a history of stable angina, managed with betablockers 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?
A
Most likely diagnosis: ruptured AAA
Triad:
- Severe abdominal pain radiating to the back + hypotension and tachycardia + pulsatile abdominal mass
Investigations:
- Immediately notify senior ED staff and request immediate senior surgical referral, anaesthetics and ICU notification
- Primary survey – ABCDE
- High flow oxygen
- 2 large bore cannula
- Bloods: X-match, FBC, UEC, coags, VBG
- IV crystalloids
- Therapeutic hypotension
- ECG
- Analgesia – opioid
- Catheterisation
- Any investigations undertaken in a patient who is haemodynamically unstable with suspected ruptured AAA should not delay time to theatre
- FAST may be performed in ED
- CT with contrast would be performed if the diagnosis was uncertain
Treatment
- Surgical management
- Endovascular aneurysm repair (EVAR)
- Most effective for ruptured AAA
- Insertion of a stent using a guidewire and angiographic guidance
- Open repair
- Endovascular aneurysm repair (EVAR)
4
Q
- 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?
A
- conservative treatment
- watchful waiting
- cardiovascular risk reduction
- smoking cessation, weightloss, control of diabetes/ BP/ lipids
- antiplatelet therapy
- endovascular aneurysm repair (EVAR)
- Self-exapading metal framework with a non-porous cloth covering; it is supplied in a constrained state
- Short transverse incisions made to access common femoral arteries in the groin.
- Main device passed into one femoral artery and guided proximally using radiological guidance to its position below the renal arteries
- Constraining mechanism removed and stent opens and expands against tissue wall.
- Contralateral femoral artery Is then exposed and a guide-wire passed proximally to enter the main graft body throught the short leg.
- Second limb of stent-graft is completed by passing another covered stent over the guidewire and securing it into the main graft body and iliac artery.
- open repair
- Midline or traverse abdominal incision
- Aorta usually reached via the peritoneal cavity
- Anticoagulated with heparin to prevent distal thrombosis
- Iliac and infrarenal arteries clamped
- Aneurysm incised and removed.
- Bleeding lumbar arteries are closed with sutures
- Proximally graft is sutured above the upper limit of aneurysm sac to the native aorta at the bifurcation distally
5
Q
- What are the common complications of endovascular (stent) repairs of abdominal aortic aneurysms?
A
- 16-30%
- Haematoma
- Infection
- Arterial Dissection
- Distal embolisation
- AV fistula formation
- Pseudoaneurysm
-
Endograft complications:
- Endoleak
- Endograft migration
- Endograft infection
- Kinking/ occlusion/ stent fractures / component separation
-
Systemic complications
- Cardiopulmonary disease (e.g. Myocardial Infarction)
- IV contrast complications
- Allergy
- Contrast nephropathy
- Ischaemia – due to thrombosis, embolism, arterial dissection, obstruction related to positioning or kinking of the graft
- Renal
- Intestinal
- Lower limb
- Pelvic
-
Other Complications
- Conversion to open repair
- Post-implantation syndrome – flu-like illness
- Abdominal compartment syndrome
6
Q
- What are the main indications for carotid endarectomy (CEA, Carotid sugery)?
A
- symptomatic patients with 70-99% stensois or select pts with 50-69% stenosis
- no symptomatic patients
diagnostics:
- cervical bruit
- TIA or stroke
- transient visual symptoms
risk factors:
- older age
- smoking
- hx of cardiovascular disease
- hx of hypertension
- hx of hypercholestrolaemia
7
Q
- 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, he is a lifelong smoker.
Physical exam is normal, other than numbess.
What is the likley diagnosis? What investigations are needed?
A
Most likely diagnosis: Transient Ischaemic Attack of the right MCA
Differential diagnosis:
- Stroke
- Hypoglycaemia
- Multiple sclerosis
- Space occupying lesion (intracranial haemorrhage, abscess, mass)
- Complex migraine
Investigations
- Bloods: FBC, UEC, BGL, Coags, Fasting lipids
- ECG
- Non-contrast Head CT – with thin slices (<2mm)
- MRI preferred to CT, if available
- CT perfusion imaging may be used in addition to routine imaging
- Vascular imaging – CTA, carotid doppler USS, or MRI
- Consider - echocardiography
8
Q
- A 71 year old man presents to 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 numbess.
What is the most likley diagnosis? What are the risk factors for this disease?
A
Most likely diagnosis: Transient Ischaemic Attack
- Risk factors
- Patient factors
- Advanced age
- Male
- Family history of CVD or Cerebrovascular disease
- Lifestyle
- Cigarette smoking
- Hypertension
- Alcohol abuse
- Inactivity
- Compounding co-morbidities
- Atrial fibrillation
- Valvular heart disease
- Carotid stenosis
- Congestive heart failure
- Diabetes mellitus
- Patent foramen ovale
- Obesity
- Hypercoagulability
- Patient factors
9
Q
- 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 90/55mmHg. 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, 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? What are the reasonable differential diagnoses?
A
ABG results show metabolic acidosis (low pH and base deficit), with lactic acidosis (Elevated lactate) and partial respiratory compensation (low PaCO2)
Most likely diagnosis: acute intestinal ischaemia (secondary to embolization)
Differential Diagnosis:
- Colitis
- Infectious
- Inflammatory (UC or Crohn’s)
- Diverticulitis
- Ulcerative
- Ischaemic
- Antibiotic
- Small or large bowel obstruction
- Sepsis
- Gastroenteritis
- Acute pancreatitis
Presentation of acute intestinal ischemia:
- Acute severe abdominal pain – contrast, central or localised to RIF
- No abdominal signs – degree of illness way out of proportion to clinical signs
- Rapid hypovolaemia – shock
- Haematochezia/ melaena
- Diarrhoea
- Risk factors for arterial disease (AF, DM, HTN, smoking, etc)
- High lactate – indicating ischemia
10
Q
- A 65 year old man presents to the emergency department with an 8 hour history of abdominal 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? How should he be managed?
A
ABG results show metabolic acidosis (low pH and base deficit), with lactic acidosis (Elevated lactate) and partial respiratory compensation (low PaCO2)
Most likely diagnosis: acute intestinal ischaemia (secondary to embolization)
Management:
- Initial resuscitation (ABCDE, supplemental O2, IV access, IV fluids)
- Consider other lifetrheating diagnosis: acute pancreatitis, ruptured AAA, perforated viscus, septic shock from intra-abdominal source
- Call: intervention radiologist and vascular/ general surgeon
- Empirical Abx: Ceftriaxone + Metronidazole
- Investigations:
- FBC, UEC, VBG (done), LFT, lipase, Coagulation profile, Group and Hold
- ECG
- FAST to rule out AAA
- Erect CXR and Supine AXR
- Mesenteric angiography/ CTA
- Definitive management:
- Early notification of surgeons and ICU
- Endovascular – thrombectomy or balloon angioplasty with arterial stent placement
- Only for patients who have no clinical or radiological signs of advanced intestinal ischaemia or infarction
- Open surgical (laparotomy) – resection of infarcted/ non-viable bowel
- Broad spectrum IV antibiotics (ampicillin and gentamicin)
- IV heparin if no contraindications
- Supportive measures
- Fluid resuscitation
- Oxygen to correct hypoxemia
- NBM
- NGT decompression
- Analgesia
11
Q
- You are the ED intern on duty. You are asked to ses and treat 75 yoa man who has presented with sudden onset of pain in his right leg. What are you going to do?
A
History
- SOCRATES of the pain
- Previous or similar episodes?
- Injury or trauma?
- Chronic ischaemia?
- Claudication
- Erectile dysfunction
- Ulcers
- Dependent rubor
- Previous amputations
- PMHx/PSHx: AF, HTN, hyperlipidaemia, DM, CVD, smoking, ulcers, AAA
- Meds/ allergies
- SHx: smoking EtOH, occupation
- FHx: CVD
- When did he last eat or drink
Examination:
- Look
- Pallor/ cyanosis
- Hair on legs
- Oedema
- Skin changes/ colour
- Surgical scars
- Feel:
- Temperature
- Capillary refill
- Pulses
- Aneurysms
- Move:
- Tone
- Power
- Reflexes
- Sensation
- Special tests – Buerger’s test
- Perform a full cardiovascular examination
- Abdominal examination – AAA
Signs and symptoms of acute limb ischaemia:
- 3 symptoms
- Pain
- Paraesthesia
- Paralysis
- 3 signs
- Pallor
- Pulseless
- Poikilothermia (perishingly cold)
Invesigations
- Bloods:
- FBC, UEC, LFT, Coags, BGL
- ECG
- ABPI
- Duplex Doppler USS
- CTA
Management
- Contact vascular surgeon
- Protect the limb with a hell pad; don’t elevate
- Analgesia
- UFH – Heparin IV bolus + IV heparin infusion
- Definitive treatment
- Thrombolysis – visible limb
- Surgical revascularisation/ embolectomy – threatened limb
- Amputation – non-viable limb
12
Q
- You are the ED intern on duty. You have seen 75yoa man with painful left leg of sudden onset. He has 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?
A
Most likely diagnosis: acute limb Ischaemia
Causes:
- Embolism
- Cardiac: AF, valvular vegetation, LV Thrombus secondary to LV dysfunction, tumour (atrial myxoma)
- Non-cardiac: atherosclerotic embolus, aneurysmal
- Thrombosis (most common for lower limb)
- Thrombosis of native vessel (atherosclerosis or aneurysm)
- Occlusion of a bypass graft
- Trauma
- Blunt
- Penetrating
- IVDU
- Rarer causes
- Vasculitis
- Aortic dissection
Plan:
- Confirm the diagnosis
- history & examination
- ABPI
- Duplex doppler USS
- CTA
- Call vascular surgeon
- Supportive care
- Protect the limb with a heel pad
- Don’t elevate
- Analgesia
- UFH IV bolus + IV heparin infusion
- Definitive treatment:
- Thrombolysis- viable limb
- Surgical revascularisation/embolectomy – threatened limb
- Amputation – non-viable limb
13
Q
- You are the ED intern on duty. You have seen 75yoa man with a painful left leg of sudden onset. He has 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?
A
Most likely diagnosis: Acute limb ischemia
14
Q
- 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 releived 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 treatmnet is needed?
A
Issues
- Peripheral vascular disease with critical limb ischaemia (rest pain, partially relieved by dependency)
- Possible abscess/ cellulitis/ gangrene at the base of right big toe
- Poorly controlled diabetes
Investigations
- FBC, UEC, LFTs, Coags, HbA1c, ESR/CRP, Blood culture
- ABPI
- Duplex Doppler USS lower limbs
- CTA
- Foot XR
Management
- Vascular consult re: revascularisation or amputation
- If abscess of right great toe – incision and drainage
- Empirical Abx: flucloxacillin
- Diabetic management: endocrinology and podiatry review, as well as other allied health staff for diabetic care
15
Q
- What factors will a vascular surgeon consider when planning treatment for peripheral vascular disease in a patient’s foot?
A
General Management considerations of PVD:
- Acute presentation
- Viable limb – revascularisation
- Non-viable limb – amputation
- Chronic presentation
- Disease severity
- Claudication – does it limit lifestyle
- Critical limb ischaemia
- Age of the patient
- Compliance to medical therapy and lifestyle modification
- Comorbidities
- Disease severity
Concerns of a vascular surgeon:
- Is the limb viable?
- Is the patient on maximal medical therapy?
- Are there sufficient viable vessels remaining past the site of obstruction?
Treatment options
- Conservative management/ medical and lifestyle treatment
- Intervention
- Balloon angioplasty +/- stenting
- Reconstructive surgery (e.g. bypass grafting)
- Amputation
- Palliative care
17
Q
- What anatomical levels are commonly used for amputations in the lower limb for peripheral vascular disease?
A
- Hip disarticulation
- Above-knee (femoral) amputation
- Through-knee disarticulation
- Below-knee (tibial) amputation
- Syme’s (Malleolar) amputation
- Ankle disarticulation
- Chopart (midfoot) amputation
- Lisfranc (midfoot) amputation
- Mid-tarsal amputation
- Toe amputation
