Vascular Flashcards
Give 5 risk factors for peripheral artery disease
- smoking
- diabetes
- hypertension
- hyperlipidaemia
- increased age
- FHx
- obesity
- inactivity
Describe the clinical features of peripheral artery disease
- cramping like pain in calf, thigh or buttocks after walking a fixed distance, releived after standing still/ resting for a minute
- hairloss
- skin changes
- thickened nails
- weak pulses, pale, cold feet
- pain at night, relieved by dangling foot out of the bed
- beurgers angle <20 degrees= severe ischaemia
- ulceration and gangrene (stage 4)
What is the definition of critical limb ischaemia?
- rest pain going on for 2 weeks despite analgesia or presence of ischaemia lesions or gangrene
give 3 differentials for peripheral vascular disease
- spinal stenosis: pain going down legs on walking variable distances or prolonged standing, relieved by sitting down for 3-10 mins
- acute limb ischaemia
- neuropathy
- sciatica
- lower limb arthritis
- MSK strain
How should suspected peripheral artery disease be investigated?
- Bloods: fbc (anaemia will precipitate symptoms), lipids, hba1c, u&e (many need contrast so need renal function check)
- Ankle brachial pulse pressure index (normal is 1-1.3)
- duplex USS of lower limb arteries
- CT w/ contrast (angio) if arterial tree not well visualised on USS or disease is very proximal
How is intermittent claudication managed?
- CVS risk factor modification
- supervised exercise programme
- antiplatelet therapy with aspirin or clopidogrel
- angioplasty if supervised exercise programme as not helped
- prescribe naftidrofuryl oxalate if they dont want referal for surgery
- bypass if claudication distance is short and angioplasty fails
Give a complication of peripheral artery disease
- sepsis secondary to infected (wet) gangrene
- acute on chronic ischaemia
- amputation
Describe the clinical features of chronic mesenteric ischaemia (usually due to atherosclerosis)
- abdo pain 10 mins - 4hrs after eating
- weightloss
- vascular comorbidities
- loose stool, N+V, generalised tenderness and bruits may also be present
How is chronic mesenteric ischaemia managed?
- antiplatelet
- CVS risk factor reduction
- mesenteric angioplasty and stending
- end arterectomy or bypass less often used
What is the difference between deep venous insufficiency and varciose veins?
deep venous insufficiency is when the veins of the deep venous system become incompetent, usually due to DVT or valvular insufficiency
How may deep venous insufficiency present?
- chronically swollen lower limbs
- aching, pruritis in lower limbs
- burting pain and tightness on walking which is relieved by elevation
- venous ulcers (usually medial malleolus)
- varicose eczema, thrombophelbitis, haemosiderin staining, lipodermatosclerosis
- post thrombotic syndrome
How is deep venous insufficiency investigated?
- duplex USS and assesment of venous reflux, stenosis and DVT
How is deep venous insufficiency managed?
- compression stockings and analgesia
- treat ulcers
- elevate feet where possible to reduce symptoms and disease progression
- little evidence for valvulopasty of venous stents
What are the 3 types of varicose veins?
- trunk: dilated, tortuous from long or short saphenous vein or their branches
- reticular: permanently dilated bluish intradermal veins, usually 1-3mm in diameter
- telangiectasia: a confluence of permanently dilated intradermal veins of less than 1mm in diameter
What are the 3 causes of varicose veins?
- primary/ simple: valvular failure resulting in dilated superficial veins in lower limb
- secondary: when superficial veins carry reverse flow (which dilates them) as a collateral mechanism compensating for obstructed neighbouring veins
- AV fistula
What are the most common presenting complaints of varicose veins?
- cosmetic deformity
- discomfort: localised to vein site, aching, tension, heaviness and itching, particularly if hot or standing long time
- nocturnal cramps
Describe the 4 common skin changes with varicose veins
- varicose eczema: eczema along vein site
- haemosiderin staining: extravascularised RBCs make the skin browny/ red around the vein
- lipodermatosclerosis: inflammation leads to skin induration and fibrosis of SC fat
- Atrophe blanche: white scarring in lower leg due to venous hypertension
- thrombophlebitis: bruising and pain along vein length due to inflammation
- also: venous ulcers
When should varicose veins be referred to vascular surgeons?
- symptomatic
- lower limb skin changes
- superficial vein thrombosis (hard,painful veins)
- venous leg ulcer (break in skin below knee, not healed in 2 weeks)
What are the 2 surgical options fo varicose veins in leicester
Open surgery: long saphenous stripping, saphenfemoral disconnection, multiple avulsions
Endovascular laser ablation: of long or short saphenous veins, under local, combined with foam scleropathy to improve cosmetic appearance
How may AAA present?
- with rupture: hypotension, shock, LOC, severe central abdo/ back pain
- asymptomatic, picked up on screening (all men over 65 get an USS)
- pulsatile masses in abdomen
How are non ruptured AAA managed?
- USS/ CT angio
- if 3-4.5cm, do yearly duplex USS to monitor
- if 4-5.4 cm 3 monthly USS monitoring
- when >5.5cm, expanding >1cm a year or symptomatic surgery is considered
- CVS risk reduction
What are the two surgical options for unruptured AAA repair?
- open repair: prosthetic graft is inserteed via midline laparotomy (used in younger pts)
- endovascular repair: needs 1.5cm normal aorta below renal vessels, lifelong monitoring and more thorough pre op assessment but fewer complications, better survival rate and recovery times.
What may cause leg ulcers
- venous disease
- arterial disease (AV malformations, atheroslcerosis)
- vasculitis (SLE, RA, scleroderma, wengers)
- lymphatic insufficiency
- neuropathic (usually diabetes)
- haematological (sickle cell)
- trauma (burns, pressure sore, cold injury)
- neoplasm (BCC, SCC, melanoma)
- others: sarcoid, pyoderma
Describe the pathophysiology of venous ulcers
- chronic venous hypertension (due to varicose veins, DVT, CVI)
- get odema in lower limb
- results in impaired tissue perfusion as oxygen and metabolites have to diffuse greater distances to get to tissue cells
- become ischaemic when walking
- then reperfusion injury when rest
- more inflammation- more odema- more tissue fibrosis
- ulceration is last after the other skin changes
How should venous ulcers be managed?
- 4 layer compression bandaging if arterial circulation is ok
- leg elevation
- improve mobility
- reduce obesity and improve nutrition
- varicose vein surgery if thats the cause
- skin grafting in selected pts
- monitor for infection
What are the 6 signs of acute limb ischaemia
pale, pulseless, paraesthesia, perishingly clold, paralysis acute onset (mins- hrs) if embolic, insidious (hrs- days) if thrombotic
What causes acute limb ischaemia
- 60% are thrombosis of atheromatous plaque
- 30% are emboli from AF, post MI, AAA, prosthetic heat valves
- 10% untreated compartment syndrome
How is an acute limb ischaemia managed?
- arrange, bloods (inc lactate, G&S), ECG, duplex USS, CT angio, urgent vascular review
- theraputic dose heparin
- if the limb is viable, there are may interventions they may have: percutaneous catheter directed thrombolysis, surgical embolectomy or endovascular revascularisation
- if irreversible they need urgent amputation
- long term they need clopidogrel or aspirin, treat cause and modify RFs
How should a DVT be managed?
- wells score- USS or/ and D dimer
- apixaban for at least 3 months (warfarin w/ LMWH to bridge if DOAC contraindicated)
- CVS RF modification
- if cant get USS within 4 hrs, give anticoag for 24 hrs in interim
- if unprovoked do CXR, FBC, serum calcium, LFTs, urinalysis, examine for cancer +/- CT CAP and mammogram
How may carotid artery disease present?
- asymptomatic but bruit picked up
- TIA (transient cerebral or monocular visual loss)
- CVA (usually hemisensory/ motor deficit affecting face arm and leg or loss of higher cortical function (dysphagia, neglect))
How is carotid artery disease investigated?
- carotid artery duplex USS
- CT or MRI angio where the artery isnt easy to asses on USS (calcification or thick neck) or if distal/ proximal disease suspected
How is carotid disease managed?
- CVS risk factor modification
- antiplatelets (aspirin or clopidogrel)
- carotid endarterectomy (if symptomatic severe stenosis as reduces stroke risk, used if pt fit for surgery)
