Vascular

Question 1

What is the definition of AAA?

Answer 1

Dilatation of the aorta >3cm or >50% in diameter

Question 2

How might someone with a ruptured AAA present?

Answer 2

• Abominal pain –> back/iliac fossa/groin
  
  • DDx renal colic
• Expansile mass
• Shock (tachycardia, hypotension, clammy, cool peripheries)
• Syncope
• Poor peripheral leg pulses

Question 3

Investigations and management of a ruptured AAA

Answer 3

• Ix- Bloods- including X-match, Hb, culture, CRP. Urgent bedside USS/ CT.
• Tx:
  
  • ABCDE (?transfusion)
  • If unstable –> fast bleep vascular surgeon and order 8 units of blood
  • BP 90-100mmHg
  • ABx- cefuroxime, metronidazole
  • Emergency surgery- tube graft

Question 4

Screening, investigations and management of a small-medium unruptured AAA

Answer 4

• Screening- all men >65y
• Surveillance- USS scan every 6 months for AAA 4-5.4cm
• Tx:
  
  • Lifestyle- X smoking, improve diet, exercise more
  • ACEi
  • Statins
  • >5.5cm –> elective stent/ EVAR

Question 5

Definite an aneurysm and describe the different types.

Answer 5

• Aneurysms= dilatation of artery 1.5x diameter
• Types:
  
  • Atheroma eg AAA
  • Dissecting eg TAA
  • Berry eg cerebral
  • Micro eg hypertensive/ DM
  • Aortic root eg syphilis
  • Mycotic eg endocarditis
  • Cardiac
  • False eg trauma. Collection of blood in adventitia which communicates with lumen.

Question 6

How might a Thoracic Aortic Dissection present? + Ix and Tx

Answer 6

• Sudden tearing chest pain –> back
• Shock/ syncope
• Tears spontaneously and occludes sequential branches:
  
  • Hemiplegia
  • Unequal arm pulses/BP
  • Acute limb ischaemia
  • Paraplegia
  • Aneuria
• Ix: CT, blood including X-match
• Tx: Antihypertensives, surgery

Question 7

Fontaine Classification of stages of PVD

Answer 7

1. ASx
2. Intermittent claudication
3. Ischaemic rest pain
4. Critical limb ischaemia + ulceration/ gangrene/impotence

Question 8

Presentation of intermittent claudication

Answer 8

• Pain on exertion in legs/ buttocks after walking a given distance (claudication distance)
• Relieved by rest

Question 9

Presentation of Critical Limb Ischaemia

Answer 9

• Triad of: Rest pain, ulcers, gangrene
• 6 P’s:
  
  • Pain
  • Pallor
  • Pulselessness
  • Paralysis
  • Paraesthesia
  • Perishing cold

Question 10

Investigations and management of critical limb ischaemia

Answer 10

• Ix: Hand help doppler, angion. ABPI <0.5
• Tx:
  
  • ABCDE, 02, analgesia, IVT
  • Urgent surgery- Embolectomy, intra-arterial thrombolysis, bypass, amputation
  • Heparin

Question 11

Investigations and management of peripheral vascular disease

Answer 11

• Ix:
  
  • Buerger’s (pale + reactive hyperaemia)
  • Bloods- FBC, CRP/ESR, U+Es, lipids
  • ECG
  • ABPI
  • Doppler USS
  • CT Angio
  • CVS Risk assessment
• Tx:
  
  • RF reduction- lifestyle, statins, clopidogrel, DM control
  • Surgical- Angioplasty +/- stent, bypass grafting, amputation
  • Claudication- supervised exercise programmes, vasoactive drugs

Question 12

What are the features, RF, Ix and Tx of wet gangrene?

Answer 12

• RF- Iscahemia, DM, malignancy
• Presentation- Unwell with pain. Necrosis and infection.
  
  • Pyrexia
  • Shock
  • Tender brown/black area with blistering and oedema
  • Necrosis + crepitus
• Ix- Culture, ABG, bloods, X-ray
• Tx- Broad spec Abx, debridgement

Question 13

Presentation and management of dry gangrene

Answer 13

• = Ischaemic muscle necrosis without infection
• Presentation- Well defined, painless, shrivelled brown/black area
• Tx- autoamputation, debridement, amputation

Question 14

Key features of venous ulcer

Answer 14

• Women > men
• Hx- obesity, immobility, DVT, varicose veins
• Leg- pigmented, hot, swollen
• Site- medial. gaitor region
• Large
• Base- superficial. Sloughy exudate.
• Edge- Irregular
• Painful

Question 15

Key features of arterial ulcer

Answer 15

• Men with CVS RF
• Leg- shiny, hairless, cold. Limb iscahemia
• Site- lat. malleolus, toes, dorsum of foot
• Small
• Base- deep with dark base (necrosis)
• Well defined edge
• Pain ++

Question 16

Key features of neuropathic ulcer

Answer 16

• History- numbness. DM/FHx
• Leg- joint destruction eg Charcot’s
• Site- heel, metatarsal head. Glove and stocking.
• Small
• Can be very deep
• Surrounded by thickened skin
• Relatively painless

Question 17

Ulcer investigations

Answer 17

• Bedside- swab, ABPI
• Imaging- Duplex uSS, CT angio
• Bloods- FBC, CRP, glucose
• Special- Biopsy

Question 18

Management of ulcers

Answer 18

• Conservative- Good nutrition. Wound dressing.
• Venous- compression if ABPI >0.8. Emollients, steroid creams. Surgical debridgement/ grafting.
• Arterial- Reduced CVS RF. Surgery- ?bypass ?angioplasty
• Neuropathic- Foot care. ?ABx, ?debridement
• Infection- Tx cellulitis

Question 19

Well’s score for DVT

Answer 19

• Active cancer
• Paralysis/ recent plaster immobilisation of leg
• Recent bedriden >3d or surgery <4w
• Localised tenderness in deep vein distribution.
• Entire leg swelling
• Calf size >3cm compared to other
• Pitting oedema
• PMH DVT
• Collateral superficial veins
• Alternative Dx just as likely (-2)
• >3= High probability –> Doppler
• 0-2= low-mod –> d-dimer –> Doppler if high

Question 20

DDx of DVT

Answer 20

• Cellulitis
• Ruptured Baker’s cyst

Question 21

Treatment of DVT

Answer 21

• Cons- mobilise
• Medical- LMWH –> PO anticoagulation for 3 months (6 months if cancer/ recurrent/ unknown cause)
• Can’t tolerate –> IVC filter to prevent PE

Question 22

Prevention of DVT

Answer 22

• Stop oestrogen 4w before surgery
• Mobilise early
• Anticoagulants
• Compression stockings

Question 23

Presentation, Ix and Tx of venous insufficiency

Answer 23

• Presentation-
  
  • ASx
  • Varicose veins
  • Bursting/ throbbing leg pain. Relieved by elevating and worsened by standing
  • Redness and swelling
  • ?Varicose eczema
• Ix- Duplex USS
• Tx- Compression, surgery