Vascular

Question 1

Peripheral Arterial Disease (PAD or LEAD)

Answer 1

Range of syndromes caused when narrowed arteries reduce blood flow to limbs

Question 2

The Fontaine Classification

Answer 2

Describes 4 stages of LEAD:
Stage 1: Asymptomatic
Stage 2a: Intermittent claudication with pain after more than 200m walking
Stage 2b: Intermittent claudication with pain after less than 200m walking
Stage 3: Rest pain
Stage 4: Ischaemic ulcers or necorsis and gangrene

Question 3

Rutherford Classification

Answer 3

Describes 7 stages of PAD:
Stage 0 – Asymptomatic
Stage 1 – Mild claudication
Stage 2 – Moderate claudication
Stage 3 – Severe claudication
Stage 4 – Rest pain
Stage 5 – Ischaemic ulceration not exceeding ulcers of the digits of the foot
Stage 6 – Severe ischaemic ulcers or frank gangrene

Question 4

Causes of PAD

Answer 4

Atherosclerosis and stenosis, damage, inflammation, degenerative diseases. Rarer causes are: aortic coarctation, arterial tumour, arterial dissection, temporal arteritis.

Question 5

Risk factors for PAD

Answer 5

Smoking, diabetes, HTN, hyperlipidaemia, Over 40 y.o, Virchow’s triad, low levels of exercise

Question 6

Virchow’s Triad

Answer 6

Factors that contribute to thrombosis:

hypercoaguability, vessel wall injury, blood stasis

Question 7

Symptoms of PAD

Answer 7

Asymptomatic, intermittent claudication, diminished pulse, 6 P’s, erectile dysfunction, pain in calf, thigh or bum
Skin changes: shiny, hair loss

Question 8

6 Ps

Answer 8

Pain, paralysis, paraesthesia, pulselessness, perishingly cold, pallor

Question 9

Investigations for PAD

Answer 9

ABPI (1.3 + abnormal, 1.0 - 1.2 normal, 0.90-0.99 Acceptable, 0.80-0.89 Some arterial disease)
Doppler
Angiography
Trendelenburg Test

Question 10

Buerger’s Disease

Answer 10

Disease of the arteries and veins. Blood vessels become inflamed, swell and blocked with blood clots damaging skin tissue leading to infection and gangrene. Smokers are all affected.

Question 11

Trendelenburg Test

Answer 11

Physical examination to determine the competency of the valves in the superficial and deep veins of the legs in patients with varicose veins.
1) Raise affected leg of supine patient and massage down to drain venous blood from limb.
2) Place torniquet on thigh
3) Ask patient to stand up and see if varicose veins reappear
If varicose veins do not fill problem is above the tourniquet leve. If the varicose veins fill back up, problem is below the tourniquet level

Question 12

Differentials for PAD

Answer 12

Spinal stenosis, Arthritis, venous claudication, Chronic compartment syndrome, Symptomatic Baker’s cyst, nerve root compression

Question 13

Compartment syndrome

Answer 13

Bleeding or pressure within a compartment causing pressure build up preventing blood flow.

Question 14

Treating Acute limb Ischaemia

Answer 14

Urgent assessment. Revascularisation and intra-arterial thrombolysis for viable limbs. Amputation for non-viable. Antiplatelet, analgesia, anticoagulation.

Question 15

Treating Claudication

Answer 15

Antiplatelet therapy: Clopidogrel
Exercise
Risk factor modification
Revascularization

Question 16

Complications for PAD

Answer 16

ulcers, gangrene, permanent limb weakness and pain

Question 17

Aortic Abdominal Aneurysm

Answer 17

Swelling of the aorta. More common in men so men in their 65th year are screened.
< 3 cm discharged from programme, >5.5 referral to a vascular surgeon

Question 18

Causes of AAA

Answer 18

Atherosclerosis, trauma, infection

Question 19

Risk factors for AAA

Answer 19

Smoking, increased age, prevalence in males, rupture for females, family history

Question 20

Signs for AAA

Answer 20

Palpable, pulsatile abdominal mass, back pain

Rupture: hypotension, pain, pulsatile mass, will go into shock (sweating, hypovolaemic, tachycardic etc)

Question 21

Investigations for AAA

Answer 21

Abdominal USS,
Computed Tomography Angiography
FBC
Cultures: positive, leukonychia

Question 22

Differentials for AAA

Answer 22

Diverticulitis, ureteric colic, IBS, IBD, appendicitis, ovarian torsion, GI haemorrhage

Question 23

Treating a rupture AAA

Answer 23

Resuscitation
Urgent surgical repair: open repair, endovascular repair
Perioperative antibiotics

Question 24

Treating a symptomatic but not ruptured AAA

Answer 24

Urgent surgical repair
Cardiovascular risk reduction
Perioperative antibiotics
Inform DVLA if size is over 6cm

Question 25

Treating incidental findings of AAA on screening

Answer 25

Surveillance
Aggressive cardiovascular risk management
Elective surgical repair
Risk reduction

Question 26

Complications of AAA

Answer 26

Abdominal compartment syndrome, ileus, AKI, anastomotic pseudoaneurysm, aortic neck dilation, amputation, spinal cord ischaemia, impaired sexual function, graft injection, gatric outlet obstruction, endoleak

Question 27

Varicose Veins

Answer 27

Subcutaneous, permanently dilated veins 3mm or more in diameter when measured in standing position

Question 28

Who is most affected with varicose veins

Answer 28

More common in females

Prevalence increases with age

Question 29

Causes of Varicose Veins

Answer 29

Previous episode of DVT
Genetics
Venous valve incompetence
Progesterone leads to passive venous dilation, leading to valvular dysfunction
Oestrogen produces collagen fibre changes and smooth muscle relaxation, leading to vein dilation

Question 30

Risk factors for Varicose Veins

Answer 30

Increasing age, female, increasing parity, DVT, occupation with prolonged standing, obesity

Question 31

Symptoms of Varicose Veins

Answer 31

Dilated tortuous veins, leg fatigue, leg cramps, restless legs, haemosiderin deposition

Question 32

Investigations for Varicose Veins

Answer 32

Duplex Ultrasound

Question 33

Duplex Ultrasound/ Doppler Ultrasound

Answer 33

non-invasive evaluation of blood flow through your arteries and vein. Doppler is the presentation of the velocity to the probe by color scale.

Question 34

Differentials for Varicose Veins

Answer 34

Telangiescatsis (spider veins), reticular veins

Question 35

Treatment for Varicose Veins

Answer 35

Compression stockings, phlebectomy/ sclerotherapy, ablative procedures i.e. stripping and ligations

Question 36

Complications of Varicose Veins

Answer 36

Chronic venous insufficiency, Haemorrhage, venous ulceration, lipodermatosclerosis, haemosiderin deposition

Question 37

Difference between Arterial Leg Ulcers and Venous Leg Ulcers

Answer 37

ALG: punched out, clear borders, associated hair loss, shiny skin, thickened toe nails, found closer to toes, necrotic tissue

VLG: found lower 1/3 leg, anterior to lateral malleolus, can be leaky, oedema, hair still present, normal pulse and legs warm, bigger in size

Question 38

True vs False aneurysm

Answer 38

False: collection of blood in the outer layer of the vessel
True: All walls affected