Vascular Flashcards
ABPI
Ankle-brachial pressure index
- Used to assess the blood supply to the lower limb
- Foot artery occlusion pressure / brachial systolic pressure
Can be used to confirm the presence of PVD and as a baseline measure before treatment
- >1.1 Calcified or incompressible vessels (e.g. in diabetes or renal failure)
- Falsely elevated in diabetic foot due to the vessel calcification
- 0.7-0.9 Mild ischaemia
- 0.4-0.7 Moderate ischaemia
- <0.4 Severe peripheral (critical) ischaemia
Duplex Doppler Ultrasonography
Used for assessment and monitoring of blood vessel flow
- Carotid disease
- PVD
- Graft surveillance
- AAA - assessment, monitoring, screening
- Renal artery stenosis
- Venous disease
Thrombophlebitis
Superficial venous inflammation that can occur in the presence or absence of a clot
- Most commonly in the lower limbs
- Causes
- Conditions that cause a hypercoagulable state
- Malignancy
- Pregnancy
- Conditions leading to venous stasis
- Immobility post-surgery
- Long haul flights
- Venous incompetence
- Varicosities
- Conditions that cause a hypercoagulable state
- Signs and symptoms
- Swelling
- Erythema
- Tenderness along the affected vein
- Hardness if a clot is involved
Trendelenburg’s operation
Procedure for primary varicose vein disease secondary to saphenofemoral valve incompetence
Performed
- Under Spinal anaesthesia
- With patient supine and a 30° head-down tilt
It identifies the
- Long saphenous vein at the saphenofemoral junction, AND
- Its tributaries
and is flush ligated to the femoral vein
Then
- The upper 10 cm length of the long saphenous vein is excised
Associated with a high recurrence rate
Contraindications
- Presence of deep vein thrombosis
- As the long saphenous vein provides collaterals > can precipitate venous claudication
Dissection of the ascending aorta
AD - a result of a tear in the intima of the aorta and propagation of dissection by blood collection in the intima-media space, leading to separation of the layers within the wall
Aetiology
-
Connective tissue disease
- Ehlers Danlos/Marfans/SLE/RA
- Congenital cardiovascular anomalies (coarctation of the aorta)
- Hypertension (biggest RF)
- Aortic atherosclerosis/Aortitis (e.g. Takayasu’s, tertiary syphilis)
- Trauma
Complications of ascending aortic dissection
-
Acute myocardial infarction
- The AAD disrupts the ostia of the coronary arteries > affects the blood supply to the heard > ischaemia or infarction
-
Aortic valve incompetence & regurgitation
- Due to dilatation of the aortic root and annulus)
- Haemorrhagic pericardial effusion > tamponade > syncope
Venous ulcers
Description
- Usually around the medial malleolus
- Large, shallow
- Painless (unless become infected)
- If infected > aching, oedematous lower limb
- Sloping edges (cf arterial ulcers > punched out edges)
- Surrounded by mottled brown/black skin or areas of venous eczema
- Ass with
- Lipodermatosclerosis
- Hyperkeratosis of the skin
RF
- Varicose veins (50%)
- Hx of DVT
- Prolonged standing/sitting
- Multiple pregnancies
- HTN
- Previous leg surgery
- Lower limb fractures
- Obesity
- Immobility
- Chronic leg oedema
Arterial leg ulcers
Description
- On the dorsum
- Painful, worse at night
- Pts find relief by hanging their leg out of the bed at night
Causes
- Peripheral arterial disease
- Atherosclerosis
RF
- Smoking
- >50 yoa
- Male gender
- HTN
- DM
- Coronary heart disease
- Cerebrovascular disease
- Dyslipidaemia
Positive Buerger’s test
Buerger’s test
Examination used in the diagnosis of peripheral arterial disease
- Patient initially supine
- Both legs raised up to 45° & maintained in that position until pallor ensues in the feet (1-2 min)
- Pallor indicates ischaemia > arterial pressure inadequate to overcome effects of gravity)
- Angle of <20° elevation causing pallor > severe ischaemia
- Pt asked to sit up with legs dangling off the side of the couch
- The time to required for pinkness to return in the feet is measured
- 10-15s - Normal > Competent arteries
- In PAD
- Feet become blue (deoxygenated blood)
- Then red (hyperaemia > post hypoxic vasodilatioN)
*
Kippel-Trenaunay syndrome
Known as Angio-osteohypertrophy syndrome
- A rare disorder ass with sporadic mutations in the somatic cells during fetal development
- Affects the development of bone, soft tissue and blood vessels
- Presents in infancy/early childhood
Triad of
- Port-wine stain (capillary hemangioma) on pt’s face
-
Varicose veins & venous malformations
- Superficial or deep veins
-
Soft tissue or bone hypertrophy affecting an extremity
- __Up to 12cm (in literature)
Factors affecting post vascular grafting prognosis
Smoking
Exercise
Healthy diet & good nutritional status (assist in healing and rehab)
Controlling cholesterol
Strict glycaemic control
HTN control
Management of suspected AAA in a haemodynamically stable patient
- FAST scan (ultrasound), then
- CT (sensitivity nearing 100%)
- To evaluate in more detail the size & shape of the aneurysm
- To look for signs of aneurysmal leak or rupture
- Crescent sign (blood within the thrombus)
- Retroperitoneal haematoma
- Wall discontinuity
- Extravasation of contrast in the peritoneal cavity
- Also measures the length of the neck of the aneurysm
- Useful in defining suitability of pt for EVAR
Diabetic foot
Diabetic foot disease is usually painless
Ulcers are punched out with a thick callus
- Falsely elevated ABPI
- Due to blood vessel calcification
- Associated with
- Peripheral neuropathy
- Affecting motor, sensory & autonomic nerve fibres
- Pt loses awareness of pain, which guards against injury
- Initiates the development of a leg ulcer
- Ulcers can become infected > sepsis
- Ischaemia
- Peripheral artery disease
- Peripheral neuropathy
Popliteal artery aneurysm
Most common type of peripheral aneurysms
- Most pts asymptomatic
- Sx
- Intermittent claudication
- Acute limb ischaemia
- Repair
- Open or endovascular
- Indications for repair
- Symptomatic pt with acute limb ischaemia or severe claudication Sx
- Asymptomatic pt with the presence of a thrombus
- This thrombus - at high risk of fragmentation with flexion & extension of the knee
- Can lead to occlusion of distal vessels & acute limb ischaemia
- If microembolisation phenomena already occurred & the pt has only a single patent run-off vessel > ^^ risk of acute limb ischaemia & limb loss
Thomboangiitis obliterans (Burger’s disease)
Inflammatory arteritis affecting the tunica intima of small to medium-sized arteries & veins
- Most commonly male pts 20-45
- Characterised by
- Small segmental occlusions of the vessels, most commonly in the limbs
- Leads to
- Rest pain
- Raynaud’s syndrome
- Painful ulceration
- Gangrene of toes
- Thrombophlebitis
- Intermittent claudications can be present, but not usually a major feature
Risk factors
- Smoking
- Chronic gum disease
- Male gender
- Age <45
ESSENTIAL TO STOP SMOKING
Causes of secondary Raynaud’s
- B - Blood disorders e.g. polycythaemia
- A - Arterial e.g. atherosclerosis, Buerger’s disease
- D - Drugs e.g. beta blockers, oral contraceptive pill
- C - Connective Tissue Disorders e.g. RA, SLE, Scleroderma, Polyarteritis Nodosa
- T - Trauma e.g. vibration injury
