Vascular Flashcards
1
Q
What should an acutely painful limb that is cold and pale be treated as?
A
Acute limb ischaemia
2
Q
What is acute limb ischaemia associated with?
A
6 Ps
- pain
- pallor
- pulselessness
- paresthesia
- perishingly cold
- paralysis
3
Q
Risk factors of acute limb ischaemia
A
Atrial fibrillation Hypertension Smoking Diabetes mellitus Recent myocardial infarction
4
Q
Investigation for acute limb ischaemia
A
CT angiogram
Urgent vascular review
5
Q
Treatment for acute limb ischaemia
A
Surgical emergency - irreversible tissue damage occurs in 6 hours
Sufficient resuscitation
IV heparin
6
Q
What should be considered in a sudden onset hot and swollen limb?
A
Deep vein thrombosis
Cellulitis
7
Q
Presentation of DVT
A
Sudden onset hot swollen limb
Pain localised to calf
Calf tenderness and firmness
History or family history or pro-thrombotic disease
8
Q
Treatment for DVT
A
Therapeutic doses of Low-Molecular Weight Heparin
Long-term anticoagulation
9
Q
Neurological causes of acute painful limb
A
Radiculopathies - back pain that radiates to affected area and worse on movement
Central - MS
Spinal - disc herniation
Peripheral - infective or traumatic
10
Q
Define an ulcer
A
Break in skin or mucous membranes
11
Q
Common causes of lower limb ulcers
A
Venous insufficiency
Arterial insufficiency
Diabetic-related neuropathy
Pressure ulcers
12
Q
Features of a venous ulcer
A
Shallow with irregular borders Granulating base Associated - varicose veins - oedema - thrombophlebitis - lipodermatosclerosis
13
Q
Risk factors for a venous ulcer
A
Increasing age Pre-existing venous incompetence or history of thromboembolism - varicose veins Pregnancy Obesity or physical inactivity Severe leg injury or trauma
14
Q
Investigations for venous ulcers
A
Dulpex ultrasound - diagnose venous insufficiency
Ankle-brachial pressure - determine whether pressure therapy suitable
Swab cultures
15
Q
Management of venous ulcers
A
Leg elevation Increased exercise Lifestyle changes - weight reduction - improved nutrition Antibiotics - evidence of infection Mulitcomponent compression bandaging Surgical treatment of varicose veins
16
Q
Features of arterial leg ulcers
A
Small deep lesion Well-defined borders Necrotic base Associated - intermittent claudication or critical limb ischaemia - cold limbs with absent pulses
17
Q
Risk factors for arterial ulcers
A
Peripheral arterial disease - smoking - diabetes - hypertension - hyperlipidaemia Increasing age Obesity Physical inactivity
18
Q
Management of arterial ulcers
A
Lifestyle changes - smoking cessation - weight loss - increased exercise Medical - statin therapy - antiplatelet - aspirin or clopidogrel - optimisation of blood pressure and glucose Surgical - angioplasty - bypass grafting
19
Q
Risk factors for neuropathic ulcers
A
Diabetes mellitus
B12 deficiency
20
Q
Clinical features of neuropathic ulcers
A
History of peripheral neuropathy
Punched out appearance
Glove and stocking distribution
Warm feed and good pulses
21
Q
Investigations for neuropathic ulcers
A
Blood glucose levels - random glucose or HbA1c
Microbiology swab - deep infection
X-ray - osteomyelitis
22
Q
Management of neuropathic ulcers
A
Diabetic control optimised
Improved diet and increased exercise
Regular chiropody to maintain good foot hygiene
23
Q
Define carotid artery disease
A
Build-up of atherosclerotic plaque in one or both common and internal carotid arteries -> stenosis or occlusion
24
Q
Stages of carotid artery disease
A
Fatty streak
Lipid core
Fibrous cap
25
Risk factors of carotid artery disease
```
Age - > 65 years
Smoking
Hypertension
Hypercholesterolaemia
Obesity
Diabetes mellitus
History/family history of cardiovascular disease
```
26
Clinical features of carotid artery disease
Asymptomatic
TIA
Stroke
Carotid bruit auscultated in neck
27
Investigations of carotid artery disease
Urgent non-contrast CT head - evidence of infarction
Bloods - FCS, U&Es, clotting, lipid profile and glucose
ECG - AF
Duplex ultrasound scans
CT angiography
28
Management of carotid artery disease
Acute
- high flow O2
- blood gluose optimisation
- ischaemic stroke - IV alteplase + aspirin
- haemorrhagic stroke - coagulopathy
- thrombectomy
Long Term
- anti-platelet - aspirin then clopidogrel
- statin - high-dose atorvastatin
- management of hypertension and/or diabetes mellitus
- smoking cessation
- regular cardiovascular exercise + active lifestyle + weight loss
- cardiac endarterectomy
29
Define an aneurysm
Abnormal dilation of a blood vessel by more than 50% of its normal diameter
30
Define an AAA
Abdominal Aortic Aneurysm
| Dilation of the abdominal aorta greater than 3cm
31
Risk factors for AAA
```
Smoking
Hypertension
Hyperlipidaemia
Family history
Male gender
Increasing age
```
32
Clinical features of AAA
```
Many asymptomatic - incidental finding or screening
Abdominal pain
Back or loin pain
Distal embolisation -> limb ischaemia
Pulsatile mass
```
33
Who is eligible for AAA screening in the UK?
Men over 65 years
34
How is AAA screening performed?
Abdominal US scan
35
Investigations for AAA
USS
| CT scan with contrast
36
Medical management of AAA
```
Less than 5.5cm monitored via Duplex USS
- 3-4.4cm - yearly
- 4.5-5.4cm - 3 monthly
Smoking cessation
Improve blood pressure control
Commence statin and aspirin therapy
Weight loss and increased exercise
```
37
Criteria for surgical management of AAA
AAA > 5.5cm
AAA expanding at > 1cm/year
Symptomatic AAA
38
Surgical management of AAA
Open repair - laparotomy and prosthetic graft
| Endovasuclar repair - introduce graft via femoral arteries
39
Complications of AAA
Rupture
Retroperitoneal leak
Embolisation
Aortoduodenal fistula
40
Presentation of ruptured AAA
```
Abdominal pain
Back pain
Syncope
Vomitting
Haemodynamically compromised on examination with puslatile abdominal mass
```
41
Management of ruptured AAA
```
High flow O2
IV access
Urgent bloods + crossmatch
Keep BP <100mmHg - reduce risk of further bleeding
Open surgical repair
CT angiograom - endovascular repair
```
42
Define aortic dissection
Tear in intimal layer of the aortic wall - blood flows between and splits apart the tunica intima and media
43
Describe the DeBakey classification of aortic dissection
Type 1 - originated in the ascending aorta and propagates to the aortic arch
- under 65s
- highest mortality
Type 2 - confined to ascending aorta
- elderly pts with atherosclerotic disease and hypertension
Type 3 - orginates distal to the subclavian artery in the descending aorta
44
Describe the Stanford classification of aortic dissection
Group A - involved ascending aorta and can propagate to aortic arch and descending aorta
Group B - Do not involve ascending aorta
45
Risk factors for aortic dissection
```
Hypertension
Atherosclerotic disease
Male gender
Connective tissue disorders
- Marfan's syndrome
- Ehler's Danlos syndrome
Bicuspid aortic valve
```
46
Clinical features of aortic dissection
Tearing chest pain - radiates through back
Tachycardia
Hypotension
New aortic regurgitation murmur
47
Investigations for aortic dissection
```
Baseline bloods - crossmatch at least 4 units
ABG
ECG - exclude cardiac pathology
CT angiograpm
Transoeophogeal ECHO
```
48
Management of aortic dissection
High flow O2
IV access - fluid resuscitation cautiously
Stanford Type A = surgical managment
Uncomplicated Stanford Type B = medical management
Antihypertensive therapy
Surveillance imaging
49
Management of Standord Type A aortic dissection
Transfer to cardiothoracic centre
Removal of ascending aorta
Replacement with synthetic graft
50
Management of uncomplicated Stanford Type B aortic dissections
Management of hypertension
- IV beta blockers - labetalol
Only surgical if presence of complications
51
Complications of aortic dissection
Aortic rupture
Aortic regurgitation
Myocardial ischaemia - secondary to coronary artery dissection
Cardiac tamponade
Storke or paraplegia - secondary to cerebral or spinal artery involvement
52
How to thoracic aneurysms form?
Degradation of tunic media
Loss of structural integrity
Dilation
53
Causes of thoracic aneurysms
```
Connective tissue diseases
- Marfan's syndrome
- Ehlers-Danlos syndrome
Bicuspid aortic valve
Trauma
Aortic dissection
Aortic arteritis
Tertiary syphilis
```
54
Risk factors for thoracic aneurysms
```
Family history
Hypertension
Atherosclerosis
Smoking
High BMI
Male gender
Advancing age
```
55
Clinical features of thoracic aneurysms
Typically asymptomatic - incidental findings
Pain
- anterior chest - ascending aorta
- neck - aortic arch
- between scapulae - descending arch
Back pain - spinal compression
Hoarse voice - damage to left recurrent laryngeal nerve
Distended neck veins
Symptoms of heart failure
Dyspnoea or cough - tracheal or bronchial compression
56
Investigations for thoracic aneurysms
Diagnosed through imaging
- seen on CXR but not sensitive enough to diagnose
- CT chest with contrast
Transoesophageal echocardiography
57
Management for thoracic aneurysms
```
Medical
- statin and antiplatelet therapy
- blood pressure controlled
- smoking cessation
Surgical
- dependent on location
```
58
Define acute limb ischaemia
Sudden decrease in limb perfusion that threatens the viability of the limb
59
Classificaiton of acute limb ischaemia
Embolisation - thrombus from proximal source travels distally to occlude the artery
Thrombosis in situ - atheroma plaque in the artery ruptures and thrombus forms on plaque's cap
Trauma - compartment syndrome
60
Clinical features of acute limb ischaemia
Sudeen onset of
- Pain
- Pallor
- Pulselessness
- Paresthesia
- Perishingly cold
- Paralysis
61
Causes of potential embolisation
```
Chronic limb ischaemia
AF
Recent MI
Symptomatic AAA
Peripheral aneurysms
```
62
Investigations for acute limb ischaemia
Routine bloods - serum lactate
ECG
Doppler ultrasound scan
CT angiography
63
Initial management of acute limb ischaemia
Surgical emergency - irreversible tissue damage withing 6 hours
High flow oxygen
Therapeutic dose heparin or bolus dose then heparin infusion
64
Conservative management of acute limb ischaemia
Prolonged course of heparin
| Regular assessment
65
Surgical management of acute limb ischaemia
```
Embolectomy
Local intra-arterial thrombolysis
Bypass surgery
Angioplasty
Irreversible limb ischaemia requires urgent amputation
```
66
Long term managment of acute limb ischaemia
```
Reduction of cardiovascular mortality risk
Change lifestyle
- regular exercise
- smoking cessation
- weight loss
Anti-platelet
- apsirin
- clopiderogrel
Resulting amputation
- occupation therapy
- physiotherapy
- long term rehabilitation plan
```
67
Complications of acute limb ischaemia
Reperfusion injury - sudden increase in capillary permeability
- compartment syndrome
- release of substances from damaged muscle cells - hyperkalaemia, acidosis and myoglobin (AKI)
68
Define chronic limb ischaemia
Peripheral arterial disease that results in symptomatic reduced blood supply to the limbs]
Typically caused by atherosclerosis
69
Risk factors for chronic limb ischaemia
```
Smoking
Diatbetes mellitus
Hypertension
Hyperlipidaemia
Increasing age
Family history
Obesity and physical inactivity
```
70
Clinical features of chronic limb ischaemia
Stage I = asymptomatic
Stage II = intermittent claudication
Stage III = ischaemic rest pain
Stage IV = ulceration or gangrene
71
Describe Buerger's test
Lie pt supine and raise legs until they go pale and lowering them until colour returns
Buerger's angle = angle at which limb goes pale
- less than 20 degrees = severe ischaemia
72
Define critical limb ischaemia
```
Advanced from of chronic limb ischaemia
Clinically defined by
- ischaemic rest pain for greater than 2 weeks duration
- presence of ischaemic lesions
- ABPI less than 0.5
```
73
Investigations for chronic limb ischaemia
Ankle-Brachial Pressure Index
Doppler ultrasound
CT angiography
74
Medical management of chronic limb ischaemia
```
Lifestyle advice
- smoking cessation
- regular exercise
- weight reduction
Statin therapy
Anti-platelet therapy
Optimise diabetes control
```
75
Surgical management of chronic limb ischaemia
Angioplasty
Bypass grafting - diffuse disease or younger pts
Amputation - ischaemia causing incurable symptoms or gangrene leading to sepsis
76
Complications of chronic limb ischaemia
Sepsis
Acute-on-chronic ischaemia
Amputation
Reduced mobility and quality of life
77
Define acute mesenteric ischaemia
Sudden decrease in blood supply to the bowel
| Resulting in bowel ischaemia, rapid gangrene and death
78
Common causes of acute mesenteric ischaemia
Thrombus-in-situ - Acute Mesenteric Arterial Thrombosis - AMAT
- atherosclerosis
Embolism - Acute Mesenteric Arterial Embolism - AMAE
- cardiac causes
- abdominal/thoracic aneurysm
Non-occlusive cause - Non-Occlusive Meseneteric Ischaemia - NOMI
- hypovolaemic shock
- cardiogenic shock
Venous occlusion and congestion - Mesenteric Venous Thrombosism - MVT
- coagulopathy
- malignancy
- inflammatory disorders
79
Clinical features of acute mesenteric ischaemia
Generalised abdominal pain
N+V
Examination unremarkable
80
Investigations for acute mesenteric ischaemia
```
ABG - serum lactate and acidosis
Routine bloods
CT scan with IV contrast
- oedematous bowel
- loss of bowel wall enhancement
- pneumatosis
```
81
Management of acute mesenteric ischaemia
Surgical emergency - urgent resuscitaiton
- IV fluids
- catheter
- fluid balance chart
Broad-spectrum antibiotics - risk of faecal contamination
Excision of necrotic or non-viable bowel
Revascularisation of bowel
82
Complications of acute mesenteric ischaemia
Bowel necrosis
Bowel perforation
Short gut sydrome - post-op
83
Define chronic mesenteric ischaemia
Reduced blood supply to the bowel which gradually decreases over time
Result of atherosclerosis in coeliac trunk, SMA or IMA
84
Risk factors for chronic mesenteric ischaemia
Smoking
Hypertension
Diabetes mellitus
Hypercholesterolaemia
85
Clinical features of chronic mesenteric ischaemia
Postprandial pain
Weight loss - decreased calorie intake and malabsorption
Concurrent vasuclar co-morbidities
Examination findings non-specific
86
Investigations for chronic mesenteric ischaemia
Blood tests
Anaemia may be confounding symptoms
CT angiography
87
Management of chronic mesenteric ischaemia
```
Modify risk factors
- smoking cessation
- anti-platelet and statin therapy
Mesenteric angioplasty with stenting - endovascular
Endartectomy or bypass - open
```
88
Complications of chronic mesenteric ischaemia
Bowel infarction
| Malabsorption
89
Investigations for peripheral and visceral aneurysms
CT angiography
MR angiography
US duplex scans
90
Management for peripheral and visceral aneurysms
```
Watchful waiting whilst optimising medical therpay
- antiplatelet + statin
- smoking cessation
Surgical intervention
- endovasuclar
- open
```
91
Presentation of popliteal aneurysm
```
Symptomatically
- acute limb ischaemia
- intermittent claudication
Incidentally
Compression symptoms on popliteal vein or nerve
```
92
Causes of femoral artery aneurysms
Percutaneous vascular interventions
| Patient self-injecting
93
Risk factors for splenic artery aneurysm
Female sex
Multiple pregnancies
Portal hypertension
Pancreatitis
94
Presentation of splenic artery aneurysm
Vague epigastric or LUQ pain
95
Causes of hepatic artery aneurysm
Percutanous instrumentation
Trauma
Degenerative disease
Post-liver transplant
96
Presentation of hepatic artery aneurysm
Asymptomatic
Vague RUQ or epigastric pain
Jaundice - if biliary obstruction
97
Presentation of renal artery aneurysm
Asymptomatic - incidental finding
Haematuria
Resistant hypertension
Loin pain
98
Define varicose veins
Tortuous dilated segments of vein associated with vascular incompetence
99
How do varicose veins form?
Incompetent valves - blood flow from deep to superficial venous system
Venous hypertension and dilation of superficial venous system
100
Causes of varicose veins
```
Idopathic - 98%
Deep vein thrombosis
Pelvic masses
- pregnancy
- uterine fibroids
- ovarain masses
Arteriovenous malformations
```
101
Risk factors for varicose veins
Prolonged standing
Obesity
Pregnancy
Family history
102
Clinical features of varicose veins
Usually present with cosmetic issues - unsightly visible veins or discolouration of skin
Pain, aching, swelling and itching - often worse at end of day
Varicosites present in course of great/short saphenous veins
Features of venous insufficiency
Saphena varix
103
Investigations for varicose veins
Duplex ultrasound - assess valve incompetence
104
Management of varicose veins
Patient eduction
- weight loss
- avoid prolonged standing
- increase exercise
Compression stockings - if interventional treatment not appropriate
Four-layer bandaging for venous ulceration
105
Indications for surgical treatment of varicose veins
Symptomatic primary or recurrent
Lower-limb skin changes
Superficial vein thrombosis - hard painful veins
Venous leg ulcer
106
Surgical management of varicose veins
Vein ligation, stripping and avulsion
Foam sclerotherapy - inflammatory response closes of vein
Thermal ablation
107
Complications of varicose veins
```
Worsen over time
Re-intervention
Post-op
- haemorrhage
- thrombophlebitis
- DVT
- disease recurrence
- nerve damage
```
108
Causes of deep venous insufficiency
```
Primary - underlying defect to vein wall or valvular compenent
- congenital defects
- connective tissue disorders
Secondary
- post-thrombotic
- post-phlebitic
- venous outflow obstruction
- trauma
```
109
Risk factors for DVI
```
Increasing age
Female gender
Pregnancy
Previous DVT
Obesity
Smoking
Long periods of standing
Family history of venous disease
```
110
Clinical features of DVI
```
Chronically swollen lower limbs
Aching, painful and pruritic
Venous claudication - bursting pain and tightness on walking
Varicose eczema
Thrombophlebitis
Haemosiderin
Skin staining
Lipodermatosclerosis
Atrophie blanche
```
111
Investigations for DVI
Doppler ultrasound scan - assess for the extent of venous reflux
Documentation of foot pulses
ABPI
112
Management of DVI
Conservative
- compression stockings
- suitable analgesic control
Surgical management less successful
113
Define thoracic outlet syndrome
Clinical features that arise from compression of the neurovascular bundle within the thoracic outlet
114
Pathophysiology of thoracic outlet syndrome
Rib anomalies - cervical ribs and costoclavicular ligament
Muscular anomalies - repetitive stress and hyperextension can cause acute spasm of scalene muscles, haemorrhage or swelling of scalene muscles -> narrowing of thoracic outlet
Result of injury - clavicular fractures can cause extra bone formation
115
Risk factors of thoracic outlet syndrome
Recent trauma
Repetitive motion occupations
Athletes
Anatomical variations
116
Clinical features of thoracic outlet syndrome
```
Symptoms worsen on certain movements
Paraesthesia and/or motor weakness
Deep vein thrombosis
Extremitiy swelling
Claudication
Acute limb ischaemia
Weakness and numbness
```
117
Investigation for thoracic outlet syndrome
```
CXR - bony abnormalities
Venous and arterial duplex ultrasound
CT imaging
Venogram
Nerve conduction studies
```
118
Management for thoracic outlet syndrome
```
Treatment only indicated in symptomatic patients
- physio
- weight loss
- botulinum toxin A injection
Thrombolysis
Anti-coagulation
Surgical decompression
```
119
Complications of thoracic outlet syndrome
Permanent nerve damage
Aneurysm dilation of subclavian artery leading to embolisation
Loss of limb function
