Vascular Flashcards
Chronic limb ischaemia/peripheral artery disease
Range of arterial syndromes caused by athersclerosis causing stenosis of arteries of the lower extremities
Risk fx: male, genetic, smoking, diabetes
Sx: intermittent claudication (cramping pain after walking, relieved by rest)
calf - femoral
buttock - internal iliac arteries
bilateral buttock - both internal iliac (Leriche syndrome)
Critical limb ischaemia - advanced chronic limb ischaemia - pain at rest ischaemic lesions e.g. gangrene/ulcers, ABPI <0.5
Signs:
Absent femoral, popliteal, foot pulses, ulcers, Buerger’s angle (angle that leg goes pale when raised. Normally stays pink)
DDx:
Spinal stenosis (bilateral pain radiating from back down leg or buttocks. Worse with spinal extension (walking downhill (lumbar extension), standing. Better with spinal flexion - walking uphill, bending down)
OA
Ix: FBC (anaemia), BM, CRP, ECG (cardiac ischaemia) Ankle-brachail pressure index (ABPI) >1.2: calcification (due to diabetes) 1-1.2: normal 0.5-0.9: PAD <0.5: critical limb ischaemia US doppler CT angiogram (if intervention)
Tx: lifestyle (quit smoking), exercise
Clopidogrel (prevent progression)
Exercise
Risk fx modification (e.g. anti-hypertensives, Bblockers, statin, ACEi)
Surgery: angioplasty, bypass graft (e.g. femoral-popliteal bypass), amputation
Acute limb ischaemia
Decrease in limb perfusion which threatens viability of limb
Surgical emergency, requires revascularisation within 4-6 hrs
Causes: emboli, thrombus
Sx: 6 Ps
Ix: lactate, ECG, group and save, US doppler, CT angiography
Tx:
Assess limb viability (non viable - tissue loss, sensory loss)
Clopidogrel + UF
Embolectomy (Fogarthy catheter), thrombolysis (urokinase)
Complications surgery: reperfusion injury - compartment syndrome (increased H+, K+, myoglobin - AKI)
Carotid a. disease
Biuild up of athersclerotic plaque in common or internal carotids causing stenosis
Sx: asymptomatic
carotid bruit
TIA/stroke
DDx: carotid dissection (young, trauma), vasculitis
Ix: FBC, BM, ECG (check AF) Carotid a. dopper US CT head, CT angiography
Tx:
Aysmptomatic
Aspirin/Clopidogrel, lifestyle changes
Symptomatic: Carotid endaretectomy ( if >70 stenosis + Aspirin + statin)
Ischaemia stroke: alteplase (within 4.5 hrs) + aspirin, thrombectomy
Haemorrhagic: neuro surg rv
Varicose veins
Dilated veins due to incompentent valves.
Increased venous pressure leads to skin changes
Risk fx: prolonged standing, obesity, pregnancy
Sx: veins, leg ache (rwise on heat), oedema, haemosiderin deposition, ucler
specialist referral: bleeding, pain, ucleration
Tx: compression stockings
sclerotherapy
radiofrequency ablation
Venous ulcers
Ulcers: abnormal break in skin
Venous ulcers: shallow, irregular border, granulating base, on gaitor region (above ankle, below knee)
Due to venous insufficiency
Sx: itching, burning
Ix: clinical, doppler US (venous insufficiency)
Tx: leg elevation, exercise, compression bandages
Arterial ulcers:
Small, deep, well-defined border, necrotic base, on pressure areas (e.g. heel)
Sx: intermittent claudication (pain during walking) or critical limb ischaemia (pain during night)
Signs: absent pulses, cold limbs
Ix: APBI, dopper US, CT angiogram
Any pt with critical limb ischaemia (ulcers) requires vascular rv
Tx:
Covnservative: lifestyle changes
Medical: statin, BP control, anti-platelets
Surgery: angioplasty, bypass graft
Neuropathic ulcers
Punched out, on feet
Hx of peripheral neuropathy (glove and stocking distribution)
Sx: burning, tingling in legs, warm feet/good pulses
Ix: BM, B12 (peripheral neuropathy), swab, ABPI/doppler
Tx: diabetic foot clinic, diet, abx if infected surgical debridement if necrotic
Breast Ca
Benign
Intraductal papilloma
Epithelial proliferation in mammary ducts
Watery or blood stained discharge
Phyllodes tumour - can become malignant
Sx: firm, lump, can increase in size
Tx: wide excision
Malignant
Risk fx: early menarche, late menopause, no children, later age at first pregnancy, BRACA 1/2 gene, oral contraceptive, HRT, obesity, benign breast (ductal hyperplasia)
Sx: lump, bloody discharge, newly inverted nipple, peau d’orange (lymphatic involvement), skin dimpling, excema nipple (Paget’s disease of nipple), enlarged lymph nodes in axilla
Ix: triple assessment - exmaination, imaging (MMG, US (<35 yrs), biopsy - core, FNA (cystic)
FBC (anaemia, low WCs - marrow involvement)
LFTs (raised Alk phos - liver mets)
Paget’s disease of nipple
Intraduct carcinoma
Red, scaly eczema nipple
Ductal carcinoma in situ
Malignant proliferation of ductal cells, but not gone pass basement membrane
Asymptomatic
Found incidentally on MMG (calcification)
Tx: wide local excision (<4cm)
Invasive Ductal carcinoma
Most common Br. Ca (85%)
Lobular carcinoma in situ
Found incidentally on biopsy, not seen in MMG
Tx: active surveillance
Lobular carcinoma
Sx: diffuse, bilateral
Tx: mastectomy
Other
mucinoid, medullary (assoc with BRAC1), tubular - better prognosis
Spread
Direct: Pec. major, serratus anterior
Blood: liver, lungs, brain
Lymphatics: axillary, internal thoracic
Prognosis
Nottingham prognostic index
0.2 x (tumour size + grade + nodal involvement)
Grade based on differentiation (tubular differentiation, nuclear pleomorphism, mitotic activity)
Tx:
Wide local excision <4cm
Mastectomy + reconstruction
Sentinel node biopsy (blue dye identifies first LN, examined)
Axillary sampling (4 LNs excised, if one +ve then axillary clearence)
Breast reconstruction:
Myocutaneous flap - Lat dorsi, transverse rectus abdominis mycutaneous flap
Breast implant
Complications axillary node clearence: damage long thoracic n (winged scapula), lymphodema
breast surgery: infection, nipple necrosis
Adjuvant:
Oestrogen receptor +ve:
Pre-menopausal: Tamoxifen (SEs: VT, endometrial Ca.)
Post-menopausal: letrozole (Aromastase inhibitors)
HER receptor +ve: Transtuzumab
Benign breast disease
Mastitis - cellulitis assoc. breast feeding
Abscess - red, tender, swelling
Fibrocystic change
Common middle aged women
Lumpy breast, tender, sx may be worse prior menstruation
Ductal hyperplasia assoc. with increased risk of br. ca
Fibroadenoma
Young women, “mice” discrete, non-tender smooth, mobile
Duct ectasia Dilatation of lactiferous ducts Lump+green nipple discharge, inversion nipple Middle aged Assoc. smoking Calcifications on MMG
Fat necrosis
Trauma
Obese women
Hard, irregular breast lump
