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Finals Revision > Vascular > Flashcards

Vascular Flashcards

1
Q

Name 5 things to look for on general inspection in a vascular exam.

A
  1. Smoking
  2. Inhalers
  3. Diabetic medication
  4. AV fistula
  5. Dressings
  6. Walking stick
  7. Weight: thin (indicating smoking) OR fat (high cholesterol)
  8. False leg/amputations
  9. Hands: nicotine stains, splinters, missing fingers
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2
Q

What does the supra-aortic pulse examination include?

A
  1. Radial pulse: rate (tachycardia or not), rhythm, radio-radial delay
  2. Brachial- character
  3. BP- normotensive vs hypertensive
  4. Subclavian pulse- bruits
  5. Carotid pulse- bruits
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3
Q

What does radio-radial delay indicate?

A

Obstruction of the aorta or one of the vessels branching off. Most common in type A aortic dissection.

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4
Q

What does the abdominal vascular examination involve?

A
  • Expose (including groin)
  • Look at abdomen: scars (e.g. ilio-femoral bypass graft)
  • Palpate: AAA with one hand first to see if PULSATILE, then both hands to see if expansile
  • Auscultation: bruits of aorta, renal
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5
Q

What does the lower limbs vascular examination involve?

A
  • Inspect including colour
  • Feel temperature: start with toes, between toes and heels
  • Femoral arteries: feel simultaenously as a weak femoral pulse is difficult to determine. Radio-femoral delay
  • Popliteal arteries: check if expansile
  • Dorsalis pedis (continuation of anterior tibial artery) and posterior tibial pulse
  • Auscultate: bruits in iliac, CFA, adductor hiatus- may only hear after exercise
  • Buerger’s Angler, Buerger’s Test
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6
Q

What is a dominant peroneal artery?

A

Anatomical variance present in 5% of the population, there is absent dorsalis pedis pulse on exam but a pulse just anterior to the lateral mallelous as the foot is supplied by branches of the peroneal vessel.

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7
Q

What is a persistent sciatic artery?

A

Rare anatomical variance characterised by a persistent sciatic arterial supply to the lower limb and absence of femoral vessels. May present with pain, pulsatile buttock or ischaemia of the leg.

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8
Q

How do you measure Buerger’s Angle and perform Bueger’s test?

A
  • Raise both feet and hold them up, the angle above the bed that the foot goes white is Bueger’s angle.
  • When foot blanches, let the legs hang over the side of the bed
  • The ischaemic foot will go brick red- indicating significant arterial disease of the lower limb.
  • Goes red due to nitric oxide and toxins
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9
Q

How do you calculate the ankle brachial pressure index?

A
  • Measure blood pressure in the arm required to collapse artery
  • Measure pressure in the ankle required to collapse the artery
  • This pressure is measured using Doppler
  • Divide arm pressure by ankle pressure
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10
Q

What do the following ABPIs indicate?

  1. 0.8-1.0
  2. 0.6-0.8
  3. <0.6
A
  1. Normal
  2. Claudicatin
  3. Critical ischaemia
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11
Q

What are the 2 reasons why diabetics may have an abnormally raised ABPI?

A
  1. Calcification so can’t overcome intra-arterial pressure
  2. Distal disease with palpable pulse but NECROSIS from more peripheral disease
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12
Q

What do the scars in this picture allow access to for vascular surgery?

A
  1. Rooftop scar: aorta above the kidneys
  2. Midline scar: abdominal aorta access, if you extend this diagonally upwards to the 6th intercostal space you can repair thoraco-aortic aneurysms which are common in Marfan’s patients.
  3. Rutherford-Morrison scar: iliac artery
  4. Groin scars: common femoral arteries
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13
Q

What do the following scars suggest?

  1. Left: Neck scar
  2. Left: Two groin scars
  3. Right: 3 scars together
A
  1. Carotid endarterectomy: stroke, mini-stroke, amarosis fugax with 70% carotid artery stenosis.
  2. Femoro-femoral bypass graft
  3. Axillo-bifemoral bypass graft- usually for occlusion
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14
Q

Why would a patient have a graft?

How would you know it’s working clinically?

A
  1. Trauma, aneurysm or occlusion
  2. If pulse is present at bottom of graft then it’s probably working
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15
Q

What are two types of graft that could be used?

A
  1. Artificial- e.g. PTFE (polytetrafluoroethylene), Dacron
  2. Autologous- e.g. use of long saphenous vein
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16
Q

Two methods by which long saphenous vein can be used as a graft in treating femoral/popliteal/tibial artery stenosis? Which do you feel a pulse in?

A
  1. Valvotomy (removal of valves) of long saphenous vein. Would feel pulse as it’s reattached superficially.
  2. Excision and reversal of the long saphenous vein. Would not feel pulse as reattached deep within leg.
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17
Q

Why are PTFE/Dacron grafts not used in the leg as commonly as autologous grafts? (3)

A
  • Higher thrombosis rate
  • Lower longevity
  • Higher risk of infection
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18
Q

What would the scars in this image suggest?

A
  1. Long saphenous vein graft (left image right leg)
  2. Femoral-popliteal bypass graft (left image left leg)
  3. Infra popliteal bypass graft (right image)
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19
Q

What causes pain in claudication?

A

Stenosis of an artery prevents enough oxygenated blood from reaching tissue on exertion. Get lactic acid build up leading to cramp.

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20
Q

3 investigations for claudication?

A
  1. Exercise treadmill ABPIs
  2. Duplex scan (BMO ultrasound to visualize artery followed by multidirectional Doppler to identify portion of artery affected)
  3. Angiography (allows detailed picture of arterial system)
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21
Q

How should claudication be managed?

A
  • Antiplatelet agent
  • Statin
  • Strict management of BP
  • Lifestyle modification- stop smoking, keep exercising etc…
22
Q

3 things needed to define critical ischaemia?

A
  1. Greater than 2 weeks duration (less than this is acute ischaemia)
  2. Ankle pressure less than 40mmHg
  3. Rest pain or tissue loss
23
Q

6 Ps that classically describe acute ischaemia? Which 2 of these Ps suggest need for immediate revascularisation?

A
  1. Painful
  2. Pulesless
  3. Perishingly cold
  4. Pale
  5. Paralysis
  6. Paraesthesia
  • Paralysis and paraesthesia: immediate revascularisation within 6 hours
24
Q

What is acute on chronic limb ischaemia? Is it more or less severe than acute ischaemia?

A
  • Acute ischaemia that occurs on background of claudication
  • Usually thrombotic occlusion of atherosclerotic vessels
  • Less severe- paraesthesia and paralysis not present as collaterals develop.
25
Q

What usually causes acute ischaemia? How do you treat this? Possible complications of this treatment?

A
  • Cause by embolus suffenly occluding vessel
  • Treated with embolectomy
  • Can get compartment surgery as tissue reperfuses
26
Q

Screening programme for AAAs?

A
  • Men invited for screening from 65 years and over
  • If their aorta is over 3cm then will be under surveillance
  • Based off of Multicentre Aneurysm Screening Study
27
Q

Why are AAAs not screened for in women?

A

AAAs are 10 times less common in women

28
Q

What aneurysm commonly accompanies AAAs?

A

Popliteal artery aneurysms

29
Q

5 complications of AAAs?

A
  1. Rupture
  2. Embolisation leading to trash foot in AAA, missing pulses in popliteal aneurysm
  3. Thrombosis can lead to acutely ischaemic leg if it embolizes
  4. Pressure of aneurysm on surrounding structures leading to DVT if popliteal aneurysm
  5. Fistulation
30
Q

What does this image show? What causes it?

A

Trash foot. Result of aneurysm repair which allows tiny emboli to go down to the foot.

31
Q

What does this image show?

A

Varicose veins- ‘dilated, tortuous, serpiginous veins’

32
Q

Common distribution of varicose veins?

A
  • Affecting the long saphenous vein along the medial thigh and calf
  • Second most common area is affecting the short saphenous vein on the posterior aspect of the calf
33
Q

Symptoms of varicose veins?

A
  • Pain on standing in particular, worse at end of day, throbbing when going to bed
  • Itching
  • Night cramps/restless leg
  • Colour changes
  • Career involving a lot of standing
34
Q

7 complications of high pressure varicose veins?

A
  1. Swelling
  2. Bleeding
  3. Eczema
  4. Thrombophlebitis
  5. Haemosiderin deposition
  6. Lipodermatosclerosis
  7. Venous ulceration
35
Q

Treatment of varicose veins?

A
  • Compression stockings: push blood from superficial system to deep system
  • Minimally invasive approach: thermal ablation or radiofrequency of long saphenous vein
  • Open surgical approach: high saphenous ligation followed by stripping and phlebectomy
36
Q

What is post-phlebitic limb?

A

Post DVT venous insufficiency. Presents with similar complications of varicose veins (swelling, bleeding, thrombophlebitis, lipodermatosclerosis etc…)

37
Q

What is thoracic outlet syndrome?

A

Compression of nerve, artery or vein between 1st rib and scellaenous anteior muscle, and clavicle.

  • Venous: upper limb DVT and long term swelling
  • Arterial: Raynaud’s, claudication, embolisation
  • Neurological: pain, radiculopathy
38
Q

How do you investigate thoracic outlet syndrome? What can cause a similar presentation?

A
  • Duplex in abduction
  • Nerve conduction studies
  • MRI, MRA, MRV
  • CXR
  • 0.3% of population have extra cervical rib which can cause a similar presentation with nothing else.
39
Q

How do you treat thoracic outlet syndrome?

A
  • Thrombolyse if venous, treat arterial problems etc…
  • Remove 1st rib to decompress area
40
Q

4 things diabetic ulcers occur secondary to?

A
  1. Peripheral vascular disease
  2. Small vessel disease
  3. Neuropathy
  4. Infection
  • To treat diabetic ulcers you need to treat all the above
41
Q

What does this image show?

A

Charcot foot with rocker-bottom sole of left foot.

Just Charcot foot on right side

These are chronic and painless but can get ulceration and osteomyelitis.

42
Q

Cause of primary Raynaud’s disease?

A

Spasm of digital arteries

43
Q

List some causes of secondary Raynaud’s disease?

A

Vibrating tools, drugs (Ergotamine), vasculitis, SLE, polyarteritis nodosa, cold agglutinins

44
Q

Causes of primary lymphoedema?

A

Hereditary e.g. Nonne-Milroy disease

Non-hereditary: lymphoedema precox (women aged 8-25), lymphoedema tarda (after age of 35)

45
Q

Causes of secondary lymphoedema?

A
  • Surgery
  • Radiotherapy
  • Chemotherapy
  • Infection: TB, filariasis
  • Cancer
46
Q

How can you confirm this is a venous malformation and not an AV malformation?

A
  • Venous malformations are NOT pulsatile and have NO bruit, and have NO signal with hand held Doppler. AV malformations have all of these.
  • Do not really need to treat venous malformations but AV malformations do need correction.
47
Q

Indications for carotid endarterectomy?

A
  • ASYMPTOMATIC: greater than 70% stenosis
  • SYMPTOMATIC: 70% lesion AND ipsilateral hemipshere symptosm of TIA, well recovered stroke, or amarosis fugax
48
Q

Complications of carotid endarterectomy?

A
  • Usual complications of surgery
  • Specific: bleeding, stroke, damage to cranial nerves XII, X, VII, VIII, damage to greater auricular nerve
49
Q

Definition of:

  • Aneurysm
  • True aneurysm (give two types)
  • False aneurysm
  • Dissection
A
  • Aneurysm: dilatation of blood vessel more than 50% of its original diameter:
  • True aneurysms involve all layers of vessel wall include fusiform and saccular
  • False aneurysm is collection of blood around the vessel wall which communicates with the vessel lumen.
  • Dissection: vessel dilatation from blood splaying apart the tunica media from the tunica intima, forming a channel within the vessel wall
50
Q

Definition of AAA? What size classifies as: small, medium, large?

A

Dilatation of the abdominal aorta to 3+ cm at level of renal arteries.

  • Small 3-4.4cm
  • Medium 4.5-5.4cm
  • Large 5.5cm or more
51
Q
A

Finals Revision (9 decks)

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