Vascular Flashcards
1
Q
At what diameter do we consider someone to have a AAA?
A
> 3cm
2
Q
What are risk factors for AAA?
A
Most common:
Smoking
HTN
Diabetes
Rarer:
Syphilis
Ehlers Danlos type 1
Marfans
3
Q
What is the difference between true and false AAAs?
A
True AAA involves all 3 layers of arterial wall
False only involves a siingle layer of fibrous tissue
4
Q
What demographic is most likely to have a true AAA?
A
Elderly men
As such, screening via US is being offered to all men aged 65
5
Q
Where does the aneurysm in AAA usually rupture?
A
80% into retroperitoneal space
20% rupture anteriorly
6
Q
What impacts the risk of rupture with AAA?
A
Size of aneurysm:
2% of 4cm aneurysms will rupture over 5 years compared with 75% of 7cm aneurysms
7
Q
What are indications for surgery in AAA?
A
> 5.5cm
Symptomatic
Rupture
8
Q
Outcomes of AAA screening?
A
<3cm - no further action
3-4.4cm - small aneurysm, scan 12 monthly
4.5-5.4 - rescan 3 monthly
>5.5 - refer within 2 weeks to vascular surgery for probable intervention
9
Q
Management of AAA if <5.5cm?
A
Abdominal US surveillance and optimise risk factors (e.g. smoking, HTN), commence aspirin/statin therapy
10
Q
Management of AAA if >5.5cm?
A
Elective endovascular repair (EVAR)
This involves placing a stent into the abdominal aorta via the femoral artery to prevent blood collecting in the aneurysm
Open repair (clamping the aorta, then replacing it with a prosthetic graft)
If aneurysm >6.5 must also inform DVLA until repaired (disqual. from driving)
11
Q
Symptoms of AAA?
A
Abdominal pain
Back/loin pain
Distal embolisation producing limb ischaemia
Signs:
Pulsatile mass felt in abdomen
12
Q
Other than US, what other imaging would you like in AAA?
A
CT scan with contrast to help plan surgery
13
Q
Main complication of EVAR?
A
Endovascular leaking (blood leaks out of the graft, allowing for aneurysm to still collect blood)
14
Q
How to treat ruptured AAA?
A
High flow O2 IV access Urgent bloods, crossmatch Maintain BP <100 (risk of dislodging clot precipitating further bleeding) Open surgical repair
15
Q
Where do thoracic aortic aneurysms affect?
A
60% ascending/aortic root
10% aortic arch
40% descending aorta
(This doesn’t add up but.. maybe 2 places affected at once?)
16
Q
What are thoracic aortic aneurysms due to?
A
Degradation of the tunica media (middle layer of artery/vein)
17
Q
What are the main causes of thoracic aortic aneurysms?
A
Connective tissue diseases (Marfan’s, Ehler’s danlos)
Bicuspid aortic valve
Trauma
Aortic dissection
Aortic arteritis (e.g. Takayasu arteritis)
Tertiary syphilis
18
Q
What are the risk factors for thoracic aortic aneurysm?
A
FHx HTN Atherosclerosis Smoking High BMI Male Age (advanced)
19
Q
Clinical features of thoracic aortic aneurysm?
A
Usually asymptomatic Pain: Asc. aorta - ant. chest Aortic arch - neck Desc. aorta - between scapulae
20
Q
What do you see on CXR with thoracic aortic aneurysm?
A
Widened mediastinal silhouette and an enlarged aortic knob
21
Q
What is the imaging of choice in thoracic aortic aneurysm?
A
CT chest with contrast
22
Q
Management of thoracic aortic aneurysm?
A
Statin + antiplatelet (aspirin)
BP management
Smoking cessation
Surgery:
Usually if >5.5cm
23
Q
What are the layers of an artery?
A
Tunica intima (inner) Tunica media (middle) Tunica adventitia (outer)
24
Q
What is an aortic dissection?
A
A tear in the intimal layer of the aortic wall causing blood to flow between and split apart the intima and media
25
How can we define aortic dissection?
Acute <14 days
| Chronic >14 days
26
What are the directions an aortic dissection can progress?
Toward the iliac arteries (anterograde dissection)
| Toward the aortic valve (retrograde dissection)
27
What classifications can we use for aortic dissection?
Stanford or DeBakey classifications
28
Risk factors of aortic dissection?
```
HTN
Atherosclerotic disease
Male
Connective tissue disorders (Ehler's Danlos type 1 or Marfan's)
Bicuspid aortic valve
```
29
Clinical features of aortic dissection?
Tearing chest pain
Radiates to the back
Signs:
Tachycardia
Hypotension
New aortic regurg. murmur
30
What investigations would you like for aortic dissection?
Baseline bloods - FBC, U+Es, LFTs, troponin, coagulation
Crossmatch of at least 4 units
ABG
ECG
Imaging:
CT angiogram
Transoesophogeal echo
31
How do we manage aortic dissection?
ABCDE + Resus.
```
Stanford type A:
Managed surgically (replacement of aorta with synth. graft)
```
Stanford type B:
If uncomplicated, manage medically (beta blockers first line [labetalol], calc. channel blockers second line)
32
What is Stanford type A and Stanford type B?
A involves ascending aorta (includes DeBakey type I + II)
| B does not involve ascending aorta (DeBakey type III)
33
What is chronic limb ischaemia?
PAD that results in symptomatic reduced blood supply to the limbs
34
What causes chronic limb ischaemia?
Atherosclerosis
| Vasculitis (rarely)
35
What are the risk factors for chronic limb ischaemia?
```
Smoking
DM
HTN
Hyperlipidaemia
Increasing age
FHx
Obesity/physical inactivity
```
36
What are the 4 stages of chronic limb ischaemia?
Stage I - Asymptomatic
Stage II - Intermittent claudication
Stage III - Ischaemic rest pain
Stage IV - Ulceration or gangrene, or both
37
What is Buerger's test?
The patient lies supine and raises their legs until they go pale. They then slowly lower their legs until the point where their legs regain colour.
The point at which they lose colour is known as Buerger's angle
38
What is critical limb ischaemia?
An advanced form of chronic limb ischaemia. It can be defined in 3 ways:
Ischaemic rest pain for greater than 2 weeks duration
Presence of ischaemic lesions or gangrene
ABPI less than 0.5
39
What are the main differentials for limb ischaemia?
```
Spinal stenosis (neurogenic claudication)
Acute limb ischaemia
```
40
What are the features of spinal stenosis?
Typically pain from the back radiating down the lateral aspect of the leg. There are often symptoms on initial movement/symptoms that are relieved by sitting rather than standing
Positional pain is the main thing that differentiates this from claudication
41
How does acute limb ischaemia present?
Sudden onset of the 6 P symptoms
42
How do we manage spinal stenosis?
Laminectomy
43
Acute limb ischaemia features?
Less than 2 weeks of clinical features
```
Features include:
Pale
Pulseless
Painful
Paralysed
Paraesthetic
Perishing with cold
```
44
How do we diagnose chronic limb ischaemia?
Clinically
45
How do we confirm the diagnosis/severity of chronic limb ischaemnia?
```
Ankle-brachial pressure index (ABPI)
Normal >0.9
Mild 0.8-0.9
Moderate 0.5-0.8
Severe <0.5
```
46
How do we investigate critical limb ischaemia?
Doppler ultrasound to investigate the severity and anatomical location of any occlusion
Patients can also maybe have a CT angiography
Also a cardiovascular risk assessment because of the high likelihood of CVS risk factors
47
How do we manage chronic limb ischaemia?
```
Lifestyle advice (smoking cessation, regular exercise, weight reduction)
Statin therapy (atorvastatin 80mg OD)
Anti-platelet therapy (clopidogrel 75mg OD)
Optimise diabetes control
```
Surgery
48
How do we manage critical limb ischaemia?
Urgent referral for surgery
Angioplasty (with or without stenting)
Bypass grafting (diffuse disease/younger patients)
Amputation
49
What are the complications of chronic limb ischaemia?
Sepsis (secondary to infected gangrene)
Acute-on-chronic ischaemia
Amputation
Reduced mobility/QoL
50
What is acute limb ischaemia?
Sudden decrease in limb perfusion that threatens the viability of the limb
51
What causes acute limb ischaemia?
Embolisation
Thrombosis in situ
Trauma (including compartment syndrome)
52
If someone presents without any risk factors for PVD and is younger than 50, what tests should be done?
Thrombophilia screen
| Homocysteine (high levels can cause disease)
53
If one leg is completely fine (pulses etc.) but the other is showing signs of acute limb ischaemia, what is the likely cause?
Embolic occlusion
54
What should you establish in your history if patient presents with acute limb ischaemia?
Potential causes of embolisation (chronic limb ischaemia, AF, MI, AAA, peripheral aneurysms)
55
How do you investigate suspected acute limb ischaemia?
Bloods, including serum lactate
Thrombophilia screen
ECG
```
Doppler ultrasound (both limbs)
CT angiography
```
56
How concerned are we about acute limb ischaemia?
Surgical emergency - complete art. occlusion can cause irreversible tissue damage within 6 hours
57
What is the initial management of acute limb ischaemia?
Refer to senior surgical
High flow O2
IV access
Heparin bolus/treatment dose
58
When do we offer conservative management in acute limb ischaemia?
Rutherford 1 and 2a
59
What is the conservative management of acute limb ischaemia?
Prolonged course of heparin
| Regular APTT monitoring and clinical review
60
When do we surgical intervention in acute limb ischaemia?
Rutherford 2b
61
How do we treat acute limb ischaemia surgically?
If embolic:
Embolectomy
Thrombolysis
Bypass surgery
If thrombotic:
Thrombolysis
Angioplasty
Bypass surgery
62
What indicates amputation in acute limb ischaemia?
Irreversible limb ischaemia (mottled non-blanching appearance with hard woody muscles)
63
What indicates a need for amputation in acute limb ischaemia?
Irreversible limb ischaemia (mottled non-blanching appearance with hard woody muscles)
64
What is the long term management for patients who have had an acute limb ischaemia?
Managing the cardiovascular mortality risk:
Smoking cessation
Weight loss
Increase in exercise
Often started on an antiplatelet such as aspirin or clopidogrel as well
65
What is an important complication of acute limb ischaemia?
```
Reperfusion injury resulting in:
Compartment syndrome
Release of substances from the damaged muscle cells, e.g. -
K+ ions
H+ ions
Myoglobin (resulting in AKI)
```
66
What is chronic mesenteric ischaemia?
Reduced blood supply to the bowel which gradually deteriorates over time as a result of atherosclerosis in the coeliac trunk, SMA or IMA
67
What are the clinical features of chronic mesenteric ischaemia?
```
Postprandial pain (10 mins-4 hours after eating)
Weight loss (decreased calorie intake/malabsorption)
Concurrent vascular comorbidities
```
68
What is the diagnostic test of choice in chronic mesenteric ischaemia?
CT angiography
69
How do we manage chronic mesenteric ischaemia?
Modify risk factors
Anti-platelet/statin
Endovascular/open procedures (angioplasty + stenting/endarctectomy or bypass)
70
What are the complications of chronic mesenteric ischaemia?
Bowel infarction
| Malabsorption
71
What is acute mesenteric ischaemia?
Sudden decrease in blood supply to the bowel, resultiing in bowel ischaemia and if not promptly treated, gangrene and death
72
What are the causes of acute mesenteric ischaemia?
Thrombus in situ (25%)
Embolism (50%)
Non-occlusive cause (20%)
Venous occlusion and congestion (10%)
73
What are the clinical features of acute mesenteric ischaemia?
Generalised abdominal pain, out of proportion to clinical findings
Nausea, vomiting (75%)
74
Investigations for acute mesenteric ischaemia?
ABG - serum lactate/acidosis
Routine blood tests
Imaging:
CT scan with IV contrast
75
What will acute mesenteric ischaemia show on CT scan?
Arterial bowel ischaemia will show:
Oedematous bowel (secondary to ischaemia + vasodilation)
Loss of bowel wall enhancement
Pneumatosis
76
Management of acute mesenteric ischaemia?
```
Resuscitation
Senior involvement
Broad spectrum abx
Catheter + fluid balance chart
Excision of necrotic or non-viable bowel
Revascularisation of the bowel
```
77
What are the complications of acute mesenteric ischaemia?
Bowel necrosis
Perforation
Mortality rate of 50%
78
What do you need to rule out in hyperhidrosis?
```
Secondary causes:
Pregnancy/menopause
Anxiety
Infection
Malignancy
Endocrine disorders
Medications
```
79
What causes deep venous insuffiency?
DVT/Valvular insufficiency
Caused by failure of the venous system
80
Risk factors for deep venous insufficiency?
```
Female gender
Pregnancy
Increasing age
Previous DVT/phlebitis
Obesity
Smoking
```
81
Clinical features of deep venous insufficiency
```
Chronically swollen lower limbs
Pruritic, painful and aching lower limbs
Varicose eczema
Thrombophlebitis
Haemosiderin skin staining
Lipodermatosclerosis
Atrophie blanche
```
82
How do we investigate deep venous insufficiency?
Doppler ultrasound scan
Routine blood tests to assess other aetiologies
Documentation of foot pulses/ABPI to assess viability of compression therapy
83
How do we manage deep venous insufficiency?
Conservative:
Compression stockings
Analgesia
Surgical:
If post DVT/thrombotic type syndrome you can do venous stenting
84
Complications of DVI?
```
Swelling
Recurrent cellulitis
Chronic pain
Ulceration
DVT
```
85
What are varicose veins?
Tortuous dilated segments of veins associated with valvular incompetence
86
What are the four major risk factors for development of varicose veins?
Prolonged standing
Obesity
Pregnancy
Family history
87
Clinical features of varicose veins
Unsightly veins
Pain/aching/swelling/itching
Variscosities in the course of the great/short saphenous veins
Features of venous insufficiency
88
What classification do we use for varicose veins?
CEAP classification
89
Investigations for varicose veins?
Duplex ultrasound
90
Conservative management of varicose veins
Education - avoid prolonged standing, weight loss, increase exercise
Compression stockings* (if interventional treatment is not appropriate)
91
Surgical treatment of varicose veins
Vein ligation, stripping and avulsion
Foam sclerotherapy
Thermal ablation
92
Complications of varicose veins
```
Surgical complications:
Haemorrhage
Thrombophlebitis
DVT
Disease recurrence
Nerve damage
```
93
What type of ulcer is most common?
Venous (80%)
| Remaining 20% are arterial and neuropathic
94
Features of a venous ulcer
```
Painful
Shallow
Irregular border
Granulating base
Gaiter region of legs
Varicose eczema
Thrombophlebitis
Haemosiderin skin staining
Lipodermatosclerosis
Atrophie blanche
```
95
Investigations in venous ulcers
Usually a clinical diagnosis
Can confirm underlying venous insufficiency with duplex ultrasound
ABPI to assess for any arterial component
Swab cultures if suspecting infection
96
Management of venous ulcers
```
Conservative:
Leg elevation
Increased exercise
Lifestyle changes
Weight reduction
*Multicomponent compression bandaging
```
If varicose veins also present, endovenous techniques or open surgery
97
Features of an arterial ulcer
```
Small deep lesions
Well defined borders
Necrotic base
Pressure areas/sites of trauma
Usually a history of intermittent claudication/critical limb ischaemia
Painful
Cold
Absent pulses
```
98
Investigating arterial ulcers
```
ABPI:
>0.9 normal
0.8-0.9 mild
0.5-0.8 moderate
<0.5 severe
```
99
Management of arterial ulcers
Conservative:
Lifestyle changes
Medical:
Aspirin/clopidogrel
Surgical:
Angioplasty
Bypass grafting
100
Neuropathic ulcer features
```
Painless ulcers at pressure points
History of peripheral neuropathy
Burning/tingling in the legs
Wasting of muscles
Punched out appearance
Glove/stocking distribution
Pulses present
```
101
Investigations for a neuropathic ulcer
Blood glucose levels
Serum B12 levels
ABPI +/- duplex (for concurrent arterial disease)
Check the extent of peripheral neuropathy with touch test/vibration test
102
Management of neuropathic ulcer
Diabetic foot clinic
| Manage diabetes
103
What is Charcot's foot?
A neuroarthropathy whereby a loss of joint sensation results in continual unnoticed trauma/deformity occurring
Can predispose patients to neuropathic ulcer formation
