vascular Flashcards
define varicose veins and how they happen
tortuous, twisted lengthened veins.
They happen due to valvular failure (eg. degenerative), resulting in backflow of blood from deep venous to superficial venous system. This results in venous hypertension and dilation, lengthening, tortuosity of vein.
who gets varicose veins?
obese, sedentary (standing/sitting), pregnancy, genetic disposition
how does someone with varicose veins present
- discomfort at site of varicose veins (aching, tension, heaviness, itching)
- worse on hot weather or prolonged standing
- nocturnal cramps
- venous insufficiency symptoms: eg. oedema, varicose eczema, haemosiderin skin staining, ulcers at the medial malleolus, thrombophlebitis, atrophe blanche cosmetic issues eg. discolouration saphena varix = dilation of saphenous vein at saphenofemoral junction, displays cough impulse
what investigations would you do for varicose veins?
duplex US is gold standard
how would you manage varicose veins?
open surgery = saphenofemoral disconnection, long saphenous stripping, multiple avulsions (vein ligation, stripping, avulsion)
endovenous laser ablation of short/long saphenous vein + foam sclerotherapy (improves cosmetic appearance)
conservative = compression stockings
define peripheral vascular disease and who gets it
symptomatic reduced blood supply to limbs
smokers, hyperlipidaemia, hypertension, DM, fam history of CVS disease, old age
what is the disease process of PVD
atherosclerosis (atheromas developing resulting in narrowing and occlusion of an artery)
what is the main 2 ways people with PVD present?
intermittent claudication =
- pain in lower limb elicited by walking.
- pain relieved by rest (esp in calf = superficial femoral artery in adductor canal)
- mechanism of pain = build up of anaerobic metabolites and substance P in muscles due to inadequate arterial supply.
Critcal limb ischaemia = pale, cold, limb with weak/absent pulse.
- particularly bad nocturnal rest pain, relieved by dangling foot out of bed.
- skin breakdown, gangrene.
- mechanism = arterial insufficiency is so severe that there is signif risk of limb loss
how is intermittent claudication different to cauda equina
cauda equina compression is pain radiating down BILATERAL legs, made worse by walking the pain is not relieved by rest or standing still
investigations for PVD?
- fbc, u & es, lipids, etc
- ankle brachial pressure index (ABPI) = can be falsely high in diabetics or elderly or renal failure patients due to calcified vessels
- cardiovascular risk assessments
- arterial duplex scan shows stenosis/occlusion
- angiogram
- CT/MRI
- Doppler US
Management of intermittent claudication
- stop smoking
- reduce cholesterol + statin (atorvastatin 80mg)
- treat diabetes, BP, IHD
- enroll in supervised exercise program
- antiplatelet therapy = 75mg aspirin or clopidogrel
- angioplasty if significant interference with persons quality of life
- surgical bypass of angioplasty is unsuccessful
How would you manage critical limb ischaemia?
URGENT SURGICAL INTERVENTION
- angioplasty alone or with bypass
- urgical bypass eg. femoropopliteal, femorodistal, etc.
- amputation if previous surgical failure or sepsis risk (good pain relief)
Define a leg ulcer and who gets it
- abnormal breaks in skin or mucous membranes.
- 80% associated with venous disease in leg
- pregnant
- obese
- old
- inactive
- people who have experienced leg trauma or venous incompetence
how do leg ulcers happen?
- people with chronic venous hypertension (eg in varicose veins) develop oedema in that lower limb
- results in impaired tissue perfusion
- tissues around ankle become ischaemic and suffer reperfusion injury on walking/elevation of leg (elevation/movement reduces venous hypertension and tissue fluid)
- this leads to an inflammatory process, resulting in further oedema and tissue fibrosis.
How do venous leg ulcers present?
- shallow
- irregular borders
- a granulated base
- venous insufficiency features itching, aching, bursting sensation before ulcer occured
- ulcer usually over medial malleolus
What is this?
What is characteristic about it and how would you investigate/ manage it?
Venous ulcer
- shallow
- irregular borders
- granulating base
- characteristically over the medial malleolus
- symptoms of chronic venous insufficiency eg. itching, aching, bursting sensation, varicose eczema, thrombophlebitis, haemosiderin staining, atrophie blanche
Investigations = duplex US, ABPI to see if compression therapy is appropriate, swabs if suspected infection
Management = Multicompotent compression bandaging (ABPI>0.6), Appropriate dressings and emollients, endovenous techniques or open surgery
What is this?
What is characteristic about it and how would you investigate/ manage it?
Arterial Ulcer = due to reduced arterial blood flow
- small deep lesions
- well defined borders
- necrotic base
- common distally, at sites of trauma, or pressure areas eg. heel
- Risks = peripheral artery disease, smoking, Dm, HTN, dislipidaemia, obesity, etc.
- Hx of critical limb ischaemia or intermittent claudication
- limbs are cold and have absent pulses
Investigations
- ABPI (>0.9 is normal, <0.5 if severe)
- To assess anatomical location of arteiral disease = duplex US, CT angiograhpy, Magnetic Resonance Angiogram
Management
- Lifestyle eg. smoking cessation, weight loss, more exercise
- Risk factor modification = Statin therapy, aspirin + clopidogrel
- Angioplasty (with or without stenting) OR bypass grafting
What is this?
What is characteristic about it and how would you investigate/ manage it?
Neuropathic Ulcer
- painless ulcers that form on pressure points
- variable in size and depth but “punched out”
- Peripheral neuropathy in “glove and stocking” distribution
- warm feet and good pulses
- Hx of peripheral neuropathy eg. DM, B12 Def
- tingling/burning of legs (painful neuropathy), amotrophic neuropathy (painful wasting of proximal quadriceps), single nerve involvment (mononeuritis multiplex eg. CNIII or median nerve)
Investigations
- Blood glucose and serum B12
- ABPI and duplex to check for arteiral disease
- microbiology swab for infection
- Xray for osteomyelitis assessment
- Assess extent of peripheral neuorpathy with Ipswich touch test + test vibration sensation with a 128Hz tuning fork
Management
- diabetic foot clinics
- optimise diabetic control (Hba1c <7)
- improve diet and exercise
- regular chiropody for good foot hygiene
