VASCULAR Flashcards
What are some different types of ulcers?
Venous
Arterial insufficiency
Neuropathic
Pressure ulcers
How do venous ulcers appear?
Shallow, irregular borders, granulating base
MEDIAL MALLEOLUS
What are venous ulcers due to?
Valvular incompetence
What are the risk factors for venous ulcers?
Increasing age
Varicose veins
Pregnancy
Obesity
What are the features of venous ulcers?
Painful
Aching
Itching
How are venous ulcers investigated
Duplex ultrasound of veins
ABPI (to assess for arterial component)
Microbiology swabs if infection suspected
What is the conservative management for venous ulcers?
Leg elevation
Exercise
Encourage weight reduction
What further management for venous ulcers is there?
Compression bandaging (ABPI must be >0.6 before)
Varicose veins should be treated
How do arterial ulcers present?
Small, deep lesion with well defined border
No granulation tissue
What are some risk factors for an arterial ulcer?
Smoking
Diabetes
HTN
Obesity
What are the features of an arterial ulcer?
History of intermittent claudication
Critical limb ischaemia (pain at night)
What are the investigations for arterial ulcers?
ABPI
What are the treatment options for arterial ulcer?
Smoking cessation, weight loss, increased exercise
Statins, anti platelet (clopidogrel/aspirin) and optimise BP
Surgical (angioplasty maybe with stenting)
When do neuropathic ulcers occur?
Result of peripheral neuropathy
What are the risk factors for neuropathic ulcers?
Diabetes mellitus
B12 deficiency
What are the features of neuropathic ulcers?
History of peripheral neuropathy
Burning / tingling in legs
“Punched out appearance”
What are the investigations of neuropathic ulcers?
Blood glucose levels
Serum B12 levels
Microbiology swab (with evidence of infection!!)
What is the management of neuropathic foot ulcers?
Optimise diabetic control
Increased exercise
Regular chiropody
What is the definition of an AAA?
Dilatation >3cm
What are the risk factors for AAA?
Smoking
HTN
Hyperlipidaemia
FH
Male
How do symptomatic patients with AAA present?
Abdo pain
Back or loin pain
Pulsatile mass in abdo
Who is offered an abdo US scan for AAA?
65 y/o men (with surveillance every 3-5 years)
How is AAA investigated?
Ultrasound scan
Follow up CT after confirmation (threshold diameter 5.5cm)
What is the medical management of AAA?
Smoking cessation
BP control
Statin and aspirin therapy
Weight loss
What are the main treatment options for AAA?
Open repair via midline laparotomy
Endovascular repair (via femoral arteries)
What are the main complications for AAA?
Retroperitoneal leak
Embolisation
Aortoduodenal fistula
How does a AAA rupture present?
Abdo pain
Back pain
Syncope
Pulsatile abdo mass
What is the management of ruptured AAA?
High flow oxygen
IV access (2x large bore cannula)
Urgent bloods (FBC, U&Es and clotting)
Crossmatch
How should BP be managed in a AAA?
Raising BP will dislodge clot so keep BP <100 (permissive hypotension)
Transferred to vascular unit
If stable do a CT to determine stability for EVAR
What is a classification system for aortic dissection?
Standford classification
What are some risk factors for aortic dissection?
HTN
Atherosclerotic disease
Male gender
Connective tissue disorder (Marfan’s)
How does an aortic dissection present?
Tearing chest pain radiating to back
Tachycardia
Hypotension
What are the differential diagnoses for tearing chest pain?
MI
PE
Pericarditis
What are the blood tests for aortic dissection?
FBC
U&Es
LFTs
Troponin
Coagulation profile
What is the first line imaging for aortic dissection?
CT angiogram
What is the initial management for aortic dissection?
Oxygen
IV access
Fluid resuscitation
What are the complications of aortic dissection?
Aortic rupture
Aortic regurgitation
MI
Cardiac tamponade
How should aortic dissections be managed?
Type A surgically
Type B initially medically (CCB to reduce strain)
What are some causes of acute limb ischaemia?
Embolisation: AF, post- MI mural thrombus
Thrombosis in situ ruptures
What are the 6 P’s of acute limb ischaemia?
Pain
Pallor
Pulselessness
Paresthesia
Perishingly cold
Paralysis
What are the differentials for loss of sensation and vascular supply to lower limb?
Acute DVT
Acute limb ischaemia
What is the initial investigation into acute limb ischaemia?
Routine bloods
Serum lactate
Thrombophlebitis screen
G&S
ECG
Doppler USS (followed by potential CT angiography)
What is the initial management of acute limb ischaemia?
High flow oxygen
Therapeutic dose of heparin (maybe prolonged)
What are the surgical options for acute limb ischaemia?
Embolectomy
Intra arterial thrombolysis
Bypass surgery
When will limb ischaemia be irreversible?
Mottled, non-blanching appearance
REQUIRED AMPUTATION
What is the long term management of patients with acute limb ischaemia?
Advise regular exercise, smoking cessation, weight loss
Anti-platelet agent (Clopidogrel / aspirin)
What should be monitored for after treatment for acute limb ischaemia?
Reperfusion syndrome
What are the lab tests for acute limb ischaemia?
ABG
Routine blood tests FBC, U&E, clotting, LFTs
What is normally the cause of chronic limb ischaemia?
Atherosclerosis
What are the risk factors for chronic limb ischaemia?
Smoking
Diabetes mellitus
HTN
Hyperlipidaemia
What are the features of chronic limb ischaemia?
• Intermittent claudication relieved by rest
How can critical limb ischaemia be differentiated from chronic?
Rest pain > 2 weeks duration requiring opiates
Presence of gangrene
ABPI <0.5
How should critical limb ischaemia be investigated?
Doppler ultrasound
CT angiography
BP, HbA1c, ECG
What are the management options for chronic limb ischaemia?
Smoking cessation, regular exercise, weight reduction
Statin
Antiplatelet
Optimise diabetes control
What are the 2 main treatment options for chronic limb ischaemia?
Angioplasty
Bypass grafting
What are the complications of chronic limb ischaemia?
Sepsis (secondary to gangrene)
Acute on chronic ischaemia
Amputation
What typically causes deep venous insufficiency?
DVT
Valvular insufficiency
What are some risk factors for deep venous insufficiency?
Increasing age
Female gender
Pregnancy
Obesity
Smoking
What are the features of deep venous insufficiency?
Chronically swollen lower limb
Bursting pain on walking
What skin changes are there for deep venous insufficiency?
Varicose eczema
Haemosiderin skin staining
Lipodermatosclerosis
What is the main investigation for diagnosing DVI?
Doppler USS
What investigation guides treatment for DVI?
Foot pulses
ABPI
For suitability for compression therapy
What is the management for DVI?
Compression stockings
Suitable analgesic control
What are the complications of DVI?
Swelling
Recurrent cellulitis
Chronic pain
Ulceration
What causes varicose veins?
Incompetent valves allow blood flow from deep to superficial venous system
Name 3 risk factors for varicose veins?
Prolonged standing
Obesity
Pregnancy
FH
How do varicose veins present?
Aching
Itching
Ulceration
What is the gold standard for investigations for varicose veins?
Doppler ultrasound
What is the management of varicose veins?
Avoid prolonged standing
Weight loss
Increase exercise
When should varicose veins be operated on?
Skin changes (pigmentation / eczema)
Venous leg ulcer
What are the surgical options for varicose veins?
Vein ligation, stripping
Thermal ablation
How does a DVT present?
Hot and swollen limb
Calf tenderness and firmness
What is the Well’s score used to assess?
Risk of DVT
What gives 1 point in the Well’s score?
Active cancer
Paralysis of lower extremities
Bedridden >3 days
Tenderness along deep venous system
Leg swollen
Calf swelling >3cm
Pitting oedema
Contralateral superficial veins (non varicose)
Previous DVT
(An alternative diagnosis is at least as likely = -2)
2 = DVT likely
What is the treatment of a DVT?
Therapeutic dose of LMWH
