Vascular Flashcards
Tx/prevention of Post surgery DVT
Stop COCP 4 weeks pre op
Mobilize as early as possible
Immobilised patients should have heparin
At risk patients should have support hosiery or intermittent pneumatic pressure until 16 hours post op
Tx of known DVT
LMWH
Stop when INR 2-3
DOAC (1st line) or Warfarin if contraindicated
3 months if DVT is post op
6 months if no precipitating cause
Lifelong if there is known thrombophilia or recurrent DVT
Anticoagulation failure to prevent a PE may indicate an IVC filter, which would stop and thrombi making their way to the lungs
Tx of a PE
Major/minor treat as DVT
Massive A-E resus IV morphine + antiemetic LMWH SBP >90 = warfarin SBP <90 = vasopressors + thrombolysis (alteplase/streptokinase)
Lifestyle interventions for high blood pressure
Lifestyle intervention
Weight loss
Decrease alcohol, sodium, caffeine,
Stop smoking
when do you start pharmocological management for hypertension
Start in all of those with stage 2 (>140/90)
Start in those under 80 with stage 1 HTN (120-139/0-89) and one of the following:
>20% 10 year CV risk Other comorbidities Renal disease Known CV disease Organ disease `
Target Blood pressures in hypertension
Clinic:
<140/90
<150/90 if 80 or above
<130/80 if diabetic
<135/85 or 145/85 if Ambulatory
What is the pharmocological management of hypertension
1st line: ACEIs (<55, non black, high renin), CCBs (>55, black, low renin)
ACEis can be swapped for ARBs if adverse reaction
2nd line: ACEi + CCB
3rd line: +loopdiuretic
4th: spironlactone if K+ <4.5, or thiazide like diuretic, BB or alpha blocker (if CCB is dihydropiridine) if K+ >4.5
Tx of hyperlipidaemia
- lifestyle advice
- statins
- Ezetimibe
- Cholestyramine or PCSK9 inhibitor (alirocumab)
- fibrates - used for familial disease or with comorbin hypertriglycerideaemia
side effects of ace inhibitors
dry cough (10%)
hyperkalaemia
worsened renal function (up to 30% rise in creatinine allowed)
first dose hypotension
contraindications for ace inhibitors
renal artery stenosis
side effects of CCBs
Peripheral oedema
Postural hypotension
Reflex tachycardia
what qRISK score indicates atorvostatin prescription
> 10%
counselling points for statins
Nausea
Headache
Muscle pain
Always report muscle pain as rarely rhabdomyolysis occurs
Tx for unruptured unprotected AAA
<5.5cm
Treat with regular USS
Modify risk factors (HTN)
75% will progress to requiring surgery with no risk factor modification
> 5.5cm
Think about surgery
Risk of rupture in AAAs >6cm goes from 1% to 25%
Expansion >1cm in a year
Surgery
Symptomatic aneurysms
Surgery
Surgery = EVAR
major risk in EVAR surgery
kidney injury - contrast used is nephrotoxic and there is often ischaemia as the aorta is clamped
Tx of popliteal aneurysms
Femoral to distal popliteal bypass grafts
Intravascular thrombolysis or embolectomy may occur at the time of the surgery for distal emboli
Tx of aortic dissection
A-E resus
Urgent cardiothoracic advice
Patients managed on ITU
BP controlled to keep around 100
IV esmolol
Type A dissection (involves ascending aorta)
Patients are considered for surgery if fit enough due to risk of tamponade
Surgery is grafting of the aortic root
High operative mortality
Type B dissection (descending only)
Medical management if there are no complications
complications of aortic dissection
tamponade
spreading dissection affecting a major artery:
Coronary arteries = MI
Brachiocephalic trunks = CNS issues with unequal arm pulses
Renal arteries = haematuria, AKI, anuria
SMA/IMA = mesenteric ischaemia
Iliac arteries = acute lower limb ischaemia
Treatment for chronic peripheral arterial disease
ABPI >0.6 - conservative management weight loss stop smoking exercise to point of claudication (improves collatorals) raise heel - reduces calf work foot care optimise BP and Diabetes if present Clopidorel + atorvostatin
ABPI <0.6 - surgical management
mild-moderate disease - percutaneous transluminal angioplasty
severe - surgical reconstruction/bypass
if surgery not possible - sympathectomy helps w pain
amputation is last resort, for intractible pain and septicaemia/gangrene
what has been shown to improve phantom limb pain in amputation
preoperative gabapentin
mirror therapy
how long do you have to re-establish flow in an acutely ischaemic limb
6 hours
Tx of acute arterial occlusive disease of peripheral limbs
A-E resus
IV heparin to prevent clot formation
Assessment of limb
Blood starting to come back via collaterals indicates the use of thrombolysis over surgery
No blood supply + neurological changes = urgent surgery indicates
Urgent CT angiogram
Can differentiate between thrombotic/embolic causes
Embolus management
Open embolectomy
Performed using a fogarty catheter
There may be some local thromboylsis if the clot has propogated beyond the original embolus
Investigation into the underlying cause
Thrombus management
Thrombolysis to restore patency
Interval angioplasty to treat underlying disease
Last resort = amputation
Only undertaken in threatened limbs where the patient is not able to undergo operative intervention
Also done if the leg is not viable
what indicates a non-viable limb in acute arterial occlusive disease
fixed staining (no blanching) and rigid muscles
management of reynauds
Keep extremities warm
Heated gloves
Stop smoking and stop exacerbating drugs
B blockers
OCP
Nifedipine is the first line medical therapy, 2nd line includes:
Losartan
Prazocin
Fluoxetine
Sympathomimectomy may provide symptomatic relief for those with severe disease but it will be short lived
management of thoracic outlet syndrome
Surgery
Excision of surgical rib/often first rib also
Grafting of the post stenotic aneurysm
when should you treat varicose veins
Grossly dilated/symptomatic veins
Haemorrhage
Skin changes
Incompetent perforator veins (can be treated minimally)
Tx for Varicose veins
Lifestyle advice
Avoid prolonged standing
Regular exercise
Lose weight
Graded compression stockings
Minor varicosities
Elderly and unfit
Endothermal ablation
Often treatment of choice
Laser fibre passed along vein under ultrasound guidance and fired to cause a thrombosis
Sclerotherapy
For cosmetically undesirable superficial varicosities
Chemical sclerosant is injected into an empty vein and then compression bandages are used for 2 weeks to allow fibrosis to occur
Surgery
Gold standard but indications are under scrutiny
Disconnects saphenous vein from deep femoral veins
Incompetent perforators are ligated also
complications of untreated varicose veins
haemorrhage
phlebitis
treatment for deep venous insufficiency
there is none
management of chronic lymphedema
Elevation
Compression stockings
Physical massage
Long term Abx for recurrent cellulitis
