Vascular Flashcards
How do venous leg ulcers come about?
- most due to venous hypertension secondary to chronic venous insufficiency
- other: calf pump dysfunction or neuromuscular disorders
- ulcers form due to capillary fibrin cuff or leucocyte sequestration
Features of venous insufficiency:
- oedema
- brown pigmentation
- lipodermatosclerosis
- eczema
What is venous insufficiency related to?
- deep: previous DVT
- superficial: varicose veins
Investigation and management of lower leg ulcers:
- doppler ultrasound looks for presence of reflux and duplex ultrasound looks at anatomy/flow of vein
- 4 layer compression banding after exclusion of arterial disease or surgery
- if failure to heal after 12 weeks or >10cm2 skin grafting
What is Marjoiln’s ulcer?
- squamous cell carcinoma
- occurring at sites of chronic inflammation e.g. burns, osteomyelitis after 10-20 years
- mainly lower limb
What are arterial ulcers?
- toes and heel
- painful
- areas of gangrene
- cold with no palpable pulses
- low ABPI measurements
What are neuropathic ulcers?
- plantar surface of metatarsal head and plantar surface of hallux
- plantar neuropathic ulcer most commonly leads to amputation in diabetics
- due to pressure
- cushioned shoes to reduce callous formation
What is pyoderma gangrenosum?
- associated with IBD/RA
- stoma sites
- erythematous nodules or pustules which ulcerate
Three patterns of presentation in patients with peripheral arterial disease:
- intermittent claudication
- critical limb ischaemia
- acute limb-threatening ischaemia
Features of acute limb-threatening ischaemia:
- pale
- pulseless
- painful
- paralysed
- paraesthetic
- perishing with cold
3 features of critical limb ischaemia:
- rest pain in foot for more than 2 weeks
- ulceration
- gangrene
ABPI suggestive of critical limb ischaemia:
<0.5
Interpretation of ABPI:
1 - normal
0.6-0.9 - claudication
0.3-0.6 - rest pain
<0.3 - impending
Features of intermittent claudication:
- aching or burning in leg muscles following walking
- able to walk predictable distance before symptoms
- relieved within minutes of stopping
- not present at rest
Assessment intermittent claudication:
- femoral, popliteal, posterior tibialis and dorsalis pedis pulses
- ABPI
- duplex US
- magnetic resonance angiography (MRA) before intervention
Management of peripheral arterial disease:
- stop smoking
- treat hypertension, diabetes, obesity
- statin (atorvastatin 80mg)
- clopidofrel
- exercise training
- severe: angioplasty, stenting, bypass surgery, amputation
Drugs to use in peripheral arterial disease:
- naftidrofuryl oxalate = vasodilator
- cilostazol: phosphodiesterase III inhibitor with both anti platelet and vasodilator effects
What is superficial thrombophlebitis?
- inflammation due to thrombosis of superficial vein
- usually long saphenous vein
- usually non-infective (bacterial can result in septic thrombophlebitis)
What is risk of superficial thrombophlebitis related to?
length of vein affected - >5cm likely to have associated DVT
Investigations superficial thrombophlebitis:
- ultrasound scan to exclude concurrent DVT
- antiembolism stockings
- consider treatment with prophylactic LMWH for up to 30 days or fondaparinux for 45 days
- if contra, 8-12 days oral NSAIDs
What are varicose veins?
- dilated, tortuous, superficial veins
- secondary to incompetent venous valves
- most commonly in legs due to reflux of great saphenous vein and small saphenous vein
Risk factors varicose veins:
- age
- female
- pregnancy: uterus causes compression of pelvic veins
- obesity
Symptoms varicose veins:
- aching, throbbing, itching
- varicose eczema (venous stasis)
- haemosiderin deposition (hyperpigmentation)
- lipodermatosclerosis (hard tight skin)
- atrophie blanche (hypopigmentation)
- bleeding
- superficial thrombophlebitis
- venous ulceration
- DVT
Management varicose veins:
- leg elevation
- weight loss
- exercise
- stockings
- endothermal ablation
- foam sclerotherapy
- surgery (ligation or stripping)
Reasons for referral of varicose veins to secondary care:
- significant symptoms
- previous bleeding from veins
- skin changes secondary to chronic venous insufficiency
- superficial thombophlebitis
- active or healed venous leg ulcer
Cervical rib:
- supernumerary fibrous band arising from 7th vertebra
- incidence of 1 in 500
- thoracic outlet syndrome
- surgical division of rib
- bilateral in 70%
- compression of subclavian artery may produce absent radial pulse on examination and positive Adsons test
- treatment if evidence of neuromuscular compromise
What is subclavian steal syndrome:
- proximal stenotic lesion of subclavian artery
- retrograde flow through vertebral or internal thoracic arteries
- decreased cerebral blood flow and syncopal symptoms
- duplex scan and/or angiogram will delineate lesion and allow treatment to be planned
What is Takayasu’s arteritis?
- large vessel granulomatous vasculitis
- intimal narrowing
- young asian females
- mild systemic illness, pulses phase with symptoms of vascular insufficiency
- treat with systemic steroids
What is coarctation of the aorta?
- aortic stenosis at site of ductus arteriosus insertion
- most common in boys and Turner’s
- symptoms of arterial insufficiency such as syncope and claudication
- blood pressure mismatch may be seen
- angioplasty or surgical resection
Axillary/brachial emobolus:
- 50% of upper limb emboli in brachial
- 30% axillary
- sudden onset: pain, pallor, paresis, pulselessness, paraesthesia
- sources: left atrium with cardiac arrhythmia, mural thrombus
- cardiac arrhythmias may result in impaired consciousness
What are arterial occlusions:
- resulting from atheroma common
- trauma may result in vascular changes and long term occlusion but rare
- claudication, ulceration, gangrene
- may result in subclavian steal syndrome
- progressive: development of collaterals, acute ischaemia may occur as result of acute thrombosis
What is Adsons test?
- for compression of subclavian artery
- lateral flexion of neck away from symptomatic side and traction of symptomatic arm
- obliteration of radial pulse
