Vascular Conditions Flashcards
What are some questions you should be asking in a history when it comes to vascular conditions?
Cardiovascular risk factors
Skin changes
Medications
Claudication
Cold peripheries
What are some cardiovascular risk factors?
Hypertension
Smoking.
Alcohol
Diabetes Mellitus
Obesity
Lack of exercise
High cholesterol
Family history if vascular disease
Male
Old age
Stress
CKD
What it’s important to examine in a patient with vascular disease?
Pulses
ABPI (Ankle Brachial Pressure Index)
Temperature of peripheries
Buergers test
How is an ABPI performed?
Determine blood pressure from the ankle (do both posterior tibial and dorsalis pedis and then take the highest value)
Determine brachial pressure
ABPI = ankle pressure / brachial pressure
What is the significance of the value of ABPI?
Determines the likelihood of peripheral arterial disease
What is considered a normal ABPI (so unlikely to have peripheral arterial disease)?
ABPI > 0.9
What does a low ABPI suggest?
More and more severe peripheral arterial disease
What does a ABPI of 1.4 and greater indicate?
Non compressible arteries so likely calcification of the arteries
What is buergers test?
When the patients leg is elevated until pallor occurs
Leg is slowly lowered to determine the point at which the pallor remains, this is called buergers angle
What buergers angle is suggestive of severe limb ischaemia?
20 degrees or less
What is chronic limb ischaemia?
Peripheral arterial diseases that results in a symptomatic reduced blood supply to the limbs
What is the pathophysiology of chronic limb ischaemia?
Typically affects the lower limbs
Due to atherosclerosis (normally)
How does chronic limb ischaemia present?
Intermittent claudication
Cold limb
Ischameic rest pain
Ulceration, gangrene or both
What is the classification system for chronic limb ischaemia?
Fontaine classification
What is stage I chronic limb ischaemia according to the Fontaine classification?
Asymptomatic
What is stage II chronic limb ischaemia according to the Fontaine classification?
Intermittent claudication
(When most patients present)
What is stage III chronic limb ischaemia according to the Fontaine classification?
Ischaemic rest pain (so no longer just on walking, at all times)
What is stage IV chronic limb ischaemia according to the Fontaine classification?
Ulceration, gangrene or both
What are all the stages in the Fontaine classification for chronic limb ischaemia?
Stage I = asymptomatic
Stage II = intermittent claudication
Stage III = ischaemia rest pain
Stage IV = ulceration, gangrene or both
What investigations should be done when suspecting chronic limb ischaemia?
FBC
U+Es
Lipids
HbA1C
Blood glucose
What methods of imaging should be done in a patient with chronic limb ischaemia?
ABPI
Doppler USS
CT angiogram
ECG
What is the medical management of chronic limb ischaemia?
Lifestyle advice (smoking sensation, alcohol reduction, weight loss)
Supervised exercise programmes
Statin therapy
Anti-platelet therapy
Optimise diabetic control
What statin is given and at what dose for chronic limb ischaemia?
Atorvastatin 80mg OD
What anti-platelet is given for chronic limb ischaemia and at what dose?
Clopidogrel (75mg OD)
What is classed as critical limb ischaemia?
What ABPI?
Chronic limb ischaemia that has had Stage III ischaemic rest pain for 2 weeks or more
Has ischaemic lesions or gangrene
ABPI < 0.5
When do you do surgical management for chronic limb ischaemia?
If medical fails
Or
Advanced to critical limb ischaemia
What are the surgical managements of chronic limb ischaemia/critical limb ischaemia?
Angioplasty +/- stenting
Bypass grafting
Combo of both
Amputation (if not suitable for revasularistation or septic due to the gangrene)
What are the clinical features/presentations of critical limb ischaemia?
Cold limb
Hyperaemic limb (blood vessels dilated to try and compensate)
Hair loss
Skin changes (atrophic skin, ulceration or gangrene)
What is the management of critical limb ischaemia?
Urgent surgical referral
Treated within 5 days for inpatient
Stable patients within 2 weeks
What is the surgical management for a patient with critical limb ischaemia?
Angioplasty +/- stenting
Bypass grafting
Both
Amputation
What are some differentials for a patient with chronic limb ischaemia?
Spinal stenosis (neurogenic claudication)
Acute limb ischaemia
What is acute limb ischaemia?
Sudden decrease in limb perfusion due to arterial blockage that threatens the viability of the limb
What is the pathophysiology of acute limb ischaemia? (THE 3 CAUSES)
-Embolism occludes artery
-Thrombosis in situ (atherosclerotic plaque ruptures and clots in place)
-Trauma (compartment syndrome
What is the presentation/clincal features of acute limb ischaemia?
6Ps
Pulselessness
Perishingly cold
Pain (out of proportion)
Pallor
Paraesthesia
Paralysis (very advanced)
What investigations would be done for a patient with potential acute limb Ischaemia?
FBC
CRP
U+Es
Coagulation
G+S
Serum lactate
What methods of imaging are done for a patient with acute limb ischaemia?
US Doppler
CT angiogram
ECG
What is the management for acute limb ischaemia?
SURGICAL EMERGENCY
High flow oxygen
If surgery not an option can try IV heparin
What are the surgical approaches to acute limb ischaemia?
Embolectomy
Intra-arterial thrombolysis
Bypass
Angioplasty
Amputation or palliative if ischaemia is irreversible
What are the risk factors for developing acute limb ischaemia?
Anything that increases risk of embolisation/clot formation:
-AFib
-Previous MI
-previous surgery
-chronic limb ischaemia
-atherosclerosis
-heart failure
-smoking
-diabetes Mellitus
-trauma
-vasculitis
-hyper coagulability (oral contraceptives)
What is the long term management of acute limb ischaemia?
Lifestyle changes (regular exercise, weight loss, smoking cessation, alcohol reduction)
Anti-platelets (clopidogrel 75mg OD)
Occupational therapy and physiotherapist)
What are the complications of acute limb ischaemia?
Ischaemic reperfusion injury when repaired
AKI + hyperkalaemia
Compartment syndrome
What is ischaemic reperfusion injury?
When an area has been deprived of oxygen has its blood flow restored leading to lots of reactive oxygen species building up and causing further tissue damage
How can acute limb ischaemia cause an AKI?
Death of skeletal muscle leads to release of myoglobins which are renal toxic
How can acute limb ischaemia lead to arrhythmias?
Cell necrosis leads to mass release of potassium leading to hyperkalaemia
What is leriche syndrome?
Atherosclerosis or the aorta iliac bifurcation which can give cauda equina like symptoms:
-bilateral pain radiating down backs of legs
-erectile dysfunction
-saddle anaesthesia
-urinary or faecal incontinence
These gradually worsen as disease progresses
What is venous insufficiency?
Failure of the venous system to sufficiently/effectively return venous blood back to arterial circulation
What can cause venous insufficiency?
Valvular dysfunction
Venous hypertension
Venous obstruction (DVT)
What are the risk factors of developing deep venous insufficiency?
-old age
-female
-pregnancy
-smoking
-obesity
-previous DVT
-previous phlebitis
-strong family history of venous disease
-occupations which have a lot of standing
What are the clinical features/how do patients with venous insufficiency present?
Chronically SWOLLEN LOWER LIMBS
Aching
Pruritic
Painful
Venous claudication
Skin changes
What are the skin changes observed with venous insufficiency?
Varicose eczema
Thrombophlebitis
Lipodermatosclerosis
Haemosiderin staining
Atrophie Blanche
What investigations do you do for venous insufficiency?
Routine bloods to exclude other disease:
FBC
U+Es
CRP
ABPI
Why do you do an ABPI for a patient with a suspected venous insufficiency?
To see if they are eligible for compression stockings
What ABPI is compression stockings considered completely safe?
Over 0.8
Less than that cant have full compression
What is the conservative management of venous insufficiency?
Compression stockings
Foot elevation
What is the surgical management of venous
Only done in special patients
Deep venous stenting
What is the inverted champagne bottle sign?
The associated skin changes that can be seen with long term. Venous insufficiency (lipodermatosclerosis)
What are varicose veins?
Tortuous dilated segments of vein associated with valvular incompetence
This leads to venous hypertension and dilation
What are the complications of venous insufficiency?
Swelling
Recurrent cellulitis
Chronic pain
Varicose veins
DVT
Marjolin ulcer (rare cutaneous squamous cell carcinoma)
What are the risk factors for developing varicose veins?
Family history
Pregnancy
Obesity
Standing all day
How do varicose veins present?
Unsightly veins
Skin discolouration
Aching or itching
Skin changes
Thrombophlebitis
Ulceration
Bleeding
What imaging is done for varicose veins?
USS duplex
What is the conservative management for varicose veins?
Patient. Education
Weight loss
Exercise
Compression. Stockings
What is the surgical management for varicose veins?
Thermal ablation
Foam sclerotherapy
Vein ligation/stripping
When are patients referred for vascular surgery with varicose veins?
Symptomatic varicose veins
Lower limb skin changes
Superficial vein thrombosis
Venous leg ulceration
What are some different types of leg ulcers?
Venous ulcer
Arterial ulcer
Diabetic ulcer
Pressure ulcer
Infective ulcer
Marjolins ulcer
What is the most common type of ulcer?
Venous ulcer
What is an ulcer?
Abnormal break in skin or mucous membrane where healing by secondary intention occurs with granulation tissue at the base healing from the bottom up
How does an arterial ulcer appear?
Small
Deep
Well defined borders
Necrotic (black) base
What causes arterial ulcers?
Reduction in arterial blood flow leading to decreased perfusion of tissues.
How do arterial leg ulcers typically present?
Painful
Little to no healing
Features of peripheral arterial disease
Hx of intermittent claudication or critical limb ischaemia
What imaging/examination is done for arterial ulcers?
ABPI
USS duplex
CT angiogram
How are arterial ulcers managed conservatively?
Lifestyle changes like smoking cessation, exercise, weight loss etc.
How are arterial ulcers managed medically?
Risk factor modification:
Statins (atorvastatin)
Antiplatelets (clopidogrel)
How are arterial ulcers managed surgically?
Angioplasty +/- stent
Bypass grafting
What is the cause of venous ulcers?
Venous insufficiency
What is the appearance of a venous ulcer?
Shallow
Irregular borders
Granulated base
Often accompanied by infection (cellulitis)
Where are venous ulcers most common?
Medial malleolus
How do venous ulcers present?
Painful (worse at end of day)
Often around ankle
What imaging/examination done for venous ulcer?
ABPI
US duplex
What is the conservative management of venous ulcers?
Lifestyle changes (weight loss and exercise)
Leg elevation
What is the medical management of venous ulcers?
Compression bandaging
What is the surgical management of venous ulcers?
Endogenous ablation
Open stripping or avulsion
How do diabetic ulcers present?
Painless
Punched out look
Sites of pressure
what investigations do you want to do for diabetic ulcers?
Blood glucose HbA1c
ABPI
What are the managements for diabetic ulcers?
Lifestyle changes weight loss
Non weight bearing shoes
Optimise diabetic control
Debridement of necrotic tissue
Amputation
What is classed as an AAA?
Dilatation of the aorta over 3cm wide/more than 50% its original diameter
How are AAAs classified and what is the most common?
Position relative to the renal arteries
Infra-renal
What are risk factors for AAA?
Cardiovascular disease increasing risk of atherosclerosis (old, smoke, obese)
Male
Trauma
Connective tissue disorders (marfans, ehlers danlos syndrome)
Caucasian
What are some negative risk factors for AAA?
Female
Asian
Diabetic
How do AAAs present?
Usually incidental
Pulsation expansive abdominal mass
Ruptured:
-extreme back/abdo pain
-hypotension
-pulsation mass
What type of AAA rupture has the best survival rate and why, retroperitoneal rupture or intraperitoneal rupture?
Retroperitoneal rupture
It is a smaller cavity which helps tamponade the bleed helping buy time
What type of AAA rupture has the best survival rate and why, retroperitoneal rupture or intraperitoneal rupture?
Retroperitoneal rupture
It is a smaller cavity which helps tamponade the bleed helping buy time
What imaging should be done immediately if suspect AAA rupture?
CT Aortogrgam
What is the screening programme for AAAs?
3-4.4cm yearly US duplex aorta
4.5-5.4cm 3monthly US duplex aorta
What aorta diameter is surgical management offered?
Over 5.5cm
What AAA diameter requires notifying to the DVLA?
> 6cm
What are the 2 methods of AAA surgical repair?
Open repair
Endovascular repair
What are the advantages and disadvantages of open repair of AAA?
+ = better long term outcomes
- = much riskier operation and need overall healthier patient to do operation
What are the advantages and disadvantages of Endovascular repair of AAA?
+ = much less invasive operation, better for more unwell patients
- = worse long term outcomes compared to open repair
What is carotid artery disease caused by?
Atherosclerosis blocking the common or the internal carotid artery
Where does atherosclerosis of the carotid artery most commonly occur and why?
At the bifurcation of the internal and external carotid
Where tuburlent flow occurs
How does carotid artery disease present?
Usually asymptomatic
But can have neurological deficit due to embolisation of the atherosclerosis leading to a stroke or TIA
What is the difference between a stroke and a TIA?
TIA = symptoms resolve in less than 24hrs
Stroke = symptoms remain after 24hrs
What imaging is done for a patient with carotid artery disease?
Urgent CT head non contrast with patients who have neurological deficit
US duplex
ECG
(Do bloods as well for CVS risk)
What is the surgical management for carotid artery disease?
Carotid endartectomy
Do you surgically treat a patient who has a complete occlusion of one of their internal carotid arteries?
No since theres no chances an embolism can go past an cause an ischaemic stroke
The other internal carotid artery provides collateral supply
What is the non surgical management of carotid artery disease?
CVS risk factor modification:
-smoking cessation
-weight loss
-anti-platelet therapy (clopidogrel)
-statins
-exercise
What medications are given for the acute management of an ischaemic stroke?
IV alteplase with 4.5hrs of onset of symptoms and 300mg aspirin
What medications are given long term for managemtn of ischaemic stroke?
300mg aspirin OD for first 2 weeks: then 75mg OD clopidogrel + 75mg aspirin (dual antiplatelet therapy)
Atorvastatin 80mg OD
B-blocker (bisoprolol)
ACE inhibitor (ramipril)
What medication. Should be given while management for acute limb Ischaemia is being determined?
LMWH like enoxaparin
What is the reversal agent for low molecular weight heparins and unfractioned heparins?
Protamine sulphate
Complete reversal for Unfractioned
Partial for LMWH
What is a May Thurner lesion?
Left common iliac vein is compress by the right common iliac artery making a left sided DVT more likley
What is a psuedoaneurysm?
When blood accumulates between the tunica media and tunica externa
How does a pseudo-aneurysm differ from a true Aneurysm?
True aneurysm all 3 layers dilate evenly
Pesuodaneurysm loss of continuity between the layers leading to blood accumulating between the outer 2 layers
What is permissive hypotension?
When fluid resus is given in a ruptured AAA but is given to achieve a hypotensive state to reduce risk of further bleeding, further rupture of embolism formation)
Systolic < 100mmHG
What is a lung related complication of transfusion of blood when managing a ruptured AAA?
Transfusion Related Lung Injury causing Bilateral pulmonary oedema
How does a Transfusion Related Lung Injury present?
Bilateral pulmonary oedema
Dyspnoea
Hypoxaemia
How do you treat a Transfusion Related Lung injury?
Stop transfusion
Respiratory support
Supportive
Inform blood bank
How is a ruptured AAA managed?
2222 activate MHP
High flow 02
IV access (2 large bore cannulae)
Urgent bloods
G+S and Crossmatch 6 units of blood
Permissive hypotension if in shock
Emergency theatre
What are the 4 locations of a AAA?
Which is the most common?
Infra renal (most common)
Juxta renal
Para renal
Suprarenal
