Vascular Conditions Flashcards
What are varicose veins?
Dilated segments of veins associated with valve incompetence. The blood flow from the deep venous system flows to the superficial venous system resulting in venous hypertension and dilatation of the superficial venous system
Give 4 causes of varicose veins
Idiopathic (98%) DVT Pregnancy Uterine fibroids Ovarian masses Arteriovenous malformations
Give 3 risk factors for varicose veins
Prolonged standing
Obesity
Pregnancy
Family history
How do varicose veins present?
Often cosmetic complaint Pain Itching Swelling Skin changes (varicose eczema) Ulceration Thrombophlebitis Bleeding
What classification system is used in varicose veins?
CEAP classification
What is meant by C0 on the CEAP
chronic venous disorders classification score?
No visible or palpable signs of venous disease
What is meant by C1 on the CEAP chronic venous disorders classification score?
Telangiectasia or reticular veins
What is meant by C2 on the CEAP chronic venous disorders classification score?
Varicose veins
What is meant by C3 on the CEAP chronic venous disorders classification score?
Oedema
What is meant by C4a on the CEAP chronic venous disorders classification score?
Pigmentation or eczema
What is meant by C4b on the CEAP chronic venous disorders classification score?
Lipodermatosclerosis or atrophie blanche
What is meant by C5 on the CEAP chronic venous disorders classification score?
Healed ulcer
What is meant by C6 on the CEAP chronic venous disorders classification score?
Active venous ulcer
How is a varicose vein diagnosed?
Duplex ultrasound to assess valve competence and DVT risk
How are varicose veins managed conservatively?
Avoid prolonged standing Weight loss Exercise Compression stockings Bandage ulcers to compress leg
How are varicose veins managed surgically?
Vein ligation, stripping and avulsion
Foam sclerotherapy
Thermal ablation
Give 3 indications for surgery in varicose veins
Symptomatic primary or recurrent varicose veins
Lower limb skin changes
Superficial vein thrombosis
Venous leg ulcer
Give 3 post-op complications of varicose vein surgery
Haemorrhage Thrombophlebitis DVT Recurrence Nerve damage
What is acute limb ischaemia?
Acute limb ischaemia is the sudden decrease in limb perfusion which threatens the viability of the limb. It results from partial or complete occlusion of arterial blood supply to the limb
Give the 3 main causes of acute limb ischaemia
Thrombosis
Embolism
Trauma
What are the symptoms of acute limb ischaemia?
Pain Pallor Paraesthesia Pulselessness Perishingly cold Paralysis
How is acute limb ischaemia classified?
I = viable IIa = marginally threatened IIb = immediately threatened III = irreversible (major tissue loss, permanent nerve damage)
How is acute limb ischaemia initially managed?
High flow oxygen
IV access
Heparin infusion
How is acute limb ischaemia managed surgically?
Embolectomy Local intra-articular thrombolysis Bypass surgery Angioplasty Amputation of limb
Give 3 complications of acute limb ischaemia
Compartment syndrome
Hyperkalaemia
Acidosis
Rhabdomyolysis
What is an ulcer?
Break in the skin or mucous membrane
What is the most common type of ulcer?
Venous ulcer (80%)
What is the pathophysiology of a venous ulcer?
Retrograde flow of blood in the venous system causes venous dilation. Blood pools distally and oxygen delivery to the skin is impaired. Ulcers form over the path of the long and short saphenous veins.
What do venous ulcers look like?
Shallow
Irregular borders
Granulating base
Other signs of venous insufficiency present –> varicose veins, oedema, lipodermatosclerosis, atrophie blanche, telangiectasia
Give 3 risk factors for venous ulcer formation
DVT Varicose veins Trauma Pregnancy Obesity
How are venous ulcers managed?
Conservative –> leg elevation, increased exercise, emollients, antibiotics, 4-layer compression bandaging
Medical –> antibiotics, radiofrequency ablation
Surgical –> varicose vein surgery
What is the pathophysiology of an arterial ulcer?
Reduction in arterial blood flow leading to reduced perfusion of the tissues and poor wound healing.
What do arterial ulcers look like?
Small, deep lesions
Necrotic base
Found at pressure areas and sites of trauma
Give 3 risk factors for arterial ulcers
Smoking Type II diabetes Hypertension Hyperlipidaemia Old age Family history Obesity
What symptoms are associated with an arterial ulcer?
Intermittent claudication Critical limb ischaemia Pain Cold limbs Necrotic toes Hair loss
How is an arterial ulcer managed?
Conservative –> stop smoking, weight loss, increase exercise
Medical –> statins, aspirin, optimise blood pressure and blood glucose
Surgical –> angioplasty, bypass grafting, skin reconstruction
What is the pathophysiology of a neuropathic ulcer?
Peripheral neuropathy causes a loss of sensation in the feet which then leads to unnoticed injuries and repeated stress causing painless ulcers at the pressure points.
Give 2 risk factors of developing a neuropathic ulcer?
Concurrent vascular disease
Diabetes
B12 deficiency
What do neuropathic ulcers look like/present as?
Variable in size and depth Punched out appearance Warm feet Good pulses Tingling in feet
How is a neuropathic ulcer managed?
Diabetic foot team Control diabetes Reduce CV risk Antibiotics Amputation in severe cases
What is Charcot’s foot?
Commonly seen alongside neuropathic ulcers. Neuroarthropathy where a loss of joint sensation results in unnoticed trauma. The foot becomes deformed and the deformity predisposed to ulcers. Presents with pain, swelling, distortion and loss of function.
What is a DVT?
Blood in the deep veins of the legs or pelvis clots and forms a mass.
Give 5 risk factors for a DVT
Immobility Surgery Obesity Heart failure Trauma Infection Sepsis Pregnancy Diabetes Smoking Malignancy Thrombocytopenia
What criteria is used to predict DVT risk?
Wells criteria
What factors are included in the Well’s score?
All score 1 point:
Active cancer
Paralysis or immobilisation of lower limb
Bedridden for >3 days or major surgery <12 weeks
Localised tenderness along route of the deep veins
Swelling of the entire leg
Calf swelling at least 3cm larger than other leg
Pitting oedema in affected leg
Collateral superficial veins
Previously documented DVT
-2 points:
Alternative diagnosis at least as likely as DVT
Give 4 signs of a DVT
Swollen calf
Red, hot, tender leg
Prominent superficial veins
Oedematous feet
Give 4 signs of a PE
Pleuritic chest pain Tachycardia Tachypnoea Cough Haematemesis Venous eczema
Give 4 ways to prevent a DVT
Exercise TED stockings Pneumatic compression boots Heparin Warfarin Remove COCP
How is a DVT diagnosed?
D-dimer
Ultrasound
CT
How is a DVT treated?
Anticoagulation for 12 weeks (heparin)
Compression stockings
Thrombolysis
What is an abdominal aortic aneurysm?
Dilatation of the aortic aneurysm greater than 3cm
Give 4 risk factors for an AAA
Trauma Infection Connective tissue disease Inflammatory disease Smoking Hypertension Hyperlipidaemia Family history Male Elderly
How can an AAA present?
Most are asymptomatic
Abdominal pain, back or loin pain, limb ischaemia, syncope
Who is screened for AAA?
Men over the age of 65
Give 3 complications of AAA
Aortoduodenal fistula
Embolism
Retroperitoneal leak
AAA rupture
How is an AAA managed?
<5.5cm –> monitor via USS, smoking cessation, control blood pressure, statins, aspirin, weight loss
>5.5cm –> open repair (midline laparotomy), endovascular repair (use a graft and stent)
>6cm –> stop driving
What is the main surgical complication of endovascular treatment of an AAA?
Endovascular leaking: incomplete seal around the aneurysm results in blood leaking around the graft. Aneurysm can continue to grow and can rupture.
How would a patient present with a ruptured AAA?
Back pain, syncope, vomiting, hypotension, pulsatile abdominal mass
How is a ruptured AAA treated?
High flow oxygen, IV access, group and save, blood transfusion
If stable –> CT scan
If unstable –> straight to surgery for endovascular repair
What is ABPI?
Non-invasive method of assessing the extent of chronic arterial disease in the lower limbs. Ratio of the blood pressure in the brachial artery and the pressure in the dorsalis pedis and posterior tibial arteries.
In ABPI what does a value >1.2 mean?
Abnormally hard vessel
In ABPI what does a value <0.9 mean?
Arterial disease
What is gangrene?
Serious condition where loss of blood supply causes visible necrosis.
Give 3 risk factors for gangrene
Diabetes
Atherosclerosis
Peripheral artery disease
Raynauds
Give 5 symptoms of gangrene
Redness Swelling Loss of sensation Pain Blisters Cold and pale skin Fever Loss of appetite Tachycardia Dizziness Shivering
What is dry gangrene?
Blood flow to the extremity is blocked
What is wet gangrene?
Combination of injury and bacterial infection
What is gas gangrene?
Infection develops deep inside the body and bacteria release gas
How is gangrene treated?
Debridement surgery Amputation Treat infection (antibiotics) Bypass surgery Angioplasty
What is claudication?
Pain or discomfort on walking which is relieved at rest. It is caused by narrowed arterial supply to the legs due to atherosclerosis which leads to peripheral artery disease.
Give 4 risk factors for leg claudication
Smoking Diabetes >70 yrs old Male Hypertension Hypercholesterolaemia Afro-caribbean descent Heart disease
