Vascular core conditions Flashcards
What causes critical limb ischaemia? 6
Obstructive atherosclerotic arterial disease
rarely: Vasculitis thromboangitis obliterans cystic adventitial disease popliteal entrapment trauma
What causes acute limb ischaemia? 9
Thrombosis at the site of an atherosclerotic stenosis
Cardiac embolisation aortic dissection aortic embolisation graft thrombosis thrombosis of a popliteal aneurysm trauma hypercoaguable state air, fat or amniotic fluid embolism
What are the risk factors for PAD?
smoking
DM
HTN
dyslipidaemia
What are the signs of acute limb ischaemia? And how long is the onset? 6
6Ps: pain pallor pulseless paraethesia paralysis perishingly cold
Minutes, hours, days
What are the signs of limb ischaemia due to an embolus?5
Onset: seconds to minutes
ischaemia is usually profound
Skin changes to the feet: fine reticular blanching or mottling in early stages, progressing to coarse fixed mottling
History of claudication
Pulses are usually present in the other leg
How to you calculate an ABPI? and what do the scores mean?
Highest ankle BP of that leg/ highest BP of both the arms
Normal= 1
claudiation= 0.6-0.9 (0.8 refer to specialist)
Rest pain= 0.3-0.6
Impending gangrene= 0.3 or less
Aside from ABPI what other investigations can be done in PAD? 4
Duplex ultrasonography- to determine site, severity and length of occluison
MR angiography- may be offered prior to revascularisation
Digital subtraction arteriography- used in endovascular management and surgical planning
Full CV risk assessment
What medications should be considered in PAD to reduce CV risk factors?
Treat HTN
Statins- reduce risk of CV events and stroke
ACEis can reduce CV morbidity in patients with PAD
What drugs should be given for symptomatic PAD?
Antiplatelets
aspirin
clopidogrel
aspirin + dipyridamole
generally pick clopidogrel, as although it’s less effective than aspirin it has fewer SE
What drugs can you give for people with intermittent claudication?
Peripheral vasodilators:
Naftidrifuryl oxalate
What are the surgical options for PAD?
Percutaneous catheter-directed thrombolytic therapy
surgical embolectomy
endovascular revascularisation- if limb is viable
revascularisation-if the limb is marginally or immediately threatened
amputation
What are the complications of PAD?
ulceration and gangrene
Multiorgan dysfunction- e.g. AKI or acute lung injury
^ due to release of inflammatory markers and activation of complement cascade in response to ischaemia or reperfusion syndrome
What is an aneurysm?
An irreversible dilatation of a blood vessel by at least 50% of the normal diameter
affects all 3 layers of the arterial wall
What causes a pseudo-aneurysm?
Blood leaking through the wall, but it is contained by the adventitia or surrounding pervivascular tissue
What is the normal diameter of the AA?
~2cm- it increases with age
What is the diameter of an AAA?
> 3cm
Where do most AAA arise?
below the level of the renal arteries
Are AAA more common in F or M?
M
Is the risk of rupture of an AAA more common in F or M?
F
What causes an aneurysm? 4 (pathophysiology)
degradation of the elastic lamellae
leukocytic infiltrate
enhanced proteolysis
smooth muscle cell loss
What are the risk factors for the majority of AAAs? 7
Severe atherosclerosis FH smoking age HTN COPD hyperlipidaemia
What are the less common risk factors for AAAs? 9
Trauma
Infection- brucellosis, salmonellosis, TB, HIV
Inflammatory disease- Behcet’s disease, Takayasu’s disease
Connective tissue disorders- Marfan’s, Ehler’s Danlos syndrome type IV
What are the signs and symptoms of an unruptured AAA? 4
Normally incidental finding- asymptomatic
Pain in back, abdomen or groin- due to pressure on nearby structures
Pulsatile abdominal swelling
May cause distal embolisation–> features of limb ischaemia
Uretrohydronephrosis- dilatation of ureter and pelvis of kidney due to obstruction
What is the sign that indicates impending AAA rupture?
Severe lumbar pain of recent onset
What are the features of a ruptured AAA? 8
Should be considered in any Px with hypotension and abnormal abdominal signs
pain in abdomen, back or loin- may be sudden and severe
Syncope
shock
collapse
Grey Turner’s sign- retroperitoneal bleeding
Pulsatile mass
AA bruit
What tests may be done in suspected AAA? 12
FBC clotting screen renal function test LFTs cross-matching if surgery is planned ESR and CRP ECG CXR lung function tests USS- used in initial assessment CT MRI angiography
What would a CT scan show in AAA? 4
visceral arterias
mural thrombus
the crescent sign= blood within the thrombus, may predict imminent rupture
para-aortic inflammation
What are the differential diagnoses for AAA?
acute gastritis appendicitis diverticulitis cholelithiasis (gallstones) Large/ small bowel obstruction MI peptic ulcer disease
What level of monitoring should be done for different sized AAA?
3-4.4cm- annual ultrasound
4.5-5.4- 3 monthly USS
>5,5cm- surgery
What are the indications for surgery in AAA? 4
> 5.5cm
rupture
rapid expansion
onset of sinister symptoms e.g. back pain, abdominal pain or tenderness
What are the surgical options for AAA?
Surgical open repair- replace aneurysmal section with prosthetic graft
Endovascular repair of AAA= EVAR
- stent passed through femoral artery
What are the pathophysiological causes of varicose veins?
Incompetent valves –> reflux of blood and increased pressure in the vein distally
What are the risk factors for varicose veins? 6
F>M pregnancy age FH Overweight leg trauma
Why does pregnancy cause varicose veins?
There is an increase of blood volume –> strain on venous system
Hormones–> relaxation of muscular walls of vessles
Enlarging uterus–> pressure on the pelvic veins and IVC
What are the signs and symptoms of varicose veins? 5
Mostly cosmetic aching legs itching over veins swollen feet and ankles discomfort after prolonged standing
What can ease the symptoms of varicose veins?
Leg elevation
compression stockings?
What are the skin complications of varicose veins? 3
Areas of pigmentation
Venous eczema
Lipodermatosclerosis=
hardened, tight red or brown skin
which if it’s wrapped around the ankle may eventually –> champaign bottle leg
Where are venous ulcers due to varicose veins most commonly seen?
In the ankle (gaiter) area
What is thrombophlebitis?
tender, inflamed varicose veins
with overlying redness and heat
which feel firm due to thrombus within the vein
tend to present acutely
What investigations can be done in varicose veins? 2
Duplex ultrasound
Triplex ultrasonography- colour flow imaging:
further refinement of the above
can sow minor valve leakages and incompetence in small perforator veins
What are the differential diagnoses for varicose veins? 4
Cellulitis
Osler-weber-rendu sydnrome
superficial phlebitis
DVT
How do you manage varicose veins?
Lose weight moderate exercise elevate legs when possible avoid standing or sitting for too long compression stockings
When should people with varicose veins seek further medical help? 4
If veins are hard or painful
There are skin changes
A break in the skin that lasts longer than 2 weeks
There is bleeding from the varicose veins
When do you refer varicose veins to a vascular service?
They are symptomatic- pain, aching, itchy etc
There are skin changes
There is superficial vein thrombosis and suspected venous incompetence
Venous leg ulcer- that hasn’t healed within 2 week, refer within 2 weeks
A healed venous leg ulcer
What are the surgical options for varicose veins?
stripping- surgical removal
ligation- tying off the vein
Foam sclerotherapy
Endothermal methods- radio frequency and laser ablation
What are the complications of varicose veins?4
bleeding- rarely occurs, due to trauma of the veins
Thrombophlebitis
DVT
skin damage
Where do the clots causing femoral embolisms usually come from?
the heart
What are the risk factors for femoral embolism?
Age
heart disease
What are the signs and symptoms of a femoral embolism?
6Ps pain pulseless paralysis parasaethesia Pershingly cold pallor
What investigations should be done for a suspected femoral embolism?
Doppler USS
arteriography= contrast fluid + X-ray- shows location and extent of blockage
Examination of heart- to find source of embolus
ECG
echocardiogram
CXR
How do you manage a femoral embolism?
Surgery within 12 hours
If there is numbness of paralysis do it within 4-6hours
anticoagulants
