Vascular Core Conditions Flashcards
What is temporal arteritis?
A Granulomatous vasculitis of large & medium sized arteries
Affects branches of the external carotid artery
Most common form of systemic vasculitis in adults
What are the causes of temporal arteritis?
Genetics
Environmental triggers
What are the RFs for temporal arteritis?
>50 Female Genetic predisposition Smoking Atherosclerosis
What are the investigations for temporal arteritis?
Bloods: ESR >50mm/hour CRP: Elevated FBC: Elevated Temporal artery biopsy Temporal artery USS
How is temporal arteritis managed?
No visual signs: Prednisolone 1mg/kg/day orally 4weeks taper dose over 6-12months
Visual signs: Methylprednisolone 1g IV/day for 3days with IV pulse therapy
Ongoing: Aspirin 75mg/daily, Prednisolone 1mg/kg/day orally for 4weeks taper over 6-12months
Where are most DVTs found?
Lower limb:
Anterior tibial vein
Posterior tibial vein
Peroneal vein
What is the pathophysiology of a DVT?
Virchow’s Triad:
Hypercoagulable state
Vascular wall injury
Circulatory stasis
What are the signs & symptoms of a DVT?
Pain Swelling/oedema Homans sign (pain in calf on dorsiflexion of foot) Warmth & erythema Local tenderness Signs of PE
How is a DVT investigated?
D-Dimer
Well’s Score
Duplex USS: Within 4hours of request (if not give 24hr dose of anticoagulant)
Pregnant/post-partum: Imaging NOT a D-Dimer
Contrast Venography
Why is a D-dimer test not a great test?
High sensitivity
Low Specificity
May be raised in: Cancer, Infection, Post-op, Following trauma or haemorrhage
What are the outcomes of the Well’s Score?
DVT unlikely: With -ve D-Dimer can discharge, +ve D-Dimer = imaging
DVT likely: Further imaging required
What is the treatment for a DVT?
Anticoagulation: Rivaroxaban
Cancer patients: LMWH
Define acute ischaemic limb?
Any sudden decrease in limb perfusion causing potential threat to limb viability
Symptoms <2 weeks
What are the causes of acute limb ischaemia?
Peripheral arterial disease VTE Vasculitis Popliteal entrapment syndrome Compartment syndrome Graft Occlusion
What is the prognosis of acute limb ischaemia?
Limb salvage 70-90%
Amputations usually from thrombotic occlusions
Where is the most common place for emboli in acute limb ischaemia to arise from?
80% from the heart
Composed of platelets
Other: Proximal arterial disease (aneurysm or stenoses)- poorer prognosis as harder to treat
What are the signs & symptoms of acute limb threatening ischaemia?
Pain: At rest worse in most distal part of the limb, relieved on hanging leg over bed side, claudication, pain worse on passive muscle movement (compartment syndrome)
Pallor: White colour, chronic critical ischaemic limb= pink (due to compensatory vasoD), sunset foot
Paraesthesia: 50% of cases, seen before motor nerves affected
Paralysis: Poor prognostic sign element of irreversibility
Perishingly cold
Pulselessness: Unreliable
Fixed mottled skin: Irreversible ischaemia
What bedside examination is useful to check for limb ischaemia?
Buergers test: Pallor on elevation of limb & erythema on lowering
What investigations should be done in acute limb ischaemia?
Arterial Doppler signals
Heart auscultation: Check for arrhythmias
Abdo assessment: AAA
Affected leg: Inspect, palpate, auscultate
ABPI: Assess severity
Bloods: FBC, U&E, Glucose, Creatinine kinase, Clotting, G&S
ABG
Imaging: MR/CT angiography
How is ABPI calculated?
Pedal Systolic pressure / Brachial artery pressure
What do the ABPI scores mean?
Normal: 1-1.2
Claudication: 0.6-0.8
Critical ischaemia: 0.2-0.4
How is acute limb ischaemia managed generally?
IV morphine Oxygen 5000u IV unfractionated Heparin IV fluids Refer: Vascular specialist
What is the definitive management for acute limb ischaemia?
Cat I: VIABLE LIMB, analgesia, oxygen, heparin, imaging within normal working hours, plan treatment
Cat IIa: THREATENED LIMB, oxygen, analgesia, heparin, immediate imaging,
Cat IIb: THREATENED LIMB & CANNOT WAIT OVERNIGHT, oxygen, analgesia, heparin, if possible imaging before theatre, DO NOT delay intervention, urgent revascularisation (op or thrombolysis)
Cat III: IRREVERSIBLE ISCHAEMIA LIMB NOT SALVAGEABLE, DO NOT attempt revascularisation, Tx (amputation, palliation)
Thrombolysis: Alternative to surgery, Streptokinase
Why should revascularisation not be attempted in catIII limb ischaemia?
Likely to kill patient
Massive release of potassium, creatine kinase, myoglobin, lactate, oxygen free radicals from ischaemic tissue
Can cause renal failure, myocardial toxicity, multi-organ failure
What are the contra-indications to thrombolysis?
Bleeding/ s. bleeding tendency Pregnancy CVA/TIA <2months ago Intracerebral tumour/AVM/aneurysm Surgery <2weks Previous GI bleed Trauma <10days
Where do most AAA occur?
90% below renal arteries
What are the causes of AAA?
Multifactorial
Altered tissue metalloproteinases
Atherosclerosis
What are the signs & symptoms of a AAA?
Asymptomatic
Abdo/back pain
Pulsatile, expansile mass
Trash feet: Dusky discolouration of digits secondary to emboli from aortic thrombus
RUPTURE: Severe sudden pain radiating to the back, death, hypoT, tachycardia, profound anaemia, signs of shock
What are the investigations for a AAA?
Clinical: pt >50 w/acute onset abdo/back pain AND hypoT
pt with known AAA either abdo/back pain OR hypoT/collapse
USS: x1.5 normal size
CT/MRI: Relation to other structures
ECG
Bloods/ABG: U&E, Creatinine, amylase, troponin, ESR, CRP, FBC
Aortography
How is a ruptured AAA managed?
>75% mortality before reaching hospital 14G IV access & fluids Blood products Intubation Central Venous Line Theatre: EVAR repair
How is a non-ruptured AAA managed?
>5.5cm treated Open laparotomy Prosthetic segment Theatre: EVAR Pre-op: Beta blocker (Metoprolol, Atenolol), statin, smoking cessation
What is the massive haemorrhage protocol?
- Administer Tranexamic Acid within 1 hour
- RESUS: Cardiac monitoring, prevent hypothermia, consider 10mls CaCl 10% over 10mins, cryoprecipitate x2
- Call for help: Take bloods & send to lab, order massive haemorrhage pack1 (4u FFP & 4u Red cells), reassess, order massive haemorrhage pack2 (4u red cells, 4u FFP, 1dose platelets)
- Stop the bleed: Direct pressure, stabilise#, surgery, Vit K & prothrombin, reversal of NOAC, cell salvage if available
What is the management of peripheral arterial disease?
Atorvastatin 80mg
Clopidogrel
Exercise
Severe PAD: Angioplasty, stenting, bypass surgery
What 3 patterns are seen in PAD?
Intermittent claudication
Critical limb ischaemia
Acute limb-threatening ischaemia
