Vascular Disease Flashcards
Phlebitis/Thrombophlebitis
- what is it
- RF
- Syx
- Mx
- Phlebitis = inflammation of a vein. Thrombophlebitis = inflamed vein caused by blood clot
- Commonly in the saphenous vein and its tributaries. May progress to DVT in 20% of cases.
RF: Varicose veins (most common RF), smoke, overweight, COCP/HRT, pregnant, recent injection or drip, thrombophilla, Ca
Syx
(1. ) Painful hard lump under skin
(2. ) Redness of skin
(3. ) Usually affects lower leg, can affect arms, penis, breast
Mx
Syx are self-limiting 1-2w although hardness of vein may persist longer
(1.) Topical NSAIDs or PO NSAIDs if more severe
(2. ) Self-care advice
- Warm towel to affected area
- Keeping active
- Elevating leg when sitting
(3. ) Compression stockings
- APBI should be measure prior to their use to exclude arterial insuffiency
Varicose veins
- what is it
- RF
- Syx
- IX
- Mx
- Incompetent valves in the perforator veins so blood flows from deep back into superficial veins and overloads them, leads to dilatation and engorgement.
- RF: inc age, FH, female, pregnancy, obesity, prolonged standing, DVT
Syx
- Engorged and dilated superficial leg veins.
- Heavy or dragging sensation in the legs
- Aching/ Itching/ Burning
- Muscle cramps
- Restless legs
- Chronic venous insufficiency (skin changes – varicose eczema, hyperpigmentation, hard tight skin, hypopigmentation).
Ix
(1. ) Tap test - thrill at SFJ (suggests incompetent valve)
(2. ) Cough test - ask pt to cough + thrill at SFJ
(3. ) Trendelengburg’s test + tourniquet
(4. ) Perthes test: tourniquet to thigh + ask pt to perform heal raise. If superficial veins disappear -> veins are functional. If increased dilation -> problem in deep veins.
(5. ) Duplex USS: assess extent of varicose veins
Mx
- Wt loss
- Active
- Keep legs elevated
- Compression stocking (PAD excluded via ABPI)
- If pregnant – syx usually resolves on their own after birth
- Surgery (Endothelial ablation/ Sclerotherapy/ stripping) if syx/complications
WHat is the difference between:
- Intermittent claudication
- Critical limb ischaemia
- Acute limb ischaemia
Intermittent claudication
- Syx occurs during exertion and relieved by rest.
- Crampy, achy pain in the calf, thigh or buttock muscles due to muscle fatigue
Critical limb ischaemia
- End-stage of PAD where there inadequate limb blood supply to allow it to function at rest.
- Pain at rest, non-healing ulcers and gangrene.
- There is a significant risk of losing the limb.
Acute limb ischaemia
- Rapid onset of ischaemia in a limb.
- Typically, due to thrombus blocking arterial supply of a distal limb, similar to a thrombus blocking a coronary artery in MI.
Presentation
- Intermittent claudication
- Acute limb ischaemia
- Critical limb ischaemia
Other signs of peripheral vascular disease
Intermittent claudication
- crampy pain occurs during exertion, improves at rest
- commonly affects calf but can affect thigh + buttock
Acute limb ischaemia (6Ps)
- Pain, Pallor, Pulseless, Paralysis, Paraesthesia, Perishing cold
Critical limb ischaemia
- Burning pain typically worse at night when leg is raised (as gravity no longer helps pull blood into foot) – pt may report of sleeping with leg hanging out
- Pain at rest, non-healing ulcers and gangrene.
- Syx of intermittent claudication
Signs
- Skin pallor
- Cyanosis
- Dependent rubor
- Muscle wasting
- Hair loss
- Ulcers
- Poor wound healing
- Gangrene
- Reduced skin temp
- Reduce sensation
- CRT >2s
Ix of peripheral vascular disease (4)
(1. ) Bueger’s Test
(a. ) Lie pt supine -> lift leg to 45 degrees at hip -> hold for 1-2mins -> look for pallor
- Pallor = PAD (not enough arterial supply to overcome gravity)
- Burger’s angle = the angle in which it does pallor
(b. ) Sit pt upright with legs hanging over bed -> watch blood flow back into legs
- Normal = pink colour
- PAD = blue -> dark red/rubor
(2. ) ABPI (<0.8 = PAD)
(3. ) Duplex USS - determines site, severity, length of stenosis
(4. ) Angiography (CT/MRI)
Mx of peripheral vascular disease
Intermittent claudication
(1. ) Lifestyle: manage modifiable RF, optimise comorbidities, supervised exercise
(2. ) Medical:
- Atorvorstain 80mg
- Clopidogrel 75mg (or aspirin)
- Naftidrofuryl oxalate (vasodilator)
(3. ) Surgery
Critical Limb Ischaemia
(1. ) Urgent vascular referral for revascularisation
- Endovascular angioplasty and stenting
- Endarterectomy
- Bypass surgery
- Amputation of the limb
Acute limb ischaemia
(1. ) Urgent referral to on-call vascular team for assessment
- Endovascular thrombolysis
- Endovascular thrombectomy
- Surgical thrombectomy
- Bypass surgery
- Amputation of the limb if it is not possible to restore the blood supply
Venous thrombosis/dvt
- presentation
- Ix
- Mx
Syx
- Unilateral
- Calf warmth/tenderness/ swelling/erythema
- Mild fever
- Pitting oedema
Ix
(1. ) Measure calf circumference
- Circumference measured at 10cm below tibial tuberosity
- >3cm difference between calves is significant
(2. ) Well’s Score - predict if DVT is likely
- If likely (i.e. >2) = leg USS
- If unlikely (i.e. <2) = Ddimer. If +ve ddimer proceed to USS
(3. ) D-dimer
- 95% sensitive but not specific for VTE. Useful for excluding VTE.
(4. ) Doppler USS
- Required to dx DVT
- If -ve USS but +ve ddimier -> must repeat USS in 6-8d
Mx
(1. ) Anticoag
- DOAC (1st line) for 3m (reversible cause present), 6m (unknown cause) 3-6m (Ca)
- LMWH if pregnant
- Warfarin if antiphospholipid syndrome
(2.) Catheter-directed thrombolysis - if proximal/iliofemoral DVT + syx for <14d
PE
- syx
- Ix
- Mx
Syx
- Sudden sob
- Pleuritic CP
- Haemoptysis
- Syncope/shock if big clot
- DVT
Signs
- tachypnoea, tachycardia and hypoxia
- right side heart strain may be present: JVP, cyanosis
Ix
(1. ) ECG:
- normal or sinus tachy
- right heart strain: p pulmonale, right axis deviation, RBBB
(2. ) Bloods: FBC, CRP, UE, clotting
(3. ) ABG: type 1 resp failure, resp alkalosis
(4. ) D-dimer - useful for r/o PE but not specific for PE
(5. ) CXR – useful for r/o pneumonia, pneumothorax
(6. ) ** CTPA (dx) **
- V/Q scan in renal impairment or pregnancy
(7. ) ECHO – if pt is thought to have massive PE + right heart strain
Well score
Risk stratifies patients with suspected PE
- If <4 = d-dimer, if high proceed to CTPA.
- If >4 = CTPA is required + LMWH administrated
Mx Acute mx: ABCDE - Oxygen - IV fluid if <90 systolic - Analgesia - Thrombolysis if haem unstable
Medical mx
(1. ) DOAC (1st line)
- LMWH alternative in pregnancy + cancer
- Provoked PE (identifiable rf) - 3m rx
- Unprovoked PE – 6m rx
(2. ) HASBLEd – to assess risk of bleeding
Aortic Dissection - what is it + classification + RF
(1. ) High mortality
(2. ) Tunica intima (innermost) tear so blood flows into intima-media space creating a false lumen.
(3. ) Three common sites for dissection: 2cm above aortic root, distal to left subclavian artery, aortic arch
(4. ) Where blood backs up into pericardial space it can lead to a cardiac tamponade
- Nearby arteries can also be compressed by the pressure within the false lumen, compression of following arteries could cause the following syx:
- Angina if coronary arteries involve
- paraplegia if spinal arteries
- limb ischemia if distal aortic involvement
- Neurological deficit due to carotid artery involvement.
Classification with The Stanford Model or DeBakey
- Type A = involves ascending aorta
- Type B = descending aorta
RF = 50-70y, HTN, smoking, CTD e.g. Marfan syndrome, FH, coarctation, bicuspid aortic valve, pregnancy, iatrogenic, cocaine use
Clinical features and signs of Aortic Dissection
“sudden severe tearing CP”
(1.) Can be painless (more common in marfan)
(2. ) Tearing CP radiating to back
- Sudden onset
- May radiate to groin
- Reaches max severity quickly
(3.) Syncope /LOC
O/e may find:
- Differences in BP between both arms
- Hypotension indicates poor prognosis
- Wide pulse pressure
- Cardiac tamponade
- Aortic regurgitation
- Neurological deficits
- Absent peripheral pulses
Aortic Dissection IX + MX
Ix
(1. ) Bloods: FBC, UE, LFT, clotting, Ddimer, troponin, VBG, G&S, crossmatch
(2. ) ECG
(3. ) CXR: widened mediastinum + left pleural effusion (leaking dissection)
(4. ) CT aortography - confirms dx*
(5. ) TTE - assess site and extent of dissection, evaluate aortic regurg or cardiac tamponade if present
Mx
- IV access
- Analgesia
- IV Bb (labetolol): manage BP + HR
- ITU/HDU
Type A
(1.) Emergency surgery (stent or graft to aorta) via vascular surgeons
Type B
(1. ) Optimise medical treatment: Bb
(2. ) Urgent surgery (TEVAR may be used) if:
- Intractable pain
- rupture or evidence of impending rupture
- end organ damage or limb ischaemia
- rapid progression
- marfan’s syndrome
AAA - what is it, who is screening offered to, RF
- Dilation of aorta by >1.5x normal size. Normal diameter is 2cm.
- Majority are abdominal however can be thoracic, iliac artery, popliteal etc.
- UK screening programme enrols men at age 65y.
- RF: atherosclerosis, FH, smoking, male, age, HTN, hyperlipidaemia, CTD.
AAA - clinical features, Ix
Syx
(1.) Asyx
(2. ) Thoracic AA
- CP
- If bleeding into pericardium can cause cardiac tamponade + fatal
(3. ) Abdominal AA
- Pain in back, abdo, flank or groin
- Hypotension
- O/e: pulsatile abdo mass + bruit
(4. ) Ruptured AAA
- Sudden severe pain in abdo, back or loin
- Syncope, LOC, shock or collapse
Ix
(1. ) Bloods: FBC, G&S, crossmatch, UE, LFT, clotting
(2. ) ECG
(3. ) Imaging
- CXR/AXR
- USS - initial assessment
- CT - more anatomical detail shown
Mx of AAA + ruptured AAA
(1. ) USS Monitor for <5.5cm
- 3-4.4cm: annual
- 4.5-5.4cm: 3m
- refer to vascular services if >5.5cm (within 2w), 3-5.5cm (within 12w)
(2. ) Surgical repair (open/ endovascular repair) for unruptured AA indicated in:
- Symptomatic
- Asyx + >4cm + grown >1cm/year
- Asyx + >5.5cm
(3.) Manage RF: smoking, BP, statins
Management of rupture AAA
(1. ) IV access
(2. ) G&S + crossmatch
(3. ) Restrictive volume resuscitation
(4. ) Surgery: stent graft therapy
- refer to vascular for emergency assessment, ensure they leave within 30 minutes of the decision to transfer
(5. ) CT angiography
Acute rheumatic fever
- what is it
- presentation
- Ix
- Dx
- Mx
- AI condition triggered by strep- it is caused by antibodies raised against streptococcus.
- Multi-system disorder that affects the joints, heart, skin and nervous system
Syx
Occurs 2-4 weeks following a strept infection, such as tonsillitis
- Fever, Sob, Rash, Joint pain
- Heart syx: pericarditis, myocarditis, endocarditis, tacy or bradycardia, mitral stenosis, HF
- Skin syx: Subcutaneous nodules (firm painless nodules on extensors), erythema marginatum rash (pink rings affecting torso and limbs).
- Nervous system syx: chorea (irregular, uncontrolled rapid movements)
Ix
- Bloods: ESR, CRP
- Throat swab for bacterial culture
- ASO antibody titres (ab against strep can support dx)
- ECHO
- ECG
- CXR
Dx: Jones Criteria
Mx
(1. ) Refer for specialist mx
(2. ) Mx involves:
- Eradicate strep infection if still present
- NSAID for joint pain
- Aspirin and steroids for carditis
- Prophylactic Abx (PO or IM benzylpenicillin)
- Mx complications: mitral stenosis, HF
