Vascular Disease Flashcards
What are venous ulcers and what causes them?
Venous ulcers arise from chronic venous insufficiency and occur after minor injury due to a pro-inflammatory environment.
Where do venous ulcers typically appear?
They appear on the gaiter area and medial malleolus. There is pruiritis, aching pain in gaiter area, night cramps and evening pedal oedema.
What are some associated features of venous ulcers?
- Hyperpigmentation
- Venous eczema
- Lipodermatosclerosis
- Telangiectasia
What are the characteristics of venous ulcers?
- Large
- More superficial
- Irregular border
- Likely to bleed
- Fibrinoid material on the base of the ulcer
What alleviates the symptoms of venous ulcers?
Elevating the leg promotes venous return.
What are non-modifiable risk factors for venous ulcers?
- Female sex
- Older age
- Family history of chronic venous insufficiency
- Previous thrombosis
- Musculoskeletal and joint disease
What symptoms are associated with venous ulcers?
- Pruritus
- Aching pain in gaiter area
- Night cramps
- Evening pedal edema
What investigations are included for venous ulcers?
- ABPI (Ankle-Brachial Pressure Index)
- CT angiogram
- MRI for deeper vessels
- Swab of wound site
What is the management of venous ulcers?
compression, manual lymphatic drainage, intermittent pneumatic compression to prevent DVT, debridement with larva and application of dressings
What are the absolute contraindications for compression therapy?
- Arterial occlusive disease
- ABPI less than 0.5
- Serious uncontrolled high blood pressure
- Heart failure
- Suspected or documented thrombosis
- Extensive thrombophlebitis
- Erysipelas
What are the complications of venous ulcers?
- Infection
- Pain
What characterizes diabetic foot ulcers?
They arise from peripheral neuropathy and microvascular disease, reducing wound healing and increasing the risk of osteomyelitis.
Where do diabetic foot ulcers typically occur?
On heels or metatarsal heads.
What is the appearance of diabetic foot ulcers?
They have a punched-out appearance. It should be managed with antibiotics like flucoxacillin first line but managing diabetes is key and cardiovascular risk factors.
What is Charcot’s foot and what causes it?
A destructive joint disorder of bone and joint fragmentation, often due to diabetic neuropathy. There are features with chondorcysts, Subchondral cysts, sclerotic bone and cartilage thinning that appears similar to osteoarthritis
What are the clinical features of Charcot’s foot?
- Swelling
- Distortion of joint
- Loss of function
- Erythematous
- Hot foot with edema
What is the management for Charcot’s foot?
- Non-weight bearing
- Inhibiting osteoclastic activity with bisphosphonates and calcitonin supplements
What causes pressure ulcers?
They occur over bony prominences due to reduced mobility, leading to localized skin breakdown from reduced blood supply, reduced lymphatic drain in age and deformation of tissue under pressure
What is compartment syndrome?
Increased pressure from fluid or restriction in osteofascial compartments, which is a surgical emergency. Reduced venous outflow decreases tissue oxygenation. Intracompartmental pressure greater than 30mmHg indicates ACS.
What is the most common location for compartment syndrome?
Anterior compartment of the leg containing extensor muscles, deep fibular nerve, tibialis anterior and tibial artery. Most common cause is tibial fracture and soft tissue injury, burns, drug overdoses and tight bandages.
What are the signs of compartment syndrome?
- Disproportionate pain
- Burning sensation
- Paraesthesia
- Deep muscular pain
What is the management for compartment syndrome?
Keep limb at heart level and relieve pressure within 6 hours of injury.
What is gangrene and what causes it?
Gangrene is caused by atherosclerosis and progressive occlusion of peripheral arterial disease. There is increased blood demand in trauma or infection which may precipitate this.
What are the types of gangrene?
- Ischaemic limb gangrene (dry gangrene)
- Venous limb gangrene
- Symmetric peripheral gangrene
- Wet gangrene
- Gas gangrene
What is the cause of wet gangrene?
from infection of sites of poor venous or arterial flow, which diabetic patients are more susceptible to. Wet gangrene should be suspected if there is associated drainage and edema in the setting of a patient with a previous foot ulcer or tissue injury secondary to diabetes.
What is the management for wet gangrene?
Surgical drainage, debridement, antibiotic therapy, and dressing to retain moisture.
What is gas gangrene?
Gas gangrene from clostridium perfingens infection, causing rapid tissue necrosis due to producing exotoxins or compartment syndrome . Typically after trauma, with traffic accidents and crush injuries with introduction of anaerobic bacteria.
How does gas gangrene present?
pain, edema, the development of hemorrhagic bullae, and color changes ranging from a pale coloration to a bronze-purplish red coloration. Urgent surgical debridement is necessary
What is the reccomended treatment for dry gangrene?
penicillin with clindamycin for 10to 14 days
What is ischaemic gangrene?
dry gangrene.
arteriole dilation as compensation, resulting in distal edema and endothelial damage. This can trigger a cycle of micro thrombosis resulting in worsening tissue damage.
How is ischaemic gangrene treated?
Restoring blood flow, but tissue may never completely recover. Medical treatment includes antiplatelet therapy, managing hypertension with ACE and beta blockers, and controlling diabetes.
What are the surgical treatments for ischaemic gangrene?
- Catheter-based intravascular thrombolysis
- Balloon angioplasty
- Bypass graft
What is venous limb gangrene?
Venous limb gangrene is where a microthrombosis occurs in the same limb as acute large vein thrombosis, especially in hypercoagulabel state.the leg will be swollen and superficial veins may be full. Oedema can make it difficult to palpate pedal pulses, but Doppler examination will appear Normal
How is venous gangrene managed?
Management includes elevation, heparinisation, thrombolysis, and treatment of the underlying cause (usually pelvic or abdominal
When is amputation indicated?
significant necrosis and sepsis or paresis, which is often above ankle. Treatment can include hyperbaric oxygen therapy
What is peripheral vascular disease (PAD)?
Atherosclerotic plaques build up in the arteries of the abdominal aorta, iliac arteries, and lower limbs. Once the arteries cannot compensate with vasodilation, this result in intermittent claudication, where there is pain on walking due to ischaemia during exertion.
What are the risk factors for PAD?
- Diabetes
- Smoking
- Obesity
- High cholesterol
- Age over 50
- Family history of PAD
- Heart disease or stroke
- High levels of homocysteine
What is the cause of PAD
Sudden ischaemia is from embolism fo cardiac orgiin or atherosclerotic disease of aorta. They arise from sites of bifurcation, with femoral artery being the most common, followed by iliac arteries, aorta and popliteal artery. Collateral vessels compensate to maintain distal perfusion, however there will be an imitation to perfusion compared to main artery.
What are the symptoms of PAD?
- Pain during walking (intermittent claudication)
- Erectile dysfunction
- Ischaemic pain at rest
What is claudication?
intermittent pain on walking from muscle pain due to lack of oxygen. Severity should be assessed by questioning how long the patient can walk before resting. Lifestyle management includes weight loss and improving diet to reduce cardiovascular risk factors.
What is the management of claudication?
supervised exercise a week for 3 months to encourage exercising to point of maximal pain. Unsupervised exercise I should be 30 minutes 3-5x a week and walking until onset of symptoms with rest to recover.
What is the pharmacological management of claudication?
Naftidrofuryl oxolate is only given when there is no improvement with exercise. It invovles nitrate acting on smooth muscle for vasodilation
What is the surgical management of claudication?
Angioplasty: using balloon to open blocked arteries and placing stent after
Bypass graft: using healthy blood vessel to direct blood flow away from diseased artery
What is a risk with PAD?
There is a risk of critical end limb ischaemia where gangrenous necrosis occurs, pain at rest and non-healing ulcers.
What are the features of critical limb threatening ischaemia?
Critical limb threatening ischaemia will have ABPI less than 0.5m ischaemic rest pain longer than 2 weeks requiring opiate analgesia and presence of ischaemic lesions or gangrene due to arterial occlusive disease. Patients will have limb hair loss, thickened nails, atrophy of skin and 6Ps.
What investigations are done for PAD?
- Assessing pulses
- Serum lactate
- ECG For arrythmia
- Doppler ultrasound to locate blood flow occlusion and determine flow velocities
- CT angiogram
- ABPI
*Buerger’s test
What is ABPI?
Ankle-brachial index to measure lower extremity arterial perfusion, comparing systolic BP in ankle from dorsalis pedis or Posterior tibial artery to brachial artery in arm. It is highest systolic pressure of each ankle divided by higher of two systolic brachial pressure. Normal ABI is between 0.9 to 1.3.
What does an ABPI value of less than 0.9 indicate?
It indicates peripheral arterial disease (PAD) with claudication between 0.5 and 0.9.
What does ABPI greater than 1.3 indicates?
arterial wall stiffening which can occur in patients with diabetes or renal failure.
dibaetes can cause falsely normal or high ABPI due to arterial calcification.
How to increase ABPI accuracy?
having the patient rest supine for at least 5 minutes to allow their blood pressure to stabilize and choosing an appropriately sized blood pressure cuff
What is the Dopppler ultrasound?
Doppler ultrasound ensures blood through through ultrasound waves.
Duplex ultrasound uses the Doppler probe and the B-mode transducer creates an image of the vessel
What is Buerger’s test used for?
To assess for severe ischaemia by observing the angle at which the limb goes pale. lying the patient supine and raising their legs until they go pale and then lowering them until the colour returns (or even becoming hyperaemic). Theangle at which the limb goes paleis termedBuerger’s angle.
Which Buerger’s angle indicates severe ischaemia?
less than 20 degrees
What is the management of PAD?
Pain relief for critical limb ischaemic pain with paracetomol and weak opioids
Balloon angioplasty and stent placement
What is the surgical management of PAD?
bypass graft to divert flow around blockage
endarterectomy to remove the obstructive plaque
Angioplasty to widen the vessel with stent caused by COMPLETE aorto-iliac occlusion. Avoid with aorto-iliac disease or femoral-popliteal disease.
What lifestyle changes can help manage PAD?
- Quitting smoking
- Lowering cholesterol
- Controlling hypertension and diabetes
What is naftidrofuryl oxalate used for?
Serotonin 5-HT2 antagonist which is a peripheral vasodilator for intermittent claudication.
What is secondary prevention of PAD?
Rivaroxaban with aspirin to prevent future atherothrombotic events
When is amputation indicated?
Amputation is indicated if there is significant necrosis, sepsis, paresis and refractory pain with above ankle amputation for extensive foot necrosis
What are the first-line antibiotics for leg ulcers?
- Flucloxacillin
- Erythromycin (alternative in pregnancy)
- Doxycycline
- Clarithromycin
What are the investigations for leg ulcers?
Ankle-brachial pressure index
FBC for CRP,
-> HbA1c
MCV for anaemia
Albumin
Palpation for abdominal aorta
Duplex ultrasound
Skin biopsy
How are venous ulcers managed?
strongest compression stockings they can tolerate, and manage oedema elevation of leg at night (avoid diuretic for persistent/worsening oedema.) stockings should be replaced every 3-6 months, once ABPI excludes arterial disease
Antibiotics like flucoxacillin
How should ulcerated legs be managed by patients?
Ulcerated leg can be washed normally with clean technique (tap water) and advise to take analgesia at least 30 minutes before dressing changes There should be a review of the ulcer and assessment of oedema and venous eczema and infection
Which type of ulcer is surgical debridement offered?
venous and pressure ulcers
What is the treatment of pressure ulcers?
Pressure ulcers may receive reconstructive surgery which is filling the wound with new tissue.
Debridement
What is the treatment of arterial ulcers?
Arterial ulcers require analgesia and can be managed with debridement , antibiotics and dressings
Surgical revascularisation wit urgent referral to vascular team, which requires vascular surgery interference.
Statin therapy
Antiplatelet therapy like aspirin or clopidogrel
Extensive disease, treated with angioplasty or bypass grafting
What is the principles of testing for leg ulcers?
Do not take sample for testing at initial presentation, even if ulcer may be infected.
Antibiotic should only be offered with symptoms/signs of infection such as pus
What is the first line antibiotic for leg ulcers?
flucoxacillin 4x a day
What is the second line for leg ulcers?
co-amoxiclav or co-trimazole
What is the first line IV antibotic for leg ulcers?
flucluxacillin and/or gentamicin and/or metronidazole
What is acute limb ischaemia?
Acute limb ischaemia is the sudden decrease in limb perfusion, due to partial/complete occlusion of arterial supply. It typically occurs due to:
Embolisation
Thrombus from atheroma plaque ruptures
Trauma due to compartment syndrome
What is the precipitation of acute limb ischaemia?
It can be precipitated by trauma, dehydration, hypotension, prolong sitting, thrmobphilia, malignancy or hypervisciosity.
What is the aetiology of acute limb ischaemia?
Aetiology of acute limb ischaemia includes recent myocardial infarction causing mural thrombus, atrial fibrillation, abdominal aortic aneurysm, chronic limb ischaemia and peripheral aneurysm.
What is the treatment for acute limb ischaemia?
Immediate hospital referral and treatment based on the underlying cause.
What are the 6 Ps of acute limb ischaemia?
- Pain
- Pallor
- Pulseness
- Paraesthesia
- Paralysis
- Perishingly cold
What is the typical cause of acute limb ischaemia?
Embolization, thrombus from atheroma plaque ruptures, or trauma.
What conditions can lead to acute limb ischaemia?
- Recent myocardial infarction
- Atrial fibrillation
- Abdominal aortic aneurysm
- Chronic limb ischaemia
- Peripheral aneurysm
What can precipitate acute limb ischaemia?
- Trauma
- Dehydration
- Hypotension
- Prolonged sitting
- Thrombophilia
- Malignancy
- Hyperviscosity
How is acute limb ischaemia classified according to the Rutherford category?
- Stage I: no immediate threat, no sensory loss, no motor deficit, audible arterial and venous Doppler.
What is Stage IIa of Rutherford?
- Stage IIa: marginally threatened but salvageable if promptly treated. Inaudible arterial doppeler but normal venous Doppler and minimal sensory loss in toes.
What are the complications of acute limb ischaemia?
Complications of acute limb ischaemia is reperfusion injury from sudden increase in capillary permeability causing:
Compartment syndrome with calf swelling, severe pain on passive muscle movement
Release of ions from rhabdomyolysis like K+, myoglobin and hydrogen ions causing acidosi.
How is PVD managed?
PVD is managed with heparin, and surgical intervention through catheters
How is PVD managed?
Treatment includes stenting and angioplasty.
How does the ischaemic limb change?
Initially the limb will appear a marble colour. Over the next few hours, there will be mottling of the skin with a light blue/puprle colour due to filling of the skin with deoxygenated blood. Darker mottling will occur.
Final stage, will have large patches of skin with blistering and liequefication.
What are the features of Stage IIb acute limb ischaemia?
- Sensory loss in toes
- Leg pain
- Mild to moderate motor deficit
- Inaudible arterial Doppler but normal venous Doppler
What is Stage III of Rutherford?
- Stage III: IRREVERSIBLE because of major tissue loss, permanent nerve damage, profound sensory loss, paralysis and inaudible arterial AN
What are the complications of acute limb ischaemia?
- Reperfusion injury
- Compartment syndrome
- Severe pain on passive muscle movement
- Acidosis
What is reperfusion injury?
The reintroduction of oxygenated blood after ischaemia causes generation of highly reactive oxygen free radicals. There is a risk of compartment syndrome from increased interstitial pressure which impairs muscle function and can cause muscle necrosis. Ther will be swelling and pain on squeezing calf or moving ankle.
What investigations are performed for acute limb ischaemia?
- FBC
- Serum lactate
- ECG
- Doppler ultrasound
- CT angiogram (gold standard)
*Serum lactate to assess ischaemia level
*Suspicion of thrombophilia if under 50 with no known risk factors
*Group and save for atypical antibodies and to determine patient blood group
What is the management of acute limb ischaemia?
Initial management is high flow oxygen and therapeutic dose of IV heparin infusion
Stage 1 and 2a: prolonged course of heparin and.monitor APPT ratio
Surgical intervention is mandatory for Rutherford 2b and above
Embolus is treated with Embelectomy using Fogarty catheter, Local inftra-arterial thrombolysis and Bypass surgery.
What is the treatment of thrombus?
Thrombus is treated with angioplasty, thrombolysis and bypass surgery. Thrombolysis typically uses streptokinase or a recombinant tissue plasminogen activator. It is ineffective with complete ischaemia as thrombolysis takes several hours so patients should be closely monitored.
What is the management of acute limb ischaemia?
Initial management is high flow oxygen and therapeutic dose of IV heparin infusion
Stage 1 and 2a: prolonged course of heparin and.monitor APPT ratio
Surgical intervention is mandatory for Rutherford 2b and above
What is the long term management of acute limb ischaemia?
Long term management is reducing risk of cardiovascular mortality with exercise, smoking cessation and weight loss. Long term medication of anti-platelet with aspirin/clidogrel or anticoagulation with warfarin/DOAC
What is the indicator of irreversible limb ischaemia?
Irreversible limb ischaemia is indicated by non-blanching appearance, mottled (spots) and hard woody muscles requiring urgent amputation. this will necessitate physiotherapist, occupational therapy and long term rehabilitation plan.
What is the initial management for acute limb ischaemia?
High flow oxygen and therapeutic dose of IV heparin infusion.
What is the treatment for an embolus in acute limb ischaemia?
- Embolectomy using Fogarty catheter
- Local intra-arterial thrombolysis
- Bypass surgery
What is the treatment for a thrombus in acute limb ischaemia?
- Angioplasty
- Thrombolysis
- Bypass surgery
What is the long-term management strategy for reducing cardiovascular mortality?
- Exercise
- Smoking cessation
- Weight loss
- Long-term anti-platelet therapy
What is the management of arterial leg ulcers?
- Surgical revascularisation
- Wound debridement
- Moist, comfortable, absorbent dressing
What is hyperbaric oxygen therapy used for?
Promote wound healing in gangrene and for carbon monoxide poisoning.
What is Raynaud’s?
Raynaud’s is a thermoregulating mechanism to restrict blood flow to the skin during cold temperatures and times of emotional stress and is transient. There is a demarcated white area. It is caused by endothelin from endothelial cells released causing vasoconstriction from increased alpha-2 adrenergic sensitivity, present on distal arterial smooth muscles of digits and affected by sympathetic nervous system.
What is a Raynaud’s attack?
Raynaud attack is with sudden development of cyanotic skin changes with blue fingers for up to 20 minutes, and vascular reperfusion occurs with rewarding. It begins in one finger and spreads to other fingers symmetrically on both hands, sparing the thumb.
What is the cause of secondary raynaud’s?
Underlying disease disrupts normal vessel reactivity to cold temperatures, with prolonged vasoconstriction resulting tin tissue ischaemia
Secondary Raynaud is associated with connective tissue disorders in people in 30s and 40s such as scleroderma, systemic lupus erythematosus, Sjogren syndrome, and antiphospholipid syndrome.
What is an indication for secondary Raynaud’s?
thumb is affected
What is severe Raynaud’s attack?
With severe Raynaud attack, it is more common in secondary raynaud’s and cause tissue ischaemia. There may be features of livedo reticularis, with netlike pattern of reddish-blue skin discolouration due to small vessel clots that is reversible with rewarding but irreversible in antiphospholipid syndorme.
What triggers Raynaud’s phenomenon?
- Cold temperatures
- Emotional stress
- Stimulation of sympathetic nervous system
What are the symptoms of a Raynaud attack?
- Cyanotic skin changes
- Blue fingers
- Pins and needles
- Pain
What is a definitive investigation for Raynaud’s?
Nailfold capillary microscopy to analyze microvascular changes.
What is the management of Raynaud’s?
Conservative management is avoiding exposure to cold, managing anxiety/emotional stresss, avoiding stimulants of sympathetic system like coffee and smoking cessation.
What is the first line pharmacological therapy for Raynaud’s?
Dihydropyridine calcium channel blockers like amlodipine and nifedipine from lowest dose up adverse effects is peripheral oedema, reflex tachycardia and headache.
What are the contraindications for dihydropyridine calcium channel blockers?
- Hypotension
- Peripheral oedema
- Angina
- Myocardial infarction
What is the second line therapy for Raynaud’s therapy?
Phosphodiesterase inhibitor
What is the 3rd line for Raynaud’s?
topical nitrate such as nitroglycerin
What is percutaneous transluminal coronary angioplasty (PTCA)?
A minimally invasive procedure to open blocked or stenosed arteries.
What are the indications for PTCA?
- Stable angina
- Acute STEMI
- Non-STEMI
- Unstable angina
What is a contraindication for PTCA?
It is contraindicated for left main CAD due to risk of acute obstruction or spasm during this.
What is arterial reconstruction therapy?
Arterial reconstruction surgery involves a grfaft known as thrombo-endarterectomy by removing atheromatous plaques and surface thrombosis from aorta dn iliac vessels. It involves arterial bypass. There is a risk of false aneurysm formation, haemorrhage and thrombosis.
What are the complications of amputations?
- Stump oedema, combined with reduced muscle tone
- Wounds and infection
- Osteomyelitis
- Neuropathic pain
What does transcutaneous oxygen tension (TcPO2) measure?
Oxygen tension in the skin derived from local capillary blood perfusion.
What indicates the need for transtibial amputation?
Presence of femoral pulse.
What complication is associated with PVD?
PVD of the lower limbs is associated with Leriche syndrome, a triad of symptoms where there is absent femoral pulses, new onset impotence and claudication.
Can present with dependent rubor, where lower limbs turn bright red when they are lower than the rest of the body and turns white when elvevated due to vasodilation and poor blood flow.
