Vascular disease Flashcards
What are chronic lung ulcers?
A chronic leg ulcer is defined as a defect in the skin below the level of the knee, which persists for
longer than 6 weeks. Roughly 70% of leg ulcerations are venous in nature. Chronic leg ulcers
normally begin as a small injury to the leg, such as a scratch. Which then develops into a large
ulceration which erodes the epidermis, and part of the dermis.
How does a venous ulcer form and what are the risk factors?
Sustained venous hypertension -> Incompetency of valves in causing venous insufficiency -> retrograde blood flow and venous hypertension -> extravasation of fibrinogen through the capillary wall, giving rise to fibrin deposition. -> poor oxygen of the skin -> Risk factors: Peripheral oedema, Venous eczema, Previous DVT, Varicose veins, Phlebitis, Paralysis
How does an arterial ulcer form and what are the risk factors?
Reduced arterial flow and and tissue hypo-perfusion
Ischaemia of skin Can be caused due to arteriolar occlusion:
- Peripheral vascular disease
- Atherosclerosis
- Diabetes
- Vasculitis
Risk factors: Obesity, hypertension, poorly controlled diabetes, angina and smoking
What are neuropathic ulcers?
Typically poorly controlled DM or alcohol/folate/B12 deficiency.
Seem in pressure areas of extremities - ‘stocking and glove.
Hyperglycaemia causes damage to the blood vessels causing peripheral vascular disease.
Reduced blood supply to the nerves causing neuropathy and painless sensation
Diabetes reduced the healing effect of the body as inflammation causes delay in formation of granulation tissue
What are pressure ulcers?
Mainy occur in elderly, immobile or paralysed patients
Due to ischaemia from sustained pressure over a bony prominence e.g. heel or sacrum.
Majority occur in hospitals
What do venous ulcers present as?
Mainly present along the medial perimalleolar surface of the leg - “gaiter area:
Painful relieved by leg elevation
Large, shallow, irregular border with an exudative and granulating base
Often present with peripheral oedema, varicose veins, venous eczema
Hyperpigmentation due to hemosiderin deposition in the skin
Lipodermatosclerosis is dermatitis and dermal fibrosis (from capillary proliferation),
Atrophy blanche (white plaques with telangiectasias &
hyperpigmentation),
What do arterial ulcers look like?
Present mainly on the dorsum of the foot or toes - Pressure sites
Painful and worse when legs are elevated
Small, deep, clearly defined edges, PUNCHED OUT appearance often with necrotic base
Very rarely bleed
Nocturnal pain is characteristic, relieved by dangling legs out of bed,
Hairlessness, pale skin, arterial bruit, absent pulses and nail dystrophy.
What do Neuropathic ulcers look like?
Punched out appearance, variable size and depth with granulating base
Deep sinus,
Over pressure areas,
Surrounding inflammation of the skin,
Painless with easy bleeding on debridement.
What is an aortic aneurysm?
Dilation of the aorta.
Anteroposterior diameter of greater than 1.5x normal size (over 3 cm for AAA)
Symptoms based on location of aneurysm for e.g. aneurysm in aortic arch will present as hoarse voice due to stretching on the left recurrant laryngeal nerve.
Can occur from trauma, infection or intrinsic abnormalities in elastin and collagen compenents. Congenital - Marfan’s, Ehlers-danlos syndrome
How does AAA present?
Most commonly infra-renal Palpable pulsatile abdominal mass, Abdominal, back, or groin pain, Compression of a nerve may result in leg pain or numbness, Collapse, Shock.
Risk factors for AAA:
smoking, positive family history, increased age (>65), male
sex and congenital connective tissue disorders.
What is ischaemic rest pain?
Burning sensation in the ball of the foot present during long periods of rest.
Can be relieved by dangling feet to increase blood flow.
What is a DVT?
A blood clot that begins to form in the leg above or behind the venous valve.
Most commonly in soleol vein.
Vein thrombi are more likely to dissociate than arterial thrombi as they do not develop within the endothelium
Treatment for DVT?
Anti-coagulants e.g. Rivoraxaban, warfarin or heparin (3 months)
Physical activity and gradient stockings
No severe symptoms - treated conventionally with serial imaging for 2 weeks
If thrombus extended to lumen of the vein - anti coagulants
Pregnant women treated with subcutaneous unfractioned LMWH
What is Raynaud’s phenomenom?
Peripheral digital ischaemia due to vasospasm -> episodes of reduced blood flow
Typically in fingers than toes
Episodes triggered by cold of emotional stress
Symptoms: Discolouration of affected extremities, paraesthesia, burning sensation and swelling as patient’s blood flow returns, reactive hyperaemia
Diagnosis of exclusion
Associated with autoimmune disorders like lupes, scleroderma (connective tissue disorders), anorexia nervosa and drugs (beta-blockers, ciclosporin, sulfalazine, the pill)
Investigations for Raynaud’s phenomenon
FBC (CRP, WBC),
Antinuclear antibodies (ANA) test – identify autoimmune conditions such as lupus,
ESR – infection.
Creatinine (may be elevated in secondary RP),
Urinalysis (haematuria or proteinuria in secondary RP).
Advice for treatment of Raynaud’s disease
Avoid the triggers such as cold, emotional and environmental stress, vibrations, smoking and sympathomimetic drugs. Prophylaxis - Nifedipine, amlodipine (calcium channel blockers) IV Iloprost (prostacyclin) Sympathectomy
What is a doppler ultrasound?
Non-invasive test that estimates the blood flow through blood vessles by bouncing high frequency sound wares off erythrocytes Can detect: Blood clots, Venous insufficiency, Arterial occlusion, Peripheral vascular disease, Aneurysms, Stenosis of arteries.
- useful in knowing whether compression bands can be given to patients with ulcer as can only do for venous ulcers (arterial ulcers already have absent pulses)
What is ischaemic penumbra?
This is where the cells are close to infarction and
necrosis, but can be saved if the blood supply was to be restored immediately.
What is collateralisation?
The penumbra cells
can be maintained for a long period of time due to a small blood supply from secondary or collateral
vessels. These collateral vessels can enlarge if they are the only source of blood to the tissues,
maintaining a period of cellular function. This process is referred to as collateralization.
What is time of reperfusion?
The time needed for the blood supply to be re-established before the penumbra cells die and
become necrotic is called the time to reperfusion.
What is meant by gangrene?
Type of necrosis caused by a critically insufficient blood supply.
Dry gangrene - Coagulative necrosis in the absence of infection shows a distinct line of demarcalation between live and dead tissue. Often due to PVD where bacteria fail to survive
Wet gangrene- Necrosis with bacteria and has worse prognosis. Infected with saprogenic C. perfringes or Bacillus fusiformis. Develops due to rapid blockage of venous and arterial blood flow leaving stagnant blood in peripheries.
affected limb is soft, oedematous, rotten and dark
Management of venous ulcers:
- Charing-cross 4-layer compression bandage
- leg elevation to reduce venous hypertension
- Doppler exam performed before bandaging for presence of pulses
- Diuretics - peripheral oedema
- Flucloxacillin and analgesia
- Pentoxifylline (PDE inhibitor) as its a vasodilator and aids healing
- Lifestyle advice (excercise, raise legs)
- Larval therapy and hydrogels for debriment, disinfection and removal of necrotic tissue
- Split thickness skin grafting can be used in resistant cases
- Lifetime compression stocking must be worn
Management of arterial ulcer
COMPRESSION BANDING MUST NOT BE USED
- Lifestyle changes (smoking cessation, healthy diet)
- Referral to tissue viability clinic
- Treat underlying cause of PVD
- Hydrogels for debridement with regular wound dressing
- Flucloxacillin if infected
- Manage gangrene of necresis
Management of neuropathic ulcers:
- debridement (larval therapy, surgically, enzymatically)
- negative pressure wound therapy
- off-loanding to reduce pressure being applied to ulcer - TOTAL CONTACT CAST
- Frrquent dressing
- Refer to podiatrist for correct foot care
- HYDROGELS NOT USED DUE TO INCREASED RISK OF GANGRENE
What is gas gangrene?
Bacterial infection that produces gas within the tissue. Mainly caused by spore-forming Clostridium and alpha toxin producing b. fusiformis
Infection spreads rapidly as gases produced by bacteria expand and infiltrate surrounding tissue
What is necrotising fascilitis?
Rapidly progressive infection of the deep fascia causing necrosis of subcutaneous tissue
Caused by bacterial infection of Group A strep (commonest), Klebsiella, clostridium, e-coli and staph aureus.
Majority caused by normal skin flora
What is claudication?
Where is it most common and why?
Symptom that describes muscle pain in lower leg on mild exertion, classically in calf. The lower limbs require more blood supply because they are bigger and have more work to do making claudication more common in lower limbs.
Associated with early-stage PVD from atherosclerosis and reduced blood flow to muscles. Also diabetes
Risk factors for claudication occurring?
What investigations would be done when suspecting claudication?
Risk factors: Smoking, diabetes, hypertension, hypercholesterolaemia and heart disease.
Doppler ultrasound
ABPi
CT Scan and Magnetic Resonance Angiography (MRA) (do FBC before as can cause renal dysfunction. Patient needs to be given iodine dye through cannula so only do immediately prior to intervention)
Auscultation to hear for bruits
Treatment for claudication:
Lifestyle changes
~Cilostazol (PDEIII Inhibitor) inhibits platelet aggregation and vasodilates
~Pantoxifylline (erythrocyte PDE Inhibitor) causing erythrocyte to be more resistant to deformity and less likely to clot. Also decreases blood viscosity by reducing plasma fibrinogen
~anti-coagulant meds (aspirin, clopidogrel)
Surgical- Angioplasty, bypass graft
What is angioplasty?
Dilation of a small balloon on a catheter in the blood vessels to expand the lumen of the artery
What are the surgical options for chronic venous insufficiency?
Endovenous Ablation - Minimally invasive. Catheter puts heat into affected vein and closes it. Once vein is closed less blood pools into leg and overall flow in improved
Saphenectomy - Stripping of the great saphanous vein with long-term compression
How would venous and arterial disease present differently on exam of the limbs?
Venous: Pitting oedema Hyperpigmentation Lipodermosclerosis Bleeding, irregular bordered leg ulcers Itchy and painful legs
Arterial: Pallor - Buerger's test Loss of pulses and hair Paraesthesia Pain Coldness in limb
How is the Buerger’s test performed?
When patient is supine, elevate both legs to 45* and hold for 2 mins
Pallor in feet indicates ischaemia and inadequate peripheral arterial pressure
Poorer the supply, the less the angle at which legs become pale
Adverse effects of calcium channel blockers
oedema, palpitations, headache, flushing, or dizziness.
What are the symptoms of acute limb ischaemia?
MEDICAL EMERGENCY REQUIRED REVASCULARISATION WITHIN 4-6 HRS
Pale, Pulseless, painful, paralysed, paraesthesia, perishing cold
Dry gangrene is a more severe sign of ALI
Caused my embolism or thrombosis
What is repurfusion injury?
Complication of acute limb ischaemia where sudden increase in capillary permeability from reperfusion can result in compartment syndrome, hyperkalaemia, hypophosphataemia, acidosis and rhabdomyolysis
Symptoms of chronic limb ischaemia including Fontaine Classification:
Intermittent claudication (pain relieved by resting and develops gradually), erectile dysfunction, pain being worse in one leg. Buerger's test - ischaemia at an angle of <20* suggests severe ischaemia
Fontaine Classification: Stage I Asymptomatic Stage II Intermittent claudication Stage III Ischaemic rest pain Stage IV Ulceration or gangrene, or both
Pathogenesis of peripheral vascular/artery disease:
Narrowing of arteries that don’t supply heart or brain
Sub-classified into functional or organic
Organic: Caused by atherosclerosis or embolus
Functional: extrecellular causes or reduced blood flow e.g. inflammation following trauma, vasospasms. Usually short-term and spontaneously solve
Arteries of legs commonly afected
What are the contents of atherosclerosis?
Cholesterol
Foam cells -
Cytokines -
Calcium
What third-artery can be checked for when doing an ankle-brachial BP doppler in diabteic patients?
Perineal artery
What third-artery can be checked for when doing an ABPi in diabteic patients whose arteries might be hard to detect?
Perineal artery
Investigations to do for leg ulcers:
ABPI to exclude significant arterial disease
Venous: Venous duplex ultrasound to look for venous incompetence
Arterial: Arterial imaging (see PAD presentation) – usually multilevel disease
Diabetic: Assess sensation – monofilament test. Check HBA1C & optimise
Foot x-rays to look for underlying osteomyelitis.
Arterial imaging as for PAD if neuroischaemic.
What would be the management plan based on the different Abdo Aorta sizes discovered during screening?
If results normal ( aorta diameter < 3cm) → no further scans
‘Small’ AAA (aorta diameter 3cm- 4.4cm) → yearly scans + lifestyle advice
‘Medium’ AAA (aorta diameter 4.5- 5.4cm) → scan every 3 months + CVD prevention therapy
‘Large’ AAA (diameter 5.5cm or greater) → referred to Vascular surgeon to
discuss further management
Differentials of chronic limb ischaemia:
Spinal Canal claudication (all pulses present)
Osteoarthritis knee/hip (pain at rest too)
Types and process of limb amputation?
Minor: Trans-metatarsal
Major: below-knee, above knee
Possible complications of limb amputation?
Infection, ischaemia, stump trauma, pressure injury
Risk of sedentary lifestyles
Rehabilitation for patients following limb amputation and list mobility aids available
Psychological impact considered
Social input and home adaptations
Physiotherapy
Stump modelling, Prosthesis fitting and ambulation
Significant recent improvements in prosthetic technologies
Phantom limb sensation/ pain
