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.
