Vascular disease Flashcards
What is superficial thrombophlebitis?
Usually occurs in the leg
Vein is painful, tender and hard with overlying redness
Treatment is analgesia
What are the differential diagnoses for DVT?
Ruptired Baker’s cyst
Oedema
Cellulitis
What is the wells score for probability of a DVT?
Lower limb trauma or surgery or immobilization in a plaster cast
Bedridden for more than 3 days or surgery within the last 4 weeks
Malignancy (including treatment up to 6 months previously)
Tenderness along deep venous system
Entire limb swollen
Calf swelling more than 3 cm compared to asymptomatic side, measured at 10 cm below tibial tuberosity
Pitting oedema (greater in symptomatic leg)
Dilated collateral superficial veins (non-varicose)
What are the types of hyperlipidaemia?
Primary: genetic predisposition to abnormal lipid metabolism (e.g. familial hypercholesterolaemia)
Secondary: systemic metabolic disturbance (e.g. obesity, alcohol, diabetes)
What are the links between cholesterol and CV risk?
Raised serum cholesterol: reflection of serum LDL –> predisposes to atheroma if levels >4
Less strong association with VLDL & triglycerides
High HDL levels are protective against atheroma
Hypercholesterolaemia –> xanthomata (eyelids/cornea/tendons)
What is the Fontaine classification of chronic lower limb arterial disease?
- Asymptomatic
- Intermittent claudication
- Ischaemic rest pain
- Ulceration/gangrene
How is ankle-brachial pressure index used to assess arterial disease?
ABPI<0.8: arterial disease present
ABPI<0.4: critical limb ischaemia
ABPI >1.2: may be false negative due to calcification giving abnormally stiff vessels (more common in diabetics)
What are chronic peripheral arterial occlusive disease causes?
Atherosclerosis: most common
Fibromuscular dysplasia: non-inflammatory arterial wall thickening
Buerger’s disease (thromboangiitis obliterans): acute inflammation and thrombosis of lower limb arteries/veins: young heavy smokers
What are intermittent claudication symptoms and signs?
Ischaemic ‘cramping’ muscle pain on walking, relieved by rest
Pain reproducible at a similar level: ‘claudication distance’
Commonly in calf: femoral disease
Thigh/buttock: ileal disease, often bilateral, ask about penile function (aortoiliac occlusive disease/Leriche syndrome)
Absent pulses
Cold, pale legs
Atrophic, hairless, shiny skin
Beurger’s test: angle <20 degrees, observe for reactive hyperaemia
Arterial ulcers
What is ischaemic pain indicative of critical lower limb ischaemia?
Classically at night in the forefoot
Pain wakes patient
Relief by swinging leg over the side of the bed/walking on a cold floor
Hx of intermittent claudication & signs of arterial insufficiency
Ulcers likely to form from minor injury –> infection of ulcers can lead to rapidly spreading gangrene (more common with DM)
What are chronic peripheral arterial occlusive disease investigations?
Bloods: FBC (rule out anaemia), HbA1c, lipids
ABPI
What are the effects of peripheral neuropathy (diabetics) on development of chronic peripheral arterial disease?
Sensory neuropathy: reduces protective reactions to minor injury, reduces awareness of infection/ischaemia
Autonomic neuropathy: anhydrosis –> dry, fissured skin, allowing entry of bacteria
Motor neuropathy: wasting of small muscles of the foot leads to loss of arches and development of abnormal pressure areas on feet
What is the pathophysiology of intermittent claudication?
Femoral artery most commonly becomes atheromatous: calf most often affected
At rest: 02 requirements met by collateral system of deep femoral artery
Exercise: 02 demand not met, calf muscle becomes ischaemic
What are leg pain differentials?
Intermittent claudication
Spinal stenosis: osteophyte formation compressing lumbar nerve root/cauda equina. Pain relieved by spine flexion. Pulses will be present. MRI diagnosis.
Venous claudication: iliofemoral occlusion, gradual onset of pain, affects whole leg. Relieved by elevation. Signs of venous disease/Hx DVT
Musculoskeletal: osteo/rheumatoid arthritis
Peripheral neuropathy
Popliteal artery entrapment: young, normal pulses
What are thrombosis predispositions (Virchow’s triad)?
Endothelial dysfunction: trauma, inflammation, atheroma
Changes in blood flow: stasis/slow flow
Changes in coagulation: inflammatory response/congenital causes
What is embolic occlusion pathophysiology?
Occlusion by a mass of material transported in the bloodstream, commonly fragments of thrombus (thromboemboli) Thromboemboli arise from... Left atrium: AF Left ventricle: post-MI Heart valves: endocarditis Mural thrombi: AAA
What are the clinical symptoms of the acute ischaemic limb?
Pulseless
Painful
Pallor
Perishingly cold
Paralysis: threatened limb
Paraesthesia (prickling/tingling): threatened limb
Fixed staining of the leg + rigid muscles indicate a non-viable limb
What are embolic occlusion features?
Sudden severe onset due to lack of collaterals
Source normally identifiable
Pulses previously normal, contralateral pulses
No history of arterial disease
What are thrombotic occlusion features?
Insidious onset due to advanced collaterals
No obvious source
Long-standing decreased pulses bilaterally
Previous history of intermittent claudication, stroke, MI
What’s the difference between Raynaud’s phenomenon/syndrome?
Raynaud’s phenomenon: episodic digital vasospasm in the absence of an identifiable associated disorder
Raynaud’s syndrome: episodic digital vasospasm occuring secondary to another condition
What are the secondary causes of Raynaud’s syndrome?
Connective tissue disorders: systemic sclerosis, mixed connective tissue disease, SLE, Sjogren’s syndrome, polyarteritis nodosa
Macrovascular disease: atherosclerosis, thoracic outlet obstruction, Buerger’s disease
Occupational trauma: vibration white finger, repeated extreme cold or chemical exposure
Drugs: beta-blockers, cytotoxic drugs
Malignancy
Atrio-ventricular fistula
What are Raynaud’s phenomenon phases and clinical characteristics?
Phase 1: pallor due to digital artery spasm
2: cyanosis: accumulation of deoxygenated blood
3: rubor: erythema due to reactive hyperaemia
Numbness/burning/pain upon return to normal.
Attacks usually <45mins
What are the types of varicose veins?
Varicose veins: abnormally dilated and lengthened superficial veins
Primary (idiopathic): 2x as common in women
Pregnancy accentuates symptoms
Likely a primary superficial valve defect + familial elements
No deep venous incompetence
Secondary: superficial varicosities occur secondary to deep venous incompetence
Previous DVT
Raised systemic venous pressure due to compression (pregnancy, pelvic tumour), AVF, severe tricuspid incompetence
What are varicose veins symptoms?
Unsightly appearance Tired/aching/throbbing legs Ankle oedema Itching/nocturnal cramps Signs of deep venous insufficiency: hameosiderosis, eczema, lipodermatosclerosis
