Vascular disease

Question 1

What is superficial thrombophlebitis?

Answer 1

Usually occurs in the leg
Vein is painful, tender and hard with overlying redness
Treatment is analgesia

Question 2

What are the differential diagnoses for DVT?

Answer 2

Ruptired Baker’s cyst
Oedema
Cellulitis

Question 3

What is the wells score for probability of a DVT?

Answer 3

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)

Question 4

What are the types of hyperlipidaemia?

Answer 4

Primary: genetic predisposition to abnormal lipid metabolism (e.g. familial hypercholesterolaemia)
Secondary: systemic metabolic disturbance (e.g. obesity, alcohol, diabetes)

Question 5

What are the links between cholesterol and CV risk?

Answer 5

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)

Question 6

What is the Fontaine classification of chronic lower limb arterial disease?

Answer 6

1. Asymptomatic
2. Intermittent claudication
3. Ischaemic rest pain
4. Ulceration/gangrene

Question 7

How is ankle-brachial pressure index used to assess arterial disease?

Answer 7

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)

Question 8

What are chronic peripheral arterial occlusive disease causes?

Answer 8

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

Question 9

What are intermittent claudication symptoms and signs?

Answer 9

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

Question 10

What is ischaemic pain indicative of critical lower limb ischaemia?

Answer 10

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)

Question 11

What are chronic peripheral arterial occlusive disease investigations?

Answer 11

Bloods: FBC (rule out anaemia), HbA1c, lipids

ABPI

Question 12

What are the effects of peripheral neuropathy (diabetics) on development of chronic peripheral arterial disease?

Answer 12

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

Question 13

What is the pathophysiology of intermittent claudication?

Answer 13

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

Question 14

What are leg pain differentials?

Answer 14

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

Question 15

What are thrombosis predispositions (Virchow’s triad)?

Answer 15

Endothelial dysfunction: trauma, inflammation, atheroma
Changes in blood flow: stasis/slow flow
Changes in coagulation: inflammatory response/congenital causes

Question 16

What is embolic occlusion pathophysiology?

Answer 16

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

Question 17

What are the clinical symptoms of the acute ischaemic limb?

Answer 17

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

Question 18

What are embolic occlusion features?

Answer 18

Sudden severe onset due to lack of collaterals
Source normally identifiable
Pulses previously normal, contralateral pulses
No history of arterial disease

Question 19

What are thrombotic occlusion features?

Answer 19

Insidious onset due to advanced collaterals
No obvious source
Long-standing decreased pulses bilaterally
Previous history of intermittent claudication, stroke, MI

Question 20

What’s the difference between Raynaud’s phenomenon/syndrome?

Answer 20

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

Question 21

What are the secondary causes of Raynaud’s syndrome?

Answer 21

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

Question 22

What are Raynaud’s phenomenon phases and clinical characteristics?

Answer 22

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

Question 23

What are the types of varicose veins?

Answer 23

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

Question 24

What are varicose veins symptoms?

Answer 24

Unsightly appearance
Tired/aching/throbbing legs 
Ankle oedema 
Itching/nocturnal cramps 
Signs of deep venous insufficiency: hameosiderosis, eczema, lipodermatosclerosis

Question 25

What is deep venous insufficiency pathophysiology

Answer 25

Postphlebitic limb
Incompetent valves of deep venous system
Soleal pump no longer efficient at returning blood to the thoracic cavity
Primary: congenital absence of valves
Secondary: DVT causing valvular damage/AVF raising venous pressure

Question 26

What is deep venous insufficiency presentation?

Answer 26

Lower limb aching pain/discomfort
Lower leg oedema 
Superficial varicose veins (raised central pressure causes perforator incompetence) 
Haemosiderin deposition in gaiter area 
Eczema over pigmented area: pruritis 
Atrophie blanche 
Lipodermatosclerosis: subcut tissue replaced by thick fibrous tissue, giving inverted champagne bottle appearance 
Ulceration

Question 27

What are deep venous insufficiency investigations?

Answer 27

Hand-held doppler: identify reflux at saphenofemoral/saphenopopliteal junctions
Duplex sonography: diagnose valvular and perforating vein incompetence, large vein occlusion
Venography: tourniquet placed around the ankle to occlude superficial veins, contrast injected into foot
Fluoroscopy then used to see the progress through the deep system
Deep vein occlusion & perforating vein reflux readily detected