Vascular disease Flashcards
Risk factors for peripheral vascular disease
Hx of CVD/cerebrovascular Smoking Diabetes HTN Hyperlipidaemia Physical inactivity Age >40yo Male *essentially anything that contributes to atherosclerosis
Compare the types of chronic PVD
Intermittent claudication
- pain on exertion (stable angina)
- relieved by rest, cramping pain in calf (femoral disease), thigh/buttock (iliac disease) after walking a certain distance
Critical limb ischaemia
- pain on rest (unstable angina)
- rest pain, night pain, relieved by hanging legs over bed, ulcers, gangrene
Mx of acute limb ischaemia
Surgical emergency: 4-6 hrs to save limb
MI of legs
What staging is used for PVD?
Fontaine Staging I - asymptomatic IIa - mid claudication IIb - moderate to severe claudication III - ischaemia rest pain IV - ulceration or gangrene
Signs and sx of PVD
Absent femoral, popliteal, foot pulses Cold white legs Atrophic skin Colour change when raising legs - Buerger's test: pallor when leg held at angle (Buerger's angle) then reactive hyperaemic when leg moved to dangle over bed
Leriche syndrome triad
Aortoiliac occlusive disease
- buttock claudication
- impotence
- absent/weak distal pulses
6 Ps of acute limb ischaemia
Pain* Pale Pulseless Poikilothermia Paralysis Paraesthesia* *earlier signs
Ix for PVD
Full cardiovascular risk assessment
- BP
- bloods: FBC, fasting glucose, lipids
- ECG
- ABPI
- colour duplex USS (show site + degree of stenosis)
- MRA/CT
What are the ranges for an ABPI reading?
0.9-1.2 = normal
<0.9 = abnormal
<0.5 = indicates chronic limb ischaemia
*beware reading less accurate in diabetic pts
What are the three types of ulcers and why do they occur?
Ulcers: loss of continuity of epithelium/endothelium
1) Arterial = inadequate arterial blood supply due to atherosclerosis leading to severe narrowing and reduced capillary blood flow
2) Venous = incompetent valves/venous outflow obstruction leads to venous stasis and venous HTN
3) Neuropathic = peripheral neuropathy leads to continuous microtraumas, allowing breakdown of tissues
Compare RFs of arterial and venous ulcers
Arterial (10-30% lower extremity ulcers)
- age, FHx, smoking, obesity + immobility, CHD/PVD, hyperlipidaemia, diabetes
Venous (67% lower extremity ulcers)
- age, FHx, smoking, obesity + immobility, recurrent DVT, orthostatic occupation, varicose veins, female
Signs and sx of arterial ulcers
Punched out appearance (deeper than venous)
Often distal; dorsum of foot, in between toes
Well-defined edges
Pale base (grey cannulation tissue)
Night pain
Hair loss, shiny skin, pale skin, absent pulses, calf muscle wasting
Signs and sx of venous ulcers
Large and shallow, less defined than arterial, sloping sides
More proximal; medial gaiter region
Painless
Venous insufficiency; itching, aching
Stasis eczema
Lipodermatosclerosis (inverted champagne bottle sign)
Atrophic blanche (white, atrophic skin surrounded by small capillaries)
Haemosiderin deposition (due to blood stasis)
Ix for arterial ulcers
Duplex USS lower limbs ABPI Percutaenous angiography ECG Bloods; fasting serum lipids, HbA1c, glucose, FBC
Ix for venous ulcers
Duplex USS lower limbs
Measure surface area of ulcer (monitor progression)
ABPI
Swab for microbiology (if signs of infection)
Biopsy (potential for Marjolin’s ulcer; SqCC in area of chronic inflammation/injury)
Mx of venous ulcers
Graded compression stockings - reduce venous stasis Debridement and cleaning Antibiotics if infected Moisturising cream for eczema/dry skin
*Good prognosis if pts mobile + compliant
What is an AAA?
Aortic abdominal aneurysm
- enlargement of abdominal aorta where diameter is >3cm or 50% larger than normal diameter
- true: all 3 layers, false: tear in 1 layer
What are the RFs for an AAA?
Smoking Age FHx Connective tissue disorders (Marfan's, Ehlers-Danos) Males Hypertension Hyperlipidaemia Inflammatory disorders (Behcet's, Takayasu's arteritis)
Compare sx of an unruptured and ruptured AAA
Unruptured
- no sx
- usually incidental finding
- potential back, abdo, loin or groin pain
Ruptured
- sharp/severe pain in back, abdo, loin or groin
- shock; hypotension, increased HR
Signs of an AAA
Pulsatile and laterally EXPANSILE abdominal mass on palpation***
Abdo bruit
Grey-Turner’s sign (more commonly caused by pancreatitis)
Ix for an AAA
Bloods; X-match, FBC, clotting screen, U&Es, LFTs
Scans; USS detects aneurysm, CTw/contrast/CT angiography to show if ruptured, MR angiography if contrast allergy
What is an aortic dissection?
TEAR IN AORTIC INTIMA that allows blood to flow into a new false channel in between the inner and outer layers of the tunica media
Usually preceded by elastin and collagen breakdown
What are the types of aortic dissection?
Stanford
Type A => ascending aorta (most common)
Type B => descending aorta
DeBakey
I => ascending, descending aortic arch
II => only ascending
III => only descending
RFs for aortic dissection
Hypertension Atherosclerotic disease Connective tissue disease (Marfan's, Ehlers-Danlos) Congenital cardiac abnormalities Smoking Cocaine/amphetamine usage Heavy lifting *most common in males aged 40-60 or males aged 30s with CTD
Sx of an aortic dissection
Sudden central tearing chest pain, commonly radiates between shoulder blades
Other sx due to obstructoin of other branches
- abdo pain = coeliac axis
- loss of consciousness = subclavian artery
- anuria = renal artery
Signs of an aortic dissection
Hypertension Diastolic murmur (common in proximal dissections) Interarm BP difference >20mmHg Features of connective tissue disease Hypotension (suggesting tamponade)
Ix for an aortic dissection
Bloods; x-match, FBC, lactate, cardiac enzymes, U&E, LFTs
ECG; exclude MI
CXR; loss of contour of aortic knuckle
**CT angiogram; shows false lumen
What leads to varicose veins?
Most commonly due to venous valve incompetence
=>
Allow flow from deep into superficial
=>
Occurs at either sapheno-femoral or sapheno-popliteal junction
=>
Venous HTN + dilatation of superficial venous system >3mm when measured in standing position
Causes of varicose veins
Primary - idiopathic Secondary - DVT - AV malformations - Pelvic masses (pregnancy, uterine fibroids, ovarian masses)
Ix for varicose veins
Duplex USS to localise sit of incompetence/reflux and exclude DVT
RFs for varicose veins
Age FHx Females Previous pregnancies Previous DVTs Prolonged standing Obesity
Signs of varicose veins O/E
Inspection; obvious when pt standing
Palpation; veins tender/hard, tap test (tap distally and feel transmitted impulse over saphenofemoral junction)
Auscultation; bruits
Trendelenburg Test; localisation of sites of valve incompetence (tourniquet on leg, elevate leg)
Mx of varicose veins
Conservative - compression stockings - lifestyle; lose wt, exercise Endovascular tx - radiofrequency ablation - endovenous laser ablation - microinjection sclerotherapy Surgical - stripping of long saphenous vein - avulsion of varicosities - saphenofemoral ligation
Complications of varicose veins
Venous insufficiency - lipidermatosclerosis - superficial thrombophelbitis - eczema - ulceration - venous pigmentation Sclerotherapy - local scarring - skin staining Surgery - haemorrhage - infection - paraesthesia - peroneal nerve injury (tingling, pain and foot drop)
*High rates of recurrence in pts
A 69 year old man with a background of hypertension complained of flank pain
all day at work. He then has sudden onset abdominal pain that radiates to his
back and groin. He arrives in an ambulance unconscious. The doctor notes Grey
Turner’s and Cullen’s signs. What is the most likely diagnosis?
a) Renal colic
b) Myocardial Ischaemia
c) Ruptured AAA
d) Pancreatitis
c) Ruptured AAA
A 65 year old gentleman is coming in for screening for a AAA following a
letter received in the post. What modality would be used as a screening
tool?
a) Abdominal Ultrasound
b) Abdominal CT
c) Abdominal X-ray
d) Doppler Ultrasound
d) Abdominal ultrasound
* screening for >65 males
The same gentleman, 3 years later (68yo) with a known AAA (last measured 5.2 cm)
comes in complaining of severe abdominal pain. What investigation would you
use to assess if it has ruptured?
a) Abdominal Ultrasound
b) Abdominal CT
c) Abdominal X-ray
d) Doppler Ultrasound
b) Abdominal CT
A 70 year old gentleman with known hypertension presents to A&E with
tearing chest pain, radiating to the back. His CXR shows a widened
mediastinum. What is the most likely diagnosis?
a) Aortic Dissection
b) STEMI
c) Teitze’s Syndrome
d) Costochondritis
a) Aortic dissection
Which of the following examination findings is not consistent with an aortic dissection? a) BP 100/40 b) Ejection systolic murmur c) Collapsing pulse d) Radio-radio delay
b) Ejection systolic murmur
A 65 year old lady with known CVD presents to the GP with pain in her
legs. She finds the pain comes on when she is walking to the shops, but is
relieved by rest. She has a 40 pack year smoking history. What is the
most likely diagnosis?
a) Acute limb ischaemia
b) Deep vein thrombosis
c) Varicose veins
d) Peripheral arterial disease
d) Peripheral arterial disease
A 60 year old male with known atrial fibrillation presents to A&E with a sudden
onset of a painful, cold leg. The doctor is unable to feel peripheral pulses, and
upon examination notes a loss of sensation and paralysis. A venous doppler is
inaudible. What is the definitive management?
a) Embolectomy
b) Watch and wait
c) Angioplasty
d) Amputation
c) Amputation
A 69 year old heavy smoker complains of pain in his leg when he walks to the
bus stop. On examination of his leg, you see shiny skin, patchy hair, weak
pulses and brittle toenails. What would be the first line investigation?
a) Angiography
b) Doppler Ultrasound
c) Magnetic Resonance Angiography
d) ABPI
d) ABPI
A 32 year old woman on the OCP complains of pain in her calf for one
day. She does not have any chest pain or shortness of breath. The nurse
tells you that the A&E doctors assessed the patient, who scored 2
although she cannot remember the name of the score. What is the most
appropriate initial investigation?
a) D-Dimer
b) MRA
c) Leg Vein USS
d) ABPI
a) Leg vein USS
A 75 year old woman with long standing hypertension has had progressive
swelling of her legs over the last 3 months. She has consulted her GP
because she has developed an ulcer on the anterior aspect of the right
shin which weeps serous fluid profusely. What is the cause of the ulcer?
a) Arterial
b) Venous
c) Neuropathic
d) Rheumatoid Arthritis
b) Venous
A 62 year old diabetic woman shows you an ulcer on the bottom of her
foot. It has a little stone lodged in it, which she hasn’t noticed. On
neurological examination, she has no peripheral sensation of light touch
up to her mid-foot. What is the cause of the ulcer?
a) Arterial
b) Venous
c) Neuropathic
d) Rheumatoid Arthritis
c) Neuropathic
A 78 year old obese woman presents with an ulcer on the top of her foot
and one between her toes. They haven’t healed in two months. They are
quite small, look punched out and yellow. She complains her feet are
always cold and has a history of coronary artery disease.
a) Arterial
b) Venous
c) Neuropathic
d) Trauma
a) Arterial
A 45 year old lady presents with a 4 cm chronic ulcer on the medial aspect
of the lower leg. She has a history of pain in the calf on walking. The skin
around the ulcer is brown and heavily indurated.
a) Arterial
b) Venous
c) Neuropathic
d) Trauma
b) Venous
A 70-year-old man has come to the GP complaining of pain in his calf for the past 3 months. The pain only comes on when he is walking and is relieved by rest. He always feels the pain in the same area of his leg. His past medical history includes hypertension and high cholesterol levels.
What is the most likely diagnosis?
A – Critical limb ischaemia B – Acute limb ischaemia C – Deep vein thrombosis D – Intermittent claudication E – Vasculitis
D - Intermittent claudication
A 55 year-old-man with a BMI 35 presents to GP with a lesion on inner aspect of his foot which causes him pain at night. On examination the lesion is well defined and has a ‘punched out’ appearance. The skin surrounding the lesion appears shiny and pale.
What is the most likely diagnosis? A – Venous ulcer B – Arterial ulcer C – Trauma D – Gangrene E - Neuropathic ulcer
B - Arterial ulcer
A 62 year-old-man presents to A+E with severe abdominal pain which radiates to his back. The pain started about 45 minutes ago and is a 9/10. On examination he looks systemically unwell and has cool peripheries to touch. HR = 140bpm; BP = 80/56.
What is the most likely diagnosis?
A – Pancreatitis B – Abdominal aortic aneurysm C – Aortic dissection D – Myocardial infarction E – Splanchnic artery occlusion
B - Abdominal aortic aneurysm
A 35-year-old man presents to A+E with sudden onset chest pain. He describes as ‘tearing’ and spreading towards his back.
On examination, BP is 180/90mmHg is the left arm and 156/80mmHg in the right arm. You also notice he is much taller than average height and has long fingers.
Which of these is the most likely diagnosis?
A – Pulmonary embolus B – Pericarditis C – Myocardial infarction D – Musculoskeletal pain E – Aortic dissection
E - Aortic dissection
A 52-year-old woman presents to her GP complaining of heaviness and aching in her legs which gets worse as the day goes on. She has also noticed swelling and discoloration in her legs, with some visible veins in the middle of her calf. The only other time she has had this before is when she was pregnant 25 years ago.
What is the most likely diagnosis?
A – Varicose veins B – Telangiectasias C – Reticular veins D – Thrombophlebitis E – Lymphedema
A - Varicose veins
