Vascular diseases Flashcards
What are the four main categories of vascular disease?
- Peripheral Vascular disease [arterial and venous]
- Ulcers
- Varicose Veins
- Aorta pathologies
What are the risk factors for vascular disease?
- Male
- Obese
- Age- Old
- FH for vascular disease
- Hypertension
- PMH of cardiovascular disease
- Smoking
SBA 1
70 y old man, calf pain for 3 months.
Pain comes on when walking, relieved by rest
Pain in same area of leg always
PMH= hypertension, hypercholesterolaemia
A – Critical limb ischaemia
B – Acute limb ischaemia
C – Deep vein thrombosis
D – Intermittent claudication
E – Vasculitis
D - Intermittent claudication
SBA 1 discussion
What vascular condition has pain at rest?
Critical limb ischaemia
Peripheral Vascular Disease:
Risk factors:
Epidemiology:
Cause:
Types:
Diagnosis
Symptoms and signs:
Investigations:
Peripheral Vascular Disease:
Risk factors:
- Hypertension
- Hyperlipidaemia
- Smoking
- Diabetes
- Sedentary lifestyle/obesity
- PMH- CVD/cerebrovascular disease
Epidemiology:
- Old
- Male
Cause:
Atherosclerosis of arteries= stenosis= ischemia
Types:
-
ACUTE
* acute limb ischaemia due to thromboembolism - CHRONIC
- intermittent claudication
- critical limb ischaemia
- arterial ulcers
- gangrene
Diagnosis
Presentation
Symptoms:
1. ACUTE LIMB ISCHEMIA
6Ps
Pain
Pallor
Perishingly cold
Pulseless
Paralysis
Parasthesia
2. CHRONIC
- Intermittent claudication
- Cramping pain- buttock, thigh, calf
- Same place every time
- Pain on exertion/walking, relieved by rest
- Worse on walking uphill
- Critical limb ischaemia
- Pain at rest
- Pain at night
- Gangrene
- Ulcers
- Hanging leg over bed helps=gravity
- Rapid deterioration
Other symptoms
- Cold, white legs
- Atrophic skin
Absent popliteal, femoral, distal pulses
- Buerger’s test
= severe limb ischaemia
- Raise leg- if turns pale when angle of 20 degrees reached
- when leg is hung over the bed, gravity causes hyperperfusion- reactive hyperaemia= v red leg
Investigations:
Duplex ultrasound
ABPI- Ankle brachial pressure index (normal range 0.9-1.2)
Blood pressure
Bloods- FBC (anaemia), lipids, fasting blood glucose
ECG + full CVD risk assessment
SBA 1 discussion
How does acute limb ischaemia present?
Acute episode
Sudden onset pain
Doesn’t go away
‘Angina of the limbs’
SBA 1 discussion
What features of DVT separate it from acute/critical limb ischaemia?
More likely to have swelling and discolouration/redness
SBA 1 discussion
What are features of vasculitis?
- Skin changes
- Exertion doesn’t cause pain
- Clotting issues??
Which type of limb ischaemia is a surgical emergency?
Acute limb ischaemia
Which part of the body is affected the most in peripheral vascular disease?
Lower extremities- eg. toes
What is the name of staging in peripheral vascular disease?
What are the five stages?
Fontaine staging
I - asymptomatic
IIa - mild claudication
IIb - moderate to severe claudication
III - pain at rest
IV- ulceration and gangrene
What is claudication distance?
Distance a person can walk before experiencing claudication pain
What are the areas of claudication in peripheral vascular disease?
Femoral/thigh
Buttock/iliac
What is Leriche syndrome and what are its symptoms?
- Aortoiliac occlusive disease
- Impotence
- Buttock pain/claudication
- Absent/weak distal pulses
What are the 6 P’s of acute limb ischaemia?
Pain
Pale
Pulseless
Perishingly cold
Parasthesia
Paralysis
Ulcers
Definition
Types
Risk factors
- Arterial
- Venous
Epidemiology
- Arterial
- Venous
Investigations
- Arterial
- Venous
Management
- Arterial
- Venous
Ulcers
Definition:
- Abnormal break in skin/mucous membranes
- Loss of continuity of epi/endothelium
Types
- Arterial
> inadequate arterial blood supply
- Venous
> Damage due to incompetent valves and venous outflow obstruction
> Venous stasis
- Neuropathic
> Result of peripheral neuropathy
Risk factors
Common for all ulcers
- FH of vascular disease/CVD
- Age
- Obesity/immobility
- Smoking
Arterial
- PMH of vascular disease/CVD
- Hyperlipidaemia
- Diabetes
- Venous
- Varicose veins
- Recurrent DVT
- Orthostatic occupation
- Female
Epidemiology
Arterial
- Ten to thirty percent of lower limb ulcers
- Old
- Obese
Venous
- Two thirds of all lower limb ulcers- more common
- Old
Symptoms and signs
Arterial
symptoms
- Painful- at night
- Punched out appearance [deep- many layers of skin hypoperfused]
- Well defined edges
- Distal- dorsum of foot/in between toes
- Pale base- grey granulation tissue
Signs
- Hair loss
- Pale skin
- Shiny skin
- Absent pulses
- Calf muscle wasting
Venous
Symptoms
- Large and shallow
- Irregular borders
- Sloping sides of borders
- Discharge/weeping
- Painless
- Proximal- medial gaiter region- [bottom half of calf]
- Swelling
- Itching
- Aching
Signs - in severe cases:
- Lipodermatosclerosis-upside down champagne bottle sign
- Atrophie blanche- white, atrophic skin surrounded by small dilated capillaries + hyperpigmentation
- Haemosiderin deposition- discolouration [congestion of blood b/c decreased blood flow=leaks out]
- Stasis eczema
Investigations
Arterial
- Duplex Ultrasound- lower limbs
- ABPI
- Percutaneous angiography
- ECG
- Bloods- Fasting lipids, glucose, Hba1c, FBC
Venous
- Duplex ultrasound- lower limb
- ABPI
- Swab- microbiology [if signs of infection]
- Measure surface area of ulcer + monitor progression
- Biopsy- rule out Marjolin’s ulcer [type of SCC]
Management
Arterial
-
Venous
- Graded compression stockings [exclude neuropathy/diabetes/PVD first]
- Debridement and cleaning
- Antibiotics if infection
- Moisturiser for eczema
Complications
- Recurrence
- Infection- leading to eg gangrene
Prognosis
- Good esp if patient mobile + few comorbidities
- Compliance is key
Pictures of venous ulcer
Picture of arterial ulcers
Pictures of neuropathic ulcers
SBA 3:
62 y old man, A and E, severe abdominal pain, radiates to back.
Pain started 45 mins ago and is 9/10.
O/E- systemically unwell, cold peripheries
Observations: 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 [rupture]
Abdominal aortic aneurysm
Definition
Types- true/false
Risk factors
Epidemiology
Symptoms
Signs
Investigations
Definition
Localised enlargement/aneurysm in aorta with a diameter of more than 3cm or 50 % larger than the normal diameter of 2cm
Types- true/false
True anerysm- affects all 3 layers
False aneurysm- tear in one layer
Risk factors
Male
Old
Smoking
Family history
Hypertension
Hyperlipidaemia
Connective tissue disease
Inflammatory disorders- eg vasculitides
Epidemiology
6% of population
Males over 65= are regularly screened
Symptoms
Unruptured:
Asymptomatic
Aneurysm incidentally discovered
Sometimes pain in back, abdomen, loin or groin
Ruptured:
Sharp severe back in back, abdo, loin/flank, and groin
Shock- hypotension
Signs
Pulsatile, laterally expansile abdominal aorta
Grey turner’s sign- if retroperitoneal haemorrhage
Abdominal bruit
Investigations
Bloods: FBC, clotting, LFT, renal function
Cross match- blood
USS- shows size of anerysm but cannot detect if ruptured/leaking
CT contrast/CT with angiography- can tell if ruptured
MR angiography
SBA 4
A 35-year-old man presents to A+E with sudden onset chest pain. He describes the pain 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
Aortic dissection
Definition
Types
Risk factors
Epidemiology
Symptoms
Signs
Investigations
Aortic dissection
Definition
Tear in the tunica intima of the aorta causing blood to flow into a new false lumen/channel between the inner and outer layers of the tunica media
Types
Stanford classification:
A- in ascending aorta [more common]
B- in descending aorta
DeBakey classification:
Type I- ascending, descending and aortic arch [whole aorta]
Type II- ascending aorta
Type III- descending aorta
Risk factors
HYPERTENSION
Male
Atherosclerotic disease
Coarctation of aorta- congenital cardiac abnormalities
Connective tissue disease- Marfans,Ehlers Danlos
Cocaine/amphetamine usage
Smoking
Heavy lifting
Epidemiology
Males
40-60 years
Younger males [30 years] with Connective Tissue Disease
72%
Symptoms
Sudden central tearing chest pain
Radiates to back between shoulder blades
Acute if less than fourteen days
Symptoms due to occlusion of other arteries due to expansion of false lumen
Loss of consciousness= subclavian artery {also causes weak pulse/bp in left arm}
Abdominal pain - coeliac artery
Anuria- renal artery
Signs
Interarm difference in BP of >20mmHg
{if compressed brachiocephalic trunk, weaker in right arm, if compressed subclavian artery, weaker in left arm}
Hypertension
Hypotension- if cardiac tamponade
Diastolic murmur
Features of connective tissue disease
Investigations
Urgent CT angiogram- shows false lumen
Bloods:
FBC
Lactate- shows hypo/malperfusion
U and E
LFT
Cardiac enzymes- rule out ACS
Blood type and cross match
ECG- ST depression- myocardial depression if ischaemia, or normal
CXR- loss of contour of aortic knuckle
Varicose veins
Definition
Types
Causes
Risk factors
Epidemiology
Symptoms
Signs
Investigations
Management
Complications
Prognosis
Varicose veins
Definition
Subcutaneous permanently dilated veins more than three mm in diameter when standing
Prominently elongated and tortuous
Pathophysiology
Venous valve imcompetence
Causes
Primary- idiopathic
Secondary-
DVT
Pelvic masses [progesterone and oestrogen venodilate]
- Pregnancy
- Ovarian masses
- Uterine fibroids
AV malformations
Risk factors
Previous DVT
Pregnant/Previous pregnancies
Age
Female
FH of varicose veins
Obesity
Prolonged standing
Epidemiology
Female
Over 15:
10% of males
20% of females
Western
Symptoms
Dilated veins
Aching legs- worse with prolonged standing
[signs of venous imcompetence]
Swelling
Itching
Bleeding
Signs
Inspection: Dilated superficial veins ON standing
Ulcers
Palpations- Tapping distal varicose veins causes transmitted impulse to be felt at saphenofemoral junction [rare in clinical practice
Tender [phlebitis] or hard veins [thrombosis]
Auscultations: Bruits
Tredelenburg Test- localises sites of venous imcompetence [not used much anymore]
Investigations
Duplex USS
- localises site of venous incompetence
- Rules out DVT
Management
Conservative
- Compression stockings
- Lifestyle changes- diet/weight loss, exercise, leg elevation
Endovascular intervention
Radiofrequency ablation- catheter heated up to destroy veins
Endovenous laser ablation
Microinjection sclerotherapy- injections to create sclerotic tissue in veins
Surgical
Auvlsion of varicosities [remove small segements of varicose veins through small incisions in skin]
Saphenofemoral ligation
Stripping of long saphenous vein
Complications
Of venous insufficency
- Lipodermatosclerosis
- Venous pigmentation
- Eczema
- Ulcers
- Superfical thrombophlebitis
Of sclerotherapy
- Skin staining
- Local scarring
Of surgery
Haemorrhage
Infection
Parasthesia
Peroneal nerve injury
Prognosis
- Slow recovery
- High recurrence
- But symptoms resolve in 95% of patients after treatment
