Vascular Examination Flashcards
VIVA
How would you investigate a patient with a suspected DVT? Consider the Wells score in your answer.
Two-level DVT Wells score ≤1: D-dimer (rules out DVT if negative) then compression ultrasound if positive
Two-level DVT Wells score ≥2: compression ultrasound and D-dimer (if negative compression ultrasound and positive D-dimer → repeat compression ultrasound 6-8 days later)
VIVA
Name five risk factors for venous thromboembolism
Five from:
Paralysis/paresis
Recent cast immobilisation of lower extremities
Recently bedridden ≥3 days
Major surgery requiring regional or general anaesthetic in the previous 12 weeks
Previous VTE
Family history of VTE
Malignancy
Clotting disorder
Obesity
Pregnancy/COCP/HRT
Sitting for a long time, e.g. long-haul flight
VIVA
What is Virchow’s Triad?
Stasis of blood
Hypercoagulability
Endothelial injury
VIVA
What is the definition of a varicose vein? List 3 risk factors.
Superficial dilated and tortuous veins leading to retrograde flow of blood. They often occur in the lower leg and lead to changes in skin pigmentation, itching and aching.
Risk factors
Prolonged standing
Female gender
Smoking
Family History
Obesity
Pregnancy
Previous damage to the venous system (e.g. DVT, phlebitis)
VIVA
What are the associated skin changes with varicose veins?
- Change in pigmentation
- Ulceration
- Venous eczema
- Lipodermatosclerosis
- Haemosiderin Deposits
VIVA
What is the gold standard for diagnosing varicose veins?
Varicose veins can usually be diagnosed clinically, but a duplex ultrasound would be the gold standard test
VIVA
Discuss the management options for varicose veins
Conservative options:
Weight loss
Avoiding prolonged standing
Exercise
Compression stockings: these cannot be used in patients with concomitant peripheral arterial disease and so ankle-brachial pressure index (ABPI) must first be carried out. If ABPI <0.8 compression stockings are contraindicated.
Surgical options may be indicated if the patient is symptomatic or in the presence of bleeding or ulcers:
Endothermal ablation: closing of the vein via catheterisation and heating the vein from inside (carried out under local anaesthetic)
Foam sclerotherapy: closing of the vein by injecting a sclerosing agent under local anaesthetic
Vein ligation and stripping: under general anaesthetic, an incision is made and the vein is tied off at both ends; the vein is then ligated and stripped out
VIVA
What investigations and imaging would you consider to investigate peripheral arterial disease?
Bedside tests: ankle-brachial pressure index, blood pressure
Imaging: duplex ultrasound (1st line), MR/CT angiography, catheter angiography
Bloods: lipid levels, fasting glucose, FBC (rule out anaemia)
VIVA
What are the advantages/disadvantages of MRA and catheter angiography?
Catheter angiography: easy to interpret, cheap, invasive
MR angiography: higher visual detail (can see plaques), can’t be used if patient has metalwork, costly
VIVA
How is peripheral arterial disease managed?
- Lifestyle: exercise, foot care, smoking cessation, weight reduction
- Medial: anti-platelet agents, lipid control, BP and diabetes control
- Surgical: percutaneous transluminal angioplasty, surgical reconstruction, sympathectomy/amputation (if revascularisation impossible)
Aortobifemoral bypass graft - details, indications, sites on examination
Details
Aorta to both femoral arteries (open operation)
Indications
Aortoiliac occlusive disease
Axillofemoral used for patients who are unable to tolerate aortobifemoral (often elderly patients or patients with significant comorbidities)
Sites on examination
Midline laparotomy scar
Bilateral groin scars
Axillofemoral / Axillobifemoral bypass graft - details, indications, sites on examination
Details
Axillary artery to one/both femoral arteries
(graft tunnelled subcutaneously)
Indications
Aortoiliac occlusive disease
Axillofemoral used for patients who are unable to tolerate aortobifemoral (often elderly patients or patients with significant comorbidities)
Sites on examination
Axillary scar
Unilateral/bilateral groin scars
Graft may be palpable
Femorofemoral bypass graft - details, indications, sites on examination
Detials
Femoral artery to femoral artery
(graft tunnelled subcutaneously or in pre-peritoneal space)
Indications
Unilateral iliac disease
Sites on examination
Bilateral groin scars
Graft may be palpable
lliofemoral bypass graft - details, indications, sites on examination
Details
Iliac artery to femoral artery
(iliac artery on ipsilateral or contralateral side may be used)
Indications
Unilateral iliac disease
Sites on examination
Two groin scars (may be on the same or opposite sides depending on operation)
Femoropopliteal / Femorotibial / Femorodistal bypass graft - details, indications, sites on examination
Details
Femoral artery to popliteal artery, a tibial artery or distally
(graft may be tunnelled subcutaneously or anatomically)
Indications
Femoropopliteal disease
Sites on examination
Groin scar
Medial lower leg scar
Graft may be palpable
Trophic changes with bilateral callous formation and early ulceration
CABG vein grafting scar
Peripheral oedema
What are the risk factors for varicose veins?
Age
Female > male
Previous DVT
Obesity
Pregnancy
What is a saphena varix?
Dilation of the saphenous vein at its confluence with the femoral vein (transmits a cough impulse)
What is Trendelenburg test and how is it performed?
Trendelenburg (/tourniquet) test may be performed if varicosities are present. It can determine the location of venous regurgitation.
Procedure:
Lift patient’s leg as high as comfortable and milk leg to empty veins
While leg is elevated, apply tourniquet or press your thumb over saphenofemoral junction
Ask patient to stand while you maintain pressure over the saphenofemoral junction
Rapid filling of the varicosities with the tourniquet still on suggests incompetent perforator veins lie below the level of the saphenofemoral junction
Now repeat the test, moving the tourniquet down 3cm each time. When varicosities do not refill, the incompetent perforator is above the tourniquet but below where it was previously applied.
What are the risk factors for peripheral arterial disease?
Diabetes
Smoking
Hypercholesterolaemia
Hypertension
Age >60 years
What is Leriche syndrome?
Aortoiliac occlusive disease that results in a triad of claudication, impotence, and absence of femoral pulses.
In what circumstance may ABPI be falsely elevated?
Calcified arteries
How would you manage venous ulceration?
– Clean and dress ulcer
– Compression bandaging (after arterial disease excluded)
– Pentoxifylline may be considered
– Manage complications (pain, infection)
– Manage associated conditions (venous eczema, oedema)
– Lifestyle advice
Patient with one red foot and one pale foot?
Causes of ‘claudication’ in presence of normal peripheral pulses?
6Ps of critically ischaemic limb?
ABPI measurements
Arterial supply to the lower limbs?
Venous vs arterial ulcers?
Features of varicose veins?
Management of varicose veins?
Causes of chronic venous insufficiency?
Features of superficial thrombophlebitis?
Causes of intradermal vs subcutaneous lumps?
Signs of inflammation?
Features of lipoma vs sebaceous cyst vs ganglion?
Define acute limb ischaemia + list main causes
decreased limb perfusion leading to threatened limb viability (<14 days)
Initial management of acute limb ischaemia
Classification of chronic limb ischaemia
ABPI interpretation + other investigations for chronic limb ischaemia
Management of chronic limb ischaemia
Screening for AAA
Complications of AAA
Define compartment syndrome + list risk factors
raised pressure within closed anatomical space, leading to reduced tissue perfusion
Presentation, diagnosis + management of compartment syndrome
Presentation of mild, moderate vs severe varicose veins
Management of varicose veins
Venous vs arterial ulcers
