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Vascular Mushkies Flashcards

1
Q

Venous examination?

A
  1. Inspection = skin changes & scars + site & size of varicosities
  2. Palpation
  3. Auscultation
  4. Doppler
  5. Completion
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2
Q

Chronic venous insufficiency skin changes?

A

HAS LEGS

  1. Haemosiderosis
  2. Atrophie Blanche
  3. Swelling
  4. Lipodermatosclerosis
  5. Eczema
  6. Gaiter Ulcers
  7. Stars, venous
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3
Q

Site of varicosities?

A
  1. Medial and above knee = great saphenous
  2. Posterior and below knee = short saphenous
  3. Few varicosities + prominent skin changes = calf perforators
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4
Q

Palpation in venous examination?

A
  1. Pitting oedema
  2. Varicosities (tenderness = thrombophlebitis, induration = thrombosis)
  3. Saphena varix @ SFJ
  4. Tap test = tap proximally and feel for impulse distally
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5
Q

Auscultation in venous examination?

A

Bruit over varicosity = AVM

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6
Q

Doppler in venous examination?

A
  1. Place probe @ SFJ/SPJ and squeeze calf
  2. Normally hear only half second whoosh when pressure is released
  3. Long whoosh suggests valve incompetence
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7
Q

Completion of venous examination?

A
  1. Trendelenburg/Tourniquet test
  2. Examine abdomen + PR
  3. Pelvis in females
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8
Q

Tourniquet/Trendelenburg test?

A
  1. Position pt supine, elevate leg and milk veins
  2. Apply tourniquet as high up as possible or compress SFJ
  3. Stand pt
  4. Controlled = incompetence ABOVE tourniquet, release tourniquet to confirm filling
  5. Uncontrolled = incompetence BELOW tourniquet, e.g. SPJ or calf perforators, repeat test with tourniquet just below knee
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9
Q

SFJ location?

A

2 finger breadths below and lateral to pubic tubercle

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10
Q

Great saphenous vein passes where respective to malleolus?

A

Anterior to medial malleolus

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11
Q

Varicose veins defn?

A

Tortuous, dilated veins of the superficial venous system due to underlying valve incompetence

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12
Q

CEAP classification acronym?

A
  1. Clinical Signs
  2. Etiology
  3. Anatomy
  4. Pathophysiology
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13
Q

3 main sites where valve incompetence occurs?

A
  1. SFJ = 3cm below and 3cm lateral to pubic tubercle
  2. SPJ = popliteal fossa
  3. Perforators = draining GSV (great saphenous vein)
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14
Q

Causes of varicose veins classification?

A

Primary and Secondary

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15
Q

Primary causes of varicose veins?

A
  1. Prolonged standing
  2. Pregnancy
  3. Obesity
  4. OCP
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16
Q

Secondary causes of varicose veins?

A
  1. Valve destruction = DVT, thrombophlebitis
  2. Obstruction = pelvic mass, DVT
  3. AVM
  4. Syndromes
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17
Q

Syndromes that cause varicose veins?

A
  1. Klippel-Trenaunay-Weber syndrome = abnormality of the deep venous system –> varicose veins, port wine stain, bony + soft tissue hypertrophy of the limbs
  2. Parkes-Weber Syndrome = multiple AVMs with limb hypertrophy
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18
Q

Symptoms of varicose veins?

A
  1. Cosmetic
  2. Pain, cramping, heaviness
  3. Tingling
  4. Bleeding = may be severe
  5. Swelling
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19
Q

Varicose veins definitive Ix?

A

Duplex US

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20
Q

Mx of varicose veins?

A
  1. Conservative = lose weight, exercise, avoid prolonged standing, compression stockings, emollients
  2. Minimally invasive therapies
  3. Surgery
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21
Q

Minimally invasive therapies for varicose veins?

A
  1. Injection sclerotherapy with 1% Na tetradecyl sulphate

2. Endovenous laser or RFA

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22
Q

Indication for minimally invasive therapies for varicose veins?

A

Small below knee varicosities not involving the GSV or SSV

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23
Q

Post-op Mx of minimally invasive therapies for varicose veins?

A
  1. Compression bandage for 24hrs

2. Compression stockings for 1 month

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24
Q

Indications for surgery for varicose veins?

A
  1. SFJ incompetence
  2. Major perforator incompetence
  3. Symptomatic = ulceration, skin changes, pain
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25
Surgical procedures for varicose veins?
1. Trendelenberg = saphenofemoral ligation 2. SSV ligation = in popliteal fossa 3. Multiple avulsions 4. Cockett's operation = perforator ligation 5. SEPS
26
SEPS?
Subfascial endoscopic perforator surgery
27
Varicose vein surgery post-op Mx?
1. Bandage tightly and elevate for 24hrs | 2. Discharge w/ compression stockings and told to walk daily
28
Complications of varicose vein surgery?
1. Early = haematoma, wound sepsis, nerve damage e.g. long saphenous 2. Late = superficial thrombophlebitis, DVT, recurrence (10% at 5 years)
29
Test for deep venous occlusion?
Perthes test = high tourniquet around pts leg + walking for 5 mins --> swelling and pain
30
Causes of post-phlebitic syndrome?
1. Reflux following DVT = 90% | 2. Obstruction following DVT = 10%
31
Venous gangrene?
Rare complication of DVT in the iliofemoral segment with 3 phases: 1. Phlegmasia alba dolens = white leg 2. Phlegmasia cerulea dolens = blue leg 3. Gangrene secondary to acute ischaemia
32
Lipodermatosclerosis?
An inflammatory sclerosing panniculitis occurring secondary to chronic venous insufficiency
33
Ix of deep venous disease?
1. Duplex US 2. Venography 3. Ambulatory venous pressures
34
Surgical Mx of post-phlebitic limb?
1. Reflux = valvuloplasty of damaged valves (Kistner Operation), or transplant of axillary vein with valve into deep venous system of leg (Trahere transplantation) 2. Obstruction = Palma oberation (use contralateral GSV and anastomose to femoral vein to bypass iliofemoral obstruction)
35
Arterial examination?
1. Inspection 2. Palpation 3. Auscultation 4. Buerger's angle 5. Completion
36
Arterial examination inspection?
1. Colour = pallor or cyanosis 2. Trophic changes = muscle atrophy, dry shiny skin, nail dystrophy and loss of hair 3. Ulcers = between toes, base of 1st and 5th metacarpals, heel 4. Gangrene 5. Scars
37
Arterial examination palpation?
1. Temperature 2. Pulses = present as present, reduced or absent 3. Capillary refill <2s
38
Lower limb pulses?
1. Aorta = just above umbilicus 2. Femoral = mid-inguinal point 3. Popliteal = b/w heads of gastrocnemius 4. Dorsalis pedis = lateral to extensor hallucis longus, absent in 5% 5. Posterior tibial = postero-inferior to medial malleolus 6. Graft + distal pulses = is the graft patent
39
Arterial examination auscultation?
1. Aorta and renal vessels 2. Iliac = midway from umbilicus to inguinal ligament 3. Femoral 4. Course of SFA if popliteal cant be palpated 5. Grafts
40
Buerger's Angle and Test?
1. Lift leg to 45 degrees and observe for pallor and venous guttering, <20 = severe ischaemia 2. Buerger's test = reactive hyperaemia on lowering the leg secondary to vasodilation of the microcirculation in response to ischaemia
41
Arterial examination completion?
1. Pulses 2. ABPI 3. DM neuropathy and valve disease
42
2 presentations of chronic limb ischaemia?
1. Intermittent claudication | 2. Critical limb ischaemia
43
Intermittent claudication fx?
1. Cramping pain after walking a fixed distance 2. Pain rapidly relieved by rest 3. Calf pain = superficial femoral disease (commonest) 4. Buttock pain = iliac disease (internal or common)
44
Critical limb ischaemia fx?
1. Ankle artery pressure <50mmHg 2. Rest pain >2 weeks = esp. at night, usually felt in the foot, pt hangs foot out of bed 3. Tissue loss = ulceration, gangrene
45
Classification system for chronic limb ischaemia?
Fontaine Classification 1. Asymptomatic 2. Intermittent claudication 3. Rest pain 4. Ischaemic ulcers or gangrene
46
What is Leriche's syndrome?
Aortoiliac Occlusive Disease, presenting with triad of: 1. Buttock claudication and wasting 2. Erectile dysfunction 4. Absent femoral pulses
47
Intermittent claudication path, site, pain and examination?
1. Path = arterial insufficiency 2. Site = calf or buttock 3. Pain = set distance, reproducible, worse up stairs, cramping, eased by standing rest 4. Examination = evidence of PVD
48
Spinal claudication path, site, pain and examination?
1. Path = nerve compression 2. Site = ill defined/whole leg 3. Pain = positional onset, better up stairs, burning pain, eased sitting forward 4. Examination = normal
49
RFs for chronic limb ischaemia?
1. Modifiable | 2. Non-modifiable
50
Modifiable RFs for chronic limb ischaemia?
1. Smoking 2. BP 3. DM 4. Lipids 5. Exercise
51
Non-modifiable RFs for chronic limb ischaemia?
1. FHx 2. PMH 3. Male 4. Age 5. Ethnicity
52
Fontaine 1 ABPI?
0.8-1
53
Fontaine 2 ABPI?
0.6-0.8
54
Fontaine 3 ABPI?
0.3-0.6
55
Fontaine 4 ABPI?
<0.3
56
Normal ABPI?
>1
57
CKF/DM calcification ABPI?
>1.4
58
Chronic limb ischaemia Ix?
1. Bedside = ABPI, ECG 2. Bloods = FBC (anaemia may worsen Sx), U&E (renovascular disease), glucose, lipids 3. Imaging = Duplex US, CT/MR angiogram, digital subtraction angiography
59
Mx of chronic limb ischaemia?
1. Conservative 2. Medical 3. Interventional 4. Surgical
60
Conservative mx of chronic limb ischaemia?
1. Walk through pain = exercise programmes 2. Foot care 3. Stop smoking 4. Weight loss
61
Medical mx of chronic limb ischaemia?
1. HTN 2. Statin 3. Antiplatelets
62
Interventional mx of chronic limb ischaemia?
1. Angioplasty +/- stenting | 2. Chemical sympathectomy
63
Surgical mx of chronic limb ischaemia?
1. Endarterectomy 2. Bypass grafting 3. Amputation
64
Bypass grafting indications?
1. V. short claudication distance (<100m) 2. Sx greatly affecting QoL 3. Rest pain
65
Practicalities of bypass grafting?
1. Need good proximal supply and distal run off 2. Saphenous vein grafts preferred below the IL 3. More distal grafts have increased rates of thrombosis
66
Classification of bypass grafting?
1. Anatomical = fem-pop, fem-distal, aortobifemoral | 2. Extra-anatomical = axillo-fem/bifem, fem-fem crossover
67
AAA palpation?
Pulsatile and expansile mass on deep palpation in the epigastrium
68
AAA defn?
Abnormal dilatation of the abdominal aorta to >50% of its normal diameter, or >3cm
69
AAA Ix?
1. US 2. CT/MRI 3. Angio
70
Complications of AAA surgery?
1, Death 2. MI 3. Renal failure 4. Spinal/mesenteric ischaemia 5. Distal trash from thromboembolism 6. Anastomotic leak 7. Graft infection 8. Aortoenteric fistula
71
Operative mortality of AAA?
1. AAA = Emergency (50%), Elective (5%) | 2. EVAR = 1%
72
Popliteal aneurysm Fx?
1. Represent >80% of all non-aortic aneurysms 2. Lump behind the knee, >2cm 3. 50% present with distal limb ischaemia (thromboembolism) 4. <10% rupture
73
Mx of popliteal aneurysm?
1. Acute = embolectomy or fem-distal bypass | 2. Stable = excision bypass
74
Indications for surgical mx of popliteal aneurysm?
1. Symptomatic 2. Containing thrombus 3. >2cm
75
Aneurysm defn?
Abnormal dilatation of a blood vessel to >50% of its normal diameter
76
Aneurysm classification?
1. True 2. False 3. Dissection
77
True aneurysm?
Dilatation of a blood vessel involving all layers of the wall and >50% of its normal diameter 1. Fusiform = AAA 2. Saccular = Berry
78
False aneurysm?
Collection of blood around a vessel wall that communicates with the vessel lumen 1. Usually iatrogenic e.g. puncture, cannulation 2. Fibrous tissue forms around haematoma --> false sac which communicates with the vessel lumen
79
Dissection?
Vessel dilatation caused by blood splaying apart the media to form a channel within the vessel wall
80
Causes of aneurysms?
1. Congenital | 2. Acquired
81
Congenital causes of aneurysms?
1. ADPKD --> Berry | 2. CTD = Marfans, ED
82
Acquired causes of aneurysms?
1. Atherosclerosis 2. Inflammatory = Takayasu's, HSP 3. Infection = Mycotic (SBE), Tertiary Syphilis, Samonella typhi 4. Trauma = penetrating
83
Infection associated with AAA?
S. typhi
84
Complications of aneurysms?
1. Rupture 2. Thrombosis 3. Distal embolisation 4. Pressure = DVT, oesophagus, nutcracker syndrome 5. Fistula = IVC, intestine
85
Aneurysm screening?
UK men offered one time US screen at 65 years
86
Most common location for false aneurysm?
Common femoral artery following puncture for a radiological procedure
87
Mx of false aneurysm?
1. US compression 2. Thrombin injection 3. Surgical repair
88
Amputation examination?
1. Inspection 2. Palpation 3. Move 4. Completion
89
Amputation inspection?
1. Stump anatomical level 2. Stump health 3. Evidence of chronic vascular disease
90
Amputation palpation?
1. Soft tissue under skin should move freely over the bone | 2. Proximal pulses
91
Amputation movement?
1. Actively flex and extend the joint above the amputation (many pts have fixed flexion deformity after BKA) 2. Ask to see prosthesis and see pt walk in it
92
Amputation exam completion?
Examine other limb for signs of PVD
93
Indications for amputations?
4Ds 1. Dead = PVD (90%), thrombangiitis obliterans 2. Dangerous = sepsis, malignancy 3. Damaged = trauma, burns, frostbite 4. Damned nuisance = pain, neurological damage
94
Complications of amputation?
1. Early = death, haemorrhage, infection (cellulitis, gangrene, osteomyelitis) 2. Late = scar contractures (fixed flexion), phantom limb pain (gabapentin/mirror box), poor stump shape inhibiting prosthesis
95
2 possible carotid artery disease findings?
1. Carotid endarterectomy scar = beneath angle of the mandible, parallel to the SCM 2. Carotid bruit = along course of common carotid, medial to the SCM in the anterior
96
Complications of carotid stenosis?
1. TIA | 2. Stroke
97
Carotid endarterecomy complications?
1. Haematoma 2. MI 3. Nerve injury
98
What nerves an be injured by a carotid endarterectomy?
1. Hypoglossal 2. Greater auricular = numb ear lobe 3. RLN = hoarse voice, bovine cough
99
Inspection and palpation of diabetic foot?
1. Inspection = bilateral arterial disease, amputations esp. digits, charcot joints, ulceration 2. Palpation = pulses may be preserved due to calcification, decreased sensation in stocking distribution
100
Diabetic foot syndrome features?
1. Macrovascular disease 2. Microvascular disease 3. Neuropathy 4. Infection and osteomyelitis
101
Aetiology of diabetic ulcers?
1. Neuropathic = 45-60% 2. Ischaemia = 10% 3. Mixed neuroischaemic = 25-45%
102
Considerations for diabetics undergoing angiography?
1. Often have a degree of renal impairment which can be dramatically worsened with contrast agents 2. Metformin must be stopped prior to the procedure to prevent lactic acidosis
103
Gangrene defn?
Irreversible tissue death from poor vascular supply
104
Classification of gangrene?
1. Pregangrene = tissue on the brink of gangrene 2. Dry = tissue death only 3. Wet = tissue death + infection
105
Causes of gangrene?
DERTI 1. DM = commonest 2. Embolism and thrombosis = foot trash in AAA repair 3. Raynaud's 4. Thrombangiitis obliterans 5. Injury = extreme cold, heat, trauma or pressure
106
Thrombangiitis obliterans aka?
Buerger's disease
107
Mx of gangrene?
1. Take cultures 2. Debridement (including amputation) 3. Benzylpenicillin +/- clindamycin
108
What is synergistic gangrene?
Involved both aerobes and anaerobes, progresses rapidly to necrotizing fasciitis and myositis
109
2 types of synergistic gangrene?
1. Fournier's = perineum | 2. Meleney's = post-op ulceration
110
Gas gangrene defn?
1. AKA Clostridial myonecrosis | 2. RFs = DM, trauma, malignancy
111
Presentation of gas gangrene?
1. Toxaemia 2. Crepitus from surgical emphysema 3. Bubbly brown pus
112
Mx of gas gangrene?
1. Debridement +/- amputation 2. Benzylpenicillin +/- metronidazole 3. Hyperbaric O2
113
Raynaud's phenomenon?
Characteristic cold induced changed associated with vasospasm
114
Raynaud's disease?
Primary Raynaud's phenomenon occurring in isolation
115
Raynaud's syndrome?
Secondary Raynaud's phenomenon association with other disease
116
Colour changes in Raynaud's?
White --> Blue --> Crimson
117
Pathogenesis of raynauds?
1. Overactive a-sympathetic receptors OR | 2. Fixed obstruction in vessel wall
118
Secondary causes of Raynaud's?
BADCAT 1. Bloods = polycythaemia, cryoglobulinaemia, cold agglutinin 2. Arterial = atherosclerosis, thrombangiitis obliterans 3. Drugs = BB, OCP, ergotamine 4. Cervical rib = thoracic outlet obstruction 5. AI = SLE, RA, SS 6. Trauma = vibration injry
119
Mx of Raynauds?
1. Conservative = wear gloves and avoid cold, stop smoking 2. Medical = Nifedipiine, IV prostacyclin 3. Surgical = cervical sympathectomy, amputate gangrenous digits
120
DDx (NOT CAUSES) of thoracic outlet obstruction?
1. Arterial = Raynauds 2. Venous = Axillary vein thrombosis or trauma 3. Neuro = cervical spondylosis, Pancoasts tumour
121
Arm signs of thoracic outlet obstruction?
Reduced venous outflow 1. Pitting oedema 2. Cyanosis 3. Pallor
122
Hand signs of thoracic outlet obstruction?
Reduced arterial inflow 1. Raynauds 2. Patchy gangrene 3. Fingertip necrosis
123
Hand and arm signs of thoracic outlet obstruction?
Neurological complications 1. Complete claw hand 2. T1 sensory loss 3. Radicular pain
124
Aetiology of thoracic outlet obstruction?
1. Congenital = cervical rib | 2. Acquired = clavicular fracture, pathological enlargement of 1st rib
125
Peripheral ulcer examination?
1. Inspection 2. Palpation 3. Completion
126
Inspection of peripheral ulcer?
3S + BEDS 1. 3S = size, site, shape 2. Base = granulation tissue, slough, floor (bone, tendon, fascia) 3. Edge = sloping, punched out, undermined, rolled, everted 4. Discharge = serous, purulent, asnguinous 5. Surroundings = cellulitis, excoriations, sensate, LNs
127
Sloping peripheral ulcer?
Healing (usually venous)
128
Punched out ulcer?
Ischaemic or neuropathic
129
Undermined ulcer?
Pressure necrosis or TB
130
Rolled ulcer?
BCC
131
Everted ulcer?
SCC
132
Peripheral ulcer palpation?
1. Lib pulses | 2. Sensation around the ulcer
133
Completion of peripheral ulcer examination?
1. Neurovascular examination | 2. ABPI must be >0.8 for compression bandaging
134
Causes of a peripheral ulcer?
1. Venous = 75% 2. Arterial = 2% 3. Mixed arteriovenous = 15% 4. Neuropathic 5. Pressure 6. Vasculitis e.g. PAN 7. Malignancy = SCC, Marjolins 8. Systemic = Pyoderma gangrenosum
135
Venous ulcer inspection?
3S BEDS 1. Site = medial malleolus 2. Size = can be large 3. Shape = uneven 4. Base = shallow, pink granulation tissue 5. Edge = sloping edge 6. Discharge = seropurulent 7. Surroundings = HAS LEGS, varicose veins
136
Venous ulcer palpation?
1. Painless 2. Warm surrounding 3. Sensate
137
Causes of venous ulcer?
1. Valvular disease 2. Varicose veins 3. Deep vein reflux 4. Outflow obstruction e.g. post-DVT 5. Muscle pump failure 6. Stroke 7. Neuromuscular disease
138
Venous ulcer Ix?
1, Bedside = ABPI, duplex US | 3. Biopsy
139
Venous ulcer Mx?
1. Conservative = leg ulcer clinic, RFs, anaglesia, bed rest, elevate leg, manuka honey (topical antiseptic) 2. 4 layer compression bandaging if ABPI > 0.8 3. Surgical = split-thickness skin grafts
140
Ischaemic ulcer inspection?
3S + BEDS 1. Site = between toes, base of 1st and 5th metatarsals, heel 2. Size = mm-cm 3. Shape = often circular 4. Base = deep (may be down to bone), may be slough but no granulation tissue 5. Edge = punched out 6. Discharge = minimal 7. Surroundings = pale, trophic changes
141
Causes of ischaemic ulcer?
1. Large vessel = atherosclerosis, thrombangiitis obliterans | 2. Small vessel = DM, PAN, RA
142
Ischaemic ulcer Mx?
1. Conservative = analgesia (ladder), RFs | 2. Medical = RFs, IV prostaglandins, chemical lumbar sympathectomy
143
Chemical lumbar sympathectomy?
1. Chemical ablation of L1-L4 paravertebral ganglia 2. Inhibit sympathetic mediated vasocontriction 3. Relief of pain 4. Often unsuccessful in DM
144
Neuropathic ulcer inspection?
3S + BEDS 1. Site = pressure areas, between toes, base of 1st and 5th metatarsals, heel 2. Size = variable 3 . Shape = corresponds to shape of pressure point 4. Base = may be deep with bone exposure 5. Edge = punched out 6. Discharge = minimal 7. Surroundings = normal skin, Charcot's joints
145
Neuropathic ulcer palpation?
1. Normal temperature and peripheral pulses | 2. Absent sensation around ulcer, absent ankle jerks
146
Cause of neuropathic ulcer?
Any cause of peripheral neuropathy
147
Pathophysiology of neuropathic ulcer?
1. Sensory neuropathy = distal limb damage not felt by pt 2. Motor neuropathy = wasting of intrinsic foot muscles and an altered foot shape 3. Autonomic neuropathy = decreased sweating --> cracked, dry foot
148
Lymphoedema pitting?
Initially pitting, later non-pitting
149
Unilateral limb swelling Ddx?
1. Infection 2. Inflammation 3. DVT 4. Venous insufficiency 5. Lymphoedema
150
Causes of bilateral limb swelling?
1. Increased venous pressure = RHF, venous insufficiency, CCBs 2. Reduced oncotic pressure = hepatic failure, nephrotic syndrome, protein losing enteropathy 3. Lymphoedema 4. Myxoedema = hypothyroidism
151
Lymphoedema defn?
Collection of interstitial fluid due to blockage or absence of lymphatics
152
Classification of causes of lymphoedema?
Primary or Secondary
153
Primary causes of lymphoedema?
1. Congenital absence of lymphatics, may or may not be familial 2. Milroy's syndrome
154
Milroy's syndrome?
Familial AD subtype of congenital lymphoedema, often presenting with unilateral limb swelling and hydrocele
155
Secondary causes of lymphoedema?
FIIT 1. FIbrosis = e.g. post-radiotherapy 2. Infection = TB 3. Infiltration = Ca (prostate, lymphoma), Lymphatic Filariasis (Wuchereria bancrofti) 4. Trauma = block dissection of lymphatics
156
Mx of lymphoedema?
1. Conservative = skin care, Grade 3 compression stockings, treat/prevent cellulitis 2. Physio = raise leg as much as possible 3. Surgical = debulking operation, bypass procedures

Medicine and Surgery Mushkies (52 decks)

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