Vascular Mushkies Flashcards
Venous examination?
- Inspection = skin changes & scars + site & size of varicosities
- Palpation
- Auscultation
- Doppler
- Completion
Chronic venous insufficiency skin changes?
HAS LEGS
- Haemosiderosis
- Atrophie Blanche
- Swelling
- Lipodermatosclerosis
- Eczema
- Gaiter Ulcers
- Stars, venous
Site of varicosities?
- Medial and above knee = great saphenous
- Posterior and below knee = short saphenous
- Few varicosities + prominent skin changes = calf perforators
Palpation in venous examination?
- Pitting oedema
- Varicosities (tenderness = thrombophlebitis, induration = thrombosis)
- Saphena varix @ SFJ
- Tap test = tap proximally and feel for impulse distally
Auscultation in venous examination?
Bruit over varicosity = AVM
Doppler in venous examination?
- Place probe @ SFJ/SPJ and squeeze calf
- Normally hear only half second whoosh when pressure is released
- Long whoosh suggests valve incompetence
Completion of venous examination?
- Trendelenburg/Tourniquet test
- Examine abdomen + PR
- Pelvis in females
Tourniquet/Trendelenburg test?
- Position pt supine, elevate leg and milk veins
- Apply tourniquet as high up as possible or compress SFJ
- Stand pt
- Controlled = incompetence ABOVE tourniquet, release tourniquet to confirm filling
- Uncontrolled = incompetence BELOW tourniquet, e.g. SPJ or calf perforators, repeat test with tourniquet just below knee
SFJ location?
2 finger breadths below and lateral to pubic tubercle
Great saphenous vein passes where respective to malleolus?
Anterior to medial malleolus
Varicose veins defn?
Tortuous, dilated veins of the superficial venous system due to underlying valve incompetence
CEAP classification acronym?
- Clinical Signs
- Etiology
- Anatomy
- Pathophysiology
3 main sites where valve incompetence occurs?
- SFJ = 3cm below and 3cm lateral to pubic tubercle
- SPJ = popliteal fossa
- Perforators = draining GSV (great saphenous vein)
Causes of varicose veins classification?
Primary and Secondary
Primary causes of varicose veins?
- Prolonged standing
- Pregnancy
- Obesity
- OCP
Secondary causes of varicose veins?
- Valve destruction = DVT, thrombophlebitis
- Obstruction = pelvic mass, DVT
- AVM
- Syndromes
Syndromes that cause varicose veins?
- Klippel-Trenaunay-Weber syndrome = abnormality of the deep venous system –> varicose veins, port wine stain, bony + soft tissue hypertrophy of the limbs
- Parkes-Weber Syndrome = multiple AVMs with limb hypertrophy
Symptoms of varicose veins?
- Cosmetic
- Pain, cramping, heaviness
- Tingling
- Bleeding = may be severe
- Swelling
Varicose veins definitive Ix?
Duplex US
Mx of varicose veins?
- Conservative = lose weight, exercise, avoid prolonged standing, compression stockings, emollients
- Minimally invasive therapies
- Surgery
Minimally invasive therapies for varicose veins?
- Injection sclerotherapy with 1% Na tetradecyl sulphate
2. Endovenous laser or RFA
Indication for minimally invasive therapies for varicose veins?
Small below knee varicosities not involving the GSV or SSV
Post-op Mx of minimally invasive therapies for varicose veins?
- Compression bandage for 24hrs
2. Compression stockings for 1 month
Indications for surgery for varicose veins?
- SFJ incompetence
- Major perforator incompetence
- Symptomatic = ulceration, skin changes, pain
Surgical procedures for varicose veins?
- Trendelenberg = saphenofemoral ligation
- SSV ligation = in popliteal fossa
- Multiple avulsions
- Cockett’s operation = perforator ligation
- SEPS
SEPS?
Subfascial endoscopic perforator surgery
Varicose vein surgery post-op Mx?
- Bandage tightly and elevate for 24hrs
2. Discharge w/ compression stockings and told to walk daily
Complications of varicose vein surgery?
- Early = haematoma, wound sepsis, nerve damage e.g. long saphenous
- Late = superficial thrombophlebitis, DVT, recurrence (10% at 5 years)
Test for deep venous occlusion?
Perthes test = high tourniquet around pts leg + walking for 5 mins –> swelling and pain
Causes of post-phlebitic syndrome?
- Reflux following DVT = 90%
2. Obstruction following DVT = 10%
Venous gangrene?
Rare complication of DVT in the iliofemoral segment with 3 phases:
- Phlegmasia alba dolens = white leg
- Phlegmasia cerulea dolens = blue leg
- Gangrene secondary to acute ischaemia
Lipodermatosclerosis?
An inflammatory sclerosing panniculitis occurring secondary to chronic venous insufficiency
Ix of deep venous disease?
- Duplex US
- Venography
- Ambulatory venous pressures
Surgical Mx of post-phlebitic limb?
- Reflux = valvuloplasty of damaged valves (Kistner Operation), or transplant of axillary vein with valve into deep venous system of leg (Trahere transplantation)
- Obstruction = Palma oberation (use contralateral GSV and anastomose to femoral vein to bypass iliofemoral obstruction)
Arterial examination?
- Inspection
- Palpation
- Auscultation
- Buerger’s angle
- Completion
Arterial examination inspection?
- Colour = pallor or cyanosis
- Trophic changes = muscle atrophy, dry shiny skin, nail dystrophy and loss of hair
- Ulcers = between toes, base of 1st and 5th metacarpals, heel
- Gangrene
- Scars
Arterial examination palpation?
- Temperature
- Pulses = present as present, reduced or absent
- Capillary refill <2s
Lower limb pulses?
- Aorta = just above umbilicus
- Femoral = mid-inguinal point
- Popliteal = b/w heads of gastrocnemius
- Dorsalis pedis = lateral to extensor hallucis longus, absent in 5%
- Posterior tibial = postero-inferior to medial malleolus
- Graft + distal pulses = is the graft patent
Arterial examination auscultation?
- Aorta and renal vessels
- Iliac = midway from umbilicus to inguinal ligament
- Femoral
- Course of SFA if popliteal cant be palpated
- Grafts
Buerger’s Angle and Test?
- Lift leg to 45 degrees and observe for pallor and venous guttering, <20 = severe ischaemia
- Buerger’s test = reactive hyperaemia on lowering the leg secondary to vasodilation of the microcirculation in response to ischaemia
Arterial examination completion?
- Pulses
- ABPI
- DM neuropathy and valve disease
2 presentations of chronic limb ischaemia?
- Intermittent claudication
2. Critical limb ischaemia
Intermittent claudication fx?
- Cramping pain after walking a fixed distance
- Pain rapidly relieved by rest
- Calf pain = superficial femoral disease (commonest)
- Buttock pain = iliac disease (internal or common)
Critical limb ischaemia fx?
- Ankle artery pressure <50mmHg
- Rest pain >2 weeks = esp. at night, usually felt in the foot, pt hangs foot out of bed
- Tissue loss = ulceration, gangrene
Classification system for chronic limb ischaemia?
Fontaine Classification
- Asymptomatic
- Intermittent claudication
- Rest pain
- Ischaemic ulcers or gangrene
What is Leriche’s syndrome?
Aortoiliac Occlusive Disease, presenting with triad of:
- Buttock claudication and wasting
- Erectile dysfunction
- Absent femoral pulses
Intermittent claudication path, site, pain and examination?
- Path = arterial insufficiency
- Site = calf or buttock
- Pain = set distance, reproducible, worse up stairs, cramping, eased by standing rest
- Examination = evidence of PVD
Spinal claudication path, site, pain and examination?
- Path = nerve compression
- Site = ill defined/whole leg
- Pain = positional onset, better up stairs, burning pain, eased sitting forward
- Examination = normal
RFs for chronic limb ischaemia?
- Modifiable
2. Non-modifiable
Modifiable RFs for chronic limb ischaemia?
- Smoking
- BP
- DM
- Lipids
- Exercise
Non-modifiable RFs for chronic limb ischaemia?
- FHx
- PMH
- Male
- Age
- Ethnicity
Fontaine 1 ABPI?
0.8-1
Fontaine 2 ABPI?
0.6-0.8
Fontaine 3 ABPI?
0.3-0.6
Fontaine 4 ABPI?
<0.3
Normal ABPI?
> 1
CKF/DM calcification ABPI?
> 1.4
Chronic limb ischaemia Ix?
- Bedside = ABPI, ECG
- Bloods = FBC (anaemia may worsen Sx), U&E (renovascular disease), glucose, lipids
- Imaging = Duplex US, CT/MR angiogram, digital subtraction angiography
Mx of chronic limb ischaemia?
- Conservative
- Medical
- Interventional
- Surgical
Conservative mx of chronic limb ischaemia?
- Walk through pain = exercise programmes
- Foot care
- Stop smoking
- Weight loss
Medical mx of chronic limb ischaemia?
- HTN
- Statin
- Antiplatelets
Interventional mx of chronic limb ischaemia?
- Angioplasty +/- stenting
2. Chemical sympathectomy