vascular revision Flashcards
Vascular exam -general exam
Look for all the vasculopaths-smoking, etc
Fistulae, inhalers
Walking sticks,
DONT MISS A MISSING LEG
examine hands, fingers missing (->trauma), nicotine stains
Pulse examination for vascular top half
go up-radial, radio-radial delay (if narrowing in arch of aorta-dissection)
Brachial
Offer BP
Subclavian pulse
Carotid pulses
then listen for bruits in neck-and ask them to breath out (helps)
offer examination of heart/pre-cordium before going to legs
most people at PACES have normal top half
Vascular exam bottom half before legs
Abdomen- look for scars, and around
feel for AAA-> above umbilicus-try and measure the size
Listen for renal/liver bruits
then go to legs-femoral pulse
Vascular exam lower limbs
Expose all the legs-
inspect feet- and look between the toes
same colour, any ulcer, gangrene (wet-infected, dry-infected)
temperature-feel all the way up
Start at femroal- bewteen asis/pubic symphysis BOTH SIDES AT ONCE
and radio-femoral (delay in coarctation of aorta)
Then popliteal-shake knee with hand-suspect aneurysm if too easy
then Pedal-dorsalis pedis, Tibialis posterior
(use them to decide if you poplitieal is there or if youre being bad)
very rarely-5%ish-no dorsalis pedis–because other peroneal artery is dominant
Or one with very faint femoral as sciatic artery is dominant
listen to bruits-Illiacs, SFA-2/3rd down to the knee- most common stenosed
then BUERGERs Test-implies significant ischemia
Buergers angle- angle between bed and leg as you raise-that foot goes white
THEN when the feet go white, swing them around and let them dangle the feet from the bed (the bad foot goes red-reflex hyperemia)
Positive buergers- white up, red down
THEN ABPI
Vascular special tests
Buergers and ABPI
then BUERGERs Test-implies significant ischemia
Buergers angle- angle between bed and leg as you raise-that foot goes white
THEN when the feet go white, swing them around and let them dangle the feet from the bed (the bad foot goes red-reflex hyperemia)
ABPI-with hand help doppler and pressure cuff
then press and check when the sound of doppler apears-thats pressure
then do– ankle, brachial, divide
>1.3-diabeteic calcified
0.6-0.8-claudication
below-critical limb ischemia
Vascular surgical scars-
Scars to expose vessels for open surgert
chest- thoracic aorta
AAA-rooftop (along the ribs), midline
Illiac- Diagonal oblique
femoral-longitudinal groin incision
neck-endcarotidectomy-diagnoanl on SEM
Axillary- At clavicule
also down the leg-usually inside of the thigh
some of these can have graft-and have connections to other arteries-ways to avoid claudication
Peripheral artery disease
Artherosclerosis-Diabetes, smoke , HTN
Old men
Either-
nothing-just risk (or cant walk enought to get claudication)
claudication
Critical/chronic limb ischemia
Claudication
Pain during walk that improves at rest
no pain at rest
usually cramping pain after a certain distance-pain is very bad
“look in a shop window/pretend theyre texting”-as a way to stop/relax
then can go the same distance
worse upstairs/uphill
pattern will tell you where stenosis is (like bum claudication, ankle, etc)
often have bruits -stenosis that can hear
No ulcers
Buergers NEGATIVE
ABPI 0.8-0.6
test- exercise ABPI
Duplex scan
Angiography
not dangerous-most are fine and will increase their distance with stop smoking, and exercise-best usually left alone. operations are for QOL
Limb loss is actually very rare
But also Risk of MI, stroke, renal failure
Chronic limb threatening ischemia
3 features
features of Arterial disease, Pain at rest or ulceration and 2w duration
if this present-need to treat as they will deteriorate-limb loss
Rest pain is all the time, worse at night, distal>proximal
Ulcers can be non painful-usually in pressure points
need stent, balloon angioplasty, bypass
Acute ischemia
6P
pain, pulseless, pale, perishingly cold,
v acute–paralysis, paresthesia
the first 4 are the common ones
foot is white at all buergers angles
6h to revascularise- if not=damage
either embolic (fine before), or artherosclerotic (can be less acute slightly) -no paralysis cause no acute change
Aneurysm, and AAA
can be aortic, kidney etc
AAA- often randomly found-at GP, or a random scan (usually prostate/kidney)
Screening ofc-observe
or when it burst
AAA-usually asx. rarely back pain
or when rupture-
and can cause emboli-can throw clots to feet-blotchy foot
Pressing on other structure
fistulae with skin, or Duodenum
AAA findings
Expansile mass
back pain
screening-USS man >65
First ix- duplex of the aorta
Varicose Veins-
dilated tortuous superficial leg veins in the distributions of veins
stand them up and obseve
sx- itchy, pain (dragging, not general “vein pain”), cosmesis, swelling, restless and cramps
complications- thrombophebitis (clot), Venous Eczema (at bottom), Bleeding, LDS, heamosidering/Ulcers
Ulcers- champagne bottle, superficial around ankle, irregular
with sloth, heamosiderin, waxy
mx-
compression stockings
Deal with reflux at the top and bottom-open surgery and strip the long saphenous
or endovenous-laser and ablate the junction
