Vascular surgery Flashcards
1
Q
Leg Ulcers
what are the 4 common types
A
- venous ulcers
- arterial ulcers
- diabetic foot ulcers
- pressure ulcers
2
Q
Leg Ulcers
why do arterial ulcers occur
A
insufficient blood supply to the skin due to peripheral arterial disease
3
Q
Leg Ulcers
why do venous ulcers occur
A
due to the pooling of blood and waste products in the skin secondary to venous insufficiency
4
Q
Leg Ulcers
what are mixed ulcers
A
a combination of arterial and venous disease causing the ulcer
5
Q
Leg Ulcers
what is an important complication of diabetic foot ulcers
A
osteomyelitis (infection in the bone)
6
Q
Leg Ulcers
why are diabetic foot ulcers more common in pts with diabetic neuropathy
A
- if no sensation, less likely to realise they’ve injured feet or have poorly fitting shoes
- damage to small and large blood vessels impairs the blood supply and wound healing
- poor healing and ulceration due to raised blood sugar, immune system changes and autonomic neuropathy
7
Q
Leg Ulcers
whom do pressure ulcers typically occur in
A
pts with reduced mobility, where prolonged pressure on particular areas (e.g. sacrum whilst sitting) lead to skin breaking down
8
Q
Leg Ulcers
why do pressure ulcers occur
A
reduced blood supply and localised ischaemia
reduced lymph drainage
deformation of the tissues under pressure
9
Q
Leg Ulcers
what measures are taken to prevent pressure ulcers
A
- individual risk assessments
- regular repositioning
- special inflating mattresses
- regular skin checks
- protective dressings and creams
10
Q
Leg Ulcers
what tool is used to estimate a pt’s risk of developing a pressure ulcer
A
the Waterlow Score
11
Q
Leg Ulcers
features of arterial ulcers
A
- occur distally (toes, dorsum of foot)
- assc w/ peripheral arterial disease: absent pulses. pallor, intermittent claudication
- smaller and deeper than venous ulcers
- well defined borders
- punched out appearance
- pale due to poor blood supply
- less likely to bleed
- painful (worse at night when lying horizontally)
- lowering legs improve pain
12
Q
Leg Ulcers
venous ulcer features
A
- occur in gaiter area
- assc w/ chronic venous changes: hyperpigmentation, venous eczema, lipodermatosclerosis
- occur after a minor injury to leg
- larger and more superficial than arterial ulcers
- irregular, gently sloping border
- more likely to bleed
- less painful than arterial ulcers
- pain relieved by elevation and worse on lowering the leg
13
Q
Leg Ulcers
inx
A
- ABPI
- bloods: infection + co-morbidities
- charcoal swabs: determine organism
- skin biopsy: where skin cancer is suspected
14
Q
Leg Ulcers
mnx of arterial ulcers
A
same as peripheral arterial disease
urgent referral to vascular to consider surgical revascularisation
If the underlying arterial disease is effectively treated, the ulcer should heal rapidly
15
Q
Leg Ulcers
whom may pts require a referral to if they have venous ulcers
A
- Vascular surgery: where mixed or arterial ulcers are suspected
- Tissue viability / specialist leg ulcer clinics in complex or non-healing ulcers
- Dermatology where an alternative diagnosis is suspected
- Pain clinics
- Diabetic ulcer services
16
Q
Leg Ulcers
what does good wound care involve in venous ulcers
A
- cleaning the wound
- debridement (removing dead tissue)
- dressing the wound
17
Q
Leg Ulcers
trx for venous ulcers
A
- compression therapy (after arterial disease is excluded with an ABPI
- PO pentoxifylline can improve healing in venous ulcers
- abx
- analgesia
18
Q
first-line treatment for superficial thrombophlebitis
A
NSAIDs
19
Q
Buerger Disease
aka
A
thromboangiitis obliterans
20
Q
Buerger Disease
what is it
A
an inflammatory condition that causes thrombus formation in the small and medium-sized blood vessels in the distal arterial system (affecting the hands and feet)
21
Q
Buerger Disease
whom does it typically effect
A
men aged 25-35
smokers
22
Q
Buerger Disease
notable features
A
- younger than 50 y
- not having RFs for atherosclerosis other than smoking
23
Q
Buerger Disease
presentation
A
- painful, blue discolouration to the fingertips or tips of toes
- pain worse at night
- may progress to ulcers gangrene + amputation
24
Q
Buerger Disease
what is a typical finding on angiograms
A
corkscrew collaterals (new collateral vessels form to bypass the affected arteries)
25
Buerger Disease
mnx
- stop smoking (most important)
| - IV iloprost
26
Buerger Disease
mnx: what is IV iloprost
a prostacyclin analogue that dilates blood vessels
27
Peripheral Arterial Disease
what is it
narrowing of the arteries supplying the limbs and periphery, reducing the blood supply to these areas
usually refers to the lower limbs, resulting in symptoms of claudication
28
Peripheral Arterial Disease
what is Intermittent claudication
a sx of ischaemia in a limb
occurs during exertion and relieved by rest
crampy, achy pain in calf, thigh or buttock muscles
29
Peripheral Arterial Disease
what is critical limb ischaemia
end-stage of peripheral arterial disease, where there is an inadequate supply of blood to a limb to allow it to function normally at rest.
30
Peripheral Arterial Disease
features of critical limb ischaemia
- pain at rest
- non-healing ulcers and gangrene
- significant risk of losing the limb
hanging their legs out of bed at night to ease the pain
31
Peripheral Arterial Disease
what is Acute limb ischaemia
rapid onset of ischaemia in a limb.
32
Peripheral Arterial Disease
what is acute limb ischaemia typically due to
thrombus (clot) blocking the arterial supply of a distal limb
33
Peripheral Arterial Disease
what is the difference between necrosis and gangrene
necrosis: death of tissue
gangrene: same but specifically due to an inadequate blood supply
34
Peripheral Arterial Disease
which medical co-morbidities increase the risk of atherosclerosis
- Diabetes
- Hypertension
- Chronic kidney disease
- Inflammatory conditions: RA
- Atypical antipsychotic medications
35
Peripheral Arterial Disease
features of acute limb ischaemia
```
Pain
Pulseless
Perishingly cold
Pallor
Paralysis
Paraesthesia
```
36
Peripheral Arterial Disease
what time of day is critical limb ischaemia worse
night when the leg is raised as gravity no longer helps pull blood into the foot
37
Peripheral Arterial Disease
when does Leriche Syndrome occur
when there is occlusion in the distal aorta or proximal common iliac artery
38
Peripheral Arterial Disease
what is the clinical triad of Leriche Syndrome
- thigh/buttock claudication
- absent femoral pulses
- male impotence
39
Peripheral Arterial Disease
RF signs on examination
- tar staining on fingers
| - xanthomata
40
Peripheral Arterial Disease
signs of CVD
- missing limbs/digits after previous amputations
- midline sternotomy scar (previous CABG)
- scar on the inner calf for saphenous vein harvesting (previous CABG)
- Focal weakness suggestive of a previous stroke
41
Peripheral Arterial Disease
what can you use to accurately assess the pulses when they are difficult to palpate.
hand-held Doppler
42
Peripheral Arterial Disease
signs of arterial disease on inspection
- Skin pallor
- Cyanosis
- Dependent rubor (a deep red colour when the limb is lower than the rest of the body)
- Muscle wasting
- Hair loss
- Ulcers
- Poor wound healing
- Gangrene (breakdown of skin and a dark red/black change in colouration)
43
Peripheral Arterial Disease
what test is used to assess for peripheral arterial disease in the leg.
Buerger’s Test
44
Peripheral Arterial Disease
describe Buerger's Test
- pt lies on back
- lift legs to 45 degrees for 2 min
- look for pallor --> PAD
- sit pt up with legs hanging over side of bed
- look at colour of legs
45
Peripheral Arterial Disease
what does a Buerger’s angle of 30 degrees mean
the legs go pale when lifted to 30 degrees.
46
Peripheral Arterial Disease
what colour will legs go when hanging off bed in buerger test in normal pt
remain a normal pink colour
47
Peripheral Arterial Disease
what colour will legs go when hanging off bed in buerger test in pts with peripheral arterial disease
- Blue initially: ischaemic tissue deoxygenates the blood
| - Dark red (rubor) after a short time: vasodilation in response to the waste products of anaerobic respiration
48
Peripheral Arterial Disease
what may indicate the skin and tissues are struggling to heal due to impaired blood flow
leg ulcers
49
Peripheral Arterial Disease
inx
- Ankle-brachial pressure index (ABPI)
- Duplex US: shows the speed and volume of blood flow
- Angiography (CT or MRI): using contrast to highlight the arterial circulation
50
Peripheral Arterial Disease
what is the Ankle-brachial pressure index (ABPI)
the ratio of systolic blood pressure (SBP) in the ankle (around the lower calf) compared with the systolic blood pressure in the arm
51
Peripheral Arterial Disease
ABPI: what is the ABPI if ankle SBP is 80 and arm is 100
80/100 = 0.8
52
Peripheral Arterial Disease
what is a normal ABPI
0.9 - 1.3
53
Peripheral Arterial Disease
what ABPI indicates mild peripheral arterial disease
0.6 – 0.9
54
Peripheral Arterial Disease
what ABPI indicates moderate to severe peripheral arterial disease
0.3 – 0.6
55
Peripheral Arterial Disease
what ABPI indicates severe disease to critical ischaemic
Less than 0.3
56
Peripheral Arterial Disease
what can an ABPI above 1.3 indicate
calcification of the arteries, making them difficult to compress. This is more common in diabetic patients.
57
Peripheral Arterial Disease
supportive mnx of intermittent claudication
- lifestyle changes
| - exercise training: regularly walking to point of near-maximal claudication and pain, then resting and repeating
58
Peripheral Arterial Disease
medical mnx of intermittent claudication
- artovastatin 80mg
- Clopidogrel 75mg OD (aspirin if clopidogrel is unsuitable)
- Naftidrofuryl oxalate (5-HT2 receptor antagonist that acts as a peripheral vasodilator)
59
Peripheral Arterial Disease
surgical mnx of intermittent claudication
- Endovascular angioplasty and stenting
- Endarterectomy – cutting the vessel open and removing the atheromatous plaque
- Bypass surgery – using a graft to bypass the blockage
60
Peripheral Arterial Disease
mnx of Critical Limb Ischaemia
urgent referral to the vascular team
analgesia
- Endovascular angioplasty and stenting
- Endarterectomy
- Bypass surgery
- Amputation
61
Peripheral Arterial Disease
mnx of Acute Limb Ischaemia
urgent referral to the on-call vascular team
- Endovascular thrombolysis
- Endovascular thrombectomy
- Surgical thrombectomy
- Endarterectomy
- Bypass surgery
- Amputation
62
Chronic Venous Insufficiency
why does it occur
usually from damage to the valves inside the veins
blood does not efficiently drain from the legs back to the heart
63
Chronic Venous Insufficiency
what may damage to the valves inside the veins be due to
- age
- immobility
- obesity
- prolonged standing
- after DVT
often associated with varicose veins
64
Chronic Venous Insufficiency
why is there venous HTN
blood pools in the veins of the legs because the valves are damaged
65
Chronic Venous Insufficiency
which area is most affected
gaiter area
66
Chronic Venous Insufficiency
what skin changes are seen
halv
- haemosiderin staining
- venous eczema
- lipodermatosclerosis
- atrophe blanche
67
Chronic Venous Insufficiency
what is haemosiderin staining
red/brown discolouration caused by haemoglobin leaking into the skin
68
Chronic Venous Insufficiency
what is venous eczema (varicose eczema)
dry, itchy, flaky, scaly, red cracked skin
caused by a chronic inflammatory response in the skin
69
Chronic Venous Insufficiency
what is Lipodermatosclerosis
hardening and tightening of the skin and tissue beneath the skin
70
Chronic Venous Insufficiency
what causes Lipodermatosclerosis
Chronic inflammation causes the subcutaneous tissue to become fibrotic (turning to scar tissue)
narrowing of the lower legs causes the typical “inverted champagne bottle” appearance.
71
Chronic Venous Insufficiency
what is inflammation of the SC fat called
panniculitis
72
Chronic Venous Insufficiency
what is atrophie blanche
patches of smooth, porcelain-white scar tissue on the skin, often surrounded by hyperpigmentation.
73
Chronic Venous Insufficiency
what can it lead to (apart from the skin changes)
- Cellulitis
- Poor healing after injury
- Skin ulcers
- Pain
74
Chronic Venous Insufficiency
mnx
- keep skin healthy
- improve venous drainage to legs
- manage complications
75
Chronic Venous Insufficiency
trx for flares of lipodermatosclerosis
Very potent topical steroids
76
Chronic Venous Insufficiency
trx for venous eczema
Topical steroids
77
Chronic Venous Insufficiency
how to improve venous drainage
- Weight loss if obese
- Keeping active
- Keeping the legs elevated when resting
- Compression stockings (exclude arterial disease first with an ankle-brachial pressure index)
78
Chronic Venous Insufficiency
mnx of complications
- Antibiotics for infection
- Analgesia for pain
- Wound care for ulceration
79
Abdominal Aortic Aneurysm
definition
dilatation of the abdominal aorta with a diameter >3cm
80
Abdominal Aortic Aneurysm
who is screened for in
all men at 65y in England are offered a screening USS
considered in women >70 with RFs: CVD, COPD, FH, HTN, hyperlipidaemia or smoking.
81
Abdominal Aortic Aneurysm
what size aorta diameter are patients referred to a vascular team
>3cm
urgently if >5.5cm
82
Abdominal Aortic Aneurysm
presentation
asymptomatic. Usually discovered on routine screening or when it ruptures
- non-specific abdo pain
- pulsatile + expansile mass when palpated with both hands
83
Abdominal Aortic Aneurysm
initial inx
US
84
Abdominal Aortic Aneurysm
dx
CT angiogram: detailed picture of the aneurysm and helps guide elective surgery to repair the aneurysm.
85
Abdominal Aortic Aneurysm
normal sized AAA
<3cm
86
Abdominal Aortic Aneurysm
small sized aneurysm
3 - 4.4cm
87
Abdominal Aortic Aneurysm
medium sized aneurysm
4.5 - 5.4cm
88
Abdominal Aortic Aneurysm
large sized aneurysm
>5.5cm
89
Abdominal Aortic Aneurysm
mnx to treat reversible RFs
- stop smoking
- healthy diet + exercise
- optimise mnx of HTN, DM, hyperlipidaemia
90
Abdominal Aortic Aneurysm
how often are follow up scans for pts w/ aneurysms 3 - 4.4cm
yearly
91
Abdominal Aortic Aneurysm
how often are follow up scans for pts with aneurysms 4.5 - 5.4m
3 monthly
92
Abdominal Aortic Aneurysm
which pts may get an elective repair
- symptomatic aneurysm
- diameter growing >1cm/yr
- diameter >5.5cm
93
Abdominal Aortic Aneurysm
what happens in an elective surgical repair
inserting an artificial “graft” into the section of the aorta affected by the aneurysm via:
- open repair via a laparotomy
- endovascular aneurysm repair (EVAR) using a stent inserted via the femoral arteries
94
Abdominal Aortic Aneurysm
DVLA rules
- inform DVLA if >6cm
- stop driving if >6.5cm
- stricter rules apply to drivers of heavy vehicles
95
Abdominal Aortic Aneurysm
presentation of a ruptured AAA
- severe abdo pain that may radiate to back or groin
- haemodynamic instability (HTN + tachy)
- pulsatile + expansile mass in the abdo
- collapse
- loss of consciousness
96
Abdominal Aortic Aneurysm
mnx of a ruptured AAA
- permissive hypotension
- surgical repair immediately in haemodynamically unstable pts
- CT angiogram to confirm in haemodynamically stable pts
97
Abdominal Aortic Aneurysm
mnx of a ruptured AAA: what is permissive hypotension
strategy of aiming for a lower than normal BP when performing fluid resuscitation.
increasing the BP may increase blood loss.
98
Aortic Dissection
what is it
break or tear in the inner layer of the aorta, allowing blood to flow between the layers of the wall of the aorta
99
Aortic Dissection
what are the 3 layers of the aorta
- intima
- media
- adventitia
100
Aortic Dissection
which layers of the aorta does blood enter
between the intima and media
a false lumen full of blood is formed within the wall of the aorta
101
Aortic Dissection
why is the R lateral area of the ascending aorta the most common site of tear of the intima layer
this is under the most stress from blood exiting the heart
102
Aortic Dissection
what are the 2 classification systems
- the Stanford system
| - the DeBakey system
103
Aortic Dissection
Type A Stanford system
affects the ascending aorta, before the brachiocephalic artery
104
Aortic Dissection
Type B Stanford system
affects the aorta, after the left subclavian artery
105
Aortic Dissection
Type I the DeBakey system
begins in the ascending aorta and involves at least the aortic arch, if not the whole aorta
106
Aortic Dissection
Type II the DeBakey system
isolated to the ascending aorta
107
Aortic Dissection
Type IIIa DeBakey system
begins in the descending aorta and involves only the section above the diaphragm
108
Aortic Dissection
Type IIIb DeBakey system
begins in the descending aorta and involves the aorta below the diaphram
109
Aortic Dissection
what events may trigger it
events that temporarily cause a dramatic increase in BP:
- heavy weightlifting
- use of cocaine
110
Aortic Dissection
what conditions or procedures increase the risk
- bicuspid aortic valve
- coarctation of the aorta
- aortic valve replacement
- CABG
- ehlers-danlos-syndrome
- Marfan's syndrome
111
Aortic Dissection
chest pain presentation
sudden, severe, ripping, tearing
front or back
may migrate over time
112
Aortic Dissection
presentation other than chest pain
- HTN
- differences in BP in arms
- radial pulse deficit
- diastolic murmur
- focal neurological deficit
- abdo pain
- collapse
- hypotension as the dissection progresses
113
Aortic Dissection
initial inx
CT angiogram
114
Aortic Dissection
inx which provides greater detail and help plan mnx
MRI angiogram
115
Aortic Dissection
Type A mnx
open surgery to remove section of the aorta and replace with synthetic graft
116
Aortic Dissection
Type B mnx
thoracic endovascular aortic repair, with a catheter inserted via the femoral artery inserting a stent graft in the affected section
117
Carotid Artery Stenosis
what is the risk it may become
parts of the plaque breaking away and becoming an embolus, travelling to the brain and causing an embolic stroke
118
Carotid Artery Stenosis
mild classification
less than 50% reduction in diameter
119
Carotid Artery Stenosis
moderate classification
50 to 69% reduction in diameter
120
Carotid Artery Stenosis
severe classification
70% or more reduction in diameter
121
Carotid Artery Stenosis
presentation
usually asymptomatic and diagnosed after a TIA or stroke
carotid bruit O/E
122
Carotid Artery Stenosis
what is a carotid bruit
a whooshing sound heard with a stethoscope over the affected carotid artery, caused by turbulent flow around the stenotic area during systole
123
Carotid Artery Stenosis
initial and diagnostic inx
Carotid ultrasound
124
Carotid Artery Stenosis
what may be used to assess the stenosis in more detail before surgical interventions
CT or MRI angiogram
125
Carotid Artery Stenosis
conservative mnx
- Healthy diet and exercise
- Stop smoking
- Mnx of co-morbidities (e.g. HTN and DM)
- Antiplatelet medications (e.g. aspirin, clopidogrel and ticagrelor)
- Lipid-lowering medications (e.g. atorvastatin)
126
Carotid Artery Stenosis
surgical mnx
- Carotid endarterectomy
| - Angioplasty and stenting
127
Carotid Artery Stenosis
damage during endarterectomy can cause facial nerve injury which causes?
facial weakness (often the marginal mandibular branch causing drooping of the lower lip)
128
Carotid Artery Stenosis
damage during endarterectomy can cause Glossopharyngeal nerve injury which causes?
swallowing difficulties
129
Carotid Artery Stenosis
damage during endarterectomy can cause Recurrent laryngeal nerve (a branch of the vagus nerve) injury which causes?
a hoarse voice
130
Carotid Artery Stenosis
damage during endarterectomy can cause Hypoglossal nerve injury which causes?
unilateral tongue paralysis
131
Lymphoedema
what is primary lymphoedema
rare, genetic condition, which usually presents before aged 30
a result of faulty development of the lymphatic system.
132
Lymphoedema
what is secondary lymphoedema
due to a separate condition that affects the lymphatic system.
133
Lymphoedema
give an example of secondary lymphoedema
when patients develop lymphoedema after breast cancer surgery, due to the removal of axillary lymph nodes in the armpit
134
Lymphoedema
what is an important Ddx and what is it
lipoedema: abnormal build-up of fat tissue in the limbs, often the legs.
135
Lymphoedema
how can you tell the difference between lipoedema and lymphoedema
the feet are spared in lipoedema
136
Lymphoedema
what positive sign suggests lymphoedema
Stemmer's sign
137
Lymphoedema
what is Stemmer's sign
- skin at bottom of 2nd or middle finger is gently pinched
| - +ve if not possible to pinch the skin, lift and tent it
138
Lymphoedema
how can limb volume be calculated
- Circumferential measurements at various points along the limb
- Water displacement
- Perometry (a square frame with perpendicular light beams is moved along the limb, measuring the outline and volume)
139
Lymphoedema
what can be used to measure the volume of fluid collected in the limb
Bioelectric impedance spectrometry:
- electrodes are placed on limb
- electrical current passed through limb , between the electrodes
- the resistance to electrical flow through the tissues estimates the volume of lymph fluid in the tissues
140
Lymphoedema
what is used to assess the structure of the lymphatic system
Lymphoscintigraphy (a type of nuclear medicine scan)
- A radioactive tracer is injected into the skin, and gamma cameras (scintigraphy) are used to assess the structure of the lymphatic system.
141
Lymphoedema
non surgical trx
- massage techniques (manual lymphatic drainage)
- compression bandages
- Specific lymphoedema exercises to improve lymph drainage
- weight loss
- good skin care
142
Lymphoedema
surgical trx
Lymphaticovenular anastomosis: attached lymphatic vessels to nearby veins
143
Lymphoedema
what should you avoid doing in pts
- taking blood
- inserting a cannula
- giving injections
- performing a BP reading
in a limb with lymphoedema
144
Lymphoedema
what is Lymphatic Filariasis
an infectious disease caused by parasitic worms spread by mosquitos
worms live in the lymphatic system where they can cause damage, leading to severe lymphoedema
145
Lymphoedema
Lymphatic Filariasis: what is elephantiasis
- most common in the tropics of Africa and Asia.
| - severe lymphoedema is associated with thickening and fibrosis of the skin and tissues
146
Varicose Veins
what are they
distended superficial veins measuring >3mm in diameter, usually affecting the legs
147
what are reticular veins
dilated blood vessels in the skin measuring less than 1-3mm in diameter.
148
what is telangiectasia
dilated blood vessels in the skin measuring less than 1mm in diameter.
aka spider veins or thread veins
149
Varicose Veins
what allows blood to flow from superficial to deep veins
they're connected by perforating veins (or perforators)
150
Varicose Veins
how are they formed
when the valves are incompetent in the perforating veins
blood flows from the deep veins back into the superficial veins and overloads them
dilatation + engorgement of the superficial veins --> varicose veins
151
Varicose Veins
RFs
- increasing age
- FH
- female
- pregnancy
- obesity
- prolonged standing
- DVT (causing damage to valves)
152
Varicose Veins
presentation
```
engorged and dilated superficial leg veins
may have:
- heavy or dragging sensation in the legs
- aching
- itching
- burning
- oedema
- muscle cramps
- restless legs
```
153
Varicose Veins
special tests
- tap test
- cough test
- Trendelenburg's test
- Perthes test
- duplex US
154
Varicose Veins
what is the tap test
pressure to the saphenofemoral junction (SFJ) and tap the distal varicose vein
feeling for a thrill at the SFJ.
155
Varicose Veins
what does a thrill suggest in the tap test
incompetent valves between the varicose vein and the SFJ.
156
Varicose Veins
what is the cough test
apply pressure to the SFJ and ask the patient to cough, feeling for thrills at the SFJ
157
Varicose Veins
what does a thrill suggest on the cough test
a dilated vein at the SFJ (called saphenous varix)
158
Varicose Veins
describe Trendelenburg's test
- patient lies down
- lift affected leg to drain the veins completely
- apply tourniquet to thigh
- stand patient up
159
Varicose Veins
Trendelenburg's test: if the varicose vein doesn't reappear, where is the incompetent valve
the incompetent valve is above the level of the tourniquet
160
Varicose Veins
Trendelenburg's test: if the varicose vein reappears, where is the incompetent valve
the incompetent valve is below the level of the tourniquet
161
Varicose Veins
describe Perthes test
- apply tourniquet to thigh
| - ask pt to perform heel raises
162
Varicose Veins
Perthes test: what does it mean if the superficial veins disappear
the deep veins are functioning
163
Varicose Veins
Perthes test: what does it mean if there is increased dilation of the superficial veins
problem in the deep veins, such as deep vein thrombosis.
164
Varicose Veins
what does duplex US show
assess the extent of varicose veins
shows the speed and volume of blood flow.
165
Varicose Veins
conservative mnx
- if pregnant, it often improves after delivery
- weight loss
- physically active
- keep leg elevated
- compression stockings
166
Varicose Veins
surgical options
- Endothermal ablation
- Sclerotherapy
- Stripping
167
Varicose Veins
surgical options: what is endothermal ablation
inserting a catheter into the vein to apply radiofrequency ablation
168
Varicose Veins
surgical options: what is sclerotherapy
injecting the vein with an irritant foam that causes closure of the vein
169
Varicose Veins
surgical options: what is stripping
the veins are ligated and pulled out of the leg
170
Varicose Veins
complications
- Prolonged and heavy bleeding after trauma
- Superficial thrombophlebitis (thrombosis and inflammation in the superficial veins)
- DVT
- All the issues of chronic venous insufficiency (e.g., skin changes and ulcers)
171
DVT
RFs (9)
- Immobility
- Recent surgery
- Long haul travel
- Pregnancy
- HRT + COCP
- Malignancy
- Polycythaemia
- SLE
- Thrombophilia
172
DVT
what are thrombophilias
conditions that predispose patients to develop blood clots
173
DVT
name some thrombophilias
- Antiphospholipid syndrome
- Factor V Leiden
- Antithrombin deficiency
- Protein C or S deficiency
- Hyperhomocysteinaemia
- Prothombin gene variant
- Activated protein C resistance
174
DVT
what is Antiphospholipid syndrome
recurrent miscarriges
175
DVT
diagnosis for Antiphospholipid syndrome
blood test for antiphospholipid antibodies
176
DVT
VTE prophylaxis
- LMWH (enoxaparin)
| - compression stockings
177
DVT
contraindications to LMWH (enoxaparin)
- warfarin or DOAC
| - active bleeding
178
DVT
contraindications for compressions stockings
peripheral arterial disease
179
DVT
how to examine for leg swelling
measure the circumference of the calf 10cm below the tibial tuberosity
180
DVT
more than how many cm makes the leg swelling significant
More than 3cm difference between calves
181
DVT
presentation
- Calf or leg swelling
- Dilated superficial veins
- Tenderness to the calf (particularly over the site of the deep veins)
- Oedema
- Colour changes to the leg
182
DVT
what predicts the risk of a patient presenting with symptoms having a DVT or PE
Wells Score
183
DVT
what Wells Score means a PE is likely
>4
184
DVT
what is the Well's Score
- clinical signs of DVT
- PE is #1 dx or equally likely
- HR >100bpm
- recent surgery or immobilisation
- previous PE or DVT
- haemoptysis
- malignancy
185
DVT
what is a sensitive (95%), but not specific, blood test for VTE
D-dimer
186
DVT
what other conditions caused a raised D-dimer
- Pneumonia
- Malignancy
- Heart failure
- Surgery
- Pregnancy
187
DVT
what is required to diagnose deep vein thrombosis
doppler US of the leg
188
DVT
negative doppler US but a positive D-dimer and the Wells score suggest a DVT is likely. What do you do
NICE recommends repeating negative ultrasound scans after 6-8 days
189
DVT
what can a Pulmonary embolism can be diagnosed with
CT pulmonary angiogram (CTPA) or ventilation-perfusion (VQ) scan
190
DVT
initial mnx for a suspected or confirmed DVT or PE
anticoagulation with apixaban or rivaroxaban started immediately
191
DVT
mnx for patients with a symptomatic iliofemoral DVT and symptoms lasting <14 days.
catheter-directed thrombolysis
| inserting a catheter under x-ray guidance through the venous system to apply thrombolysis directly into the clot.
192
DVT
mnx for long term anticoagulation
- DOACs: most pts
- warfarin: antiphospholid syndrome
- LMWH: pregnant
193
DVT
how long should you continue anticoagulation for if there is a reversible cause
3 months then review
194
DVT
how long should you continue anticoagulation for if the cause is unclear, there is recurrent VTE, or there is an irreversible underlying cause such as thrombophilia
Beyond 3 months (often 6m in clinical practice)
195
DVT
how long should you continue anticoagulation if pt has active cancer
3-6 months
196
DVT
when are Inferior Vena Cava Filters used
unusual cases of patients with recurrent PEs or those that are unsuitable for anticoagulation.
197
DVT
what are IVC filters
- devices inserted into IVC
| - filters blood and catches any blood clots travelling from the venous system, towards the heart and lungs.
198
DVT
what does NICE recommend if patients has their first VTE without a clear cause
- review medical history, baseline blood results and physical examination for evidence of cancer.
199
DVT
what does NICE recommend In patients with an unprovoked DVT or PE that are not going to continue anticoagulation
consider testing
- antiphospholipid antibodies
- Hereditary thrombophilias (only if they have a 1st degree relative also affected by a DVT or PE)
200
fibrinolytic drugs (homework)
examples
alteplase, streptokinase
201
fibrinolytic drugs (homework)
common indications 1
1) acute ischaemic stroke within 4.5h
2) STEMI within 12h (if no PCI)
3) massive PE w/ haemodynamic instability
202
fibrinolytic drugs (homework)
mechanisms of action
- catalyses the conversion of plasminogen to plasmin
| - which acts to dissolve the fibrinous clots + re-canalise occluded vessels
203
fibrinolytic drugs (homework)
adverse effects
- N+V
- hypotension
- serious bleeding
- cardiogenic shock
- cardiac arrest
204
fibrinolytic drugs (homework)
mnx for serious bleeding from alteplase
- coagulation factors
- antifibrinolytic drugs (tranexamic acid)
but avoidable as alteplase usually has a very short half lige
205
fibrinolytic drugs (homework)
what can reperfusion of infarcted brain or heart tissue lead do
cerebral oedema and arrhythmias
206
fibrinolytic drugs (homework)
CIs
factors that predispose to bleeding:
- recent haemorrhage
- recent trauma/surgery
- bleeding disorders
- severe HTN
- peptic ulcers
- previous streptokinase trx
207
fibrinolytic drugs (homework)
important interactions
- risk of haemorrage is increased in pts taking anticoagulants and antiplatelets
- ACEi appear to increase the risk of anaphylactoid reactions
208
fibrinolytic drugs (homework)
where and who can administer it
- only in high dependency areas: A+E, hyperacute stroke unit, coronary care unit
- staff with expertise in their use
209
fibrinolytic drugs (homework)
monitoring
- vital signs every 15min for the first 2h
210
Carotid Doppler reveals 75% stenosis in the left carotid artery but no sx on the right upper or lower limb
mnx?
optimal medical mnx
because to perform endarterectomy, must be >70% stenosis and have sx
211
can AF increase the risk of acute limb ischaemia
yes
embolism of a left atrial appendage thrombus is a common cause
212
when would you opt for Surgical embolectomy vs surgical bypass in acute limb ischaemia
A leg affected by embolus requires immediate surgical revascularisation with embolectomy
long-standing atherosclerotic disease --> surgical bypass
213
unprovoked DVT. What inx should pts be offered to help identify possible malignancy
CT abdo + pelvis
