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Vascular surgery Flashcards

1
Q

Leg Ulcers

what are the 4 common types

A
  • venous ulcers
  • arterial ulcers
  • diabetic foot ulcers
  • pressure ulcers
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2
Q

Leg Ulcers

why do arterial ulcers occur

A

insufficient blood supply to the skin due to peripheral arterial disease

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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

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4
Q

Leg Ulcers

what are mixed ulcers

A

a combination of arterial and venous disease causing the ulcer

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5
Q

Leg Ulcers

what is an important complication of diabetic foot ulcers

A

osteomyelitis (infection in the bone)

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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
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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

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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

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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
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10
Q

Leg Ulcers

what tool is used to estimate a pt’s risk of developing a pressure ulcer

A

the Waterlow Score

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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
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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
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13
Q

Leg Ulcers

inx

A
  • ABPI
  • bloods: infection + co-morbidities
  • charcoal swabs: determine organism
  • skin biopsy: where skin cancer is suspected
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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

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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
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16
Q

Leg Ulcers

what does good wound care involve in venous ulcers

A
  • cleaning the wound
  • debridement (removing dead tissue)
  • dressing the wound
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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
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18
Q

first-line treatment for superficial thrombophlebitis

A

NSAIDs

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19
Q

Buerger Disease

aka

A

thromboangiitis obliterans

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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)

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21
Q

Buerger Disease

whom does it typically effect

A

men aged 25-35

smokers

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22
Q

Buerger Disease

notable features

A
  • younger than 50 y

- not having RFs for atherosclerosis other than smoking

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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
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24
Q

Buerger Disease

what is a typical finding on angiograms

A

corkscrew collaterals (new collateral vessels form to bypass the affected arteries)

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25
Q

Buerger Disease

mnx

A
  • stop smoking (most important)

- IV iloprost

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26
Q

Buerger Disease

mnx: what is IV iloprost

A

a prostacyclin analogue that dilates blood vessels

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27
Q

Peripheral Arterial Disease

what is it

A

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

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28
Q

Peripheral Arterial Disease

what is Intermittent claudication

A

a sx of ischaemia in a limb

occurs during exertion and relieved by rest

crampy, achy pain in calf, thigh or buttock muscles

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29
Q

Peripheral Arterial Disease

what is critical limb ischaemia

A

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.

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30
Q

Peripheral Arterial Disease

features of critical limb ischaemia

A
  • 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

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31
Q

Peripheral Arterial Disease

what is Acute limb ischaemia

A

rapid onset of ischaemia in a limb.

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32
Q

Peripheral Arterial Disease

what is acute limb ischaemia typically due to

A

thrombus (clot) blocking the arterial supply of a distal limb

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33
Q

Peripheral Arterial Disease

what is the difference between necrosis and gangrene

A

necrosis: death of tissue
gangrene: same but specifically due to an inadequate blood supply

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34
Q

Peripheral Arterial Disease

which medical co-morbidities increase the risk of atherosclerosis

A
  • Diabetes
  • Hypertension
  • Chronic kidney disease
  • Inflammatory conditions: RA
  • Atypical antipsychotic medications
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35
Q

Peripheral Arterial Disease

features of acute limb ischaemia

A 
Pain
Pulseless
Perishingly cold 
Pallor
Paralysis 
Paraesthesia
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36
Q

Peripheral Arterial Disease

what time of day is critical limb ischaemia worse

A

night when the leg is raised as gravity no longer helps pull blood into the foot

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37
Q

Peripheral Arterial Disease

when does Leriche Syndrome occur

A

when there is occlusion in the distal aorta or proximal common iliac artery

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38
Q

Peripheral Arterial Disease

what is the clinical triad of Leriche Syndrome

A
  • thigh/buttock claudication
  • absent femoral pulses
  • male impotence
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39
Q

Peripheral Arterial Disease

RF signs on examination

A
  • tar staining on fingers

- xanthomata

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40
Q

Peripheral Arterial Disease

signs of CVD

A
  • 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
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41
Q

Peripheral Arterial Disease

what can you use to accurately assess the pulses when they are difficult to palpate.

A

hand-held Doppler

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42
Q

Peripheral Arterial Disease

signs of arterial disease on inspection

A
  • 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)
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43
Q

Peripheral Arterial Disease

what test is used to assess for peripheral arterial disease in the leg.

A

Buerger’s Test

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44
Q

Peripheral Arterial Disease

describe Buerger’s Test

A
  • 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
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45
Q

Peripheral Arterial Disease

what does a Buerger’s angle of 30 degrees mean

A

the legs go pale when lifted to 30 degrees.

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46
Q

Peripheral Arterial Disease

what colour will legs go when hanging off bed in buerger test in normal pt

A

remain a normal pink colour

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47
Q

Peripheral Arterial Disease

what colour will legs go when hanging off bed in buerger test in pts with peripheral arterial disease

A
  • Blue initially: ischaemic tissue deoxygenates the blood

- Dark red (rubor) after a short time: vasodilation in response to the waste products of anaerobic respiration

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48
Q

Peripheral Arterial Disease

what may indicate the skin and tissues are struggling to heal due to impaired blood flow

A

leg ulcers

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49
Q

Peripheral Arterial Disease

inx

A
  • 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
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50
Q

Peripheral Arterial Disease

what is the Ankle-brachial pressure index (ABPI)

A

the ratio of systolic blood pressure (SBP) in the ankle (around the lower calf) compared with the systolic blood pressure in the arm

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51
Q

Peripheral Arterial Disease

ABPI: what is the ABPI if ankle SBP is 80 and arm is 100

A

80/100 = 0.8

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52
Q

Peripheral Arterial Disease

what is a normal ABPI

A

0.9 - 1.3

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53
Q

Peripheral Arterial Disease

what ABPI indicates mild peripheral arterial disease

A

0.6 – 0.9

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54
Q

Peripheral Arterial Disease

what ABPI indicates moderate to severe peripheral arterial disease

A

0.3 – 0.6

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55
Q

Peripheral Arterial Disease

what ABPI indicates severe disease to critical ischaemic

A

Less than 0.3

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56
Q

Peripheral Arterial Disease

what can an ABPI above 1.3 indicate

A

calcification of the arteries, making them difficult to compress. This is more common in diabetic patients.

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57
Q

Peripheral Arterial Disease

supportive mnx of intermittent claudication

A
  • lifestyle changes

- exercise training: regularly walking to point of near-maximal claudication and pain, then resting and repeating

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58
Q

Peripheral Arterial Disease

medical mnx of intermittent claudication

A
  • artovastatin 80mg
  • Clopidogrel 75mg OD (aspirin if clopidogrel is unsuitable)
  • Naftidrofuryl oxalate (5-HT2 receptor antagonist that acts as a peripheral vasodilator)
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59
Q

Peripheral Arterial Disease

surgical mnx of intermittent claudication

A
  • Endovascular angioplasty and stenting
  • Endarterectomy – cutting the vessel open and removing the atheromatous plaque
  • Bypass surgery – using a graft to bypass the blockage
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60
Q

Peripheral Arterial Disease

mnx of Critical Limb Ischaemia

A

urgent referral to the vascular team

analgesia

  • Endovascular angioplasty and stenting
  • Endarterectomy
  • Bypass surgery
  • Amputation
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61
Q

Peripheral Arterial Disease

mnx of Acute Limb Ischaemia

A

urgent referral to the on-call vascular team

  • Endovascular thrombolysis
  • Endovascular thrombectomy
  • Surgical thrombectomy
  • Endarterectomy
  • Bypass surgery
  • Amputation
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62
Q

Chronic Venous Insufficiency

why does it occur

A

usually from damage to the valves inside the veins

blood does not efficiently drain from the legs back to the heart

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63
Q

Chronic Venous Insufficiency

what may damage to the valves inside the veins be due to

A
  • age
  • immobility
  • obesity
  • prolonged standing
  • after DVT
    often associated with varicose veins
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64
Q

Chronic Venous Insufficiency

why is there venous HTN

A

blood pools in the veins of the legs because the valves are damaged

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65
Q

Chronic Venous Insufficiency

which area is most affected

A

gaiter area

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66
Q

Chronic Venous Insufficiency

what skin changes are seen

A

halv

  • haemosiderin staining
  • venous eczema
  • lipodermatosclerosis
  • atrophe blanche
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67
Q

Chronic Venous Insufficiency

what is haemosiderin staining

A

red/brown discolouration caused by haemoglobin leaking into the skin

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68
Q

Chronic Venous Insufficiency

what is venous eczema (varicose eczema)

A

dry, itchy, flaky, scaly, red cracked skin

caused by a chronic inflammatory response in the skin

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69
Q

Chronic Venous Insufficiency

what is Lipodermatosclerosis

A

hardening and tightening of the skin and tissue beneath the skin

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70
Q

Chronic Venous Insufficiency

what causes Lipodermatosclerosis

A

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.

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71
Q

Chronic Venous Insufficiency

what is inflammation of the SC fat called

A

panniculitis

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72
Q

Chronic Venous Insufficiency

what is atrophie blanche

A

patches of smooth, porcelain-white scar tissue on the skin, often surrounded by hyperpigmentation.

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73
Q

Chronic Venous Insufficiency

what can it lead to (apart from the skin changes)

A
  • Cellulitis
  • Poor healing after injury
  • Skin ulcers
  • Pain
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74
Q

Chronic Venous Insufficiency

mnx

A
  • keep skin healthy
  • improve venous drainage to legs
  • manage complications
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75
Q

Chronic Venous Insufficiency

trx for flares of lipodermatosclerosis

A

Very potent topical steroids

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76
Q

Chronic Venous Insufficiency

trx for venous eczema

A

Topical steroids

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77
Q

Chronic Venous Insufficiency

how to improve venous drainage

A
  • Weight loss if obese
  • Keeping active
  • Keeping the legs elevated when resting
  • Compression stockings (exclude arterial disease first with an ankle-brachial pressure index)
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78
Q

Chronic Venous Insufficiency

mnx of complications

A
  • Antibiotics for infection
  • Analgesia for pain
  • Wound care for ulceration
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79
Q

Abdominal Aortic Aneurysm

definition

A

dilatation of the abdominal aorta with a diameter >3cm

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80
Q

Abdominal Aortic Aneurysm

who is screened for in

A

all men at 65y in England are offered a screening USS

considered in women >70 with RFs: CVD, COPD, FH, HTN, hyperlipidaemia or smoking.

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81
Q

Abdominal Aortic Aneurysm

what size aorta diameter are patients referred to a vascular team

A

> 3cm

urgently if >5.5cm

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82
Q

Abdominal Aortic Aneurysm

presentation

A

asymptomatic. Usually discovered on routine screening or when it ruptures

  • non-specific abdo pain
  • pulsatile + expansile mass when palpated with both hands
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83
Q

Abdominal Aortic Aneurysm

initial inx

A

US

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84
Q

Abdominal Aortic Aneurysm

dx

A

CT angiogram: detailed picture of the aneurysm and helps guide elective surgery to repair the aneurysm.

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85
Q

Abdominal Aortic Aneurysm

normal sized AAA

A

<3cm

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86
Q

Abdominal Aortic Aneurysm

small sized aneurysm

A

3 - 4.4cm

87
Q

Abdominal Aortic Aneurysm

medium sized aneurysm

A

4.5 - 5.4cm

88
Q

Abdominal Aortic Aneurysm

large sized aneurysm

A

> 5.5cm

89
Q

Abdominal Aortic Aneurysm

mnx to treat reversible RFs

A
  • stop smoking
  • healthy diet + exercise
  • optimise mnx of HTN, DM, hyperlipidaemia
90
Q

Abdominal Aortic Aneurysm

how often are follow up scans for pts w/ aneurysms 3 - 4.4cm

A

yearly

91
Q

Abdominal Aortic Aneurysm

how often are follow up scans for pts with aneurysms 4.5 - 5.4m

A

3 monthly

92
Q

Abdominal Aortic Aneurysm

which pts may get an elective repair

A
  • symptomatic aneurysm
  • diameter growing >1cm/yr
  • diameter >5.5cm
93
Q

Abdominal Aortic Aneurysm

what happens in an elective surgical repair

A

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
Q

Abdominal Aortic Aneurysm

DVLA rules

A
  • inform DVLA if >6cm
  • stop driving if >6.5cm
  • stricter rules apply to drivers of heavy vehicles
95
Q

Abdominal Aortic Aneurysm

presentation of a ruptured AAA

A
  • 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
Q

Abdominal Aortic Aneurysm

mnx of a ruptured AAA

A
  • permissive hypotension
  • surgical repair immediately in haemodynamically unstable pts
  • CT angiogram to confirm in haemodynamically stable pts
97
Q

Abdominal Aortic Aneurysm

mnx of a ruptured AAA: what is permissive hypotension

A

strategy of aiming for a lower than normal BP when performing fluid resuscitation.

increasing the BP may increase blood loss.

98
Q

Aortic Dissection

what is it

A

break or tear in the inner layer of the aorta, allowing blood to flow between the layers of the wall of the aorta

99
Q

Aortic Dissection

what are the 3 layers of the aorta

A
  • intima
  • media
  • adventitia
100
Q

Aortic Dissection

which layers of the aorta does blood enter

A

between the intima and media

a false lumen full of blood is formed within the wall of the aorta

101
Q

Aortic Dissection

why is the R lateral area of the ascending aorta the most common site of tear of the intima layer

A

this is under the most stress from blood exiting the heart

102
Q

Aortic Dissection

what are the 2 classification systems

A
  • the Stanford system

- the DeBakey system

103
Q

Aortic Dissection

Type A Stanford system

A

affects the ascending aorta, before the brachiocephalic artery

104
Q

Aortic Dissection

Type B Stanford system

A

affects the aorta, after the left subclavian artery

105
Q

Aortic Dissection

Type I the DeBakey system

A

begins in the ascending aorta and involves at least the aortic arch, if not the whole aorta

106
Q

Aortic Dissection

Type II the DeBakey system

A

isolated to the ascending aorta

107
Q

Aortic Dissection

Type IIIa DeBakey system

A

begins in the descending aorta and involves only the section above the diaphragm

108
Q

Aortic Dissection

Type IIIb DeBakey system

A

begins in the descending aorta and involves the aorta below the diaphram

109
Q

Aortic Dissection

what events may trigger it

A

events that temporarily cause a dramatic increase in BP:

  • heavy weightlifting
  • use of cocaine
110
Q

Aortic Dissection

what conditions or procedures increase the risk

A
  • bicuspid aortic valve
  • coarctation of the aorta
  • aortic valve replacement
  • CABG
  • ehlers-danlos-syndrome
  • Marfan’s syndrome
111
Q

Aortic Dissection

chest pain presentation

A

sudden, severe, ripping, tearing

front or back

may migrate over time

112
Q

Aortic Dissection

presentation other than chest pain

A
  • HTN
  • differences in BP in arms
  • radial pulse deficit
  • diastolic murmur
  • focal neurological deficit
  • abdo pain
  • collapse
  • hypotension as the dissection progresses
113
Q

Aortic Dissection

initial inx

A

CT angiogram

114
Q

Aortic Dissection

inx which provides greater detail and help plan mnx

A

MRI angiogram

115
Q

Aortic Dissection

Type A mnx

A

open surgery to remove section of the aorta and replace with synthetic graft

116
Q

Aortic Dissection

Type B mnx

A

thoracic endovascular aortic repair, with a catheter inserted via the femoral artery inserting a stent graft in the affected section

117
Q

Carotid Artery Stenosis

what is the risk it may become

A

parts of the plaque breaking away and becoming an embolus, travelling to the brain and causing an embolic stroke

118
Q

Carotid Artery Stenosis

mild classification

A

less than 50% reduction in diameter

119
Q

Carotid Artery Stenosis

moderate classification

A

50 to 69% reduction in diameter

120
Q

Carotid Artery Stenosis

severe classification

A

70% or more reduction in diameter

121
Q

Carotid Artery Stenosis

presentation

A

usually asymptomatic and diagnosed after a TIA or stroke

carotid bruit O/E

122
Q

Carotid Artery Stenosis

what is a carotid bruit

A

a whooshing sound heard with a stethoscope over the affected carotid artery, caused by turbulent flow around the stenotic area during systole

123
Q

Carotid Artery Stenosis

initial and diagnostic inx

A

Carotid ultrasound

124
Q

Carotid Artery Stenosis

what may be used to assess the stenosis in more detail before surgical interventions

A

CT or MRI angiogram

125
Q

Carotid Artery Stenosis

conservative mnx

A
  • 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
Q

Carotid Artery Stenosis

surgical mnx

A
  • Carotid endarterectomy

- Angioplasty and stenting

127
Q

Carotid Artery Stenosis

damage during endarterectomy can cause facial nerve injury which causes?

A

facial weakness (often the marginal mandibular branch causing drooping of the lower lip)

128
Q

Carotid Artery Stenosis

damage during endarterectomy can cause Glossopharyngeal nerve injury which causes?

A

swallowing difficulties

129
Q

Carotid Artery Stenosis

damage during endarterectomy can cause Recurrent laryngeal nerve (a branch of the vagus nerve) injury which causes?

A

a hoarse voice

130
Q

Carotid Artery Stenosis

damage during endarterectomy can cause Hypoglossal nerve injury which causes?

A

unilateral tongue paralysis

131
Q

Lymphoedema

what is primary lymphoedema

A

rare, genetic condition, which usually presents before aged 30

a result of faulty development of the lymphatic system.

132
Q

Lymphoedema

what is secondary lymphoedema

A

due to a separate condition that affects the lymphatic system.

133
Q

Lymphoedema

give an example of secondary lymphoedema

A

when patients develop lymphoedema after breast cancer surgery, due to the removal of axillary lymph nodes in the armpit

134
Q

Lymphoedema

what is an important Ddx and what is it

A

lipoedema: abnormal build-up of fat tissue in the limbs, often the legs.

135
Q

Lymphoedema

how can you tell the difference between lipoedema and lymphoedema

A

the feet are spared in lipoedema

136
Q

Lymphoedema

what positive sign suggests lymphoedema

A

Stemmer’s sign

137
Q

Lymphoedema

what is Stemmer’s sign

A
  • skin at bottom of 2nd or middle finger is gently pinched

- +ve if not possible to pinch the skin, lift and tent it

138
Q

Lymphoedema

how can limb volume be calculated

A
  • 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
Q

Lymphoedema

what can be used to measure the volume of fluid collected in the limb

A

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
Q

Lymphoedema

what is used to assess the structure of the lymphatic system

A

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
Q

Lymphoedema

non surgical trx

A
  • massage techniques (manual lymphatic drainage)
  • compression bandages
  • Specific lymphoedema exercises to improve lymph drainage
  • weight loss
  • good skin care
142
Q

Lymphoedema

surgical trx

A

Lymphaticovenular anastomosis: attached lymphatic vessels to nearby veins

143
Q

Lymphoedema

what should you avoid doing in pts

A
  • taking blood
  • inserting a cannula
  • giving injections
  • performing a BP reading

in a limb with lymphoedema

144
Q

Lymphoedema

what is Lymphatic Filariasis

A

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
Q

Lymphoedema

Lymphatic Filariasis: what is elephantiasis

A
  • most common in the tropics of Africa and Asia.

- severe lymphoedema is associated with thickening and fibrosis of the skin and tissues

146
Q

Varicose Veins

what are they

A

distended superficial veins measuring >3mm in diameter, usually affecting the legs

147
Q

what are reticular veins

A

dilated blood vessels in the skin measuring less than 1-3mm in diameter.

148
Q

what is telangiectasia

A

dilated blood vessels in the skin measuring less than 1mm in diameter.

aka spider veins or thread veins

149
Q

Varicose Veins

what allows blood to flow from superficial to deep veins

A

they’re connected by perforating veins (or perforators)

150
Q

Varicose Veins

how are they formed

A

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
Q

Varicose Veins

RFs

A
  • increasing age
  • FH
  • female
  • pregnancy
  • obesity
  • prolonged standing
  • DVT (causing damage to valves)
152
Q

Varicose Veins

presentation

A 
engorged and dilated superficial leg veins
may have:
- heavy or dragging sensation in the legs 
- aching 
- itching
- burning 
- oedema
- muscle cramps 
- restless legs
153
Q

Varicose Veins

special tests

A
  • tap test
  • cough test
  • Trendelenburg’s test
  • Perthes test
  • duplex US
154
Q

Varicose Veins

what is the tap test

A

pressure to the saphenofemoral junction (SFJ) and tap the distal varicose vein
feeling for a thrill at the SFJ.

155
Q

Varicose Veins

what does a thrill suggest in the tap test

A

incompetent valves between the varicose vein and the SFJ.

156
Q

Varicose Veins

what is the cough test

A

apply pressure to the SFJ and ask the patient to cough, feeling for thrills at the SFJ

157
Q

Varicose Veins

what does a thrill suggest on the cough test

A

a dilated vein at the SFJ (called saphenous varix)

158
Q

Varicose Veins

describe Trendelenburg’s test

A
  • patient lies down
  • lift affected leg to drain the veins completely
  • apply tourniquet to thigh
  • stand patient up
159
Q

Varicose Veins

Trendelenburg’s test: if the varicose vein doesn’t reappear, where is the incompetent valve

A

the incompetent valve is above the level of the tourniquet

160
Q

Varicose Veins

Trendelenburg’s test: if the varicose vein reappears, where is the incompetent valve

A

the incompetent valve is below the level of the tourniquet

161
Q

Varicose Veins

describe Perthes test

A
  • apply tourniquet to thigh

- ask pt to perform heel raises

162
Q

Varicose Veins

Perthes test: what does it mean if the superficial veins disappear

A

the deep veins are functioning

163
Q

Varicose Veins

Perthes test: what does it mean if there is increased dilation of the superficial veins

A

problem in the deep veins, such as deep vein thrombosis.

164
Q

Varicose Veins

what does duplex US show

A

assess the extent of varicose veins

shows the speed and volume of blood flow.

165
Q

Varicose Veins

conservative mnx

A
  • if pregnant, it often improves after delivery
  • weight loss
  • physically active
  • keep leg elevated
  • compression stockings
166
Q

Varicose Veins

surgical options

A
  • Endothermal ablation
  • Sclerotherapy
  • Stripping
167
Q

Varicose Veins

surgical options: what is endothermal ablation

A

inserting a catheter into the vein to apply radiofrequency ablation

168
Q

Varicose Veins

surgical options: what is sclerotherapy

A

injecting the vein with an irritant foam that causes closure of the vein

169
Q

Varicose Veins

surgical options: what is stripping

A

the veins are ligated and pulled out of the leg

170
Q

Varicose Veins

complications

A
  • 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
Q

DVT

RFs (9)

A
  • Immobility
  • Recent surgery
  • Long haul travel
  • Pregnancy
  • HRT + COCP
  • Malignancy
  • Polycythaemia
  • SLE
  • Thrombophilia
172
Q

DVT

what are thrombophilias

A

conditions that predispose patients to develop blood clots

173
Q

DVT

name some thrombophilias

A
  • Antiphospholipid syndrome
  • Factor V Leiden
  • Antithrombin deficiency
  • Protein C or S deficiency
  • Hyperhomocysteinaemia
  • Prothombin gene variant
  • Activated protein C resistance
174
Q

DVT

what is Antiphospholipid syndrome

A

recurrent miscarriges

175
Q

DVT

diagnosis for Antiphospholipid syndrome

A

blood test for antiphospholipid antibodies

176
Q

DVT

VTE prophylaxis

A
  • LMWH (enoxaparin)

- compression stockings

177
Q

DVT

contraindications to LMWH (enoxaparin)

A
  • warfarin or DOAC

- active bleeding

178
Q

DVT

contraindications for compressions stockings

A

peripheral arterial disease

179
Q

DVT

how to examine for leg swelling

A

measure the circumference of the calf 10cm below the tibial tuberosity

180
Q

DVT

more than how many cm makes the leg swelling significant

A

More than 3cm difference between calves

181
Q

DVT

presentation

A
  • 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
Q

DVT

what predicts the risk of a patient presenting with symptoms having a DVT or PE

A

Wells Score

183
Q

DVT

what Wells Score means a PE is likely

A

> 4

184
Q

DVT

what is the Well’s Score

A
  • clinical signs of DVT
  • PE is #1 dx or equally likely
  • HR >100bpm
  • recent surgery or immobilisation
  • previous PE or DVT
  • haemoptysis
  • malignancy
185
Q

DVT

what is a sensitive (95%), but not specific, blood test for VTE

A

D-dimer

186
Q

DVT

what other conditions caused a raised D-dimer

A
  • Pneumonia
  • Malignancy
  • Heart failure
  • Surgery
  • Pregnancy
187
Q

DVT

what is required to diagnose deep vein thrombosis

A

doppler US of the leg

188
Q

DVT

negative doppler US but a positive D-dimer and the Wells score suggest a DVT is likely. What do you do

A

NICE recommends repeating negative ultrasound scans after 6-8 days

189
Q

DVT

what can a Pulmonary embolism can be diagnosed with

A

CT pulmonary angiogram (CTPA) or ventilation-perfusion (VQ) scan

190
Q

DVT

initial mnx for a suspected or confirmed DVT or PE

A

anticoagulation with apixaban or rivaroxaban started immediately

191
Q

DVT

mnx for patients with a symptomatic iliofemoral DVT and symptoms lasting <14 days.

A

catheter-directed thrombolysis

inserting a catheter under x-ray guidance through the venous system to apply thrombolysis directly into the clot.

192
Q

DVT

mnx for long term anticoagulation

A
  • DOACs: most pts
  • warfarin: antiphospholid syndrome
  • LMWH: pregnant
193
Q

DVT

how long should you continue anticoagulation for if there is a reversible cause

A

3 months then review

194
Q

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

A

Beyond 3 months (often 6m in clinical practice)

195
Q

DVT

how long should you continue anticoagulation if pt has active cancer

A

3-6 months

196
Q

DVT

when are Inferior Vena Cava Filters used

A

unusual cases of patients with recurrent PEs or those that are unsuitable for anticoagulation.

197
Q

DVT

what are IVC filters

A
  • devices inserted into IVC

- filters blood and catches any blood clots travelling from the venous system, towards the heart and lungs.

198
Q

DVT

what does NICE recommend if patients has their first VTE without a clear cause

A
  • review medical history, baseline blood results and physical examination for evidence of cancer.
199
Q

DVT

what does NICE recommend In patients with an unprovoked DVT or PE that are not going to continue anticoagulation

A

consider testing

  • antiphospholipid antibodies
  • Hereditary thrombophilias (only if they have a 1st degree relative also affected by a DVT or PE)
200
Q

fibrinolytic drugs (homework)

examples

A

alteplase, streptokinase

201
Q

fibrinolytic drugs (homework)

common indications 1

A

1) acute ischaemic stroke within 4.5h
2) STEMI within 12h (if no PCI)
3) massive PE w/ haemodynamic instability

202
Q

fibrinolytic drugs (homework)

mechanisms of action

A
  • catalyses the conversion of plasminogen to plasmin

- which acts to dissolve the fibrinous clots + re-canalise occluded vessels

203
Q

fibrinolytic drugs (homework)

adverse effects

A
  • N+V
  • hypotension
  • serious bleeding
  • cardiogenic shock
  • cardiac arrest
204
Q

fibrinolytic drugs (homework)

mnx for serious bleeding from alteplase

A
  • coagulation factors
  • antifibrinolytic drugs (tranexamic acid)

but avoidable as alteplase usually has a very short half lige

205
Q

fibrinolytic drugs (homework)

what can reperfusion of infarcted brain or heart tissue lead do

A

cerebral oedema and arrhythmias

206
Q

fibrinolytic drugs (homework)

CIs

A

factors that predispose to bleeding:

  • recent haemorrhage
  • recent trauma/surgery
  • bleeding disorders
  • severe HTN
  • peptic ulcers
  • previous streptokinase trx
207
Q

fibrinolytic drugs (homework)

important interactions

A
  • risk of haemorrage is increased in pts taking anticoagulants and antiplatelets
  • ACEi appear to increase the risk of anaphylactoid reactions
208
Q

fibrinolytic drugs (homework)

where and who can administer it

A
  • only in high dependency areas: A+E, hyperacute stroke unit, coronary care unit
  • staff with expertise in their use
209
Q

fibrinolytic drugs (homework)

monitoring

A
  • vital signs every 15min for the first 2h
210
Q

Carotid Doppler reveals 75% stenosis in the left carotid artery but no sx on the right upper or lower limb

mnx?

A

optimal medical mnx

because to perform endarterectomy, must be >70% stenosis and have sx

211
Q

can AF increase the risk of acute limb ischaemia

A

yes

embolism of a left atrial appendage thrombus is a common cause

212
Q

when would you opt for Surgical embolectomy vs surgical bypass in acute limb ischaemia

A

A leg affected by embolus requires immediate surgical revascularisation with embolectomy

long-standing atherosclerotic disease –> surgical bypass

213
Q

unprovoked DVT. What inx should pts be offered to help identify possible malignancy

A

CT abdo + pelvis

Finals (47 decks)

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