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VASCULAR SURGERY Flashcards

1
Q

What is peripheral arterial disease?

A

refers to the narrowing of the arteries supplying the limbs and periphery, reducing the blood supply to these areas - usually lower limbs

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2
Q

What is intermittent claudication?

A

Crampy muscular pain which is brought on by exertion, relieved by rest and reproducible on walking that distance again
It’s due to inadequate oxygen delivery to the muscles

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3
Q

What is is critical limb ischaemia?

A

Ischaemic rest pain for more than 2 weeks or the presence of tissue loss (ulcers or gangrene)

The far end of the spectrum of chronic limb ischaemia.it often occurs after. A history of intermittent claudication
The limb is at risk

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4
Q

What are the signs of critical limb ischaemia?

A

The features are pain at rest, non-healing ulcers and gangrene
Pain often wakes pt up at night and hurts the most in the toes/forefoot due to loss of gravity’s help
Pt typically need to hand their legs from the side of the bed or resort to sleeping in chairs

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5
Q

What is acute limb ischaemia?

A

a sudden decrease in limb perfusion that threatens limb viability. In acute limb ischaemia, decreased perfusion and symptoms and signs develop over less than 2 weeks

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6
Q

What usually causes acute limb ischaemia?

A

Thrombus blocking arterial supply of distal limb

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7
Q

What is gangrene?

A

refers to the death of the tissue, specifically due to an inadequate blood supply.

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8
Q

Which arteries does atherosclerosis affect?

A

Medium and large arteries

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9
Q

What are the consequences of the atheromatous plaques formed in atherosclerosis?

A

Stiffening of the artery walls, leading to hypertension and strain on the heart whilst trying to pump blood against increased resistance
Stenosis, leading to reduced blood flow
Plaque rupture, resulting in a thrombus that can block a distal vessel and cause ischaemia

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10
Q

What are the non-modifiable risk factors for atherosclerosis?

A

Older age
FHx
Male

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11
Q

What are the modifiable risk factors for atherosclerosis?

A

Smoking
Alcohol consumption
Hypertension
Hypercholesterolaemia
Poor diet (high in sugar and trans-fat and low in fruit, vegetables and omega 3s)
Low exercise / sedentary lifestyle
Obesity
Poor sleep
Stress

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12
Q

Which medical comorbidities increase the risk of atherosclerosis?

A

Diabetes
Hypertension
Chronic kidney disease
Inflammatory conditions such as rheumatoid arthritis
Atypical antipsychotic medications

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13
Q

What are some possible end results of atherosclerosis?

A

Angina
MI
TIA
Stroke
PAD
Chronic mesenteric ischaemia

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14
Q

Where does pain in intermittent claudication tend to occur?

A

Calf muscles usually but can also affect the thigh and buttocks

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15
Q

What are the features of critical limb ischameia?

A

Chronic rest pain, which may be worse at night because of the decrease in blood pressure when asleep and the loss of beneficial gravitational effects on lower limb circulation. People may report sleeping with the leg hanging out of bed, or sleep in a chair to relieve symptoms in the affected foot.

There may sometimes not be a history of intermittent claudication - may not have been clinically apparent in a person with limited mobility/diabetic neuropathy
Dependent rubor, pallor on elevation of the extremity, and reduced capillary refill.
Skin changes including ischaemic ulcers, non-healing foot wounds, and gangrene. Tissue loss usually affects the toes.
Absent foot pulses — however, foot pulses may be palpable in distal embolisation.

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16
Q

What is Leriche syndrome?

A

occurs with occlusion in the distal aorta or proximal common iliac artery.

There is a clinical triad of:
Thigh/buttock claudication
Absent femoral pulses
Male impotence

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17
Q

What are the signs of PAD o/e?

A

Risk factors - tar staining, xanthomata
CVD - missing limbs/digits after previous amputations, midline sternotomy scare from previous CABG, scar on inner calf for saphenous vein harvesting which may indicate previous CABG, focal weakness may suggest previous stroke
Weak peripheral pulses
Skin pallor
Cyanosis
Dependant rubor
Muscle wasting
Hair loss
Ulcers
Poor wound healing
Gangrene
Reduced skin temp
Reduces sensation
Prolonged cap refill
Changes during Buergers test

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18
Q

What is dependant rubor?

A

a deep red colour when the limb is lower than the rest of the body

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19
Q

How do you do Buerger’s test?

A

Buerger’s test is used to assess for peripheral arterial disease in the leg.

There are two parts to the test.
The first part involves the patient lying supine. Lift the patient’s legs to an angle of 45 degrees at the hip. Hold them there for 1-2 minutes, looking for pallor. Pallor indicates the arterial supply is not adequate to overcome gravity, suggesting peripheral arterial disease. Buerger’s angle refers to the angle at which the leg is pale due to inadequate blood supply. For example, a Buerger’s angle of 30 degrees means that the legs go pale when lifted to 30 degrees.
The second part involves sitting the patient up with their legs hanging over the side of the bed. Blood will flow back into the legs assisted by gravity. In a healthy patient, the legs will remain a normal pink colour. In a patient with peripheral arterial disease, they will go:
Blue initially, as the ischaemic tissue deoxygenates the blood
Dark red after a short time, due to vasodilation in response to the waste products of anaerobic respiration (rubor)

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20
Q

What are the features of arterial ulcers?

A

caused by ischaemia secondary to an inadequate blood supply
Are smaller than venous ulcers
Are deeper than venous ulcers
Have well defined borders
Have a “punched-out” appearance
Occur peripherally (e.g. on the toes)
Have reduced bleeding
Are painful

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21
Q

What are the features of venous ulcers?

A

caused by impaired drainage and pooling of blood in the legs.
Occur after a minor injury to the leg
Are larger than arterial ulcers
Are more superficial than arterial ulcers
Have irregular, gently sloping borders
Affect the gaiter area of the leg (from the mid-calf down to the ankle)
Are less painful than arterial ulcers
Occur with other signs of chronic venous insufficiency (e.g., haemosiderin staining and venous eczema)

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22
Q

How do you investigate PAD?

A

CV examination
Assess sensory and motor function of legs
Assess for muscle tenderness
Routine bloods - serum lactate to assess the level of ischaemia, Creatine kinase can be a marker of rhabdomyolysis, thrombophilia screen, group and save, FBC, U&E, coag profile, lipid profile, HbA1c
Arterial doppler examination or ABPI/TBPI
ECG - arrhythmia may precipitate an embolic event
Duplex ultrasound
Angiography CT or MRI
Percutaneous transluminal angioplasty - gold standard

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23
Q

What is the ABPI?

A

the ratio of systolic blood pressure in the ankle compared with the systolic blood pressure in the arm.

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24
Q

Outline how we interpret the results of the ABPI?

A

<0.5 suggests severe arterial disease.
Refer the person urgently for specialist vascular assessment. Compression treatment is contraindicated
0.5-0.8 suggests the presence of arterial disease or mixed arterial/venous disease. Refer the person for specialist vascular assessment. Compression should generally be avoided
0.8-1.3 suggests no evidence of significant arterial disease. Compression can be safely applied
>1.3 may suggest the presence of arterial calcification, such as in some people with diabetes, rheumatoid arthritis, systemic vasculitis, atherosclerotic disease, and advanced chronic renal failure. For values above 1.5, the vessels are likely to be incompressible, and the result cannot be relied on to guide clinical decisions.

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25
Q

What does an ABPI >1.3 indicate?

A

can indicate calcification of arteries, making them diffiuclt to compress
More common in diabetic patients

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26
Q

How do you manage intermittent claudication?

A

Lifestyle changes e.g. stop smoking and high protein/low fat and carb diet
Optimise treatment of comorbidities
Supervised exercise programme
Secondary prevention - Atorvastatin 80mg and Clopidogrel 75mg OD
Naftidrofuryl oxalate

Surgical options

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27
Q

What are the surgical options for PAD?

A

Endovascular angioplasty and stenting
Endarterectomy
Bypass surgery

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28
Q

What does Endovascular angioplasty and stenting involve?

A

involve inserting a catheter through the arterial system under x-ray guidance. At the site of the stenosis, a balloon is inflated to create space in the lumen. A stent is inserted to keep the artery open. Endovascular treatments have lower risks but might not be suitable for more extensive disease.

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29
Q

What does an endarterectomy involve?

A

The surgeon makes a small incision along the blocked or narrowed artery and physically removes the plaque.

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30
Q

What does an bypass surgery involve?

A

surgeons create an alternative conduit for blood flow to circumvent the area of blockage and restore direct flow to the lower leg and foot. This is done using your own saphenous vein or an artificial vein

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31
Q

How do you manage critical limb ischaemia?

A

Urgent referral to vascular team
Analgesia (paracetemol -> opioids)

Urgent revascularisation can be achieved by:
Endovascular angioplasty and stenting
Endarterectomy
Bypass surgery
Amputation of the limb if it is not possible to restore the blood supply

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32
Q

How is acute limb ischaemia managed?

A

Arrange emergency assessment by a vascular specialist

ABC approach
Analgesia
IV 5000 units ofunfractionated heparin to prevent thrombus propagation

Definitive management - endovascular or surgical interventions

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33
Q

What does endovascular thrombolysis involve?

A

inserting a catheter through the arterial system to apply thrombolysis directly into the clot

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34
Q

What does endovascular thrombectomy involve?

A

Inserting a catheter through the arterial system and removing the thrombus by aspiration or mechanical devices

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35
Q

What does surgical thrombectomy involve?

A

cutting open the vessel and removing the thrombus

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36
Q

What usually causes peripheral arterial disease? What are other causes?

A

Atherosclerosis

Less common:
Inflammatory disorders e.g. vasculitis
Non-inflammatory arteriopathies e.g. fibromuscular dysplasia

Chronic limb threatening ischaemia can also be caused by:
Thromboembolism
Buerger’s disease
Trauma
Dissection
Physiological entrapment syndromes
Cystic adventitial disease

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37
Q

What causes acute limb ischaemia?

A

Most commonly Embolisation - may be from AF, post-MI, mural-thrombus, AAA or prosthetic heart valves
Thrombus - atheroma plaque rupture
Trauma, dissection, compartment syndrome - less common

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38
Q

What proportion of people >60 have some degree of PAD/

A

20%

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39
Q

What are the complications of PAD/

A

Impairment of quality of life by claudication and limitation of mobility
Psychosocial consequences e.g. depression
Ulceration and gangrene
Risk of amputation
Procedural complications
Higher risk of vascular complications e.g. MI, stroke, vascular dementia, mesenteric disease, Reno vascular disease

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40
Q

What are complications of acute limb ischaemia?

A

Compartment syndrome
Reperfusion injury

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41
Q

What is compartment syndrome?

A

An acute increase in pressure within a compartment which endangers the perfusion of tissues, requiring emergency decompression

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42
Q

What is reperfusion injury?

A

the damage that occurs after blood supply is restored to a tissue or organ after a period of ischemia.
products of cell death (for example potassium, phosphate and myoglobin) are released when blood flow to the ischaemic limb is restored. This can result in rhabdomyolysis, cardiac dysrhythmia, AKI, multiorgan failure, and DIC.

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43
Q

How do we differentiate between ischaemia caused by embolus vs caused by thrombus?

A

Embolus - onset is acute <24 hours, limb appears white because there is no collateral circulation and vascular examination in other leg is usually normal, no history of claudicatipn, clinically obvious source of embolus e.g. AF

Thrombosis - onset is more gradual, leg may not be white and symptoms less severe due to collateral circulation. Presentation is usually with worsening claudication and rest pain. Pulses in other leg may also be absent. Evidence of widespread vascular disease e.g. MI, stokes

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44
Q

Why is the pain in critical limb ischaemia worse at night?

A

because of the decrease in blood pressure when asleep and the loss of beneficial gravitational effects on lower limb circulation

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45
Q

How do you assess cardiovascular risk?

A

QRISK assessment tool

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46
Q

How should you manage people with a CVD risk of <10%?

A

Lifestyle - stop smoking, weight loss if overweight, healthy eating, alcohol consumption in recommended limits, physically active
Optimise management of comorbidities - - AF, CKD, DM, dyslipidaemia, hypertension, obesity, periodontitis, RA, SLE, serious mental health problems

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47
Q

How should you manage people with a CVD risk of >10%?

A

Lifestyle advice
Optimise management of comorbidities

Atorvastatin 20mg daily
Antihypertensive

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48
Q

What are the differential diagnoses for PAD?

A

Neurogenic claudication - pain typically starts in the buttock and radiates down the leg
PVD - pain starts in calf and typically radiates up the leg

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49
Q

What is neurogenic claudication?

A

Intermittent leg pain from impingement of the nerves emanating from the spinal cord
results from compression of the spinal nerves in the lumbar spine
The most common symptoms of lumbar spinal stenosis

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50
Q

What is a percutaneous transluminal angioplasty?

A

A balloon is used to widen the artery, which in some cases, may be enough on its own. In many cases, a stent is also placed.
Only good for short lesions <5cm

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51
Q

What are the stages of atherosclerosis?

A

Endothelial dysfunction
Formation of fatty streak in tunica intima
Migration of leukocytes and smooth msucle cells into vessel wall
Foam cell formation
Degradation of extracellular matrix

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52
Q

What are the 3 main presentations of peripheral arterial disease?

A

intermittent claudication
critical limb ischaemia
acute limb-threatening ischaemia

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53
Q

Whats the typical presenting complaint for rest pain and why?

A

burning pain in the ball of the foot and toes that is worse at night when the patient is in bed.
The pain is exacerbated by the recumbent position because of the loss of gravity-assisted flow to the foot.

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54
Q

How does chronic limb ischaemia present?

A

as intermittent claudication or critical limb ischaemia i.e. circulation is so severely impaired that there is an imminent risk of limb loss

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55
Q

How soon would complete arterial occlusion lead to irreversible tissue damage?

A

<6 hours

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56
Q

What are the typical features of acute limb ischaemia?

A

Pain
Pulselessness
Pallor
Paralysis
Paraesthesia
Perishing with cold

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57
Q

What do the supervised exercise programmes for intermittent claudication involve?

A

two hours of supervised exercise a week for a 3-month period and encouraging people to exercise to the point of maximal pain

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58
Q

why should people exercise to maximal pain with intermittent claudication

A

It is thought that exercise can encourage the development of collateral circulation, causing smaller arteries to enlarge, allowing them to carry more blood, and therefore more oxygen to the muscles.

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59
Q

Whats the moa of naftidrofuryl oxalate?

A

Blocks 5-HT2 receptors and causes vasodilation

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60
Q

What dose of naftidrofuryl oxalate should be given for PVD?

A

100-200mg 3 times a day

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61
Q

What monitoring should be done for naftidrofuryl oxalate?

A

It should be assessed for improvement after 3-6 months and LFTs should be checked as it can cause liver toxicity
If all ok it should be continued for life

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62
Q

How is CVD prevented in PVD?

A

Clopidogrel 75mg daily
Atorvastatin 80mg daily
Both of these for life

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63
Q

Outline the classification tool used for acute limb ischaemia?

A

Rutherford

Category 1 - no immediate threat.
Category 2a - inaudible arterial dopler and minimal sensory loss e.g. just toes - salvageable if promptly treated
Category 2b - sensory loss, rest pain, mild/moderate motor deficits, inaudible arterial Doppler - salve a gable only if immediately revascularised
Category 3 - profound sensory loss, paralysis, inaudible arterial and venous Doppler - irreversible

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64
Q

What are the options for definitive management of acute limb ischaemia?

A

Endovascular therapies, for example:
Percutaneous catheter-directed thrombolytic therapy.
Percutaneous mechanical thrombus extraction.

Surgical interventions, for example:
Surgical thromboembolectomy.
Endarterectomy.
Bypass surgery.
Amputation if the limb is unsalvageable.

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65
Q

What are anterograde and retrograde angiograms?

A

Antegrade is used when the vascular sheath is oriented in the same direction as blood flow. Retrograde indicates that the sheath is pointed in the opposite direction of the blood flow within the vessel.

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66
Q

What are the pros and cons of anterograde and retrograde angiogram approach?

A

Anterograde - better wire control with short wire, short distance to lesion
Retrograde allows you to view both legs

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67
Q

What can increase your risk of Coronary artery calcification ?

A

CKD
Diabetes
Advanced age
Rheumatoid arthritis
Systemic vasculitis
Atherosclerotic disease

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68
Q

What is TBPI?

A

Toe brachial pressure index

a noninvasive way of determining arterial perfusion in feet and toes. Used when the ABPI is abnormally high due to plaque and calcification of the arteries in the leg

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69
Q

How do you interpret TBPI readings?

A

> 0.7 normal
0.64-0.7 borderline
<0.64 is abnormal and suggests arterial disease

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70
Q

What are the pros and cons of duplex ultrasound for investigating PAD?

A

Pros - quick, done as outpatients or at bedside, non-invasive, no radiation, no contrast, cheap, easy to use, accessible
Cons - operator dependant, may not be able to look at iliac blood vessels or crural blood vessels

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71
Q

What are the pros and cons of CT angiogram for investigating PAD?

A

Pros - often available, 3D image, head-to-toe image, good for aneurysms, good for large blood vessels

Cons - radiation, contrast, not good for soft tissue imaging, picks up a lot of calcification which causes artefacts

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72
Q

What are the pros and cons of CT MRI for investigating PAD?

A

Pros - detailed, good for soft tissue, good for all sized vessels

Cons - contrast, bad for aneurysms, diffiuclt to get hands on, expensive, takes a long time, may be tricky for pt as they have to lie flat for at least 20 minutes, can cause renal fibrosis in CKD patients (although newer contrasts are much safer), can’t be used on pt with pace makers or metal work

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73
Q

What are the pros and cons of percutaneous transluminal angiography for investigating PAD?

A

Pros - stents and angioplasties can be performed at the same time, good for any vessel size, can treat any pathology

Cons - contrast, risks damage to vessels as very invasive, operant dependant,m expensive, specialist so needs trained radiographer and specific X-ray

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74
Q

When is a carbon dioxide angiography indicated?

A

high-risk states for iodinated contrast-induced nephropathy and iodinated contrast allergy

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75
Q

What was the BASIL-2 study?

A

Bypass vs Angioplasty in Severe Ischaemia of the Leg - an ongoing study
It suggested that bypass surgery should be the choice if the pt is expected to live >2years and has a suitable saphenous vein to harvest

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76
Q

What is a major amputation?

A

Any amputation be formed proximal to the ankle or wrist

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77
Q

What are primary, secondary and traumatic amputations?

A

Primary - amputation performed without an attempt at limb salvage
Secondary - amputation following a failed attempt at revasculiarsation
Traumatic - limb loss that occurs in the field at the time of injury

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78
Q

What is a hemicorporectomy?

A

a radical surgery in which the body below the waist is amputated, transecting the lumbar spine. This removes the legs, the genitalia (internal and external), urinary system, pelvic bones, anus, and rectum

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79
Q

What is a hemipelvectomy/ Hindquarter amputation?

A

a surgical procedure that involves the removal of portion of the pelvic girdle as well as the amputation of the whole leg on the affected side

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80
Q

What is a Hip Disarticulation?

A

amputation of the lower limb through the hip joint

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81
Q

What is a transfemoral amputation?

A

Above the knee amputation

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82
Q

What is Knee Disarticulation?

A

Amputation through the knee joint

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83
Q

What is a transtibial amputation?

A

Amputation below the knee

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84
Q

What is an ankle Disarticulation?

A

Amputation through the ankle joint

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85
Q

What is Syme’s amputation?

A

Amputation at the level of the ankle joint and the foot is removed but the heel pad is saved so the pt can put weight on the leg - designed to minimize disability and preserve function

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86
Q

What is residual limb pain caused by?

A

Very likely post operative pain
Peripheral nerve neuroma formation at the end of cut peripheral nerve
Prosthetic pain caused by ill fitting prosthesis

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87
Q

What is phantom limb pain?

A

pain that is localized in the region of the removed body part.
Cause of Phantom limb pain is not fully understood , but it is distressing and has a significant impact on patients life.

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88
Q

Whats the epidemiology of acute limb ischaemia?

A

1 in 12,000 per year

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89
Q

What are the symptoms of compartment syndrome?

A

Disproportionate ‘crescendo pain’ which is unresponsive to analgesia
Paraesthesia may occur
Pulselesssness and paralysis may occur later on

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90
Q

Whats the aetiology of compartment syndrome?

A

Repurfusion injury post revasculairsation in acute limb ischaemia
Other causes - fractures, crash injuries, burns

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91
Q

How do you investigate compartment syndrome?

A

Clinical diagnosis

The most reliable diagnostic test is siting an intra-compartmental pressure monitor - normal compartmental pressures are 0-8mm Hg
A creatine kinase level may aid diagnosis, if elevated

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92
Q

How do you manage compartment syndrome?

A

Keep the limb at a neutral level with the patient
Improve oxygen delivery with high flow oxygen
Augment blood pressure with bolus of intravenous crystalloid fluids- this transiently improves perfusion of the affected limb
Remove all dressings / splints / casts, down to the skin
Treat symptomatically with opioid analgesia
FASCIOTOMY
the skin incisions are then left open and a re-look is planned for 24-48 hours. This is to assess for any dead tissue that needs to be debrided.
If the remaining tissues are healthy, the wounds can then be closed

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93
Q

What monitoring needs to be done after compartment syndrome has occurred?

A

Monitor renal function closely, due to the potential effects of rhabdomyolysis or reperfusion injury.

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94
Q

Outline the pathophysiology of atherosclerosis?

A

Endothelial dysfunction (allows LDL in)
High amounts of circulating LDLs -> deposit in tunica intima and become oxidised due to ROS from dysfunctional endothelium
Oxidised LDL activate endothelial cells causing them to express receptors for WBC
Adhesion of WBC to activated endothelial cells allows monocytes and T helper cells to move into the tunica intima. Monocytes become macrophages when in tissues
Macrophages engulf oxidised LDL and become foam cells
Foam cells promote migration of smooth muscle cells from tunica media into tunica intima. And promotes smooth muscle cell proliferation. This proliferation causes synthesis of collagen = hardening of plaque
Foam cells die and release lipid content = drives growth of plaque
As plaque grows it increases in pressure which can lead to rupture

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95
Q

Whats the reason for the vast majority of lower limb amputations carried out in the UK?

A

PAD with or without diabetes

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96
Q

What pre-op management must be done for amputation?

A

Salvage a as much of limb as possible whilst eliminating the problem, enabling good healing and long-term function
Optimise the existing comobirities
Consider psychological impact
Consider social impact

97
Q

What post-op management must be done for amputation?

A

Psychoglocial impact
Risk of infection, ischaemia, prevention of stump trauma, pressure injury
Social input and house adaptations
Physiotherapy
Stump modelling, prosthesis fitting and ambulating
Phantom limb sensation and pain management

98
Q

Outline the prognosis of those presenting with intermittent claudication over a 5 year period?

A

Approximately 70-80% will remain with stable claudication
10-20% will go on to have worsening symptoms
5-10% will go on to develop critical limb ischaemia

10-15% die of CV causes within 5 years and a further 20% will have a non-fatal CV event

99
Q

What is Virchow triad?

A

Venous stasis - e.g. immobility, varicose veins, surgery
Vascular injury - stress, hypertension, bacteria, foreign materials etc
Hypercoagulability - e,.g. Coag factor disorders, pregnancy, nephrotic syndrome, cancer, advances age, smoking, contraceptives, obesity

100
Q

What are the signs of unsalvageable limbs? And what are the options if you suspect this?

A

Fixed skin mottling and complete paralysis
Revasculairsation is dangerous so the choice is amputation or palliative care

101
Q

Outline what happens in a percutaneous transluminal angioplasty?

A

Place on table with a fluoroscope (x-ray video for guidance)
Skin is numbed
Femoral artery is usually insertion site
Balloon tip catheter is passed through until reached artery being treated
Dye is injected
Angiograms are taken to identify exact location
Ballon is moved until tip is at site of stenosis
Balloon is rapidly inflated and deflated to push the plaque and vessel wall out, re-establishing blood flow
In some cases a stent may be placed to hold the aretry open

102
Q

What are the indications for percutaneous transluminal angioplasty?

A

Acute limb ischaemia
Critical limb-threatening ischaemia - life expectancy of 2 years or less, or those who do not have an autogenous vein available (otherwise use bypass surgery)

103
Q

What are the indications for compression stockings?

A

Varicose veins
Venous eczema
After DVT for prevention of post-thrombotic syndrome
Venous ulcers
Lipodermatosclerosis
Post-thrombotic syndrome
Superficial vein thrombosis
Lymphoedema
Lipoedema

ABPI 0.8-1.3

104
Q

When are compression stockings contraindicated?

A

Suspected or proven peripheral arterial disease.
Peripheral arterial bypass grafting.
Peripheral neuropathy or other causes of sensory impairment.
Any local conditions in which compression stockings may cause damage for example, fragile skin, dermatitis, gangrene, or recent skin graft).
Known allergy to the material of the stockings.
Severe leg oedema.
Major limb deformity or unusual leg size or shape preventing correct fit.
Acute infection of the leg or foot.
Suspected acute deep vein thrombosis.
Suspected skin cancer.
ABPI <0.8 or >1.3

105
Q

What is DVT?

A

the formation of a thrombus in a deep vein, which partially or completely obstructs blood flow.

106
Q

Where do DVTs usually occur?

A

Deep veins of legs or pelvis but may affect upper limbs, intracranial and splnchnic veins

107
Q

What is a provoked DVT?

A

associated with a transient risk factor

These risk factors can be removed, thereby reducing the risk of recurrence.

108
Q

What are considered transient risk factors for provoking a DVT?

A

Significant immobility
Surgery
Trauma
Pregnancy or puerperium
Combined contraceptive pill
HRT

109
Q

What is an unprovoked DVT?

A

DVT occurring in the absence of a transient risk factor. The person may have no identifiable risk factor or a risk factor that is persistent and not easily correctable (such as active cancer or thrombophilia). Because these risk factors cannot be removed, the person is at an increased risk of recurrence.

110
Q

What does the term venous thromboembolism mean?

A

used to describe any thromboembolic event occurring within the venous system, including DVT and PE.

111
Q

Outline the epidemiology of a DVT?

A

Venous thromboembolism is a common disease that is often asymptomatic. It presents with clinical symptoms in around 1–2 per 1000 people every year.
2/3rds of all cases are DVT and 1/3rd PE
The incidence of DVT during pregnancy is approximately 1 in 1000 live births.
In people who are critically ill, an incidence of up to 37.2% has been reported.

112
Q

What are the risk factors for DVT?

A

A history of DVT.
Cancer
Age over 60 years.
Being overweight or obese.
Male sex.
Heart failure.
Medical illness
Acquired or familial thrombophilia.
Inflammatory disorders
Varicose veins.
Smoking.

Risk factors that temporarily raise the likelihood of DVT include:
Recent major surgery.
Recent hospitilisation.
Recent trauma.
Chemotherapy.
Significant immobility
Prolonged travel (>4 hours).
Significant trauma or direct trauma to a vein
Hormone treatment
Pregnancy and the postpartum period.
Dehydration.

113
Q

What are the complications of a DVT?

A

Death due to PE
Post-thrombotic syndrome
Bleeding associated with anticoagilation treatment
Heparin-induced thrombocytopenia

114
Q

What is post-thrombotic syndrome?

A

a chronic venous hypertension causing limb pain, swelling, hyperpigmentation, dermatitis, ulcers, venous gangrene, and lipodermatosclerosis.
It can be debilitating with significant impact on quality of life.

115
Q

How common is post-thrombotic syndrome?

A

It affects up to 50% of people usually within 2 years of DVT of the lower limbs

116
Q

What is the typical presentation of DVT?

A

Unilateral localised, throbbing pain that occurs when walking or bearing weight
Calf swelling (rarely whole leg swelling)
Tenderness.
Skin changes-oedema, redness, and warmth.
Vein distension

117
Q

How should you assess leg and thigh swelling for suspected DVT?

A

measure the circumference of the leg 10 cm below the tibial tuberosity and compare with the asymptomatic leg. A difference of more than 3 cm between the extremities increases the probability of DVT.

118
Q

What scoring system is used to assess the likelihood of DVT?

A

2-level DVT Wells score

119
Q

Whats the Well’s criteria for DVT?

A

Active cancer
Bedridden recently >3days or major surgery within 12 weeks
Calf swelling >3cm compared to other leg
Collateral superficial veins present
Entire leg swollen
Localised tenderness along deep venous system
Pitting oedema, confined to symptomatic leg
Paralysis, paresis or recent plaster immobilization of lower extremity
Previously documented DVT

Alternative diagnoses to DVT as likely or more likely is -2 points

120
Q

How do you interpret the Well’s score results?

A

DVT likely if 2 points or more
DVT unlikely if 1 point or less

121
Q

What are the DDx for DVT?

A

Physical trauma - muscle or tendon tear, haematoma, fracture
Cardiovascular disorders e.g. superficial thrombophlebitis, postthrombotic syndrome, venous obstruction or insufficiency, Arteriovenous fistulas and congenital vascular abnormalities, acute arterial ischaemia, vasculitis, HF
Ruptured bakers cyst
Cellulitis
Dependant oedema
Lymphatic obstruction
Septic arthritis
Cirrhosis
Nephrotic syndrome
Compartment syndrome

122
Q

How should you manage suspected DVT in a woman who is pregnant or has given birth within the past 6 weeks?

A

Refer immediately for same-day assessment and management

123
Q

How should you manage someone with a suspected likely DVT based on the results of the two-tier Wells score?

A

Offer a proximal leg vein ultrasound with results available in 4 hours

If USS cannot be performed within 4 hours of request then offer a D-dimer test then an interim therapeutic anticoagulation and a proximal leg vein USS with results available within 24 hours

124
Q

How should you manage someone who is unlikely to have a DVT based on the results of the two-tier Wells score?

A

Offer a D-dimer test with the results available within 4 hours

If the results cannot be obtained within 4 hours then offer interim therapeutic anticoagulation whilst awaiting the result

If D-dimer results are positive offer a proximal leg vein ultrasound scan
If D-dimer results are negative then stop the interim therapeutic anticoagulation and consider an alternative diagnosis

125
Q

What should you give a pt if interim therapeutic anticoagulation is required for suspected DVT?

A

Offer apixaban or rivaroxaban first line
If these are not suitable, LWMH for at least 5 days followed by dabigatran or edoxaban, or LMWH concurrently with a vitamin K antagonist for at least 5 days.

126
Q

What monitoring should be done for a pt starting interim anticoagulation for suspected DVT?

A

Baseline blood tests - FBC, U&E, LFTs, PT, APTT
(Dont wait for results before starting treatment)

Review, and if necessary act on, the results of baseline blood tests within 24 hours of starting interim therapeutic anticoagulation

127
Q

How should I follow up a person with confirmed deep vein thrombosis?

A

Maintenance treatment with an oral anticoagulant following acute treatment for at least 3 months. Ensure monitoring for this unless DOACs
Ensure that people with unprovoked DVT are investigated for the possibility of an undiagnosed cancer, thrombophilia testing

128
Q

What should be tested for after an unprovoked DVT?

A

Test for antiphospholipid antibodies
and hereditary thrombophilia (if they have a first degree relative who has had a DVT or PE)

129
Q

What are thrombophilia and give examples?

A

Conditions that predispose patients to develop blood clots.

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

130
Q

What is D-dimer most useful for when diagnosing DVT?

A

D-dimer is sensitive but not specific. This makes it helpful in excluding VTE where there is low suspicion
It is almost always raised in DVT but other conditions can also raise it- pneumonia, malignancy, HF, surgery and pregnancy

131
Q

What should you do if you get a negative ultrasound scans but a positive D-dimer and the Wells score suggest a DVT is likely?

A

Repeat the ultrasound scan 6-8 days after

132
Q

How is a PE diagnosed?

A

CT pulmonary angiogram or a ventilation-perfusion scan

133
Q

How do you manage a pt with a symptomatic iliofemoral DVT and symptoms lasting less than 14 days?

A

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

134
Q

What are the options for long term anticoagulation in VTE?

A

DOAC
Warfarin
LMWH

135
Q

What are examples of DOACs?

A

apixaban, rivaroxaban, edoxaban and dabigatran

136
Q

What are the pros of DOACs for long term anticoagulation for VTE?

A

Dont require monitoring
Suitable for most patients, including patients with cancer.

137
Q

Whats the moa of warfarin?

A

Vitamin K antagonist

138
Q

Whats the target INR for warfarin when treating DVTs or PEs?

A

Between 2-3

139
Q

Who is warfarin the first-line option for long term anticoagulant in VTE?

A

For pt with antiphospholipid syndrome (they also need initial concurrent treatment with LMWH)

140
Q

Whats the first-line anticoagulant in pregnancy when a long term anticoagulation for VTE is needed?

A

LMWH

141
Q

How long should long term anticoagulation continue for when managing a VTE?

A

3 months if there is a reversible cause (then review)
Beyond 3 months if the cause is unclear, there is recurrent VTE, or there is an irreversible underlying cause such as thrombophilia (often 6 months in practice)
3-6 months in active cancer (then review)

142
Q

What is an inferior vena cava filter?

A

devices inserted into the inferior vena cava, designed to filter the blood and catch any blood clots travelling from the venous system, towards the heart and lungs. They act as a sieve, allowing blood to flow through whilst stopping larger blood clots

143
Q

When are IVC filters used?

A

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

144
Q

Whats the moa of apixaban, edoxaban and rivaroxaban?

A

direct and reversible inhibitors of factor Xa

145
Q

Whats the moa of dabigatran?

A

a reversible inhibitor of free thrombin, fibrin-bound thrombin, and thrombin-induced platelet aggregation.

146
Q

What are varicose veins?

A

dilated, tortuous, superficial veins They are often visible and palpable

147
Q

Where are varicose veins most commonly found?

A

On the legs

148
Q

What are varicose veins an indication of?

A

superficial lower extremity venous insufficiency

149
Q

Whats the pathophysiology of varicose veins?

A

Veins contain valves that only allow blood to flow in one direction, towards the heart. In the legs, as the muscles contract, they squeeze blood upwards against gravity. The valves prevent gravity from pulling the blood back into the feet. When the valves become incompetent, the blood is drawn downwards by gravity and pools in the veins and feet.

The deep and superficial veins are connected by vessels called the perforating veins (or perforators), which allow blood to flow from the superficial veins to the deep veins. When the valves are incompetent in these perforators, blood flows from the deep veins back into the superficial veins and overloads them. This leads to dilatation and engorgement of the superficial veins, forming varicose veins.
(Summary - incompetent valves in perforating veins)

Other pathological factors, such as weakness or degeneration of the vein wall, may also be involved in the development of varicose veins.

150
Q

What are risk factors for varicose veins?

A

Increasing age
FHx
Female sex
Pregnancy
Obesity
Prolonged standing or sitting
History of DVT

151
Q

What are the complications of varicose veins?

A

Bleeding, especially when the varicose veins are large, traumatized, or located over bony prominences.
Superficial vein thrombosis- characterized by the appearance of hard, painful veins
DVT
Changes in skin pigmentation.
Skin ulceration (occurs in 3–6% of people with varicose veins)
Depression (due to cosmetic skin changes)
Decreased quality of life.

152
Q

What self-care advice can be given to relieve the symptoms and reduce the risk of complications of varicose veins?

A

;lose weight
Engage in light-moderate physical activity
Avoid factors that exacerbate symptoms e.g. sitting or standing
Elevate legs when possible

153
Q

When does NICE recommend referral to a vascular service for varicose veins?

A

Primary or recurrent varicose veins associated with lower limb symptoms, typically pain, aching, discomfort, swelling, heaviness, and itching.
Lower limb skin changes thought to be caused by chronic venous insufficiency
Superficial vein thrombosis
Active venous leg ulcer that has not healed within 2 weeks
Healed venous leg ulcer

154
Q

How can you manage varicose veins?

A

Improve venous draining - Class 1 or 2 compression stockings, keep active, keep legs elevated when resting, weight loss

Keep skin healthy - Keep skin healthy - monitor health and avoid skin damage, use of emollients, topical steroids to treat flares of venous eczema and Lipodermatosclerosis

155
Q

What interventional treatments can be done for varicose veins?

A

Duplex ultrasound

Enothermal ablation
Foam scleropathy
Surgery - ligation and stripping of the affected vein

156
Q

What is endothermal ablation?

A

Using energy either from high-frequency radio waves or lasers to seal the affected veins.

157
Q

What is foam scleropathy?

A

injection of an irritant foam into the vein, resulting in an inflammatory response that causes closure of the vein.

158
Q

How do you exclude arterial insufficiency before prescribing compression stockings?

A

Measure ABPI
If <0.5 definitively avoid. Also mostly avoid is 0.5-0.8 or if >1.3

159
Q

Whats the difference between varicose and reticular veins?

A

Varicose veins are >3mm in diameter
Reticular veins are dilated to 1-3mm in diameter

160
Q

What is telangiectasia?

A

Dilated blood vessels in the skin measuring <1mm in diameter

161
Q

Why can varicose veins cause a brown discolouration to the lower legs?

A

When blood pools in the distal veins, the pressure causes the veins to leak small amounts of blood into the nearby tissues. The haemoglobin in this leaked blood breaks down to haemosiderin, which is deposited around the shins in the legs - hemosiderin staining

162
Q

Why can varicose veins lead to venous eczema?

A

Pooling of blood in the distal tissues results in inflammation. The skin becomes dry and inflamed, referred to as venous eczema.

163
Q

What is lipodermatosclerosis.?

A

a chronic inflammatory condition characterised by subcutaneous fibrosis and hardening of the skin on the lower legs

164
Q

Whats the most common cause of lipodermatosclerosis?

A

venous reflux due to varicose veins

165
Q

How do varicose veins present?

A

engorged and dilated superficial leg veins.

They may be asymptomatic or have symptoms of:
Heavy or dragging sensation in the legs
Aching
Itching
Burning
Oedema
Muscle cramps
Restless legs

Signs and symptoms of chronic venous insufficiency

166
Q

What are the Signs and symptoms of chronic venous insufficiency?

A

Hemosiderin staining
Leg ulcers that wont heal
Venous eczema
Lipodermatosclerosis
Atrophie blanche
Cellulitis
Pain
Heaviness
Aching
Itching of leg
(Symptoms worse at end of day and relieved by leg elevation)

167
Q

What is the Tap test for varicose veins?

A

apply pressure to the saphenofemoral junction (SFJ) and tap the distal varicose vein, feeling for a thrill at the SFJ. A thrill suggests incompetent valves between the varicose vein and the SFJ.

168
Q

What is the cough test for varicose veins?

A

apply pressure to the SFJ and ask the patient to cough, feeling for thrills at the SFJ. A thrill suggests a dilated vein at the SFJ (called saphenous varix).

169
Q

What is Trendelenburg test for varicose veins?

A

with the patient lying down, lift the affected leg to drain the veins completely. Then apply a tourniquet to the thigh and stand the patient up. The tourniquet should prevent the varicose veins from reappearing if it is placed distally to the incompetent valve. If the varicose veins appear, the incompetent valve is below the level of the tourniquet. Repeat the test with the tourniquet at different levels to assess the location of the incompetent valves.

170
Q

What is Perthes test for varicose veins?

A

Perthe’s test is used to distinguish between venous valvular insufficiency in the deep, perforator and superficial venous systems.
1. Apply a tourniquet at the proximal mid-thigh level whilst the patient is standing.
2. Ask the patient to walk around the room (or continually alternate between standing on tip-toes and flat feet) for 5 minutes.

Interpretation
If the varicose veins become less distended, it suggests that there is no deep venous valvular insufficiency, because the calf muscle is able to empty the varicose veins by pumping blood from the superficial venous system to the deep venous system. This result would suggest there is a primary problem with the superficial veins.
If the varicose veins remain distended (or become more distended) it suggests there is also a problem with the deep venous system, preventing the drainage of blood from the superficial varicose veins. In this circumstance, the patient may also experience pain in the leg due to venous hypertension. A potential cause of deep venous obstruction is a deep vein thrombosis.

171
Q

What is chronic venous insufficiency?

A

When blood does not efficiently drain from the legs back to the heart. Usually, this is the result of damage to the valves inside the veins.
Causes venous hypertension

172
Q

What is atrophie blanche?

A

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

173
Q

What are the common types of skin ulcers?

A

Venous ulcers
Arterial ulcers
Diabetic foot ulcers
Pressure ulcers

174
Q

What are mixed ulcers?

A

a combination of arterial and venous disease causing the ulcer.

175
Q

What are arterial ulcers caused by?

A

insufficient blood supply to the skin due to peripheral arterial disease.

176
Q

What is an ulcer?

A

A break in continuity of the skin which has not healed within 2 weaks

177
Q

What causes diabetic foot ulcers?

A

Pt with diabetic neuropathy are less likely to realise they have injured their feet or have poorly fitting shoes. Additionally, damage to both the small and large blood vessels impairs the blood supply and wound healing. Raised blood sugar, immune system changes and autonomic neuropathy also contribute to ulceration and poor healing.

178
Q

What are the risk factors for a pressure ulcer?

A

Significantly limited mobility
Significant loss of sensation
Previous or current pressure ulcer
Nutritional deficiency
Inability to reposition themselves
Significant cognitive impairment

179
Q

What causes pressure ulcers?

A

When an area of skin and the tissues below are damaged as a result of being placed under pressure sufficient to impair its blood supply

Caused by a combination of reduced blood supply and localised ischaemia, reduced lymph drainage and an deformation of the tissues under pressure.

180
Q

What is done to attempt to prevent pressure ulcers in hospital?

A

Individual risk assessments
Regular repositioning
Pressure redistributing devices e.g. high spec mattress
Regular skin checks - integrity, colour changes, variations in heat firmness and moisture, blanchable erythema
Protective dressings and barrier creams

181
Q

What risk assessment tool is used for estimating an individual pt risk of developing a pressure ulcer?

A

A waterlow score

182
Q

What are the scoring criteria on the waterlow score?

A

Build/weight for height
Skin type/visual risk areas
Sex and age
Malnutrition Screening Tool
Continence
Mobility

Additional points in special risk categories to select pt - Tissue malnutrition, neurological deficit, major surgery/trauma

183
Q

How do you interpret the waterlow score?

A

Potential scores range from 1 to 64.
A total Waterlow score ≥10 indicates risk for pressure ulcer
A high risk score is ≥15
A very high risk exists at scores ≥20

184
Q

How often should someone be repositioned to prevent them getting a pressure ulcer?

A

If at risk of developing a pressure ulcer than at least every 6 hours
If at high risk then at least every 4 hours

185
Q

Whats the most common type of leg ulcer?

A

Venous leg ulcers - 60-80% of cases

186
Q

Where do venous leg ulcers typically occur?

A

In the gaiter area of the leg (ankle to mid-calf)

187
Q

What causes venous leg ulceration?

A

Venous valve incompetence or an impaired calf muscle pump = sustained venous hypertension = enlarged veins, oedema, venous skin changes = as the skin condition and subcutaneous tissue worsen it becomes increasingly more vulnerable to ulceration

188
Q

What are risk factors for developing venous leg ulcers?

A

Increasing age.
Obesity.
Immobility.
Limited range of ankle function.
Previous ulcer.
Personal or family history of varicose veins.
PHx of DVT
Female sex.
Multiple pregnancies.
Arteriovenous fistula.
History of leg fracture or trauma.
Sedentary lifestyle.
Prolonged standing.

189
Q

Whats the estimated lifetime risk of developing a venous leg ulcer?

A

1%

190
Q

What are the complications of venous leg ulcers?

A

Chronic pain
Impaired mobility
Infection - osteomyelitis and septicaemia
Allergic contact dermatitis
Maligannt transformation in ulcer base (marjolin’s ulcer)
Sinus formation and fistula
Negative impacts on QOL and family functioning
Considerable cost to NHS

191
Q

What does a venous ulcer typically look like?

A

Gentle sloping, irregular edges
Large
SUperficial
More likely to bleed
Moderate-heavy exudate
Slough at base with white granulation tissue

192
Q

How should you assess a venous leg ulcer?

A

History
Examination - assess ulcer, signs of infection, pitting oedema, skin changes, varicose veins?, check joint mobility of ankle, check for PAD signs (hair loss, pallor, cold on palpating, cap refill, peripheral pulses etc)

193
Q

How should you assess an ulcer?

A

Site
Wound edge
Size
Depth
Appearance of wound bed - granulation tissue and slough or necrotic tissue
Amount of exudate
Signs of infection

194
Q

What investigations should be done for a suspected venous leg ulcer?

A

ABPI to exclude arterial insufficiency
FBC - anaemia may delay healing, high WBC and Plt may indicate infection
ESR or CRP - inflammation and infection
Urea and creatinine
Albumin - low may indicate malnutrition which can delay healing
HbA1c
Bacteriological swabs when clinical evidence of infection

195
Q

When should you refer a person with a venous leg ulcer to a specialist?

A

If diagnostic uncertainty
Ulcer is rapidly deteriorating to has an atypical location and/or appearance
Suspected alternative cause of ulceration e.g. malignancy, diabetes, arterial
Person has poor ankle mobility, reduced joint function or history of falls
Suspected iliac vein stenosis
Ulcer is recurrent
Suspected complication
Delayed or no healing after 2 weeks of compression therapy

196
Q

How should a venous leg ulcer be cleaned and dressed?

A

Wash in tap water and carefully dried
Debridement of slough or necrotic tissue from wound surface
Simple non-adherent dressing - frequency of dressing changes depend as on exudate volume and stage of ulcer healing

197
Q

How should compression therapy be used to treat a venous leg ulcer?

A

ABPI measured first to exclude arterial insufficiency
Start compression therapy immediately if appropriate - offer the strongest compression they can tolerate

198
Q

What can you prescribe to increase micro circulatory blood flow and improve ulcer healing?

A

pentoxifylline 400mg 3 times daily for up to 6 months
An effective adjunct to compression therapy

199
Q

Whats the MOA of pentoxifylline?

A

It’s a haemorrheologic agent
It acts to lower blood viscosity by increasing erythrocyte flexibility, reducing plasma fibrinogen, inhibiting neutrophil activation, and suppressing erythrocyte/platelet aggregation; it also has antioxidant and anti-inflammatory effects.

200
Q

How should you manage infection in a person with venous leg ulcer?

A

Consider taking a swab for microbiological testing
Oral anti optic - flucloxacillin 500mg 4 times a day for 7 days
Compression therapy can be continued if tolerated
Reassess in 2-3 days
Urgent hospital referral if signs suggesting a more serious illness or condition

201
Q

What do arterial ulcers look like?

A

Small
Deep
Well-defined borders
Punched out appearance
Pale colour
Less likely to bleed

202
Q

Where do arterial ulcers tend to occur?

A

Dismally - toes and heel of foot

203
Q

Outline how the pain differs in arterial and venous ulcers?

A

Arterial ulcers are more painful and the pain is worse at night when lying horizontal. The pain is worse on elevating and improved by lowering the leg

Venous ulcers are less painful and the pain is relieved by elevation and worse on lowering the leg

204
Q

How do we manage arterial ulcers?

A

The management of arterial ulcers is the same as peripheral arterial disease, with an urgent referral to vascular to consider surgical revascularisation. If the underlying arterial disease is effectively treated, the ulcer should heal rapidly

205
Q

What is Marjolin’s ulcer?

A

Squamous cell carcinoma that occurs at sites of chronic inflammation e.g. scar or ulcer
They mainly occur on the lower limb

206
Q

Where do neuropathic ulcers tend to occur?

A

Plantar surface of metatarsal head and plantar surface of hallux (pressure points)

207
Q

What is Raynaud’s phenomenon?

A

episodic vasospasm of the arteries or arterioles in the extremities (usually the digits) which leads to colour change including:
Pallor (due to decreased blood flow), followed by cyanosis (due to deoxygenation) and/or rubor

208
Q

What are the 2 types of Raynauds?

A

Primary - Raynaud’s disease (occurs without an associated underlying condition) - most common 80-90% of cases
Secondary - Raynaud’s phenomenon (occurs in association to an underlying cause)

209
Q

Who does Raynaud’s disease typically present in?

A

Young women e.g. 30 years old

210
Q

What are some Secondary causes of Raynaud’s phenomenon?

A

Connective tissue disorders - scleroderma, RA, SLE
Carpal tunnel syndrome
Leukaemia
Haematological conditions e.g.Cryoglobulinaemia, polycthemia, protein C, protein S or Antithrombin deficiency, factor V leiden, paraproteineaemia
Endocrine conditions e.g. hypothyroidism, Phaeochromocytoma, carcinoid syndrome
Use of vibrating tools
Drugs - oral contraceptive pill, beta blocker, lidocaine, adrenaline etc
Extrinsic vascular compression e.g. cervical rib and carpal tunnel syndrome

211
Q

What are the most common triggers for Raynaud’s phenomenon?

A

Exposure to cold and emotional stress

212
Q

What proportion of those with systemic sclerosis also have Raynaud’s phenomenon?

A

Over 90%

213
Q

Whats the prognosis of Raynaud’s phenomenon?

A

Typically benign which does not progress or lead to tissue damage. It may go into remission.

214
Q

Whats the typical presentation of Raynaud’s phenomenon ?

A

A history of clearly demarcated pallor of the digit, followed by at least one other colour change (cyanosis and/or erythema) — symptoms are usually precipitated by cold or emotion
Colour changes typically start at the tip of the finger and then spread downwards or to more digits.
The classical tri-phasic colour change may not always be present but blanching must occur for a diagnosis of Raynaud’s phenomenon to be made.
The colour change may be associated with other symptoms such as transient numbness of affected finger tips, paraesthesia on rewarming and discomfort.

215
Q

What area of the body can Raynaud’s phenomenon affect?

A

Digits
Tip of nose
Ear lobes
Tongue
Nipples

216
Q

What are the features of that are specific to secondary Raynaud’s disease?

A

Digital ulcers, gangrene, severe ischaemia in 1 or more digits
Onset over the age of 30
Episodes that are intense, painful or asymmetrical
History of connective tissue disorder or other causes of digital vasa spasm
Positive anti-nuclear antibody (ANA) tests
Abnormal nail-fold capillaries

217
Q

What investigations should be done for Raynaud’s phenomenon?

A

FBC
ESR
Antinuclear antibodies

218
Q

What are the DDx of Raynaud’s phenomenon?

A

Chilblains
Acrocyanosis
Erythromelalgia
Occlusive vascular disease
Vasculitis
Haematological malignancy, cryodiseases and hyperviscocity syndromes
Live do reticularis
Peripheral nerve injury
Reflex sympathetic dystrophy

219
Q

What are the complications of Raynaud’s phenomenon?

A

Primary Raynaud’s phenomenon does not progress to tissue damage — in people who are severely affected it can cause significant discomfort and reduce quality of life.
Secondary Raynaud’s phenomenon is associated with complications such as digital ischaemia, digital ulceration, necrosis, scarring and secondary infection.

220
Q

When should you arrange immediate admission for raynauds?

A

The person has severe ischaemia of one or more digits.

221
Q

When should you refer a pt with raynauds to rheumatology?

A

All people with suspected secondary Raynaud’s phenomenon.
All children aged 12 years or younger with Raynaud’s phenomenon.
If symptoms are worsening, severe or unresponsive to standard treatment.

222
Q

How should you manage a person with raynauds?

A

If caused by a drug then review the need for it and, if possible, stop it
Lifestyle measures - keep whole body warm, avoid smoking, minimise stress of its a trigger, exercise regularly

If lifestyle measures fail and symptoms are having a significant negative impact then consider a trial of nifedipine as prophylaxis

223
Q

What proportion of people of nifedipine have side efefcts and what are these?

A

75%

oedema, palpitations, headache, flushing, or dizziness.

224
Q

Whats the moa of nifedipine?

A

It’s a calcium channel blocker - causes vascular smooth muscle relaxation

225
Q

What is lymphoedema?

A

a chronic condition caused by impaired lymphatic drainage of an area. The tissues affected become swollen with excess, protein-rich fluid. It can affect any part of the body, but usually develops in the arms or legs.

226
Q

What is primary lymphoedema?

A

a rare, genetic condition, which usually presents before aged 30. It is a result of faulty development of the lymphatic system.

227
Q

What is secondary lymphoedema?

A

When lymphatic system is damaged e.g. from surgery, trauma, infection

228
Q

What is the most common example of secondary lymphoedema?

A

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

229
Q

What is Lipoedema?

A

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

This affects women more often than men. It can cause pain, psychological distress and significantly affect the patient’s quality of life.

230
Q

How are lymphoedema and Lipoedema differentiated?

A

The feet are spared in lipoedema, unlike lymphoedema.

231
Q

How do you asses lymphoedema?

A

Stemmer’s sign
Limb volume - circumferential measurements, water displacement and perometry
Bioimpedance testing
Imaging - lymphoscintigram, MRI, USS, CT

232
Q

What is Stemmer’s sign?

A

The skin at the bottom of the second toe or middle finger is gently pinched together using two fingers. If it is possible to lift and “tent” the skin, Stemmer’s sign is negative. If it is not possible to pinch the skin together, lift and “tent” it, Stemmer’s sign is positive, suggesting lymphoedema.

233
Q

How can we use water displacement to assess for lymphoedema?

A

where the affected limb is placed in a tank of water and the amount of water that’s displaced is measured to calculate the volume of the limb

234
Q

What is perometry?

A

where infrared light is used to measure the outline of an affected limb and calculate its volume

235
Q

What is bioelectric impedance spectrometry?

A

Electrodes are placed on the limb, and an electrical current is passed through the limb, between the electrodes. The resistance to electrical flow through the tissues estimates the volume of lymph fluid in the tissues.

236
Q

What is Lymphoscintigraphy?

A

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.

237
Q

How is lymphoedema managed?

A

Manual lymphatic drainage
Compression bandages
Specific lymphoedema exercises to improve lymph drainage
Weight loss if overweight
Good skin care
Lymphaticovenular anastamosis
Antibiotics for any cellulitis that develops

238
Q

What is lymphaticovenular anastamosis?

A

a surgical procedure that involves attaching lymphatic vessels to nearby veins, allowing the lymphatic vessel to drain directly into the venous system.

239
Q

What is superficial thrombophlebitis?

A

Inflammation of a superficial vein which results from a blood clot
It may occur after recently using an IV line, or after trauma to the vein

GI AND SURGERY (31 decks)

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