Vascular Teaching Flashcards
What are the complications of varicose veins?
Phlebitis - 20%
Bleeding - 3%
Skin changes - 25%
Ulcers 5-10%
History - varicose veins
Symptoms -
Previous treatment
Medical history inc DVT, diabetes, anticoagulants
Physical exam for varicose veins
Site of varicosities
Signs of venous hypertensive complications - eczema, oedema, ulcers, scars from surgery, muscle wasting immobility
Palpate arterial pulses, look for tender and lumpy veins
Control at SFJ/SPJ - supine vs standing
Percuss - tapping test
Auscultation - trial or bruit over SFJ
Auscultation for reflux using hand-held Doppler
Key investigation in varicose veins?
Duplex ultrasound scan Confirms or establishes source of reflux Provides a roadmap Assesses the deep veins Allows treatment planning and helps guide treatment
Colour Doppler - physiology
Treatment of varicose veins - conservative
Leg elevation, exercise and weight loss
Compression stockings - difficult for patients to integrate into daily routine but are uncomfortable, lengthy treatment and do not cure the underlying problem
NOT TED stockings
NICE not recommended alone, but in
- pregnancy (40% increase in blood volume)
- pts unsuitable for invasive treatment
Truncal varicosities
Disconnection procedures for varicose veins
Endovenous therapy - laser vs radio frequency in varicose veins
Endovenous surgery - radiofrequency ablation
Cyanoacrylate embolisation - glue
Varicose vein
Venous ulcers - management
Assessment of the ulcer
Sensible dressing selection
Compression therapy - venous ulceration
Compression therapy - mechanism of action and art to successful compression??
Aetiology of DVT - … triad
Virchow triad
Changes to flow
Changes to blood coaguability
Changes to vessel wall
Management of DVT
Prevention is the best management Risk assess Periop prophylaxis Mechanical - TED stocking, early mobilisation, active intermittent mechanical compression Coaguability - LMWH heparin
Manage DVT itself - anticoagulation, compression hosiery 2 week minimum
Role of thrombolysis
catheter directed thrombolysis
- mechanical clot disruption/aspiration, pharmacological lysis agents - e.g. alteplase
Iliofemoral DVT (only)
Venous infaction - beware, persistence of symptoms e.g. swelling
Post-thrombotic syndrome
A combination of patient reported symptoms and objective findings such as swelling and skin changes in patients following DVT of the upper or lower extremity
20-50% of patients after symptomatic DVT
5-10% will suffer severe PTS
Pathophysiology of PTS and CVI
Venous infarction
Preventing upper extremity PTS
Aneurysm - define
Permanent and irreversible, localised dilation of a blood vessel to at least 50% more than its expected normal diameter
Ectasia - define
Permanent and irreversible, localised dilation of less than 50% of the normal diameter
Arteriomegaly - what is this ?
Diffuse ectasia involving multiple arterial segments
Aetiology of aneurysm
Degenerative Familial Vasculitic Connective tissue abnormalities Infected ‘mycotic’
Age and gender distribution for aneurysm
More common in men
Why Infra-renal aorta?
Presentations of AAA
Asymptomatic Rupture Compression Embolism Thrombosis Fistulation Infection
Diagnosis of aneurysms ?
Clinical exam
Ultrasound imaging
Cross-sectional imaging
Diagnosis of aneurysms - asymptomatic?
Ultrasound in asymptomatic individuals - highly reliable, cheap, portable
Ruptured AAA
Rupture risk - AAA
When to treat AAA
Screening for AAA
Common condition, serious condition Detectable at an asymptomatic stage Reliable test for diagnosis Non-invasive test Inexpensive - £63 per person Men over 65 years target Effective treatment - open and endovascular Better outcome with early treatment
UK national screening for AAA
Open repair vs endovascular repair for AAA
EVAR vs OPEN repair?
Ischaemia - define
Deficiency in supply of blood flow (perfusion) to the tissue bed
Absolute ischaemia - define
Insufficient perfusion to continue normal cellular process - is limb threatening
Relative ischaemia - define
Insufficient perfusion to permit full function, ok at rest
Acute ischaemia - define
Sudden occurrence of absolute ischaemia - 6PS
Chronic ischaemia - define
Established insufficient perfusion > 2 weeks
Absolute - critical ischaemia - gangrene, rest pain
Relative - depends on need, asymptotic, claudication
6 Ps of acute ischaemia
A sudden decrease in limb perfusion causing a potential threat to limb viability Pale Painful Pulseless Perishingly cold Paraesthetic Paralysed
Algorithm for limb ischaemia
Acute limb ischaemia - causes
Embolisation - AF, endocarditis, proximal aneurysm
Thrombotic - rupture of an atherosclerotic plaque
Aneurysm - e.g. popliteal thrombosis
Trauma - fracture/dislocation, knife/gunshot wound, IV drug use, iatrogenic
Thrombotic disease
Involves acute clot on underlying atherosclerosis
Thrombosis can clear acute clot and allow angioplasty/stent of underlying plaque
Surgery usually involves bypass
Trauma management - limb ischaemia
Compartment syndrome
When ischaemia muscle gets re-perfumed
Muscle oedema, pressure in compartment increases, causes micro vascular compromise and muscle necrosis
Intense pain - especially to passive movement
Paraesthesia in feet
Lack of pulse is late sign
Chronic ischaemia (PVD, PAD, PAOD)
Risk factor mods
- smoking, antiplatelets, statin, ACEi, claudication clinic
Try not to intervene unless critical = absolute ischaemia
Critical ischaemia - treatment options
Angioplasty +/- stent often first option
Long segment occlusion, vein conduit - bypass
Amputation if tissue loss is advanced, low chance of revascularisation succeeding
Palliative if frail and not compos mantis
Angioplasty
Seldinger technique
Trans-luminal
Sub-intimal
Technical innovations - crossing devices, debunking, lithoplasty
Stent developments - drug elution, covered stents
Trials against surgery, favour surgery slightly
Bypass surgery - anatomical
