Vascular_1 Flashcards
What’s Burger’s test?
Burger’s test = test for arterial sufficiency
Normally when a foot is elevated (from lying down) it will still have a pink colour -> as the perfusion is normal
1. Elevation Pallor
If the patient has a problem with peripheral vessels/ischaemic leg -> we elevate their foot 15-30 degrees angle-> foot becomes pale -> the angle is known as vascular angle or Burger’s angle
*elevation of <20 degrees and pallor = severe ischaemia
- Rubor of dependancy
The patient is then asked to sit down/ leg is lowered -> we observe how long does it take for the colour to return & how the colour looks like = rubor (redness) (e.g. the foot may become very red = sunset foot)
What’s ‘sunset foot’ is the result of?
If there is a peripheral vascular problem in a person, then the pink colour of the foot (after elevation) will be slow to return and may be rather red than pink-> rubor/ sunseting
Reason: This is due to the dilatation of the arterioles in an attempt to rid the metabolic waste that has built up in a reactive hyperaemia.
(3) criteria for aneurysm surgery
The three criteria for aneurysm surgery are:
- An asymptomatic aneurysm larger than 5.5 cm in diameter
- An asymptomatic aneurysm which is enlarging by more than 1 cm per year
- A symptomatic aneurysm-> the only criteria, apart from emergency rupture, which requires urgent surgery rather than an elective procedure.
What’s EVAR?
- procedure
- complications
Elective endovascular repair (EVAR)
Procedure: stent is placed into the abdominal aorta via the femoral artery to prevent blood from collecting in the aneurysm.
Complication of EVAR: an endo-leak, where the stent fails to exclude blood from the aneurysm, and usually presents without symptoms on routine follow-up
What are the criteria defining low rupture risk AAA
How to treat?
Low rupture risk
- asymptomatic, aortic diameter <5.5cm
- treat with abdominal US surveillance and optimise cardiovascular risk factors (e.g. stop smoking)
What are the criteria for high rupture risk AAA ?
How to treat?
High rupture risk
- symptomatic, aortic diameter >=5.5cm or rapidly enlarging (>1cm/year)
- treat with elective endovascular repair (EVAR) or open repair if unsuitable
Pulseless peripheries in a young woman of Asian/Japan origin - possible diagnosis
Takayasu’s arteritis
Pathophysiology of a Subclavian Steal Syndrome
Subclavian steal syndrome
- a stenosis or occlusion of the subclavian artery, proximal to the origin of the vertebral artery
- increased metabolic needs of the arm -> retrograde flow and symptoms of CNS vascular insufficiency
What is the clinical presentation of a subclavian steal syndrome?
Subclavian steal syndrome -> syncope or neurological deficits when the blood supply to the affected arm is increased through exercise
Coarctation of aorta
what are possible clinical signs (on examination)
- Weak arm pulses may be seen
- radio-femoral delay
What may be seen on the X-ray if coarctation of the aorta is long-standing and why?
Collateral flow through the intercostal vessels may produce notching of the ribs
Management of peripheral arterial disease
(1st line, 2nd line, 3rd line)
A_. Lifestyle:_ exercise (supervised exercise programme), stop smoking, lower cholesterol
B. Medication:
- Atorvastatin 80mg for all with CVS risk
- Clopidogrel (in preference to Aspirin) if established PAD
C. Severe:
- angioplasty
- stenting
- bypass surgery
What’s critical limb ischaemia?
New, acute event (e.g. acute blockage) in a patient known to have chronic ischaemia
Trophic changes seen on the lower limb
- hair loss
- pale skin
- onychogryphosis (thickened, distorted nail)
- fungal infection
Where to look for ulcers while examining lower limb arterial system?
- between toes
- pressure points (e.g. heel, ‘bulb’ of the foot)
Where to start to feel: distally vs proximally for:
A. Temperature
B. Pulses
A. Temperature -> distal (periphery)
B. Pulses -> proximal (if proximal not felt, less likely to feel peripheral) -> start from femoral then move down the popliteal and lastly do feet pulses
Expansile vs pulsatile pulse on AAA - what’s the difference?
Place your fingers tips on each margin side of the aorta
Expansile: fingers would move outwards with each contraction (fingers separated and then return) -> suggest AAA
Pulsatile: pulse being felt during systole but fingers are not separated (upward movement)-> normal physiology of the aorta
Oedema
Pitting vs non-pitting
- Pitting -> applied pressure cause lasting indentation
- Non-pitting -> no lasting indentation under pressure
How to perform Allen test?
* in clinical practice/usually preferred to assess with USS as it would be more reliable
- Ask the patient to elevate their hand and move it around/make a fist
- Occlude both arteries
- When it is pale -> let one artery occlusion go/ the other keep in
- Repeat on the other side
- Which one filled with blood quicker? The one that fills quicker is perhaps dominating one
Doppler USS
- what’s normal and what’s abnormal to hear?
- triphasic -> normal
- bi-phasic/monophasic -> arterosclerosis
What’s saphena varix?
Saphena varix - dilation of saphenous vein and saphenofemoral junction
What is the cause of atrophie blanche?
What diseases are associated with it?
Atrophie blanche - due to occlusion of small blood vessels in the middle and deep dermis, which prevents normal healing.
Associations (atrophie blanche may follow ulceration due to): diabetic vascular disase, cutenous small vessel disease, any wound of the lower leg
