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
Where do we check for cap refill?
On the most distal part - not on the nail though
Oedema
Pitting vs non-pitting
- Pitting -> applied pressure cause lasting indentation
- Non-pitting -> no lasting indentation under pressure
What’s thrombophlebitis?
Inflammatory process causing blood clots to form in the vein
(e.g. DVT)
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
Why do w do Allen test?
ABG/arterial cannulation
- may cause obstruction by clot-> ischemia
- do Allen’s to check which hand has dual supply -> take blood from the one that has dual supply
Bypass surgery
- to determine which artery to choose: saphenous or radial
- if Allens test takes more than 5 s for the colour to return - radial artery is perhaps NOT a good choice
(less than 3 - good choice; 3-5 consider but evaluate further)
How many fingers do we use to asses radial and femoral pulse?
3 fingers
Where do we feel for a femoral pulse?
Between ASIS and pubic symphysis
Pulse is present on one side and not on the other -> what does it potentially mean?
Acute ischaemia
What bones do we feel against while palpating for the pulses:
A. femoral
B. popliteal
A. Femoral -> neck of femur
B. Popliteal -> distal femoral
Where to feel for a posterior tibialis pulse?
Between medial malleolus and Achilles tendon
*feel with three fingers
Where to feel for Dorsalis Pedis pulse?
lateral to extensor hallucis longus (tendon)
*feel against navicular bone
* to feel that pulse we do not need to apply a lot of pressure
What arteries to ascultate during vascular exam?
- carotids
- abdomen -> iliac artery
- groins -> femorl a.
Doppler USS
- what’s normal and what’s abnormal to hear?
- triphasic -> normal
- bi-phasic/monophasic -> arterosclerosis
Causes of varicose veins?
- 98% are idiopathic
- secondary causes: DVT, AVM, pelvic masses (pregnancy, uterine fibroids and ovarian masses)
Risk factors for varicose vein
- prolonged standing
- obesity
- pregnancy
- family history
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
What classification is used for varicose veins?
CEAP classification
C - clinical features
E - aEtiology
A - anatomical
P - pathophysiology
On what occasion NICE recommends the use of compression stocking for varicose veins? Why?
Compression stockings to be used only if interventional treatment is not applicable - as patient would need to use them for the rest of their lives
Criteria to refer the patient with varicose veins to vascular surgeon (for the surgery)
- symptomatic (primary or recurrent) varicose veins
- venous ulcers form
- changes to the skin e.g. pigmentation, eczema (thought to be caused by venous insufficiency)
- superficial vein thrombosis
Types (names only) of surgeries used for Rx of varicose veins
- thermal ablation
- foam sclerotherapy
- vein ligation, stripping and avulsion
Describe shortly what thermal ablation for varicose veins involve
Thermal ablation
heating the vein from inside (radiofrequency or laser catheter) -> vein is damaged and closes off
*done with the guidance of USS
Describe shortly what foam sclerotherapy for varicose veins involves?
Foam sclerotherapy
sclerosing/irritating agent is injected into the varicose vein -> inflammation is triggered -> vein is closed off
*done under USS guidance
Describe shortly what vein ligation, stripping and avulsion for varicose veins involve
Vein ligation, stripping and avulsion
The incision in the groin (or popliteal fossa) is made -> refluxing vein is identified -> then it is tied off and stripped away
