Venous/arterial Disease Flashcards
Describe the clinical features of intermittent claudication/peripheral arterial disease?
Variable period of exercise –> ischaemic pain in limb
Relieved by rest
How would you clinically assess someone with suspected intermittent claudication?
- history of symptoms and risk factors
- examine legs/feet for signs of ischaemia
- feel for femoral, popliteal and foot pulses
- measure ABPI
How do you measure/calculate ABPI?
Measure BPs manually, using doppler probe, in both arms + ankle (using posterior tibial, dorsals pedis and peroneal arteries if possible)
ABPI = highest ankle pressure / highest arm pressure
What is a normal ABPI?
0.9 - 2.1
What ABPI value would indicate claudication?
0.4 - 0.85
severe = 0 - 0.4
Which investigations should be done if considering revascularisation for lower limb ischaemia?
Duplex USS
MR angiography
What are the first steps in management of intermittent claudication?
STOP SMOKING
Lifestyle advice
Supervised exercise program –> exercise to maximal pain
What is the next step in management of intermittent claudication if lifestyle measures don’t work?
Angioplasty + stent
Surgery –> use of prosthesis/vein to bypass area of occlusion
What are the clinical features of critical limb ischaemia?
Pain in toe/foot AT REST due to ischaemia (nerve ending pain)
Worse at night, helped by getting up and walking about
What might you find on examination in critical limb ischaemia?
Cool to touch Absent pulses Colour change Hairless Thick nails Shiny skin Venous guttering Ulcers Gangrene
What are the management options for critical limb ischaemia?
Pain control - paracetamol + opioid + antiemetic Imaging if considering revascularisation - duplex USS, MR angiography Angioplasty or bypass surgery Amputation
What are varicose veins?
Dilated, tortuous, superficial veins
–> due to abnormal transmission of deep vein pressure
Which veins are usually affected in varicose veins?
Long and short saphenous veins
What are primary varicose veins?
Exist with normal deep vein pressures
What are secondary varicose veins?
Due to raised deep vein pressures e.g. post DVT
How does a DVT lead to the development of varicose veins?
Increases the deep vein pressure due to:
- deep vein obstruction
- deep valve incompetence
What are the risk factors for varicose veins?
Age
Pregnancy
Obesity
What are the symptoms of varicose veins?
Variable, often asymptomatic
- achy, heavy, legs
- burning, throbbing, muscle cramping
- swelling
- itching
- skin discolouration
What are some complications of varicose veins?
- bleeding
- thrombophlebitis
- discolouration: haemosiderin deposits due to blood breakdown
- lipodermatosclerosis
- ulceration
Which investigation should be done for varicose veins?
Duplex USS
What in the initial, non interventional management of varicose veins?
Information
Graduated compression stockings
When are graduated compression stockings contraindicated?
Low ABPI
What are the interventional management options for varicose veins?
Endovenous:
- foam sclerotherapy
- ablation (mechanical, laser or radio frequency)
Surgical
What is the definition of an aneurysm?
Part of artery with dilatation > 50% of its original diameter
How is screening for AAA done in the UK?
Abdominal USS
Offered to men when they turn 65
What are the possible different findings on AAA screening and how are they managed?
No aneurysm (< 3cm) --> no further screening
Small AAA (3-4.4cm) --> repeat scan every year
Medium AAA (4.5-5.4cm) --> repeat scan every 3 months
Large AAA (>5.5cm) --> refer to surgeon within 2 weeks
Which type of imaging is used to give more information after USS?
CT (arterial phase)
What are the clinical features of an unruptured AAA?
Usually asymptomatic
Abdominal/back pain
Pulsatile mass on abdominal palpation
What are the clinical features of a ruptured AAA?
Intermittent or continuous abdominal pain
–> radiates to back, iliac fossa or groin
Collapse
Expansile mass (expands and contracts)
Shock
What are the two options for repair of an AAA?
Open repair
EVAR - endovascular aneurysm repair (stenting)
How is an open repair of AAA carried out?
Laparotomy
Clamp aorta and iliacs
Dacron Graft placed
What are the features of EVAR?
Stent inserted via femoral artery
Avoids major surgery, faster recovery
Failure rates higher than with surgery so more likely to require further interventions
What are the 3 parts of Virchow’s triad which predispose to VTE?
Hypercoagulable state
Endothelial injury
Circulatory stasis
How do you investigate a suspected PE?
Pre-test probability –> Well’s score
- if moderate/high risk –> scan
- if low risk –> check D-dimers
- D-dimer high –> scan
- D-dimer normal –> VTE excluded
Which scan is gold standard for PE?
CTPA
Which scan can be used if CTPA is contraindicated?
V/Q scan
How do you investigate a suspected DVT (without PE)?
Doppler USS leg
What is the treatment for a DVT?
Oral anticoagulation (DOAC - direct oral anticoagulation e.g. apixaban or rivaroxaban)
What is the treatment for PE (depending on risk)?
High risk –> thrombolysis (fibrinolysis), then DOAC
Intermediate/low risk –> DOAC
How long should a provoked VTE with a reversible factor be treated?
3-6 months
How long should a provoked VTE with an irreversible factor be treated?
Depends on factor
3-6 months or lifelong
How long should an unprovoked VTE be treated?
Long term
unless risk of bleeding
