3. Vascular Disease

Question 1

Three divisions of peripheral vascular disease?

Answer 1

Acute limb ischaemia - sudden decrease in limb perfusion
Critical limb ischaemia - pain at rest
Intermittent ischaemia - pain on exertion

All start as atherosclerosis causing stenosis

Question 2

Symptoms of acute limb ischaemia?

Answer 2

Pain
Pale
Pulseless
Paralysis
Parasthesia
Perishingly cold

Question 3

Symptoms of critical limb ischaemia and claudication?

Answer 3

Hair loss
Numbness
Brittle, slow growing toe nails
Absent pulses
Ulcers
Atrophic skin 

Often asymptomatic - remember claudication is only on movement

Question 4

What is beurger’s test?

Answer 4

Raise foot 45 degree, leg should stay same colour.
If develops pallor then PVD suspected.

less than 20 degrees is severe limb ischaemia.

If you swing the leg back down and it goes red, this is hyperemia.

Question 5

Vascular disease investigation?

Answer 5

1. Cardio exam - BP, HR, bloods, ECG
2. Ankle brachial pressure index - gold diagnostic - take bp in arm and leg and divided leg by arm, it should be 0.9-1.2. if lower, abnormal. <0.5 is chronic
3. Colour duplex USS
4. Magnetic resonance angiogram

Question 6

Three types of ulcers?

Answer 6

Arterial
Venous
Neuropathic

Question 7

Arterial ulcer symptoms?

Answer 7

Punched out appearance, deep
Distal
Well defined
Pale base - grey
Hair loss, shiny and pale skin around
Calf muscle wasting - no blood supply
Absent pulses

Question 8

Venous ulcer signs?

Answer 8

Large shallow, sloping and poorly defined
More proximal
Swelling, itching or aching
May be associated with - stasis eczema, lipodermatosclerosis (upside down champagne bottle), atrophie blanche (area of white, atrophied skin), hemosiderin depositation (darkened areas)

Question 9

Investigating arterial and venous ulcers?

Answer 9

Duplex USS of lower limbs.
ABPI

Venous - swab for micro, biopsy
Arterial - ECG, perc angio, bloods.

Question 10

How to manage venous ulcers?

Answer 10

Compression stockings
Debridement and cleaning
Antibiotics if infected
Moisturising

Question 11

What is a true and false aneurysm?

Answer 11

True - where all three layers of blood vessels are incorporated
False - only one layer, creates a pouch

Question 12

Unruptured AAA symptoms?

Answer 12

Asymptomatic
Often incidentally
Pulsatile, laterally expansile mass
Abdo bruit

Question 13

Ruptured AAA symptoms?

Answer 13

Sudden, severe pain in back, groin or abdo
Syncope
Shock
Pulsatile, laterally expansile mass
Abdo bruit
Grey-Tuner's sign (bruising on flanks)

Question 14

AAA investigations?

Answer 14

Bloods (incl. cross match)
Abdominal ultrasound (gold standard) to detect pressure and see how wide (wider than 3cm)
CT angiogram to see if rupture (gold for rupture)
Magnetic angiogram if renal impairment.

Question 15

Diff of aortic dissection?

Answer 15

Type A (most common) always incldudes ascending aorta - type 1 - before and after aortic arch
type 2 - is only ascending aorta
Type B - Type 3, only descending aorta

Aortic dissection (false aneurysm that is above the diaphragm)

Question 16

Aortic dissection symptoms and signs?

Answer 16

Tearing pain down chest and radiating to back
Blackout and dysphagia - from carotid
Angina - coronary
Loss of consciousness - subclavian
Renal failure - renal artery

HTN
BP difference between arch of more than 50%
Murmur heard on back
Signs of aortic regurg
OR 
Signs of connective tissue disorder

Question 17

Aortic dissection investigation?

Answer 17

Bloods (risk factors)
ECG (causes)
CXR (aortic knuckle, widened mediastinum, globular heart)
CT angiogram (gold standard)

Question 18

What are varicose veins?

Answer 18

Subcutaneous, permanently dilated veins more than 3mm in diameter standing.

Question 19

Causes of varicose veins?

Answer 19

Primary - idiopathic
Secondary - 
1. Venous outflow obstruction - pregnancy, ascites, pelvic malignancy, ovarian insufficiency (??)
DVT
AV malformation

Question 20

Varicose veins symptoms?

Answer 20

Visible dilation
Leg itching with prolonged standing
Swelling and itching
Bleeding

Question 21

Signs of varicose veins?

Answer 21

Veins feel tender or hard
Tap test - tap distally and feel thrill at sapheno-femoral junction
Auscultation for bruits
Trendelenburg test (tourniquet above knee whilst leg in air, rapid filling when taking off)

Question 22

Investigations for varicose veins?

Answer 22

Duplex USS (gold standard)
DVT assessment

Question 23

Manage varicose veins?

Answer 23

Compression stockings
Lifestyle changes
Radiofrequency ablation
Endovenous laser ablation
Microinjection sclerotherapy
Stripping long saphenous vein
Saphenofemoral ligation
Avulsion of varicosities

Question 24

What is gangrene?

Answer 24

Tissue necrosis causes by ischaemia, infarction or trauma

Question 25

Types of gangrene?

Answer 25

Wet - tissue become pus-y
Dry
Gas - bubbles of gas beneath skin

Question 26

DVT Symptoms?

Answer 26

Erythema
Warmth
Swollen limb
Varicosities
Painless
Homan's sign, dorsiflex causes deep pain
Check for a PE (Well's criteria)

Question 27

DVT investigations?

Answer 27

Doppler USS (gold standard)
Impedence phlethysmography
D-dimer - strong negative predictive value (if negative, almost certainly unlikely)

Question 28

DVT treatment?

Answer 28

DOACs
LMWH
Compression stockings and exercise for prevention