2. Vascular Disease Flashcards by E E

Define Abdominal Aortic Aneurysm and state 2 types

A localized dilation of the abdominal aorta to >1.5x its original diameter OR >3cm.

Can be fusiform (bulges on both sides) or saccular (bulges on one side)

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State causes/RF of AAA

Atheroma (RF: HTN, smoking, hypercholestrolaemia)
Connective Tissue Disease (Ehler Danlos, Marfans)
Trauma
M (F = increased rupture risk)

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Whats the difference between true and pseudo-aneurysms?

True aneurysm are dilatations involving ALL layers of the arterial wall
Pseudoaneurysms involve a collection of blood in the outer layer, which communicates with the lumen.

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Symptoms and signs of AAA

Majority asymptomatic
Large –> pain or pulsating sensations in the back

Pulsatile and expansive abdominal aortic mass

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Ruptured AAA Symptoms and signs

Severe abdominal pain, radiating to the back/groin (often confused with renal colic)
Bleeding can result in hypovolaemic shock (low BP/ high HR) which can result in collapse
Retroperitoneal bleeding may result in Grey Turner’s or Cullen’s Sign

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Investigations/Management of AAA

Who is screened?

USS (based on aneurysm size)

1) Small (3-4.4cm) - 1yr follow-up scan
2) Medium (4.5cm-5.4cm) - 3mths follow-up scan; conservative: stop smoking, lose weight, exercise; medical: statins, BP meds, aspirin
3) Large (>5.5cm) or growth >1cm/yr - surgical: open aortic surgery (young pts, longer recovery) OR endovascular repair (less peri-operative mortality, higher risk of further procedures)

All males over 65 screened

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Aortic Dissection definition and classification

A tear in the tunica intima resulting in blood accumulation between the inner and outer tunica media (false lumen).

Type A - Tear in the ascending aorta Type B - Tear in the descending aorta (after the left subclavian branch)

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Aortic Dissection RF (6)

Hypertension
Atherosclerosis
Connective tissue disorders - SLE, Marfan’s, Ehler’s Danlos
Iatrogenic - angiography/angioplasty
Congenital - coarctation of aorta
Cocaine

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Aortic Dissection Signs and Symptoms

S - Central
O - Sudden
C - Tearing 
R - Back
A - depends on position of tear: Carotids - blackout, hemiparesis; Coronary - MI, angina; Renal - AKI, renal failure; Coeliac trunk - abdo pain

TC
BP > 20mmHg discrepancy b/t arms 
Wide pulse pressure
Radio-radial delay
Murmur heard on back below scapula
Signs of aortic insufficiencyL collapsing pulse, EDM

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Investigations for aortic dissection

Investigations

Bloods

FBC, U&Es (renal damage)
X Match 10 units of blood
Cardiac enzymes (troponin) – usually negative

CXR - Widened mediastinum and aortic notch visible

ECG - often normal, maybe some ischaemia

CT angiography - Visualisation of dissection and intimal flap
- If CT unavailable in acute setting, Transoesophageal Echo very sensitive

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Management of Aortic Diseection

Beta blockers + analgesia

Ruptured – haemodynamic support and resuscitation

Type A – Open Surgery

Type B – Endovascular Repair/ conservative management

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A 69 year old man with a background of hypertension complained of flank pain all day at work. He then has sudden onset abdominal pain that radiates to his back and groin. He arrives in an ambulance unconscious. The doctor notes Grey Turner’s and Cullen’s signs. What is the most likely diagnosis?

Renal colic
Myocardial Ischaemia
Ruptured AAA
Pancreatitis

Ruptured AAA

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A 65 year old gentleman is coming in for screening for a AAA following a letter received in the post. What modality would be used as a screening tool?

Abdominal Ultrasound
Abdominal CT
Abdominal X-ray
Doppler Ultrasound

Abdominal Ultrasound

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The same gentleman, 3 years later with a known AAA (last measured 5.2 cm) comes in complaining of severe abdominal pain. What investigation would you use to assess if it has ruptured?

Abdominal Ultrasound
Abdominal CT
Abdominal X-ray
Doppler Ultrasound

Abdominal CT

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A 70 year old gentleman with known hypertension presents to A&E with tearing chest pain, radiating to the back. His CXR shows a widened mediastinum. What is the most likely diagnosis?

Aortic Dissection
STEMI
Teitze’s Syndrome
Costochondritis

Aortic Dissection

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Which of the following examination findings is not consistent with an aortic dissection?

BP 100/40
Ejection systolic murmur
Collapsing pulse
Radio-radio delay

Ejection systolic murmur

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Define Peripheral Arterial Disease

Definition:Narrowing of arteries other than those supplying the brain/heart. Most commonly seen in the legs.

Intermittent claudification
Critical Limb Ischaemia
Acute Limb Ischaemia

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Intermittent Claudication Definition, RF

Symptoms

Cramping muscular pain in the calf, thigh or buttocks precipitated by exercise and relieved by rest (Reproducible claudication distance)
RF – smoking, HTN, DM, cholesterol
M >50 yrs alongside CVD

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Intermittent Claudication Signs

Reduced peripheral pulses
“punched out” ulcers
Hair loss
Cyanosis
Brittle toenails
Beurger’s Angle < 20°

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Leriche’s Syndrome Definition and signs

Blockage of the abdominal aorta as it bifurcates into the common iliac arteries

Triad
Bilateral Claudication
Erectile Dysfunction
Reduced Femoral Pulses

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Critical Limb Ischaemia Triad

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(Advanced stages of PAD)

Triad of:

Rest Pain – burning pain at rest, alleviated by standing
Arterial Ulcers
Gangrene

Prognosis of PAD

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Intermittent Claudication:
80% chance of improving
5% intervention
1% amputation
15% dead within 5 years

Critical Limb Ischaemia:
90% major intervention
25% major amputation
50% dead within 5 years

Investigations of Claudication

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ABPI (Ankle Brachial Pressure Index):

When the blood pressure in the ankles is lower than the brachial pressure – indicates PAD
If suspected PAD but normal ABPI – exercise testing ABPI conducted

Doppler Ultrasound:

Sound waves measuring blood flow through arteries/veins
Non-invasive and cheap
Poor visualisation below the knee

Magnetic Resonance Angiography:

Gold standard for demonstrating anatomy
Contrast agents may be nephrotoxic

ABPI Index

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> 0.95: Normal
0.5-0.95: Claudication
0.3-0.5: Rest Pain
<0.3: Critical Ischaemia

Vessel Calcification (making arteries more difficult to compress) may cause false negatives or high ABPI indices

Acute Limb Ischaemia Definition and 2 causes

Sudden lack of blood flow to the limb – often caused by an embolus or thrombus – surgical emergency - Thrombus – due to PAD (leading to vessel blockage) - Embolus – cardiac origin

Acute Limb Ischaemia classification

Viable – No neurological signs + audible doppler at ankle Threatened – Sensory loss, tense calf, no audible doppler Dead – Complete neurological deficit, fixed mottling

The 6 Ps of Acute Limb Ischaemia

``` Pain Pallor Pulselessness Perishingly Cold Parasthaesia Paralysis ``` NB last 2 = Profound deficits = indicates a non-viable limb

A 65 year old lady with known CVD presents to the GP with pain in her legs. She finds the pain comes on when she is walking to the shops, but is relieved by rest. She has a 40 pack year smoking history. What is the most likely diagnosis? Acute limb ischaemia Deep vein thrombosis Varicose veins Peripheral arterial disease

Peripheral arterial disease

A 60 year old male with known atrial fibrillation presents to A&E with a sudden onset of a painful, cold leg. The doctor is unable to feel peripheral pulses, and upon examination notes a loss of sensation and paralysis. A venous doppler is inaudible. What is the definitive management? Embolectomy Watch and wait Angioplasty Amputation

Amputation

A 69 year old heavy smoker complains of pain in his leg when he walks to the bus stop. On examination of his leg, you see shiny skin, patchy hair, weak pulses and brittle toenails. What would be the first line investigation? Angiography Doppler Ultrasound Magnetic Resonance Angiography ABPI

ABPI

DVT Definition and Causes (broad)

Deep Vein Thrombosis = Formation of a clot (thrombus) in the deep veins, most commonly in the pelvis or leg Virchow’s Triad: venous stasis, vessel wall injury, blood hypercoagulability

RF for DVT

Acquired - Age - Pregnancy - Trauma - Surgery - Cancer - Oestrogen Inherited - Antithrombin Deficiency - Protein C/S deficiency - Anti Phospholipid Syndrome

DVT signs and symptoms

Presentation - 50% asymptomatic - Leg swelling - Calf tenderness - Erythema ``` Examination Pitting oedema Calf warmth Calf swelling >3cm difference Prominent superficial veins ```

DVT Investigations

Investigations Dictated by the Two-Level DVT Well’s Score: >2 points => DVT likely: - Leg Vein USS - > if –ve perform D-dimer; if D-dimer +ve repeat USS 6-8 days later <2 points => DVT unlikely: D-Dimer test-> if +ve perform leg vein USS NB/ in pregnancy D-Dimer has a high false positive rate!

Management of DVT

Anticoagulation: Low Molecular Weight Heparin for at least 5 days Warfarin – start within 24hrs for at least 3 months Others: - Inferior Vena Cava filters – temporary measure - Thrombolytic therapy BUT huge bleeding risk(give if symptoms < less than two weeks, pt normally well w/ good life expectancy and low risk of bleeding) - Thrombectomy – surgical removal of the clot

DVT prevention

Stop OCP 4 weeks pre surgery Compression stockings LMWH for high risk patients

A 38 year old lady presents with swelling in her leg, and associated calf tenderness. She has been taking the OCP for several years. What is the best management for this patient? ``` Warfarin + LMWH Warfarin Aspirin LMWH + Aspirin LMWH ```

Warfarin + LMWH Warfarin is the best long term anti-coagulant BUT warfarin is paradoxically pro-thrombotic for the first 48hrs Warfarin inhibits Factors 2, 7, 9, 10 (procoagulant) AND Protein C and S (anticoagulant) Protein C has a very short half life Early drop in protein C therefore results in a hypercoagulable state Heparin is given to combat this; stopped when the INR > 2 OR administered >5 days

A 72 year old gentleman is complaining of pain in his right leg. He is 8 days post operative for a tibia/fibula fracture repair. What is the minimum amount of time the patient must be anticoagulated for? 3 months 6 months 1 year Lifelong

3 months

A 32 year old woman on the OCP complains of pain in her calf for one day. She does not have any chest pain or shortness of breath. The nurse tells you that the A&E doctors assessed the patient, who scored 2 although she cannot remember the name of the score. What is the most appropriate initial investigation? ``` D-Dimer MRA Leg Vein USS ABPI CTPA ```

Leg Vein USS

Arterial Ulcers Definition

= Ischaemic ulcers Caused by a lack of blood flow commonly due to PAD

Arterial Ulcers Presentation:

``` In between toes/lateral aspect of foot and ankle “punched out” appearance – well defined Very painful Evidence of gangrene/necrosis Minimal exudate Surrounding skin – cold, shiny, hairless ```

Venous Ulcers Definition and Pathophysiology

Definition: Ulcers due to inappropriate valvular function – often chronic wounds Pathophysiology: Valvular incompetence leads to venous hypertension - blood and proteins leak into the extravascular space leakage of fibrinogen and fibrin build up results in reduced oxygen delivery accumulation of leukocytes leads to release of proteolytic enzymes and ROS

Venous Ulcer Presentation:

``` Found in the “gaiter” region Shallow, irregular, sloping edges Usually painless (some pain on walking) “Wet” – heavy exudate Surrounding skin – oedematous,lipodermatosclerosis, haemosiderin deposition ```

Neuropathic Ulcers (Not on sofia) - pathophysiology and presentation

``` Pathophysiology: People with diabetes develop peripheral neuropathy due to various metabolic and neurovascular factors. This leads to a loss of pain/feeling in the toes and feet – blisters and sores appear and pressure injuries therefore go unnoticed Presentation: Ulcers found on the plantar aspect/under the heel Even wound margins Deep ulcer Calloused skin May be pockets of infection Palpable pulses and warm foot ```

A 75 year old woman with long standing hypertension has had progressive swelling of her legs over the last 3 months. She has consulted her GP because she has developed an ulcer on the anterior aspect of the right shin which weeps serous fluid profusely. What is the cause of the ulcer? Arterial Venous Neuropathic Rheumatoid Arthritis

Venous

A 62 year old diabetic woman shows you an ulcer on the bottom of her foot. It has a little stone lodged in it, which she hasn’t noticed. On neurological examination, she has no peripheral sensation of light touch up to her mid-foot. What is the cause of the ulcer? Arterial Venous Neuropathic Trauma

Neuropathic

A 78 year old obese woman presents with an ulcer on the top of her foot and one between her toes. They haven’t healed in two months. They are quite small, look punched out and yellow. She complains her feet are always cold and has a history of coronary artery disease. Arterial Venous Neuropathic Trauma

Arterial

A 45 year old lady presents with a 4 cm chronic ulcer on the medial aspect of the lower leg. She has a history of pain in the calf on walking. The skin around the ulcer is brown and heavily indurated. Arterial Venous Neuropathic Trauma

Venous

Varicose Veins Definition and Pathophysiology

Definition: Long, tortuous and dilated veins of the superficial venous system Pathophysiology: In healthy veins, there is blood flow from superficial to deep Valves prevent the flow of blood in the opposite direction Valvular insufficiency results in venous hypertension and dilation of the superficial veins

Varicose Veins Risk Factors

Obesity Pregnancy OCP Family History

Varicose Veins Signs and Symptoms

Presentation - Pain - Unsightly legs - Cramps - Tingling/heaviness - Restless leg Examination - Oedema - Excema - Ulcers - Phlebitis - Atrophie Blanche - Lipodermatosclerosis

Management of Varicose Veins

Endothermal Ablation - Radiofrequency Ablation - Endovenous Laser Treatment US guided Foam Sclerotherapy - Foam injected into veins resulting in scarring of the veins, sealing them shut - Surgery Ligation and stripping

2. Vascular Disease Flashcards

(52 cards)