4.01 Vascular Surgery - Presentations Flashcards
(32 cards)
What are the two common presentations of vascular disease?
- lower limb ulcers
- acutely painful limb
An acutely painful limb that is cold and pale should be treated as what?
Acute limb ischaemia until proven otherwise, and is a surgical emergency.
What are the associated signs of acute limb ischaemia?
Hint: 6 Ps
- pain
- pallor
- perishingly cold
- paraesthesia
- paralysis
- pulselessness
Give some risk factors for acute limb ischaemia.
- atrial fibrillation
- hypertension
- smoking
- diabetes mellitus
- recent myocardial infarction
What investigations are warranted if acute limb ischaemia is suspected?
CT angiogram for confirmation and anatomical delineation, along with urgent vascular review.
In acute limb ischaemia, how long does it take for irreversible tissue damage to occur?
Approximately 6 hours - patients should be sufficiency resuscitated and started on IV heparin whilst decisions for definitive versus conservative treatments are made.
An acutely painful limb that is hot and swollen should be treated as what?
Deep vein thrombosis (DVT) until proven otherwise.
NB pain is often localised to the calf, associated with calf tenderness of firmness.
Give some risk factors for deep vein thrombosis.
- PMHx or FHx of pro-thombotic diseases (e.g. CVA, MI)
- recent immobility
- recent surgery
- COCP
- pregnancy
What score should be calculated in a patient you are suspecting a DVT in?
Comment upon the significance of the score and the subsequent management.
Well’s score should be calculated (see image).
Score ≥1 arrange ultrasound Doppler scan
Score =0 use D-Dimer to exclude DVT.
Outline the management of DVT.
If confirmed by ultrasound Doppler, DVT can be initially treated with therapeutic doses of Low-Molecular Weight Heparin (LMWH), before being swapped to a DOAC for 3-6 months.
NB those with an iliofemoral DVT with severe symptoms require urgent vascular review. Usually presents with complete leg swelling, with a blue or white discolouration.
Give some differentials for an acutely painful limb that is hot and swollen.
- cellulitis
- septic arthritis
- gout
Give some differentials for an acutely painful limb.
- acute limb ischaemia
- DVT
- cellulitis
- septic arthritis
- gout
- radiculopathy
- trauma
Which examinations are imperative when assessing the acutely painful limb?
- cardiovascular
- peripheral vascular
- neurological
- musculoskeletal
What is an ulcer?
An abnormal break in the skin or mucous membrane
Give some causes of ulcers.
- venous insufficiency (most common, 80%)
- arterial insufficiency
- diabetic-related neuropathy
- infection
- trauma
- vasculitis
- malignancy (SCC)
- pressure ulcers
Describe the characteristics of:
a) venous ulcers
b) neuropathic ulcers
c) arterial ulcers
a) shallow ulcers with a granulated base, often with other clinical features of venous insufficiency present
b) painless ulcers over areas of abnormal pressure, often secondary to joint deformity in diabetics
c) found at distal sites, with well-defined borders and evidence of arterial insufficiency
What is the pathophysiology of venous ulcers?
Valvular incompetence or venous outflow obstruction causes impaired venous return, with the resultant venous hypertension causing ‘trapping’ of WBCs in capillaries and the formation of a fibrin cuff around the vessel.
The fibrin cuff hinders oxygen transportation into the tissue, causing the WBCs to become activated and the subsequent release of inflammatory mediators.
The inflammatory mediators cause tissue injury, poor healing and necrosis.
Give the risk factors for venous ulcers.
- increasing age
- pre-existing venous incompetence (incl. varicose veins)
- history of VTE
- pregnancy
- obesity
- physical inactivity
- severe leg injury or trauma
What are the clinical features of venous ulcers?
- painful (esp. at end of day)
- found in gaiter region of legs
Associated symptoms of chronic venous disease, such as aching, itching, or a bursting sensation, will be present before venous leg ulcers appear.
On examination there may be varicose veins with ankle or leg oedema, along with other features of venous insufficiency:
- varicose eczema
- thrombophlebitis
- haemosiderin skin staining
- lipodermatosclerosis
- atrophie blanche
What investigations are warranted following the identification of a venous ulcer?
- confirm venous insufficiency using Duplex ultrasound
- ABPI to assess for arterial components to ulcers
- swab cultures if infection is suspected
What test must be performed before applying mutlilayer compression bandaging for venous ulceration?
ABPI - only apply bandaging if ABPI >0.6
What is the pathophysiology of arterial ulcers?
An ulcer caused by a reduction in arterial blood flow, leading to decreased perfusion of the tissues and subsequent poor healing.
What is the management of venous ulcers?
- leg elevation
- increased exercise
- weight reduction
- multicomponent compression bandaging
- emollients
If there are varicose veins, these can be treated with endovenous techniques or open surgery, as improving venous return will allow for the healing of venous ulcers.
What are the risk factors for arterial ulcers?
Same risk factors for peripheral arterial disease:
- smoking
- diabetes mellitus
- hypertension
- hyperlipidaemia
- increasing age
- family history
- physical inactivity
