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D3 > Vascular > Flashcards

Vascular Flashcards

1
Q

Chronic Limb Ischaemia

A

5% males >50 have intermittent claudication

Definition - ankle artery pressure <50 (toe <30mmHg)

  • and either persistent rest requiring analgesia for 2+ weeks
  • or ulceration gangrene
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2
Q

Chronic Limb Ischaemia Cause

A

Atherosclerosis - typical ASx until 50% stenosis

Vasculitis + fibromuscular dysplasia > v rare causes

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3
Q

Atherosclerosis

A
  1. Endothelial injury: haemodynamic, HTN, ↑ lipids
  2. Chronic inflammation
     Lipid-laden foam cells produce GFs, cytokines,
    ROS and MMPs
     → lymphocyte and SMC recruitment
  3. SM proliferation: conversion of fatty streak to
    atherosclerotic plaque

NB. Arteriosclerosis = general arterial hardening
Atherosclerosis = arterial hardening specifically due to
atheroma

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4
Q

Atheroma

A

 Fibrous cap: SM cells, lymphocytes, collagen

 Necrotic centre: cell debris, cholesterol, Ca, foam cells

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5
Q

Chronic Limb Ischaemia RF + ass vasc disease

A 
Modifiable 
 Smoking
 BP
 DM control
 Hyperlipidaemia
 ↓ exercise 
Non-Modifiable
 FH and PMH
 Male
 ↑ age
 Genetic
Ass Vasc Disease
 IHD: 90%
 Carotid stenosis:15%
 AAA
 Renovascular disease
 DM microvascular disease
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6
Q

Chronic Limb Ischaemia Presentation

Intermittent Claudication

A

 Cramping pain after walking a fixed distance
 Pain rapidly relieved by rest
 Calf pain = superficial femoral disease (commonest)
 Buttock pain = iliac disease (internal or common)

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7
Q

Chronic limb ischaemia presentation

Critical Limb Ischaemia

A

Critical Limb Ischaemia - Fontaine 3 or 4

Rest pain 
 Especially @ night
 Usually felt in the foot
 Pt. hangs foot out of bed
 Due to ↓ CO and loss of gravity help

Ulceration
Gangrene

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8
Q

Chronic Limb Ischaemia
Presentation

Leriche’s Syndrome - Aortoiliac Occlusive Disease

A

Atherosclerotic occlusion of abdominal aorta and iliacs

Triad
 Buttock claudication and wasting
 Erectile dysfunction
 Absent femoral pulses

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9
Q

Chronic Limb Ischaemia
Presentation

Buerger’s Disease

A

Thromboangiitis Obligerans

Young, male, heavy smoker

Acute inflammation and thrombosis of arteries and
veins in the hands and feet → ulceration and gangrene

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10
Q

Chronic Limb Ischaemia Signs

A 
Pulses: pulses and ↑ CRT (norm ≤2sec)
Ulcers: painful, punched-out, on pressure points
Nail dystrophy / Onycholysis
Skin: cold, white, atrophy, absent hair
Venous guttering
Muscle atrophy

↓ Buerger’s Angle
 ≥90: normal
 20-30: ischaemia
 <20: severe ischaemia

+ve Buerger’s Sign
 Reactive hyperaemia due to accumulation of
deoxygenated blood in dilated capillaries

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11
Q

Clinical Classification of Chronic limb ischaemia

A

Fontaine

  1. Asympto (subclinical)
  2. Intermittent claudication
    a. >200m
    b. <200m
  3. Ischaemic rest pain
  4. Ulceration / gangrene

Rutherford

  1. Mild claudication
  2. Moderate claudication
  3. Severe claudication
  4. Ischaemic rest pain
  5. Minor tissue loss
  6. Major tissue loss
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12
Q

Chronic Limb Ischaemia Ix

A

Doppler Waveforms
 Normal: triphasic
 Mild stenosis: biphasic
 Severe stenosis: monophasic

ABPI (another card)

Walk test

  • walk on treadmill at certain speed + incline to establish maximum claudication distance
  • ABPI measured before and after 20% drop is sign
Bloods
 FBC + U+E: anaemia, renovascular disease
 Lipids + glucose
 ESR: arteritis
 G+S: possible procedure

Imaging: assess site, extent and distal run-off
- Colour duplex US
- CT / MR angiogram: gadolinium contrast
- Digital subtraction angiography
 Invasive :. not commonly used for Dx only.
 Used when performing therapeutic angioplasty
or stenting

Other
ECG: ischaemia

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13
Q

ABPI in CLIschaemia

A

Clinical Fontaine ABPI
Calcification: CRF, DM >1.4
Normal ≥1

Asymptomatic Fontaine 1 0.8-0.9

Claudication Fontaine 2 0.6-0.8

Rest pain Fontaine 3 0.3-0.6

Ulceration and gangrene Fontaine 4 <0.3

NB. Falsely high results may be obtained in DM / CRF due
to calcification of vessels: mediasclerosis
 Use toe pressure with small cuff: <30mmHg

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14
Q

Chronic limb ischaemia conservative Mx

A 
Most pt can be managed like this
^exercise (exercise program)
Stop amoking
Wt loss 
Foot Care

Prog: 1/3 improve, 1/3 stay the same, 1/3 deteriorate

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15
Q

Chronic Limb Ischaemia Medical Mx

A

Risk factors: BP, lipids, DM
 β-B don’t worsen intermittent claudication but use w caution in CLI

Antiplatelets: aspirin / clopidogrel

Analgesia: may need opiates

(Parenteral prostanoids ↓ pain in pts. unfit for surgery)

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16
Q

Endovascular Mx of Chronic Limb Ischaemia

A

Percutaneous Transluminal Angioplasty ± stenting

Good for short stenosis in big vessels: e.g. iliacs, SFA

Lower risk for pt.: performed under LA as day case

Improved inflow → ↓ pain but restoration of foot pulses is required for Rx of ulceration / gangrene.

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17
Q

Surgical Reconstruction of Chronic Limb Ischaemia

Indication
Pre-op
Practicalities

A

Indicated > V short claudication distance (<100m)

  • Sx greatly affecting pt QUAL
  • Development of rest pain

Pre-op - need good optimisation of cardioresp co-morbidities

Practicalities - need good proximal supply + distal run-off
> saphenous vein grafts preferred below IL
> more distal grafts have ^ rates of thrombosis

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18
Q

Surgical Reconstruction of Chronic Limb Ischaemia

Classification
+ altenratives

A

Classification

  • anatomical - fem-pop, fem-distal, aortobifemoral
  • extra-anatomical - axillofem/-bifem, fem-fem crossover

Other
- endarterectomy - core out atheromatous plaque
- sympathectomy - cheimcal EtOH injeuction) or surgical
> caution in DM w neuroapthy
- amputation

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19
Q

Chronic limb ischaemia Prognosis

A

1yr after onset of CLI
 50% alive w/o amputation
 25% will have had major amputation
 25% dead (usually MI or stroke)

Following amputation
 Perioperative mortality
 BK: 5-10%
 AK: 15-20%
 1/3 → complete autonomy
 1/3 → partial autonomy
 1/3 → dead
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20
Q

Acute Limb Ischaemia

A

Acute <14d
Acute on chronic - worsening Sx + signs <14d
Chronic - ischaemia stable >14d

Severity
Incomplete - limb not threatened

Complete - limb thretened (loss of limb unless intervention w/i 6 hours

Irreversible - requires amputation

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21
Q

Causes of Acute Limb Ischaemia

A

Thrombosis in situ (60%)
 A previously stenosed vessel w plaque rupture
 Usually incomplete ischaemia

Embolism (30%)
 80% from LA in AF
 Valve disease
 Iatrogenic from angioplasty / surgery
 Cholesterol in long bone #
 Paradoxical (venous via PFO)
 Typically lodge at femoral bifurcation
 Often complete ischaemia

Graft / stent occlusion
Trauma
Aortic dissection

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22
Q

Acute Limb Ischaemia Presentation

A 
Painful
Perishingly cold 
Pulseless
Pale
Paralysis
Paraesthesia
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23
Q

Thrombosis (Acute limb ischaemia)

A

Onset - hrs/days
Severity - less severe - collaterals
Claudication - present
Contralateral pulses - absent

Dx - angiography
Rx - thrombolysis, bypass surgery

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24
Q

Embolus (acute limb ischaemia)

A 
Onset - sudden 
Severity - Profound ischaemia 
Embolic source - AF oft
Claudiction - Absent
Contralateral pulse - present

Dx - clinical
Rx - embolectomy + warfarin

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25
Q

Acute Limb Ischaemia Ix

A

Blood
 FBC, U+E, INR, G+S
 CK

ECG

Imaging
 CXR
 Duplex doppler

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26
Q

Acute Limb Ischaemia

General Mx

A

Discuss w senior as time is crucial.
NBM
 Rehydration: IV fluids
 Analgesia: morphine + metoclopramide
 Abx: e.g augmentin if signs of infection
 Unfractionated heparin IVI: prevent extension

Complete occlusion?
 Yes: urgent surgery: embolectomy or bypass
 No: angiogram + observe for deterioration

Angiography
 Not if complete occlusion - 
introduces delay: straight to theatre.
 If incomplete occlusion, pre-op angio will guide any
distal bypass.
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27
Q

Acute Limb Ischaemia Embolus Mx

A

Embolectomy
 Under LA or GA
 Wire fed through embolus
 Fogarty catheter fed over the top
 Balloon inflated and catheter withdrawn, removing the embolism.
 Send embolism for histo (exclude atrial myxoma)
 Adequacy confirmed by on-table angiography

  1. Thrombolysis
     Consider if embolectomy unsuccessful
     E.g. local injection of TPA
  2. Other options
     Emergency reconstruction
     Amputation

Post-embolectomy
 Anticoagulate: heparin IVI → warfarin
 ID embolic source: ECG, echo, US aorta, fem and pop

Complications
>Reperfusion injury
 Local swelling → compartment syndrome
 Acidosis and arrhythmia 2ndary to ↑K
 ARDS
 GI oedema → endotoxic shock
>Chronic pain syndromes
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28
Q

Acute Limb Ischaeima

Thrombosis M

A

 Emergency reconstruction if complete occlusion
 Angiography + angioplasty
 Thrombolysis
 Amputation

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29
Q

Carotid Artery Disease

Define Stroke

Define TIA

A

Stroke: sudden neurological deficit of vascular origin
lasting >24h

TIA: sudden neurological deficit of vascular origin
lasting <24h (usually lasts <1h) w complete recovery

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30
Q

Carotid Artery Disease

Pathogenesis
Presentation
Ix

A

Pathogenesis
 Turbulent flow → ↓ shear stress @ carotid bifurcation
promoting atherosclerosis and plaque formation.
 Plaque rupture → complete occlusion or distal emboli
 Cause 15-25% of CVA/TIA

Presentation
 Bruit
 CVA/TIA

Ix
 Duplex carotid Doppler
 MRA

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31
Q

Carotid Artery Disease Mx

A

Conservative - aspirin/clopidogrel, control RF

Surgical Endarterectomy (unblock)
Symptomatic (ECST, NASCET)
 ≥70% (5% stroke risk per yr)
 ≥50% if low risk (<3%, typically <75yrs)
 Perform w/i 2wks of presentation

Asymptomatic (ACAS, ACST)
 ≥60% benefit if low risk

32
Q

Complications of Endarterectomy

A

Stroke or death 3%
HTN 60%
Haematoma
MI

Nerve Injury

  • hypoglossal - ipsilateral tongue deviation
  • great auricular - numb ear lobe
  • recurrent laryngeal - hoarse voice, bovine cough
33
Q

Carotid Artery Disease

Mx Stenting

A

less invasive than endarterecrtomy

Less invasive: ↓ hospital stay, ↓ infection, ↓ CN injury

There is concern over ↑ stroke risk, esp. pts. >70yrs

Meta-analysis shows no sig difference in mortality vs.
CEA @ 120d

Younger pts. have best risk / benefit ratio

34
Q

Aneurysm

A

Abnormal Dilatation of blood Vessel >50% of its normal diameter (across all layers)

35
Q

Aneurysm Classification

True Aneurysm

A

 Dilatation of a blood vessel involving all layers of
the wall and is >50% of its normal diameter
 Two different morphologies
> Fusiform: e.g AAA
> Saccular: e.g Berry aneurysm

36
Q

Aneurysm Classification

False Aneurysm

A

 Collection of blood around a vessel wall that
communicates c¯ the vessel lumen.
 Usually iatrogenic: puncture, cannulation

37
Q

Aneurysm Classification

Dissection

A

Vessel dilatation caused by blood splaying apart

the media to form a channel w/i the vessel wall.

38
Q

Aneurysm Causes

A

Congenital
 ADPKD → Berry aneurysms
 Marfan’s, Ehlers-Danlos

Acquired
 Atherosclerosis
 Trauma: e.g. penetrating trauma
 Inflammatory: Takayasu’s aortitis, HSP
Infection
   >Mycotic: SBE
   >Tertiary syphilis (esp. thoracic)
39
Q

Aneurysm Complications

A 
Rupture 
Thrombosis
Distal Embolization
Pressure - DVT, oesophagus, nutcracker syndrome
Fistula (IVC, intestine)
40
Q

Popliteal aneurysm

A

Less common than AAA
50% pt w PA also have AAA

Presents - v easy palpable popliteal pulse
> 50% bilateral
> rupture rare
> thrombosis + distal embolism main complication
- causes acute limb ischaemia

Mx
Acute - embolectomy or fem-distal bypass
Stable - elective grafting + tie off vessel

41
Q

Abdominal Aortic Aneurysm

A

Dilatation of abdominal aorta to 3+cm
90% infrarenal, 30% involve iliac arteries

Present 
usually ASx (incidental)
May > back pain or umbilical pain radiating to groin
Acute limb ischaemia
Blue toe syndrome (distal embolisation
Acute Rupture
42
Q

AAA Exam + Ix

A

Examination
 Expansile mass just above the umbilicus
 Bruits may be heard
 Tenderness + shock suggests rupture

Ix
 AXR: calcification may be seen
 Abdo US: screening and monitoring
 CT / MRI: gold-standard
 Angiography
 Won’t show true extent of aneurysm due to endoluminal thrombus.
 Useful to delineate relationship of renal arteries

43
Q

AAA Conservative Mx

A 
Conservative 
- Manage CV RF esp BP
- Trial suggest AAA <5.5cm
in maximum diameter can be monitored by US (/CT)
 <4cm: yearly monitoring
 4-5.5cm: 6 monthly monitoring

Screening - UK M offered one time screen at 65

44
Q

AAA Surgical Mx

A

Aim to treat aneurysm before it ruptures.
 Elective mortality: 5%
 Emergency mortality: 50%

Operate when risk of rupture > risk of surgery

Indications
 Symptomatic (back pain = imminent rupture)
 Diameter >5.5cm
 Rapidly expanding: >1cm/yr
 Causing complications: e.g. emboli

Open or EVAR (endovasc aneurysm repair)
 EVAR has ↓ perioperative mortality
 No ↓ mortality by 5yrs due to fatal endograft failures.
 EVAR not better than medical Rx in unfit pts.

45
Q

Thoracic Aortic Dissection

A

Blood splays apart laminar planes to form channel w/i aortic wall

Atherosclerosis and HTN cause 90%

Minority caused by connective tissue disorder
 Marfan’s, Ehlers Danlos
 Vitamin C deficiency

46
Q

Thoracic Aortic Dissection Presentation

A

Sudden onset, tearing chest pain
 Radiates through to the back
 Tachycardia and hypertension (primary + sympathetic)

Distal Propagation > sequential occlusion of branches 
 Left hemiplegia
 Unequal arm pulses and BP
 Paraplegia (anterior spinal A.)
 Anuria

Proximal propagation
 Aortic regurgitation
 Tamponade

Rupture into pericardial, pleural or peritoneal cavities - commonest cause of death

47
Q

Stanford Classification

Thoracic Aortic Dissection

A 
Type A: Proximal
 70%
 Involves ascending aorta ± descending
 Higher mortality due to probable cardiac involvement
 Usually require surgery

Type B: Distal
 30%
 Involves descending aorta only: distal to L SC artery
 Usually best managed conservatively

48
Q

Thoracic Aortic Dissection Ix

A

ECG - exclude MI
TTE/TOE - haemodynamically unstable pts
CT MRI - if stable

49
Q

Thoracic Aortic Dissection Mx

A

Resuscitate

Investigate
 Bloods: x-match 10u, FBC, U+E, clotting, amylase
 ECG: 20% show ischaemia due to involvement of the
coronary ostia

Imaging
 CXR
 CT/MRI: not if haemodynamically unstable
 TOE: can be used if haemodynamically unstable

Treat
Analgesia
↓SBP (systolic)
 Labetalol or esmolol (short t½)
 Keep SBP 100-110mmHg

Type A: open repair
 Acute operative mortality: <25%

Type B: conservative initially
 Surgery if persistent pain or complications
 Consider TEVAR if uncomplicated

50
Q

Gangrene

A

Death of tissue from poor vascular supply

51
Q

Gangrene classification + presentation

A

Wet - tissue death + infection
Dry - tissue death only
Pregangrene - Tissue on brink of gangrene

Presents
black tissues +/- slough
May suppuration sepsis

52
Q

Gas Gangrene

A

Clostridium perfringes myositis

RF- DM, trauma, malignancy

Presentation
 Toxaemia
 Haemolytic jaundice
 Oedema
 Crepitus from surgical emphysema
 Bubbly brown pus

Rx
 Debridement (may need amputation)
 Benzylpenicillin + metronidazole
 Hyperbaric O2

53
Q

Synergistic Gangrene

A

Aerobes and anaerobes

Fournier’s - perineum
Meleney’s - post op ulceration

54
Q

Gangrene Mx

A

Mx - take cultures
- debridement (include amputation)
Benpen +/- clindamycin

55
Q

Varicose Veins

A

Tortuous, dilated veins of the superficial venous system

One-way flow from sup → deep maintained by valves
 Valve failure → ↑ pressure in sup veins → varicosity

3 main sites where valve incompetence occurs:

SFJ: 3cm below and 3cm lateral to pubic tubercle

SPJ: popliteal fossa

Perforators: draining GSV
 3 medial calf perforators (Cockett’s)
 1 medial thigh perforator (Hunter’s)

56
Q

Varicose Vein Causes

A 
Primary
Idiopathic (congenitally weak valves)
 Prolonged standing
 Pregnancy
 Obesity
 OCP
 FH
Congenital valve absence (v. rare) 
Secondary 
 Valve destruction → reflux: DVT, thrombophlebitis
 Obstruction: DVT, foetus, pelvic mass
 Constipation
 AVM
 Overactive pumps (e.g. cyclists)
 Klippel-Trenaunay
 PWS, varicose veins, limb hypertrophy
57
Q

Varicose Veins Sx and Signs

A 
Sx 
 Cosmetic defect
 Pain, cramping, heaviness
 Tingling
 Bleeding: may be severe
 Swelling

Signs
 Ulcers: medial malleolus / gaiter area
 Oedema
 Thrombophlebitis

Skin changes
 Venous stars
 Haemosiderin deposition
 Venous eczema
 Lipodermatosclerosis (paniculitis)
 Atrophie blanche
58
Q

Varicose Veins Ix + Referral Criteria

A 
Ix
Duplex ultrasonography
 Anatomy
 Presence of incompetence
 Caused by obstruction or reflux

Surgery: FBC, U+E, clotting, G+S, CXR, ECG

Referral Criteria
 Bleeding
 Pain
 Ulceration
 Superficial thrombophlebitis
 Severe impact on QoL
59
Q

Varicose Veins CEAP classification

A

Chronic venous disease

 Clinical signs (1-6 + sympto or asympto)
 Etiology
 Anatomy
 Pathophysiology

60
Q

Varicose Veins Conservative Mx

A

Treat contributing factors (wt loss, relieve constipation)

education - avoid prolonged standing, regular walks

Class II Graduated compression stockings
(18-24mmHg)
- Sx relief + slows progression

Skin care - maintain hydration w emollients
- treat ulcers rapidly

61
Q

Varicose Veins Minimally Invasive therapy

A

Indication - small below knee not involving Great Saphenous Vein or Small Saphenous Vein

Techniques - LA, GA

  • Injection sclerotherapy - 1% Na teradecyl sulphate
  • endovenous laser or radiofrequency

Post-op

  • compression bandage for 24h
  • compression stockings for 1mo
62
Q

Varicose Veins Surgical Mx

A

Indications
 SFJ incompetence
 Major perforator incompetence
 Symptomatic: ulceration, skin changes, pain

Procedures
 Trendelenberg: saphenofemoral ligation
 Small SV ligation: in the popliteal fossa
 LSV stripping: no longer performed due to potential for saphenous nerve damage.
 Multiple avulsions
 Perforator ligation: Cockett’s operation
 Subfascial endoscopic perforator surgery (SEPS)

Post-op

  • bandage tightly
  • elevate 24h
  • discharged w compression stockings + instructed to walk daily
63
Q

Varicose Vein surgical complications

A 
 Haematoma (esp. groin)
 Wound sepsis
 Damage to cutaneous nerve (e.g. long saphenous)
 Superficial thrombophlebitis
 DVT
 Recurrence: may approach 50%
64
Q

Leg Ulcers

A

Interruption of continuity of epithelial surface

Causes

  • venous (commonest)
  • arterial - large or small vessel
  • neuropathic (EtOH, DM)
  • traumatic (pressure)
  • systemic - pyoderma gangrenosum etc
  • neoplastic - SCC
65
Q

Venous Leg Ulcers

A

75%

Painless, sloping, shallow ulcers
Usually on medial melleolus (gaiter area)
Assw haemosiderin deposition + lipodermatosclerosis

RF - venous insufficiency, varicosities, DVT, obesity

66
Q

Arterial leg ulcers

A 
2%
Hx of vasculopathy + RF
Painful deep punched out lesions
Occur at pressure points
> heal
> tips of and between toes
> metatarsal (esp 5th)
Other signs of chronic leg ischaemia
67
Q

Neuropathic leg ulcers

A

painless w insensate surrounding skin

warm foot w good pulses

68
Q

Leg ucler complications

A

Oesteomyelitis

Dev SCC in ulcer (Marjolin’s ulcer)

69
Q

Leg Ulcer Ix

A

ABPI if poss

Duplex ultrasonography

Biopsy may be neessary (look for malignancy

70
Q

Mx of Venous leg ulcers

A

refer leg ulcer community clinic
Focus on preention (graduated compression stockings, venous surgery)
Optimise RF -nutrition, smoking

Specific Rx 
- analgesia
- bed rest + elevate leg
- 4 layer graded bandage (if ABPI >0.8)
- Pentoxyfylline PO
   > microcirculatory blood flow
   > improves healing rates

Other options (no proven benefit)

  • desloughing (larval therapy, hydrogel)
  • topical antiseptics - iodine, manuka honey
  • split thickness skin grafting may be considered
71
Q

Bilateral Leg Swelling Differential

A

↑ Venous Pressure
RHF
Venous insufficiency
Drugs: e.g. nifedipine

↓ Oncotic Pressure
Nephrotic syndrome
Hepatic failure
Protein losing enteropathy

Lymphoedema

Myxoedema
Hyper- / hypo-thyroidism

72
Q

Unilateral Leg Swelling Differentials

A

Venous insufficiency
DVT
Infection/inflammation
Lymphoedema

73
Q

Lymphoedema definition + primary

A

Collection of interstitial fluid due to blockage or absence of lymphatics

Primary

  • congen absence of lymphatics
  • presents - congen from birth, praecox (after birth <35y), tarda (>35y)

Milroy’s Syndrome

  • famillial AD subtype of congenital lymphoedema
  • F>M
74
Q

Secondary Lymphoedema

A

FIIT
Fibrosis (post radio etc)

Infiltration
 Ca: prostate, lymphoma
 Filariasis: Wuchereria bancrofti

Infection - TB

Trauma - block dissection of lymphatics

75
Q

Lymphoedema Ix + Mx

A

Ix
 Doppler US
 Lymphoscintigraphy
 CT / MRI

Mx
Conservative
 Skin care
 Compression stocking
 Physio
 Treat or prevent comorbid infections

Surgical: debulking operation

D3 (14 decks)

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