peripheral vascular disease

Question 1

lower limb venous flow

Answer 1

low pressure system
requires ‘pump’
needs valves to prevent backflow

Question 2

what happens if the valves stop working in the lower limb venous system

Answer 2

blood travels from high pressure (deep veins) to low pressure (superficial veins) > chronic venous insufficiency

Question 3

chronic venous insufficiency

Answer 3

reflux between deep and superficial systems
causes increase in hydrostatic pressure in superficial system > venous hypertension > inflammatory response including leucocyte activation and abnormal healing response > vein wall fibrosis

Question 4

varicose veins

Answer 4

valves connecting deep and superficial systems become incompetent
leads to venous dilation

Question 5

investigation for varicose veins

Answer 5

duplex

and clinical examination

Question 6

management for varicose veins

Answer 6

conservative: graduate compression stockings

endovenous/surgical: foam sclerotherapy, endothermal ablation, open surgery

Question 7

3 clinical entities of limb ischaemia

Answer 7

acute limb ischaemia
acute on chronic limb ischaemia
chronic limb threatening limb ischaemia

Question 8

acute limb ischaemia is due to

Answer 8

embolism
thrombus
trauma
laterogenic

Question 9

how does embolism cause acute limb ischaemia

Answer 9

cardiac- usually context of AF (formed in left atria) or MI (left ventricle)
sometimes paradoxical embolus
non-cardiac- atheroembolism (diseased aorta, AA) or aortic mural thrombus

Question 10

paradoxical embolus

Answer 10

clot from deep venous system passes through patent foramen ovale into arterial system

Question 11

how does thrombus cause acute limb ischemia

Answer 11

hypercoagulable states

chronic atherosclerotic stenosis

Question 12

investigation for acute and chronic limb ischaemia

Answer 12

measure severity by ABI
duplex US and doppler
ECG- MI arrhythmia
CT angiography-

Question 13

management of limb ischaemia

Answer 13

medical: dependent of extent, IV heparin, IV fluids 
surgical:
mild- moderate: thrombolysis 
if embolus: embolectomy
bypass (acute-on-chronic)
compartment syndrome: fasciotomies

Question 14

management of chronic limb ischaemia

Answer 14

exercised program
anti-platelet and statin (clopidogrel) 
(Naftidrofuryl oxalate as vasodilator) 
surgical: not generally recommended 
- percutaneous transluminal angioplasty
- bypass

Question 15

acute on chronic limb ischaemia

Answer 15

acute occlusion on background of underlying disease
same initial management as Acute limb ischaemia
urgent arterial imaging required

Question 16

aneurysm

Answer 16

dilation of vessel by more than 50% of the normal

Question 17

true aneurysm

Answer 17

the vessel wall is intact

Question 18

flase aneurysm

Answer 18

breach in vessel wall

Question 19

presentation of ruptured AAA

Answer 19

sudden onset epigastric/central pain
may radiate to back
mimic renal colic
collapse

Question 20

AAA when examined

Answer 20

may look well 
hypo/hypertension
pulsatile, expansive mass 
transmitted pulse 
peripheral pulse

Question 21

screening for AAA

Answer 21

normal: <3cm
small 3-4.4cm- requires annual US
medium 4.5-5.4cm- require quarterly US and prevention therapy
large: >5cm - possible elective repair

Question 22

surgical and enodvascular intervention of AAA

Answer 22

open aneurysm repair

endovascular stent insertion

Question 23

surgical and enodvascular intervention of AAA

Answer 23

open aneurysm repair

endovascular stent insertion

Question 24

Diabetic foot sepsis includes…

Answer 24

diabetic neuropathy
peripheral vascular disease
infection

Question 25

clinical findings of diabetic foot sepsis

Answer 25

pyrexia, tachycardia, tachypnoeic, confused | swollen digits, swollen forefoot, tenderness, ulcer, erythema, necrosis

Question 26

management of diabetic foot sepsis

Answer 26

vascular surgical emergencies | antibiotics

Question 27

DVT

Answer 27

deep venous thrombosis | thrombi form in venous valve pockets ad other sites of presumed stasis

Question 28

PE

Answer 28

pulmonary emboli | thromboemboli detach and travel through the right side of the heart to block vessel in lungs

Question 29

virchows triad

Answer 29

``` Hypercoaguable state (blood clotting components) endothelial injury (blood vessels) circulatory stasis (blood flow) ```

Question 30

presentation of DVT

Answer 30

swollen painful limbs redness and heat tender along veins dub acute development

Question 31

d-dimer

Answer 31

breakdown product of cross linked fibrin

Question 32

diagnosis of VTE

Answer 32

Wells score- doesnt confirm if wells score shows unlikey to be VTE- do d-dimers if d-dimers raised- radiological imaging to confirm DVT- ultrasonography and doppler PE- computed tomopraphic pulmonary angiography or V/Q isotope lung scanning

Question 33

management of DVT

Answer 33

oral anti-coagulation- apixaban or rivaroxaban, vitamin K- warfarin

Question 34

PE management

Answer 34

high risk- thrombolysis then oral anti-coagulation