Peripheral vascular system Flashcards
Aortic aneurysm - Def, screening, Ix, Sy, Mx, Ruptured AAA
D - Dilatation >50%, true involve all layers, pseudo are blood in the adventitia with a communication. Infrarenal most common.
Screening - all men at 65yrs.
Ix - USS 3cm across.
Sy - none/abdo/back pain.
Mx - EVAR if >5.5cm, symptomatic, or expanding >1cm/year.
Ruptured AAA - abdo pain rad to back/illiac fossa/groin, collapse, expansile abdo mass, shock. Mx - warn surgeon/theatre, blood crossmatch, IV access x2, keep systolic <100, prophylactic Abx.
Peripheral arterial disease - def, Sy, Classification, Ix, Mx, Buerger’s disease
Def - athero causing stenosis of arteries.
Sy - Cramping claudication in calf, thigh, buttock after walking set distance, relieved by rest. Ulceration, gangrene, foot pain at rest = critical ischaemia. Absent pulses, cold white legs, atrophic skin, Buergers angle <20’ in severe disease.
Fontaine classification - 1=asy, 2=intermittent claud, 3=ischaemic rest pain, 4=Ulceration/gangrene (critical).
Ix - ABPI- - normal 1-1.2, PAD 0.5-0.9, critical 0.5, N.B increased by calcified vessels in DM. Duplex USS. MR angiography to assess runoff.
Mx - RF - quit smoking, HTN, chol, clopidogrel. Exercise to develop collaterals. Surgery - PTA if single segment, or bypass graft. Amputation if intractable pain, sepsis or gangrene.
Buerger’s disease (thrombophlebitis obliterans) - non-atheroma vasculitis in young heavy smokers.
Acute limb ischaemia - Def, Sy, Ix, Mx
Def - thrombus in situ or emboli from aneurysm/heart. High mort and amputation rate.
Sy - 6Ps - pale, pulseless, painful, paralysed, paraesthetic, perishingly cold. If known PAD may just be sudden deterioration in sy.
Ix - Duplex USS, CTangiogram.
Mx - Surgical emergency with hours to save limb. Open surgery or embolectomy/thrombolysis. Anticoagulate post op and look for cause. N.B. post op may have reperfusion injury and compartment syndrome.
Carotid artery disease - Sy, Ix, Mx
Sy - stroke/TIA.
Ix - All people with non-disabling stoke/TIA should have carotid doppler within 7dys. If >50% (American) or 70% (European guidelines) should have endarterectomy within 2wks.
Mx - Endarterectomy if indicated. Also BP, statin, aspirin.
Varicose veins - Def, Sy, Ix, Mx
D - Long tortuous, dilated veins caused by valvular incompetence.
Sy - Pain, cramps, tingling, heaviness, restless legs. Oedema, eczema, haemosiderin, atrophie blanche (white scarring post ulcer), lipodermatosclerosus (hard skin).
Ix - USS. Trendelenburg’s test.
Mx - only refer if bleeding, pain, ulceration, phlebitis, severe impact on QOL. Avoid standing, support stockings, loose weight, exercise. Endovascular - radiofrequency ablation, endovenous laser treatment, injection sclerotherapy (below knee). Surgery - saphenofemoral ligation (trendelenburg procedure), stripping. Bandage and elevate legs post-op.
Gangrene - Def, types, Mx
D - Death of tissue from critical ischaemia.
Dry - no infection.
Wet - death and infection.
Gas - necrotising myositis by clostridium causing gas production and creps.
Necrotising fasciitis - rapidly progressing infection of deep fascia. Intense pain. Group a b-haem strep or polymicrobial. Fournier’s - if in scrotum/perineum.
Mx - Radical debridement, revascularisation, Abx - benpen and clindamycin. Hyperbaric O2.
Raynaud’s syndrome - Def, Sy, Cause, Ix, Mx
Def - peripheral digital ischaemia due to vasospasm.
Sy - Fingers/toes ache, go pale, blue, then red (reactive hyperaemia).
Cause - idiopathic=Raynaud’s disease or Raynaud’s phenomenom - b-blockers, systemic sclerosis, SLE, RA, dermatomyositis, polymyositis, vibrating tools, Beurgers disease, atheroma, polycythemia rubra vera, monoclonal gammaopathies, hypothyroidism.
Ix - Exclude underlying cause.
Mx - Keep warm, stop smoking. nifedipine or sildenafil.
DVT - RF, Sy, Ix, Mx, postphlebitic syndrome
RF - Age, pregnancy, on oestrogen, trauma, surgery, past DVT, cancer, obesity, immobility.
Sy - calf warmth, tenderness, swelling, erythema. Mild fever, pitting oedema.
Ix - Wells score - if likely USS, if not D-dimer. DDX - cellulitis, ruptures Baker’s cyst.
Mx - LMWH or NOAC stop when INR 2-3, start warfarin. 3m if provoked, 6m if not, until end of treatment if Ca and lifelong if recurrent/thrombophilia. IVC filters can be used in active bleeding.
Postphlebitic syndrome - pain, aching, heaviness, discolouration seen post DVT. Mx - compression stockings.
Lymphoedema - Def, Sy, Mx
Def - oedema caused by destruction/blockage of the lymphatics after cancer surgery/radiation or due to lymphatic filariasis (elephantitis post mosquito, blood film!).
Ix - usually none, isotope lymphangiography can locate blockage.
Mx - Compression and exercise.
