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Finals > Vascular > Flashcards

Vascular Flashcards

1
Q

What is the definition of an abdominal aortic aneurysm

A

an increase in diameter of the aortic below the diaphragm of >50% of the normal diameter/>3cm

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2
Q

RFs for abdominal aortic anuerysm

A 
male
age
smoking
HTN
hyperlipidaemia
family hx
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3
Q

sx of abdominal aortic aneurysm

A

most are asx- found on screening or incidentally

  • abdo pain
  • back/loin pain
  • distal embolism (limb ischaemia)
  • aortioenteric fistula (bloody stool)
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4
Q

signs of abdominal aneurysm

A
  • pulsatile mass on abdo jusy above umbilicus
  • retroperitoneal haemorrhage are rarely present - grey turner (bruising of flank)
  • shock, syncope if ruptured
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5
Q

what is the screening for aortic aneurysm

A

abdo USS for all men in 65th year

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6
Q

ix for aortic aneurysm

A

uss

CT with contrast

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7
Q

management of abdo aortic aneurysm

A
  • 3-4.4cm- yearly USS
  • 4.5-5.4cm- 3 monthly USS

Repair if

  • symptomatic
  • growth >4cm and growing >1cm in 1 year
  • > =5.5cm
  • open or endovascular repair (via femorals)
  • smoking cessation
  • HTN control
  • statin and aspirin
  • wt loss
  • exercise
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8
Q

what is a potentially serious complication of aortic aneurysm repair that occurs post-operatively

A

endovascular leaking

  • proper seal not achieved around graft
  • often asx, so USS in f/u is required
  • if left untreated, may cause a rupture
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9
Q

sx and signs of ruptured AAA

A
  • abdo/back pain
  • syncope
  • vomiting
  • haemodyn unstable
  • pulsatile mass on abdo
  • tender abdo

classic triad (50% of cases)

  1. flank/back pain
  2. hypotension
  3. pulsatile abdo
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10
Q

management of ruptured AAA

A
  • ghihg flow O2
  • IV access- 2x wide bore cannulas
  • urgent FBC, UE, X match for minimum of 6U
  • aim for BP <=100mmHg
  • open repair if unstable
  • CTA if stable in order to plan repair
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11
Q

causes of thoracic aortic aneurysm

A 
connectvie tissue issues
biscuspid aortic valv
trauma
aortic dissection
aortic arteritis (Takayasu)
tertiary syphillis
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12
Q

sx thoracic aortic aneurysm

A

normally asx and found incidentally
- pain localise to location
(ant aorta- ant. chest, aortic arch- neck, descending aortia- between scap)

  • back pain- spinal cord compression
  • hoarse voice- L recurrent laryngeal
  • distended neck vessels and facial oedema- SVC compression)
  • sx of HF- aortic valve involvement
  • dyspnoea/cough- trachea/bronchial compression/sx of HF
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13
Q

sx of thoracic aortic rupture

A
  • sudden onset pain in back, chest, neck and/or abdo

- haemodynamically unstable

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14
Q

ix for ?thoracic aortic aneurysm in someone who has chest/back pain

A
  • CT chest with contrast
  • transoesophageal echo
  • FBC, UE, clotting
  • ECG
  • CXR- wide silhouette, enlarged aortic knob, tracheal deviation
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15
Q

Management of thoracic aortic aneurysm

A
  • statin- atorvostatin
  • aspirin
  • BP control
  • smoking cessation
  • surgery- >5.5cm if in ascending aortic or arch/ >6cm in descending aorta
  • people with Marfan’s / have had previous dissection– surgery (high risk)
  • ongoing imaging as recurrence is not uncommone- CT or MRI
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16
Q

What is aortic dissection

A
  • tunica intima tears, causing blood flow between the tunicaintima and tunica media
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17
Q

definition of acute and chronic aortic dissection

A

acute- <=14d

chronic >14d

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18
Q

what is a retrograde aortic dissection

A
  • goes towards the aortic valve/up the root of the aorta
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19
Q

complications that can occur due to retrograde dissection of the aorta

A

valve prolapse,
bleeding into pericardium
therefore cardiac tamponade

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20
Q

Classification used for aortic dissection

A
  • Stanford
    A- Ascending aorta, propogates to arch and descending aorta (T1, T2)
    B- does not involve the ascending aorta (T3)
  • DeBakey
    T1- originates from ascending aorta and goes to at least the arch
    T2- confined to ascending aorta
    T3- originates distal to the subclavian artery in the descending aorta
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21
Q

RF for dissection or thoracic aortic aneurysm

A
  • HTN
  • age
  • male
  • fam hx
  • smoking
  • BMI
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22
Q

sx of aortic dissection

A
  • tearing sensation in chest

- radiates to back (classically)

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23
Q

pathophysiology of aortic anryeusm

A
  • degradation of tunica media- which provides elasticity and strength to the wall
  • leads to dilatation of the vessel
  • can be caused by atherosclerosis, trauma, infection, arteritis, connective tissue disorders
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24
Q

signs of aortic dissection

A
  • tachycardia and hypotension
  • new aortic regurg murmur

end organ hypertension:

  • UO
  • paraplegia
  • lower limb ischaemia
  • abdo pain due to isch
  • reduced GCS
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25
Q

ix for ?aortic dissection

A
  • FBC, UE, LFT, coag
  • X match at least 4u
  • trop (?MI)
  • ABG
  • ECG
  • **CT angio
  • transoesophageal echo may also be useful
26
Q

Management of aortic dissection

A

A-E
- high flow O2
- IV access with cautious fluid resus (<110mmHg)
- surgery
- if uncomplicated type B (not involving asc aorta)- labetolol/CCB, as retrograde dissection is high risk in this type
^^ do surgery in B only if pt is not stable

27
Q

complications of aortic disseciton

A
  • aneurysm
  • rupture
  • aortic regurg
  • MI (coronary artery dissection)
  • cardiac tamponade
  • stroke, paraplegia
28
Q

classificaiton of carotid artery disease

A
  • Mild= <50% diameter reduction
  • Moderate- 50-69%
  • Severe 70-99%
  • total 100%
29
Q

sx of carotid artery disease

A

TIA

  • stroke
  • likely to be asx due to collateral supply from the contralateral internal carotid artery, vertebral artery via circle of willis
30
Q

sign of cartoid artery disease

A
  • carotid bruits
31
Q

ix for ?carotid artery disease

A
  • stroke/TIA- urgent non-contrast CT head
  • duplex USS or CT angio of carotids done as screening after all strokes/ TIAs
  • bloods- FBC, UE, clotting, lipid profile, glucose
  • ## ECG (AF)
32
Q

immediate management of ?carotid artery disease

A

Short term- stroke management:

  • high flow O2
  • blood c=glucose optimisation
  • swallowing screen assessment
  • ischaemic stroke- IV alteplase within 4.5hours, 300mg aspirin
  • haemorrhagic- correct coagulopathy, refer for surgery
  • thrombectomy if evidence of ischaemic and occlusion of anterior circulation on CT angiography
33
Q

LT management of carotid artery disease

A

Long term

  • aspirin 300mg OD for 2w, then clopi 75mg OD
  • statin
  • HTN and DM control]
  • smoking cessation
  • regular exercise
  • wt loss
  • carotid endaterectomy if 50-99% occlusion
34
Q

risks of ccarotid endarterectomy

A
  • stroke (embolisation)
  • hypoglossal N damage
  • glossopharyngeal N damage
  • vagus N damage
  • MI
  • bleeding
  • infection
35
Q

sx of glossopharyngeal damage

A
  • pain in nasopharynx/ear/throat
  • dysphagia
  • taste impaired over post 1/3 tongue
  • impaired sensation over post 1/3 tongue, palate
  • absent gag reflex
36
Q

sx of hypoglossal damage

A
  • paralysis of 1/2 of tongue (deviates to side is damaged)
  • fasciculations
  • slurred speech
  • difficultly eating and swallowing
37
Q

sx of vagus nerve damage

A
  • hoarseness
  • dysphagia, dysarthria
  • aspiration
  • nausea, vomiting, slow HR, low BP
  • uvula deviation away from lesion
38
Q

skin changes seen in chronic venous disease

A
  • lipodermatosclerosis - inflammation of SC fat, pain/hardening of skin, redness, often tapering at the ankles (champagne bottle)
  • haemosiderin deposition- brown discolouration
  • atophie blanche- white scarring
  • venous eczema
39
Q

ix for ?venous disease

A

ABPI_ normal (0.8-1)

  • doppler USS and/or venography
  • swab for cultures of ulcers
40
Q

Management of venous disease

A
  • leg elevation
  • increase exercise, wt reduction, smoking cessation
  • compression bandaging (not if also have arterial disease)
  • dressings (alignate, hydrocolloid), emollients
  • vein stripping/ablation if varicose veins also present
  • fluclox if infected
41
Q

ix for ?arterial disease of lower leg

A
  • ABPI <0.8
    0. 8- mild, 0.5-0.7- mod, <0.5- severe
  • dupplex USS
  • MRA/CTA
42
Q

management of peripheral arterial disease eg ulcers

A
  • smoking cessation, weight loss, exercise
  • statin
  • dual antiplatelet- aspirin , clopi
  • BP and glucose control
  • fluclox is infected

intermeittment claudication

  • artorvostatins 80mg
  • clopi 75mg
  • naftidrofuryl oxalate
  • angioplasty, stening
  • endarterectomy
  • bypass

Crticial limb

  • angioplasty, stenting
  • bypass
  • amputation

Acute limb isch

  • endovasc thrombolysis/thrombectomy
  • surgical thrombectomy
  • endarterectomy
  • bypass
  • amputation
43
Q

hx of chronic limb ischaemia

A
  • cramping pain in calf after walking

- relieved by rest

44
Q

ix for chronic limb ischaemia

A
  • ABPI
  • doppler USS
  • MRA, CTA
45
Q

Management of chronic limb ischaemia

A
  • walk until yu feel moderat epain, rest , walk again- repeat for 30-45mins
  • walk for 3 or more days a week
  • statins
  • control HTN
  • aspirin, clopidogrel
  • angioplasty
46
Q

what is critical limb ischaemia

A
  • chronic limb ischaemia progressing to rest pain
47
Q

sx of critical limb ischaemia

A

6 Ps are late signs (pallor, pain, paraesthesia, pulselessness, perishingly cold, paralysis)

  • lack of hair
  • aterial ulcers that are non healing, necrotic patches
  • burning, stabbing pains with relentless, increasing intensity
  • pain only relieved by opioids
  • may radiate up leg into groin
  • loss of sensation and movement
  • rubor- foot may be flushed as capillaries dilate in response to ischaemia
48
Q

ix critical limb ischaemia

A

ABPI

angiograms- MRA, CRA

49
Q

tx critical limb ischaemia

A
  • aspirin, clopi
  • statin
  • angioplasty
  • surgery- stent, bypass
  • amputation
50
Q

3 causes of acute limb ischaemia/threatened limb

A
  • embolisation- AF, post MI, abdo arotic aneurysm , prosthetic valves
  • thrombosis in situe (plaque rupture)
  • trauma, incl compartment syndrome
51
Q

sx of acute limb ischaemia

A

6 Ps- acute

  • pain!
  • pallor!
  • pulselessness!
  • perishingly cold
  • paralysis
  • paraesthesia
  • suddent onset
  • mottled, non blanching rash, with hard woody muscles- irreversible
  • note– can be acute-on-chronic
52
Q

Clasificaion of acute limb ischaemia

A

I- viable

  • non sensory, motor deficit
  • audible dopplers

IIA- marginally threatened

  • salvageable
  • minimal sensory loss
  • no motor deficit
  • inaudible arterial doppler
IIB- immediately threatened
- salvageable
0 sensory loss
- mild/mod motor deficit
- inaudible arterial doppler

III- irreversible

  • major tissue loss
  • mottle, non blanching rash with hard, woody muscles
  • total sensory loss, paralysis
  • inaudible arterial and venous dopplers
53
Q

Ix for ?acute limb ischaemia

A
  • routine bloods, lactate, thrombophilia screen if <50yo, G&S
  • NV exmination of both limbs
  • ECG
  • Doppler USS of both limbs
  • **MRA/CTA
54
Q

tx acute limb ischaemia

A
  • high flow O2
  • IV acess
  • IV heparin
  • surgery- embolectomy via catheter, by pass, intraarterial thrombolysis , angioplasty, amputation

LT

  • exercise, weight loss, smoking cessation
  • aspirin, clopi
  • warfarinf, DOAC
  • ta underlying conditions (AF)
  • OT/PT
55
Q

what is reperfusion injury

A
  • release of substances from damaged cells- K, H, myoglobin
  • causing hyperkalaemia, acidosis, AKI respectively
  • the oedema from abnormal capillary permeability following reperfusion can also cause compartment syndrome
56
Q

how to prevent reperfusion injury

A
  • monitor UEs closely

- quick haemdialysis if needed

57
Q

what scoring system do you use to assess the risk of someone with AF risk of stroke

A

CHA2DS2-VASc

Cong HF (1)
HTN- >140.90 (1)
Age >=75 (2)
DM (1)
Stroke/TIA/thomboembolism (2)
Vascular disease (peripheral, MI) (1)
Age 65-74 (1)
Sex category- female (1)

1- consider antiplt/antocoag
>=2- anticoag unless CIed

58
Q

what scoring system do you use for someone on an anticoagulant to assess their risk of bleeding

A

HASBLED

  • HTN (>160mmHg)
  • abnormal renal/liver function Cr >200, bilirubin >2x bilirubin or AST/ALP/AP >3x
  • stroke
  • bleeding (major) or predisposition
  • Labile INR (in 2-3 range <60% of time)
  • Elderly (>65)
  • Drugs (antiplatelets, NSAIDs) or alcohol (
59
Q

DVT sx

A 
painful calf
red
swollen
warm
calf firmness
if iliofemoral- blue leg, white leg
60
Q

What score do you use to decide ix of ?DVT

A

Well’s

61
Q

how do you ix a DVT according to well’s score

A

0- mod sensitivity d-dimer for all
-ve- no further imaging
+ve - USS
+ve USS- anticoag

1-2- high sensitivity d-dimer testing

  • negative- no further ix
  • positive- anticoag

> =3
- USS for all

62
Q

tx DVT

A

DOAC- apix or rivarox

or - LMWH for 5d then dabigtran

Finals (15 decks)

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