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Vascular Flashcards

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1
Q

Define acute limb ischaemia

A

a sudden decrease in arterial perfusion in a limb which threatens the viability of the limbs

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2
Q

Define Chronic limb ischaemia

A

Peripheral arterial disease resulting in a symptomatic reduced blood supply to the limbs
Intermittent claudication –> critical limb ischaemia

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3
Q

Causes of acute limb ischaemia?

A

Thrombus
Emboli - AF, post-MI mural thrombus, abdominal aortic aneurysm, or prosthetic heart valves
Trauma - also compartment syndrome

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4
Q

Causes of chronic limb ischaemia?

A

Atherosclerosis

Vasculitis

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5
Q

RFs for chronic limb ischaemia?

A 
	Smoking
	Diabetes mellitus
	Hypertension
	Hyperlipidaemia
	Increasing age
	Family history
	Obesity and physical inactivity 
	Renal failure
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6
Q

6 Ps of acute limb ichaemia in order of when they usually occur?

A

Pain
Pallor
Pulselessness
Perishingly cold
Paraesthesia - indication for immediate revascularisation
Paralysis - indication for immediate revascularisation

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7
Q

Explain the Rutherford classification of acute limb ischaemia

A

I: Viable, No immediate threat, No sensory or motor loss, audible arterial and venous doppler

IIA: Marginally threatened, salvageable if prompt tx, minimal sensory loss, no motor deficit, inaudible arterial and audible venous doppler

IIB: Immediately threatened, salvageable if immediate revascularisation, sensory loss in toes or more with rest pain, mild/moderate motor deficit, inaudible arterial and audible venous doppler

III: Irreversible, major tissue loss + permanent damage, profound sensory loss, profound paralysis, inaudible arterial and inaudible venous doppler

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8
Q

Explain the Fontaine classification of chronic limb ischaemia

A

Stage 1: Asymptomatic
Stage 2: Intermittent claudication
Stage 3: Ischaemic rest pain
Stage 4: Ulceration/gangrene

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9
Q

Where is the disease in calf claudication?

A

Superficial femoral artery

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10
Q

Where is the disease in buttock claudication?

A

Iliac artery

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11
Q

Define critical limb ischaemia (3 points)

A

Ischaemic rest pain for >2 weeks
Ulcers or gangrene
ABPI <0.5 or ankle pressure <40mmHg

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12
Q

Leriche Syndrome pathophysiology and triad of symptoms?

A

aortoiliac occlusive disease
buttock claudication
erectile dysfunction
absent/weak distal pulses

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13
Q

What Buerger’s angle indicates severe ischaemia

A

<20 degrees

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14
Q

What bloods to do in acute limb ischaemia?

A 
	FBC
	Serum lactate: to assess level of ischaemia 
	Thrombophilia screen
	Clotting profile 
	Group and save
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15
Q

Gold standard ix for chronic limb ischaemia?

A

MRI/CT angiogram

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16
Q

Acute limb ischaemia Mx?

A

Surgical emergency (Rutherford IIB)
o High-flow oxygen
o Gain IV access
o Initiate heparin

If embolic cause, options are:
• Embolectomy via a Fogarty catheter
• Local intra-arterial thrombolysis
• Bypass surgery, if there is insufficient flow back

If thrombotic cause, options are:
• Local intra-arterial thrombolysis
• Angioplasty
• Bypass surgery

If irreversible - amputation

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17
Q

Long term mx of acute limb ischaemia?

A

Reduce cardiovascular mortality risk
Lifestyle: regular exercise, smoking cessation, weight loss
Anti-platelet agent: low-dose aspirin or clopidogrel

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18
Q

Chronic limb ischaemia mx?

A

Lifestyle: smoking cessation, regular exercise (programme), weight loss
Statin therapy: atorvastatin 80mg OD
Anti-platelet: clopidogrel 75mg OD
Optimise diabetes control
Praxilene: if not fit for surgery
Surgery: angioplasty +/- stenting or bypass graft

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19
Q

Complications of acute limb ischaemia tx?

A

Reperfusion injury - can cause compartment syndrome and AKI

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20
Q

Complications of chronic limb ischaemia?

A

 Sepsis secondary to infected gangrene
 Acute-on-chronic ischaemia
 Amputation

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21
Q

Characteristics of venous eczema?

A

Itchy red, blistered and crusted plaques; or dry fissured and scaly plaques on one or both lower legs (commonly mistaken for cellulitis).
Atrophie blanche: star-shaped ivory-white depressed atrophic plaques with red dots within the scar (dilated capillaries) and surrounding hyperpigmentation (due to haemosiderin deposition)
Orange-brown patches of pigmentation caused by haemosiderin deposition
Lipodermatosclerosis

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22
Q

Characteristics of Lipodermatosclerosis?

A 
Skin hardening (often referred to as induration)
Hyperpigmentation
Erythema
Swelling
Inverted champagne bottle appearance
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23
Q

Characteristics of venous ulcers?

A

Large, irregular border with sloping edges
Shallow depth
Often located over the medial aspect of the ankle (referred to as the gaiter region).
Associated with mild pain

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24
Q

Characteristics of arterial ulcers?

A

Small, clearly defined border, irregular edge
Dry necrotic base
Deep
Often in between toes/dorsum of feet over bony prominences
Painful

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25
How does a saphena varix present?
Lump 2-4cm inferior-lateral to the pubic tubercle Blue tinge Soft to palpate Vanishes on lying down (differentiates from inguinal hernia)
26
RFs for varicose veins?
``` Prolonged standing Obesity Pregnancy Family history Valve damage: post DVT High flow: AV fistula Venous outflow obstruction: DVT, pelvic masses (pregnancy), ascites, lymphadenopathy ```
27
Where do the great and lesser saphenous veins run?
Great saphenous vein: medial side of leg | Lesser saphenous vein: lateral side of lower leg
28
Complications of varicose veins?
``` Swelling Skin changes: haemosiderin deposition, lipodermatosclerosis Venous ulceration Thrombophlebitis Varicose eczema Bleeding (if trauma occurs) ```
29
Explain the trendelenburg test for varicose veins
Allows localisation of the sites of valvular incompetence Leg is elevated and the veins are emptied Tourniquet placed over the saphenofemoral junction Pt stands and filling of the veins is observed - if remains collapsed incompetent valve is at level of SFJ If they fill then incompetent valve is inferior
30
Clinical tests for varicose veins?
Tap test Trendelenburg test Cough impulse test (Cruveihier's test) Perthe's test
31
What does Perthe's test tell you?
Distinguishes between venous valvular insufficiency in the deep, perforator and superficial venous systems
32
Gold standard ix for varicose veins?
Duplex ultrasound
33
Conservative tx of varicose veins?
Education: avoid prolonged standing, weight loss, increase exercise (promotes calf muscle action) Compression stockings
34
When to refer varicose veins to vascular team?
Symptomatic primary or recurrent varicose veins Lower-limb skin changes, e.g. pigmentation/eczema, thought to be caused by chronic venous insufficiency Superficial vein thrombosis (hard, painful veins) with suspected venous incompetence Venous leg ulcer: a break in the skin below the knee that has not healed within 2 weeks
35
Invasive tx of varicose veins?
1. endothermal ablation 2. ultrasound-guided foam sclerotherapy 3. vein ligation, stripping and avulsion
36
Post-op complications of varicose vein tx?
 Haemorrhage  Thrombophlebitis – especially for foam/ablation treatments  DVT – especially for endovenous treatments  Disease recurrence  Nerve damage: saphenous or sural nerves
37
Characteristics of neuropathic ulcers?
Punched out lesion with deep sinus Variable depth - partial thickness to severe Under pressure points - plantar aspect of 1st/5th MTP joint
38
RFs for arterial ulcers?
``` o Coronary heart disease o History of stroke or TIA o Diabetes mellitus o Peripheral arterial disease e.g. intermittent claudication, critical limb ischaemia o Obesity and immobility ```
39
Tx of venous ulcers?
4 layer compression banding
40
Ix for neuropathic ulcer?
* Blood glucose * Serum B12 * ABPI +/- duplex to assess for concurrent arterial disease * Microbiology swab and X-ray (for osteomyelitis) if signs if infection
41
RFs for neuropathic ulcers?
``` DM B12 deficiency Alcohol Charcot Marie Tooth Concurrent peripheral vascular disease ```
42
What is wet gangrene?
necrosis with superimposed infection
43
What is dry gangrene?
necrosis in absence of infection
44
What is gas gangrene?
subset of necrotising myositis caused by spore-forming Clostridial species
45
What is necrotising fasciitis?
a life-threatening infection of deep fascia causing necrosis of subcutaneous tissue
46
RFs for gangrene?
``` o Diabetes o Peripheral vascular disease o Leg ulcers o Malignancy o Immunosuppression o Steroid use o Puncture/surgical wounds o Trauma ```
47
Indications for amputation?
Peripheral vascular disease: most common reason for lower limb amputation Trauma: most common reason for upper extremity amputation Infection Malignancy Congenital abnormalities
48
Complications of amputation?
Intra-operative: Haemorrhage Anaesthetic risks: damage to teeth/throat/larynx, reaction to medications, nausea and vomiting, cardiovascular and respiratory complications ``` Early: Pain: patient usually has an epidural post-op and a perineural nerve catheter inserted to give LA directly into the nerves for major amputations Bleeding Infection Scarring Blood clots ``` Late: Phantom limb: neuropathic analgesics, e.g. pregabalin/amitriptyline, can help Reintervention: if poor healing, may require more proximal amputation Contractures: adjacent joint contractures, prevent with early aggressive mobilisation Post-amputation neuroma: prevent with proper nerve handling at time of procedure - tx = targeted muscle reinnervation Bone overgrowth
49
Types of upper limb amputations?
Transcarpal: transect finger flexor/extensor tendons Wrist disarticulation Transradial: middle third of forearm Transhumeral Shoulder disarticulation: retain humeral head to maintain shoulder contour
50
Types of knee amputation?
Transfemoral: usually cut 10-15cm above knee joint to allow for prosthetic fitting Through-knee Below-knee: 12-15 cm below knee
51
Types of ankle/foot amputation?
Syme: ankle disarticulation, patent tibialis posterior artery required, usually for forefoot gangrene in diabetes Pirogoff: hindfoot amputation, removal of forefoot and talus followed by calcaneotibial arthrodesis Chopart/Boyd: hindfoot amputation, partial foot amputation through the talonavicular and calcaneocuboid joints, primary complication: equinus deformity Lisfranc: midfoot, equinovarus deformity common Transmetatarsal Great toe: preserve 1cm at base of proximal phalanx
52
UK AAA screening?
``` Abdominal US scan for all men at age 65  < 3cm: discharge  3.1 – 4.4cm: annual ultrasound  4.5 – 5.4cm: 3 monthly ultrasound  > 5.5cm: treat ```
53
RFs for AAA?
``` o Severe atherosclerotic damage to aortic wall o Smoking o Hypertension o Hyperlipidaemia o Family history o Male gender o Increasing age ```
54
Types of AAA repair?
Surgical open repair: involves midline laparotomy/long transverse incision, exposing + clamping the aorta proximally and iliac arteries distally, before segment is removed and replaced with a prosthetic graft Endovascular repair (EVAR): involves introducing a stent-graft system via femoral arteries and fixing the stent across the aneurysm
55
Pros of EVAR?
Avoids open abdominal surgery Quicker recovery Avoids aortic-cross clamping Reduced mortality in first 4 years of follow-up
56
Cons of EVAR?
Follow-up with USS/CT scans essential to monitor the endograft Higher rates of failure and reintervention Complication: endovascular leaking when an incomplete seal forms around the aneurysm resulting in blood leaking around the graft - can cause aneurysm to expand and rupture
57
Complications of AAA repair?
Failure of repair Infection Haemorrhage Complications of arterial surgery: bleeding, thrombosis, embolism, graft infection, MI, AV fistula formation Complications of aortic surgery: gut ischaemia, renal failure, respiratory distress, trauma to ureters or anterior spinal arteries leading to paraplegia, aorto-enteric fistulae
58
Stanford classification of aortic dissection?
Type A: tear in ascending aorta (70%) - cardiothoracic surgeons Type B: tear in descending aorta distal to left subclavian artery (30%) - vascular surgeons
59
RFs for aortic dissection?
HTN Male Connective tissue disorders: Marfan’s, Ehlers-Danlos Cardiac: acute atherosclerosis with dilation Trauma Iatrogenic: aortic manipulation in cardiac surgery Congenital cardiac abnormalities: bicuspid aortic valve, coarctation of the aorta Inflammation: Takayasu’s
60
Acute mx of aortic dissection?
1. Beta-blocker + opioid analgesia Type A: cardiothoracic surgical removal of ascending aorta Type B: TEVAR
61
Complications of aortic dissection?
Backward tear: aortic incompetence/regurgitation, inferior MI Forward tear: unequal arm pulses/BP, stroke, renal failure Aortic rupture Aortic regurgitation Myocardial ischaemia, secondary to coronary artery dissection Cardiac tamponade Stroke or paraplegia, secondary to cerebral artery or spinal artery involvement
62
Complications of carotid endarterectomy?
o Bleeding o Stroke as a result of surgery itself o Damage to recurrent laryngeal nerve o Damage to hypoglossal nerve
63
Contents of thoracic outlet?
brachial plexus subclavian artery subclavian vein
64
Causes of thoracic outlet syndrome?
hyperextension injuries repetitive stress injuries external compression anatomical abnormalities e.g. cervical rib
65
Risk scoring of subclavian steal syndrome?
Pre-Subclavian Steal – demonstrating purely a reduced anterograde vertebral flow Intermittent Alternating Flow – antegrade flow occurs in the diastolic phase and retrograde flow occurs in the systolic phase Advanced Disease – there is a permanent retrograde flow
66
What is subclavian steal syndrome?
During exercise, a proximal stenosing lesion of the subclavian artery causes reversal of blood flow in the ipsilateral vertebral artery to meet the demands of the arm - this causes syncope/neurological deficits
67
Ix and Mx for subclavian steal?
Ix: Duplex USS Mx: percutaneous angioplasty ± stenting or bypass - optimise CV RFs
68
Special cast for diabetic foot ulcers?
Total contact casting - takes the weight off

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