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Vascular Flashcards

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1
Q

What is peripheral arterial disease?

A

Narrowing or arteries to limbs and peripheries-> reduces blood supply

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2
Q

What is intermittent claudication?

A
  • Ischaemia in limb
  • During exertion + relieved by rest
  • Crampy/achy pain in leg
  • Associated with muscle fatigue when walk intensely
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3
Q

What is critical limb ischaemia?

A
  • End stage PAD
  • Inadequate blood supply
  • Pain at rest
  • Non-healing ulcers + gangrene
  • Risk of losing leg
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4
Q

What is acute limb ischaemia?

A

Rapid ischaemia due to clot blocking arterial supply

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5
Q

What is gangrene?

A

Death of tissue due to inadequate blood supply

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6
Q

What is ischaemia?

A

Inadequate oxygen causing tissue necrosis + death

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7
Q

What is artherosclerosis?

A
  • Chronic inflammation + activation of immune system-> lipid deposits + plaques
  • Happens to medium and large arteries
  • Can lead to stiff walls (HTN), heart strain, stenosis, plaque rupture + thrombus
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8
Q

What are the signs of critical limb ischaemia?

A
  • Pain
  • Pallor
  • Pulseless
  • Paralysis
  • Paraesthesia
  • Perishing cold
  • Often worse at night when raised
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9
Q

What can cause critical limb ischaemia?

A
  • Thrombosis
  • Emboli-> more sudden presentation
  • Graft/angioplasty occlusion
  • Trauma
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10
Q

How should critical limb ischaemia be investigated?

A
  • Neuro exam
  • Obs
  • Arterial + venous dopplers
  • CT angiogram
  • Rutherford scoring
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11
Q

What is the Rutherford scoring system?

A
  • For critical limb ischaemia-> risk of limb
  • Stage I-> viable
  • Stage IIa
  • Stage IIb-> immediate threat to limb
  • Stage III-> irreversible damage
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12
Q

How is critical limb ischaemia treated?

A
  • Heparin infusion

- Revascularisation-> within 4-6 hours

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13
Q

Wha tis the main post-op complication of revascularisation?

A

Reperfusion injury-> functional loss of nerves + muscles, can cause compartment syndrome

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14
Q

What is Lerich syndrome?

A

Occlusion of distal aorta or proximal common iliac artery

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15
Q

What is the clinical triad or Lerich syndrome?

A

Thigh/buttock claudication + absent femoral pulse + male impotence

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16
Q

What are some signs of peripheral arterial disease?

A
  • RFs-> tar staining on fingers, xanthomata
  • CVD-> amputations, midline sternotomy, focal weakness (previous stroke)
  • Weak peripheral pulses
  • Reduced skin temperature, reduced sensation, prolonged CRT
  • Arterial-> pallor, cyanosis, dependent rubour, muscle wasting, hair loss, ulcers, poor wound healing, gangrene
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17
Q

What is Buerger’s test?

A
  • Lie on back + lift leg to 45 degrees for 1-2 minutes
  • Pallor-> arterial supply unable to overcome gravity
  • Assess Buerger’s angle-> where legs go pale
  • Sit up with legs off bed-> should go pink
  • PAD-> go blue (ischaemic tissue- deoxygenated blood) then dark red (vasodilation due to waste products of anaerobic)
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18
Q

What causes an ulcer?

A

Skin/tissue struggling to heal due to impaired blood flow

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19
Q

What are the signs of an arterial ulcer?

A
  • Small
  • Deep
  • Well definited border
  • ‘Punched out’
  • Peripheral (eg toes)
  • Reduced bleeding
  • Painful-> worse at night + improved when lower leg (gravity helps)
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20
Q

What are the signs of a venous ulcer?

A
  • Larger
  • More superficial
  • Irregular or sloping borders
  • Affect gaiter area (mid calf to ankle)
  • Less painful
  • Worse when lower leg
  • Other chronic venous insufficiency signs
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21
Q

How should peripheral arterial disease be investigated?

A
  • ABPI
  • DUplex US-> speed + volume of flow
  • Angiography
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22
Q

What is ABPI?

A
  • Ankle-brachia pressure index
  • Ratio of systolic in ankle to arm using doppler probe
  • Ankle systolic 80 and arm 100-> ABPI of 0.8
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23
Q

What ABPI result is normal?

A

0.9-1.3

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24
Q

What ABPI result shows mild PAS?

A

0.6-0.9

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25
What ABPI result shows moderate-severe PAD?
0.3-0.6
26
What ABPI result shows severe to critical ischaemia?
<0.3
27
What ABPI result indicates calcification?
>1.3
28
How is intermittent claudication managed?
- Risk factor and lifestyle management - Exercise training - Medical-> high dose statin, aspirin/clopidogrel, Naftidrofuryl - Surgical-> endovascular angiogram + stent, endartectomy, bypass
29
How is acute limb ischaemia managed?
- Urgent referral - Endovascular thrombolysis or thrombectomy - Surgical thrombectomy - Endartectomy - Bypass - Amputation
30
What are varicose veins?
Distended superficial leg vein-> >3mm diameter + usually legs
31
What are reticular veins?
Dilated vessels in the skin-> 1-3mm
32
What is telangiectasia?
-Spider/thread veins-> <1mm
33
How do varicose veins develop?
- Valves allow flow in 1 direction towards heart - Legs contract + squeeze blood up against gravity - Incompetent-> blood back down + pools in veins + feet - Perforating veins connect deep + superficial-> incompetent valves mean flow back to superficial-> dilation + engorged
34
What happens in chronic venous insufficiency?
- Blood pools + pressure causes leakage to tissues - Brown deposits/discolouration to shins-> Hb in blood breaks down to haemosiderin - Venous eczema-> inflammation + dry - Lipodermatosclerosis-> tight + hard skin + tissues (fibrosis)
35
What are the risk factors for varicose veins?
- Older age - FH - Female - Pregnancy - Obesity - Prolonged standing - DVT
36
How do varicose veins present?
- Engorged + dilated superficial leg veins - Heavy/dragging feeling - Aching - Itching - Burning - Oedema - Muscle cramps - Restless legs - Chronic insufficiency
37
What special tests should be done in varicose veins?
- Tap test - Cough test - Trendelenburg's - Perthe's test - Duplex US
38
How is the tap test performed?
- Pressure to SFJ + tap distal varicose vein - Feel for thrill - Suggests incompetent venous valve between 2
39
How is the cough test performed?
- Pressure to SJF + cough | - Thrills-> dilated vein at SJF
40
How is Trendelenburg's test (for varicose veins) performed?
- Lie down + lift leg to drain veins - Apply tourniquet to thigh - Stand up - Assess where incompetent valve is - When vein appears-> valve below level of tourniquet - Not reappear-> distal to valve
41
How is Perthe's test performed?
- Tourniquet to thigh - Heel raises when standing to pump calf muscles - Superficial veins disappear-> deep vein is functioning - If superficial dilatation increases-> deep vein problem
42
How are varicose veins?
- If pregnant-> improve after delivery - Simple-> weight loss, activity, keep leg elevated, compression stockings - Surgical-> endothermal ablation, sclerotherapy, stripping
43
What are the complications of varicose veins?
- Prolonged bleeding - Superficial thrombophlebitis - DVT - Chronic venous insufficiency
44
What causes arterial ulcers?
Insufficient blood supply-> eg PAD
45
What causes venous ulcers?
Pooling of blood and waste products in skin-> secondary to venous insufficiency
46
What causes diabetic foot ulcers?
- Neuropathy-> less likely to realise injured/poor fitting shoes - Damage to small + large blood vessels-> impair supply + healing - Raised BMs, immune system change, autonomic neuropathy etc to contribute
47
What is a major complication of diabetic foot ulcers?
Osteomyelitis
48
What causes pressure ulcers?
- Reduced mobility + prolonged pressure on area - Reduced supply - Local ischaemia - Reduced lymphatic drainage - Abnormal change in shape (deformation) or tissues under pressure
49
How can pressure ulcers be prevented?
- Risk assessment-> Waterlow score - Regular repositioning - Inflating mattress - Skin checks - Dressings/creams
50
What is the Waterlow score?
Risk assessment tool for pressure ulcers
51
How are ulcers investigated?
- ABPI - Bloods-> infection, co-morbidities - Charcoal swabs-> infection + organism - Skin biopsy-> may be SCC (need 2WW)
52
How are arterial ulcers managed?
- Same as PAD - Urgent referral - Consider revascularisation - Treat underlying disease
53
How are venous ulcers managed?
- Tissue viability/specialist leg ulcers clinic - Derm-> when alternative diagnosis possible - District/tissue viability nurse-> clean, debride, dress wound - Compression therapy-> venous after arterial excluded - Antibiotics - Analgesia - Pentoxifylline
54
What is lymphoedema?
Impaired lymph drainage causing excess protein-rich fluid to accumulate in the tissues
55
What is lipoedema?
- Abnormal build up of fat in the legs - Feet are spared - Differential for lymphoedema (involves feet)
56
What is primary lymphoedema?
- Genetic - Rare - Faulty development of lymphatic system - Presents before age 30
57
What is secondary lymphoedema?
Due to a condition-> commonly removal of axillary LNs in breast cancer surgery`
58
How is lymphoedema assessed?
- Stemmer's sign - Limb volume-> circumference measurement or perometry - Bioelectric impendance spectrometry - Lymphoscintigraphy
59
How is lymphoedema managed?
- Manual-> massage, compression bandages, exercise, weight loss, skin care - Lymphaticovenular anastamosis surgery - CBT - Antidepressants - Avoid bloods + cannulas in limb
60
What is lymphatic filariasis?
- Parasitic worms spread by mosquitoes - Live in system + cause damage - Thicken + fibrose-> elephantitis
61
What is an aneurysm?
Dilation of all layers of a vessel
62
What is a pseudoaneurysm?
Dilation of only the adventitia layer of a blood vessel
63
What are common sites of an aneurysm?
Aorta, iliac artery, femoral, popliteal
64
What are the types of aneurysm?
- Saccular-> 'berry' | - Fusiform-> whole vessel
65
What is an abdominal aortic aneurysm?
Dilation of more than 3cm of abdominal aorta-> often rupture + bleed (death)
66
What are the risk factors for abdominal aortic aneurysm?
- Men (at younger age than women) - Smoking - HTN - FH - CVD - Trauma - Infection - Connective tissue disorder
67
Who is offered screening for abdominal aortic aneurysm?
- All men age 65+ | - Consider in women age 70+ with risk factors
68
Who is referred after screening for abdominal aortic aneurysm?
- For abdominal US when diameter >3cm | - Urgently if >5.5cm
69
How does abdominal aortic aneurysm present?
- Asymptomatic - Non-specific abdo pain - Pulsatile + expansive mass in abdomen
70
How is abdominal aortic aneurysm diagnosed?
US or CT angiogram
71
How is abdominal aortic aneurysm classified?
- Small-> 3 to 4.4cm - Medium-> 4.5 to 5.4cm - Large-> 5.5cm+
72
How is abdominal aortic aneurysm managed?
- Stop progression with RF management - Screening + follow up scans-> yearly (small) or 3 monthly (medium) - Elective repair-> if 5.5cm+ or grows 1cm/year+ with open repair or stenting (endovascular aneurysm repair) - Inform DVLA-> if 6cm+ and stop driving if 6.5cm+
73
How does ruptured abdominal aortic aneurysm present?
- Severe abdo pain-> radiates to back or groin - Haemodynamic instability - Pulsatile + expansive abdo mass - Collapse
74
How is ruptured abdominal aortic aneurysm managed?
- Immediate surgical repair - Permissive hypotension-> aim for low BP to reduce loss - Prophylactic antibiotics-> cefuroxime + metronidazole - CT angiogram-> diagnose or exclude
75
What is aortic dissection?
- Break or tear in inner layer of aorta - Blood accumulates between wall layers-> false lumen - Usually between intima + media
76
What are the layers of an artery?
- Intima - Media - Adventitia
77
Where is aortic dissection most common?
- Ascending aorta-> often right lateral as most stress from blood exiting heart - Aortic arch
78
How is aortic dissection classified?
- Stanford-> A (ascending) or B (descending) | - DeBakey-> types I, II, IIIa, IIIb (ascend to descend)
79
What are the risk factors for aortic dissection?
- HTN - CVD factors - Biscuspid aortic valve - Coarctation of aorta - AV replacement - CABG - Ehler-Danlos - Marfans
80
How does aortic dissection present?
- Sudden severe ripping/tearing chest pain - Different location-> where + time - HTN then hypotension - Difference of 20mmHg+ between arms - Radial pulse deficit - Diastolic murmur - Focal neurology - Collapse
81
How is aortic dissection diagnosed?
- CT angiogram - MRI angiogram - ECG + CXR-> exclude other causes
82
How is aortic dissection managed?
- Emergency surgery-> graft or thoracic EVAR (stent) - Morphine - BP + HR control with beta-blockers
83
What are some complications of aortic dissection?
- MI - Stroke - Paraplegia - Tamponade - AV regurgitation - Death
84
What is carotid artery stenosis?
Narrowing of carotid arteries in neck secondary to atherosclerosis
85
What are the risk factors of carotid artery stenosis?
Same as CVD
86
What are the risks of carotid artery stenosis?
Increased risk of CAD, MI, stroke + TIA
87
How does carotid artery stenosis present?
- Asymptomatic - Post-TIA/stroke - Carotid bruit-> whooshing during systole
88
How is carotid artery stenosis classified?
- Mild-> <50% reduction in diameter - Moderate-> 50-69% - Severe-> 70%
89
How does carotid artery stenosis get diagnosed?
- Post- TIA/stroke - Carotid US - CT/MRI angiography
90
How is carotid artery stenosis managed?
- Lifestyle and risk factor management - Antiplatelets-> aspirin, clopidogrel, ticagrelor - Surgery-> endartectomy (1st line), angioplasty, stenting
91
What are some complications of endartectomy?
- Stroke - Damage to CNs VII, IX or XII - Recurrent laryngeal palsy
92
What is Buerger disease?
Thromboangiitis obliterans-> inflammatory + causes thrombi in small + medium vessels of hands + feet
93
Who is most at risk of developing Buerger disease?
Men age 25-35 who smoke
94
What is the diagnostic criteria for Buerger disease?
Age <50, smoker, no other RFs
95
How does Buerger disease present?
- Painful + blue discolouration to fingertips + toes - Pain worse at night - Can progress to ulcers + gangrene
96
What is the typical angiogram finding in Buerger disease?
Corkscrew collaterals-> new vessels formed to bypass arteries
97
How is Buerger disease managed?
- Stop smoking | - IV iloprost-> prostacylin analogue that dilates BVs

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