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Vascular Flashcards

1
Q

What are the 6 Ps of acute limb ischaemia

A

Pain

Pallor

Pulselessness

Paraesthesia

Perishing cold

Paralysis

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2
Q

Give an overview of acutely painful, cold and pale limbs

A

Treat as acute limb ischaemia until proven otherwise

Ask about: AF, HTN, smoking, diabetes, recent MI

CT angiogram, urgent vascular review

Get irreversible tissue damage in 6 hours

Start on IV heparin whilst decisions being made

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3
Q

Give an overview of acutely painful, hot and swollen limbs

A

Assess for potential DVT

Ask about: pro-thrombotic disease, recent immobility, recent surgery

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4
Q

What investigations are needed for acutely painful limb

A

Document neurovascular status at initial clerking

CT angiography

Routine bloods (+ group and save)

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5
Q

Give an overview of lower limb ulcers

A

Abnormal breaks in skin or mucous membrane

Most are venous

Often related to diabetic neuropathy

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6
Q

What are the 3 types of lower limb ulcers

A

Venous: shallow, granulating base, clinical features of venous insufficiency

Neuropathic: painless, over areas of abnormal pressure, often due to joint deformity in diabetes

Arterial: at distal sites, well-defined borders, evidence of arterial insufficiency

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7
Q

What are venous ulcers

A

Caused by venous insufficiency

Shallow

Irregular border

Granulating base

Characteristically over medial malleolus

Prone to infection (often present with cellulitis)

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8
Q

What are the risk factors for venous ulcers

A

Increasing age

Pre-existing venous incompetence

Pregnancy

Obesity

Physical inactivity

Severe trauma

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9
Q

How might venous ulcers present

A

Painful (worse at end of day)

In gaiter region of leg

Aching, itching, bursting sensation

May have varicose veins

Leg oedema

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10
Q

What investigations are needed for venous ulcers

A

Duplex ultrasound

Ankle brachial pressure index

Swab culture

Thrombophilia/vasculitis screen (young patients)

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11
Q

What is the management for venous ulcers

A

Leg elevation

Increase exercise

Weight loss

Antibiotics (if infected)

Multicomponent compression bandaging

Can operate on varicose veins

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12
Q

Give an overview of arterial ulcers

A

Due to reduced arterial blood flow

Small, deep lesions

Well-defined border

Necrotising base

At sites of trauma/pressure areas

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13
Q

What are the risk factors for arterial ulcers

A

Smoking

Diabetes

Hypertension

Hyperlipidaemia

Increasing age

Family history

Obesity

Physical inactivity

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14
Q

How might arterial ulcers present

A

History of intermittent claudication/critical limb ischaemia

Pain

Develop over a long period of time

Cold limb

Thickened nails

Necrotic toes

Hair loss

Reduced/absent pulses

Sensation maintained

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15
Q

What investigations are needed for arterial ulcers

A

Ankle brachial pressure index (> 0.9 = normal, 0.9 - 0.8 = mild, 0.8 - 0.5 = moderate, < 0.5 = severe)

Duplex ultrasound

CT angiography

MRA

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16
Q

What is the management for arterial ulcers

A

Urgent vascular review

Smoking cessation

Weight loss, exercise

Statins

Antiplatelets

Manage HTN and diabetes

Angioplasty (+/- stenting)

Bypass grafting (extensive disease)

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17
Q

What are neuropathic ulcers

A

Due to peripheral neuropathy

Painless ulcers on pressure points

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18
Q

What are the risk factors for neuropathic ulcers

A

Diabetes

B12 deficiency

Foot deformity

Peripheral vascular disease

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19
Q

How might neuropathic ulcers present

A

History of peripheral neuropathy

Burning

Tingling

Single nerve involvement

Punched out appearance

Glove and stocking distribution neuropathy

Good pulses

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20
Q

What is carotid artery disease

A

Buildup of atherosclerotic plaque in common or internal carotid artery

Causes stenosis and occlusion

Can cause ischaemic stroke (plaque rupture, atheroembolism)

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21
Q

What are the risk factors for carotid artery disease

A

> 65

Smoking

Hypertension

Hypercholesterolaemia

Obesity

Diabetes

History of cardiovascular disease

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22
Q

How might carotid artery disease present

A

Usually asymptomatic

TIA/stroke

Carotid bruit

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23
Q

What investigations are needed for carotid artery disease

A

Urgent non-contrast CT head

Routine bloods

Glucose

ECG

Duplex ultrasound (estimate degree of stenosis)

CT angiography

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24
Q

What is the acute management for carotid artery disease

A

Oxygen

Blood glucose optimisation

Ischaemic stroke: alteplase, aspirin

Haemorrhagic stroke: correct coagulopathy, refer to neurosurgery

Thrombectomy

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25
What is the long term management for carotid artery disease
Antiplatelet therapy (aspirin, clopidogrel) Statin Aggressive management of hypertension and diabetes Smoking cessation Lifestyle advice Carotid endarthrectomy
26
What is abdominal aortic aneurysm
Dilation of abdominal aorta to > 3 cm
27
What are the risk factors for abdominal aortic aneurysm
Smoking Hypertension Hyperlipidaemia Family history M>F Age
28
How might abdominal aortic aneurysm present
Usually asymptomatic Abdominal/back/loin pain Distal embolisation (limb ischaemia) Shock Syncope Pulsatile mass in abdomen Signs of retroperitoneal haemorrhage
29
Describe the screening programme for abdominal aortic aneurysm
Abdominal ultrasound Men > 65 If found: surveillance or elective repair
30
What investigations are needed for abdominal aortic aneurysm
Ultrasound CT with contrast (once diagnosis confirmed)
31
What is the management for abdominal aortic aneurysms < 5.5 cm
Monitor with duplex ultrasound ( 3 - 4.4 = yearly, 4.5 - 5.4 = 3 monthly) Smoking cessation Better BP control Statins Antiplatelet therapy Weight loss Exercise
32
What are the indications for surgery in abdominal aortic aneurysm
> 5.5 cm Expanding > 1 cm per year Symptomatic AAA in otherwise fit patient (In unfit patients, can leave until 6 cm)
33
What are the 2 methods of surgery for abdominal aortic aneurysm
Open repair Endovascular repair (introduce graft through femoral artery)
34
Give an overview of ruptured abdominal aortic aneurysm
Abdominal/back pain, syncope, vomiting, haemodynamic instability, pulsatile abdominal mass, abdominal tenderness Oxygen, IV fluids Unstable patients: open repair Stable patients: CT angiogram (see if suitable for endovascular repair)
35
What is aortic dissection
Tear in tunica intima of aortic wall Causes blood to flow between tunica intima and media, which split Acute (< 14 days) or chronic (>14 days) M>F Associated with connective tissue disorders 50 - 70
36
In which directions may aortic dissection progress
Anterograde: towards iliac arteries Retrograde: towards aortic valves
37
What are the classification systems for aortic dissection
Stanford classification: type A (involves ascending aorta), type B (doesn't involve ascending aorta) DeBakey classification: type 1 (originates in ascending aorta), type 2 (confined to ascending aorta), type 3 (originates distal to subclavian artery in ascending aorta)
38
How might aortic dissection present
Tearing chest pain Radiates to back Tachycardia, hypotension New aortic regurgitation murmur
39
What investigations are needed for aortic dissection
Routine bloods (+ troponin + crossmatch) ABG ECG CT angiogram (first line) Transoesophageal ECHO
40
What is the management for aortic dissection
Oxygen, IV fluids Lifelong antihypertensives Surveillance imaging Surgical repair
41
Why does thoracic aortic aneurysm develop
Degeneration of tunica media (artery loses structural integrity)
42
What are the risk factors for thoracic aortic aneurysm
Family history Hypertension Atherosclerosis Smoking Obesity M>F Advancing age
43
How might thoracic aortic aneurysm present
Usually incidental finding Pain: anterior chest (ascending aorta), neck (aortic arch), between scapulae (descending aorta) Back pain Hoarse voice (damage to left recurrent laryngeal nerve) Distended neck veins Symptoms of heart failure Dyspnoea/cough
44
What investigations are needed for thoracic aortic aneurysm
Routine bloods ECG CXR (widened mediastinal silhouette, enlarged aortic knob, possible tracheal deviation) CT chest with contrast Transoesophageal ECHO
45
What is the management for thoracic aortic aneurysm
Statins Antiplatelet therapy Smoking cessation Surgery for: ascending aorta > 5.5 cm, aortic arch > 5.5 cm, descending aorta > 6 cm
46
What is acute limb ischaemia
Sudden decrease in limb ischaemia that threatens viability of limb Complete or partial occlusion of artery can lead to rapid ischaemia and poor functional outcome Irreversible tissue damage in 6 hours
47
What investigations are needed for acute limb ischaemia
Routine bloods (+ serum lactate + thrombophilia screen) ECG Doppler ultrasound CT angiography
48
What is the management for acute limb ischaemia
Oxygen, IV fluids Start heparin Surgery HDU admission post-op Lifestyle advice Antiplatelet therapy Consider anticoagulants
49
What is chronic limb ischaemia
Peripheral artery disease that causes symptomatic reduction in blood supply to limb Usually due to atherosclerosis
50
What are the risk factors for chronic limb ischaemia
Smoking Diabetes Hypertension Hyperlipidaemia Increasing age Family history Obesity Physical activity
51
What are the stages of chronic limb ischaemia
Stage 1: asymptomatic Stage 2: intermittent claudication Stage 3: ischaemia at rest Stage 4: ulceration or gangrene
52
What is critical limb ischaemia
Advanced form of chronic limb ischaemia Pain at rest for > 2 weeks Presence of ischaemic lesion or gangrene ABPI < 0.5
53
How might chronic limb ischaemia present
Limb pale and cold Weak/absent pulses Hair loss Skin changes Thickened nails
54
What investigations are needed for chronic limb ischaemia
Clinical diagnosis Ankle brachial pressure index Doppler ultrasound CT angiography or MR angiography
55
What is the management for chronic limb ischaemia
Lifestyle advice Statins Antiplatelet therapy Optimise diabetic control Surgery (angioplasty, bypass graft) Amputation
56
What is acute mesenteric ischaemia
Sudden decrease in blood supply to bowel
57
How might acute mesenteric ischaemia present
Generalised abdominal pain Out of proportion to clinical signs Nausea and vomiting At late stage, global peritonism
58
What investigations are needed for acute mesenteric ischaemia
ABG Routine bloods CT with contrast (oedematous bowel, loss of bowel wall enhancement, pneumatosis)
59
What is the management for acute mesenteric ischaemia
Urgent resus Broad spectrum antibiotics Early ITU input Excision of necrotic/non-viable bowel Revascularisation of bowel
60
What is chronic mesenteric ischaemia
Reduced blood supply to bowel Due to atherosclerosis in: coeliac trunk, superior mesenteric artery, inferior mesenteric artery > 60s F>M
61
How might chronic mesenteric ischaemia present
Postprandial pain (10 mins - 4 hrs after eating) Weight loss (malabsorption) Change in bowel habits Other vascular event Nausea and vomiting Generalised abdominal tenderness Abdominal bruit
62
What investigations are needed for chronic mesenteric ischaemia
Routine bloods CT angiography
63
What is the management for chronic mesenteric ischaemia
Smoking cessation Antiplatelet therapy Statins Endovascular or open procedure (stenting, bypass)
64
What is a pseudoaneurysm
Breach to artery wall, causing accumulation of blood between tunica media and adventitia Direct communication between vessel lumen and aneurysm lumen Usually following damage to vessel wall Most common in femoral artery
65
How might pseudoaneurysm present
Pulsatile, tender, painful lump Possible limb ischaemia If infected: erythematous, tender, purulent discharge, systemic features of sepsis
66
What investigations are needed for pseudoaneurysm
Distal pulse status Duplex ultrasound (gold standard) CT Routine bloods Blood cultures Pus swab and culture
67
What is the management for pseudoaneurysm
Ultrasound-guided compression Ultrasound-guided thrombin injection Endovascular stenting Surgery (repair artery directly)
68
What are varicose veins
Tortuous dilated segments of vein, associated with valvular incompetence Mostly idiopathic
69
What are the risk factors for varicose veins
Prolonged standing Obesity Pregnancy Family history
70
How might varicose veins present
Cosmetic concerns Aching Itching If left untreated: skin changes, ulceration, thrombophlebitis, bleeding Can have clinical features of venous insufficiency: ulceration, varicose eczema, haemosiderin deposition
71
What investigations are needed for varicose veins
Duplex ultrasound
72
What is the management for varicose veins
Education Compression stockings 4-layer bandaging Surgery
73
What is thoracic outlet syndrome
Compression of neurovascular bundle as it passes through thoracic outlet Compression of: brachial plexus, subclavian artery, subclavian vein
74
Give an overview of subclavian steal syndrome
Syncope or neurological deficit when blood supply to the affected arm is increased through exercise Due to proximal stenosing lesion or occlusion of subclavian artery Blood drawn away from collateral circulation

Surgery (7 decks)

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