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Y6 > Vascular > Flashcards

Vascular Flashcards

1
Q

When should you refer a possible abdominal aortic aneurysm to vascular surgery?

A

If >5.5cm OR growing >1cm a year

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2
Q

What is Buerger’s disease?

A

aka thromboangiitis obliterans: small and medium vessel vasculitis that is strongly associated with smoking

Features:
* Extremity ischaemia: intermittent claudication + ischaemic ulcers
* Superficial thrombophlebitis
* Raynaud’s phenomenon

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3
Q

What are some complications of varicose veins?

A
  • varicose eczema (also known as venous stasis)
  • haemosiderin deposition → hyperpigmentation
  • lipodermatosclerosis → hard/tight skin
  • atrophie blanche → hypopigmentation
  • bleeding
  • superficial thrombophlebitis
  • venous ulceration
  • deep vein thrombosis
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4
Q

What is the management of varicose veins?

A

Conservative treatments include:
* leg elevation
* weight loss
* regular exercise
* graduated compression stockings

Surgical:
* endothermal ablation
* foam sclerotherapy

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5
Q

What are reasons for referral to secondary care in patients with varicose veins?

A
  • significant/troublesome lower limb symptoms e.g. pain, discomfort or swelling
  • previous bleeding from varicose veins
  • skin changes secondary to chronic venous insufficiency (e.g. pigmentation and eczema)
  • superficial thrombophlebitis
  • an active or healed venous leg ulcer
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6
Q

What are risk factors for varicose veins?

A
  • Increasing age
  • Female
  • Pregnancy - uterus compresses pelvic veins
  • Obesity
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7
Q

What does secondary prevention of peripheral arterial disease include?

A

Statin
Clopidogrel (preferred over aspirin)

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8
Q

What are the features of acute limb ischaemia?

A

6Ps:
* Pain
* Pulseless
* Pallor
* Paresthesia
* Paralysis
* Perishingly cold

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9
Q

What are the presentations of peripheral arterial disease?

A
  • Intermittent claudication
  • Critical limb ischaemia
  • Acute limb-threatening ischaemia
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10
Q

What is the management of acute limb ischaemia?

A

Initial:
* ABC approach
* analgesia: IV opioids are often used
* intravenous unfractionated heparin (which can be reversed with protamine sulfate)
* vascular review

Surgery:
* intra-arterial thrombolysis
* surgical embolectomy
* angioplasty
* bypass surgery
* amputation: for patients with irreversible ischaemia

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11
Q

What causes acute limb ischaemia?

A

Thrombus (due to rupture of atherosclerotic plaque) - features include:
* pre-existing claudication with sudden deterioration
* no obvious source for emboli
* reduced or absent pulses in contralateral limb
* evidence of widespread vascular disease (e.g. myocardial infarction, stroke, TIA, previous vascular surgery)

Embolus (e.g. secondary to atrial fibrillation) - features include:
* sudden onset of painful leg (< 24 hour)
* no history of claudication
* clinically obvious source of embolus (e.g. atrial fibrillation, recent myocardial infarction)
* no evidence of peripheral vascular disease (normal pulses in contralateral limb)
* evidence of proximal aneurysm (e.g. abdominal or popliteal)

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12
Q

What are features of critical limb ischaemia?

A
  • Rest pain in foot for more than 2 weeks
  • Ulceration
  • Gangrene

Patients often report hanging their legs out of bed at night to ease the pain.

An ankle-brachial pressure index (ABPI) of < 0.5 is suggestive of critical limb ischaemia.

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13
Q

What are features of intermittent claudication?

A
  • aching or burning in the leg muscles following walking
  • patients can typically walk for a predictable distance before the symptoms start
  • usually relieved within minutes of stopping
  • not present at rest
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14
Q

What surgical management is used in critical limb ischaemia?

A

Endovascular revascularization:
* Percutaenous transluminal angioplasty ± stent placement
* Used for short segment stenosis (e.g. < 10 cm), aortic iliac disease and high-risk patients

Surgical revascularization - open surgery:
* Surgical bypass with an autologous vein or prosthetic material
* Endarterectomy
* Used for long segment lesions (> 10 cm), multifocal lesions, lesions of the common femoral artery and purely infrapopliteal disease

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15
Q

What does an ABPI of >1.2 indicate?

A

Calcified, stiff arteries

This can be caused by diabetes, RA, systemic vasculitis, atherosclerotic disease and advanced chronic renal failure.

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16
Q

What imaging is used for surveillance of AAA?

A

Ultrasound scan:
* Every 3 months if medium size (4.5 - 5.4 cm)
* Every 12 months if small size (3 - 4.4 cm)

17
Q

What invervention is usually done in a large aneurysm?

A

Elective endovascular repair (EVAR) - stent placed in via femoral artery, to prevent blood from pooling in aneurysm

or open repair if unsuitable

18
Q

What is usually done in terms of blood products for a person with suspected ruptured AAA?

A

Cross match, usually 6 units

19
Q

WHat is the difference between group & save and cross match?

A

Group and save - find out the patients blood type and store the sample. You do not select and store suitable blood products for transfusion.

Crossmatch - confirm the patients blood type and select suitable blood products for them, you then mix a small amount of the patients blood with the blood to be transfused to check for any reaction. When you crossmatch, there is specific blood put aside for your patient which they can be transfused.

20
Q

What is permissive hypotension?

A

Also known as hypotensive resuscitation, is a concept in trauma management where systolic blood pressure is allowed to remain low (typically around 80-90 mmHg) during the initial resuscitation of patients with severe haemorrhage. The aim of this approach is to avoid the potential complications associated with aggressive fluid resuscitation such as dislodging blood clots and exacerbating bleeding (known as ‘popping the clot’), dilution of clotting factors leading to coagulopathy, and contributing to oedema at the injury site.

Seen particularly in cases of traumatic injury like a suspected ruptured abdominal aortic aneurysm until surgical control of bleeding can be achieved.

21
Q

What is the pathophysiology of AAA formation?

A

Loss of the intima with loss of elastic fibres from the media. This process is associated with, and potentiated by, increased proteolytic activity and lymphocytic infiltration.

22
Q

What should you do when a patient presents with superficial thrombophlebitis?

A

Assess for DVT

Around 20% with superficial thrombophlebitis will have an underlying DVT - an inflammed vein > 5 cm is more likely to have an associated DVT

23
Q

What does treatment of superficial thrombophlebitis involve?

A

Topical/oral NSAIDs
LMWH
Compression stockings - after excluding arterial insufficiency

24
Q

What is subclavian steel syndrome?

A
  • Proximal stenotic lesion of the subclavian artery
  • Results in retrograte flow through vertebral or internal thoracic arteries
  • Causes decrease in cerebral blood flow and produces syncopal symptoms
  • A duplex scan and/ or angiogram will delineate the lesion and allow treatment to be planned
25
Q

What is the presentation of Leriche syndrome?

A

Triad:
* Claudication of the buttocks and thighs
* Absent or decreased femoral pulses
* Erectile dysfunction

26
Q

Where does claudication affecting the following vessels produce pain?

  • Iliac artery
  • Femoral artery
A
  • Iliac artery - bottocks and thighs
  • Femoral artery - calves
27
Q

What is a Marjolin ulcer?

A
  • Squamous cell carcinoma
  • Occurring at sites of chronic inflammation e.g; burns, osteomyelitis after 10-20 years
  • Mainly occur on the lower limb
28
Q

What are features of neuropathic ulcers?

A
  • Commonly over plantar surface of metatarsal head and plantar surface of hallux
  • The plantar neuropathic ulcer is the condition that most commonly leads to amputation in diabetic patients
  • Due to pressure
  • Management includes cushioned shoes to reduce callous formation
29
Q

What investigation is done in varicose veins / chronic venous insufficiency?

A

Venous duplex USS

30
Q

Which vessels do upper limb emboli usually affect?

A

50% of upper limb emboli will lodge in the brachial artery
30% of upper limb emboli will lodge in the axillary artery

Same principle as acute limb ischaemia - sudden onset,

31
Q

What is the difference between a doppler ultrasound and duplex ultrasound?

A

Doppler:
* Measures the speed and direction of blood flow in the vessels
* Useful in acute scenarios
* Assesses obstruction, abnormal blood flow or insufficient blood flow

Duplex:
* Combines traditional ultrasound ( creates images of structures) with Doppler ultrasound
* Visualises anatomical structures and provides blood flow information within those structures
* Used for more comprehensive information on size, structure and blood supply

32
Q

What is the screening programme for AAA?

A

All men aged 65 years are offered aneurysm screening with a single abdominal ultrasound.

Screening has shown to decrease death from abdominal aortic aneurysm by 44% over 4 years.

33
Q

What can be used to reverse local anaesthetic toxicity?

A

20% lipid emulsion (IV) - local anaesthetics (which are highly lipophilic) are absorbed into the lipid emulsion of the plasma and removed from tissues affected by toxicity

*Toxicity is usually caused by IV administration or excess administration

34
Q

What should you always do before using compression stockings in venous ulceration?

A

ABPI to rule out peripheral arterial disease as this is a contraindication

35
Q

What non-medical management can you do in peripheral arterial disease?

A

Exercise training - patients are asked to exercise to the point of maximal pain tolerance (under supervision) and then rest, to try and increase collateral circulation.

36
Q

How do you differentiate intermittent claudication from spinal stenosis?

A

Intermittent claudication (vascular cause): pain in buttocks, thighs and/or legs on walking, better with rest

Spinal stenosis (neurogenic cause): pain on rest, gets better with exercise

37
Q

How can you classify AAAs

A

Location
Size
Morphology (shape)
Aetiology

Y6 (24 decks)

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