Vascular Flashcards
1
Q
Define intermittent claudication
A
-> Symptom of ischaemia in a limb, occurring during exertion and relieved by rest.
-> Crampy, achy pain in the calf, thigh or buttock muscles associated with muscle fatigue when walking beyond a certain intensity.
2
Q
Define acute limb ischaemia
A
- Rapid onset of ischaemia in a limb.
- Either due to thrombus or embolus (secondary to AF)
3
Q
Define critical limb ischaemia and 3 features
A
- End-stage of peripheral arterial disease
- Features include 1 or more of :
- Rest pain in foot for >2 wks (pain worse at night, hang it out of bed to ease)
- Ulceration
- Gangrene
4
Q
Presentation of acute limb ischaemia
A
6 P’s
- Pain
- Pallor
- Pulseless
- Paralysis
- Paraesthesia (abnormal sensation or “pins and needles”)
- Perishing with cold
5
Q
What is Leriche syndrome
A
- Occurs with occlusion in the distal aorta or proximal common iliac artery
- Triad of : Thigh/buttock claudication, absent femoral pulses
and male impotence
6
Q
Signs of arterial disease on examination
A
- Skin pallor
- Cyanosis
- Dependent rubor (a deep red colour when the limb is lower than the rest of the body)
- Muscle wasting
- Hair loss
- Ulcers
- Poor wound healing
- Gangrene
7
Q
what test can be done to assess for peripheral arterial disease
A
-> Buerger’s Test
8
Q
Investigations for peripheral arterial disease
A
-> Ankle-brachial pressure index (ABPI)
-> Duplex ultrasound – 1st line
-> Angiography (CT or MRI) – using contrast to highlight the arterial circulation
9
Q
Stepwise management of intermittent claudication
A
- Lifestyle changes - stop smoking
- Exercise training
- Medical treatments : atorvostatin, clopidogrel, naftidofuryl oxalate
- Surgical options
10
Q
what should all patients with PAD be started on ?
A
- Atorvastatin 80mg
- Clopidogrel
11
Q
Initial management of acute limb-threatening ischaemia
A
- Analgesia
- IV unfractionated heparin
- Vascular review
12
Q
Management of critical limb ischaemia
A
Urgent revascularisation with :
- Endovascular angioplasty and stenting
- Endarterectomy
- Bypass surgery
- Amputation of the limb if it is not possible to restore the blood supply
13
Q
Management of acute limb ischaemia
A
- Endovascular thrombolysis
- Endovascular thrombectomy
- Surgical thrombectomy
- Bypass surgery
- Endarterectomy
- Amputation
14
Q
Stepwise diagnosis of DVT
A
- D dimer
- Doppler USS
- CTPA (if PE concerns)
15
Q
How long is anticoagulation continued for in a DVT
A
- 3mnths if provoked
- 6 mnths in unprovoked
- 3-6 months in active cancer
16
Q
Define varicose veins, reticular veins and telangiectasia
A
- Varicose veins : distended superficial veins >3mm.
- Reticukar veins : dilated blood vessels in skin 1-3mm.
- Telangiectasia : dilated blood vessels in the skin <1mm.
17
Q
Signs of chronic venous insufficiency
A
- Brown discolouration to lower legs (haemosiderin)
- Venous eczema
- Lipodermatosclerosis (champagne bottle legs)
18
Q
Special tests for varicose veins
A
- Tap test : pressure on SFJ and tap vein, feel trill at SFJ
- Cough test : trill when applying to pressure on SFJ and pt coughs
- Trendelenberg’s test
- Perthes test
19
Q
Management of varicose veines
A
- Weight loss, staying active, elevating leg and graduated compression stockings
- Surgical : endothermal ablation, foam sclerotherapy, surgical stripping
20
Q
RF for varicose veins
A
- Increasing age
- Female
- Pregnancy
- Obesity
21
Q
what is chronic venous insufffiency ?
A
- When blood does not efficiently drain from the legs back to the heart
- Blood pools in the vein causing venous hypertension
22
Q
what does chronic venous insufficiency result in ?
A
- Haemosiderin staining (red/brown discolouration of the skin)
- Venous eczema
- Lipodermatosclerosis : hardening and tightening of skin and rissue beneat the skin
- Atrophie blanche : patches of smooth, porcelain-white scar tissue
23
Q
4 common types of skin ulcers
A
Venous ulcers
Arterial ulcers
Diabetic foot ulcers
Pressure ulcers
24
Q
Causes of aterial and venous ulcers
A
- Arterial ulcers : insufficient blood supply to the skin due to peripheral arterial disease.
- Venous ulcers : due to the pooling of blood and waste products in the skin secondary to venous insufficiency.
25
Features of arterial ulcers
- Occur distally (toes and heels)
- Associated with PAD : absent pulses, pallor and intermittent claudication
- Smaller and deeper than venous ulcers
- Well defined borders
- Have a “punched-out” appearance
- Pale colour due to poor blood supply
Are less likely to bleed
- Painful !
- Pain worse at night (when lying horizontally)
- Pain is worse on elevating and improved by lowering the leg (gravity helps the circulation)-
26
Features of venous ulcers
- Proximal to medial malleolus
- Associated with chronic venous changes : hyperpigmentation, venous eczema and lipodermatosclerosis
- Occur after a minor injury to the leg
- Larger and more superficial than arterial ulcers
- Irregular, gently sloping border
- More likely to bleed
- Less painful than arterial ulcers
- Have pain relieved by elevation and worse on lowering the leg
27
Management of arterial ulcers
- Same as PAD : urgent vascular referral
28
Management of venous ulcers
- Cleaning the wound
- Debridement
- Dressing the wound
- Compression therapy
29
Defintion and types of lymphoedema
- Impaired lymphatic drainage
- Primary : rare genetic condition, presents befpre 30
- Secondary : a separate condition affects lymphatic drainage (e.g. after breast cancer surgery due to removal of axillary lymph nodes)
30
Important differential of lymphoedema
- Lipoedema
- This is abnormal build-up of fat
- Spares the feet, ulike in lymphoedema
31
In what ways can lymphoedema be assessed
1. Negative Stemmer's sign
2. Assessing limb volume
3. Bioelectric impedance spectrometry to measure volume of fluid in the limb
4. Lymphoscintigraphy : to assess structure of lymphatic system
32
Non surgical management of lymphoedema
-> Massage techniques to manually drain the lymphatic system
-> Compression bandages
-> Specific lymphoedema exercises to improve lymph drainage
-> Weight loss if overweight
-> Good skin care
33
Surgical management of lymphoedema
Lymphaticovenular anastomosis
34
what is lymphatic filariasis
- Disease caused by parasitic worms spread by mosquitos causing severe lymphoedema
35
How is the severity of carotid artery stenosis classified
1. Mild – less than 50% reduction in diameter
2. Moderate – 50 to 69% reduction in diameter
3. Severe – 70% or more reduction in diameter
36
What may be heard on examination in carotid artery stenosis
Carotid bruit
37
Diagnosis of carotid artery stenosis
Carotid Ultrasound
38
Surgical interventions for carotid artery stenosis
- Carotid endarterectomy
- Angioplasty and stenting
39
Injuries caused by carotid endarterectomy
-> Facial nerve injury causes facial weakness (often the marginal mandibular branch causing drooping of the lower lip)
-> Glossopharyngeal nerve injury causes swallowing difficulties
-> Recurrent laryngeal nerve (a branch of the vagus nerve) injury causes a hoarse voice
- Hypoglossal nerve injury causes unilateral tongue paralysis
40
What is Buerger disease (thromboangiitis obliterans)
- Inflammatory condition causing thrombus formation in distal arterial system (hands and feet)
41
What are the notable features of buerger disease
- <50 (usually men 25-35)
- NOT having RF for atherosclerosis (other than smoking = strong association)
42
How does Buerger disease present
- Painful, blue discolouration to the fingertips or tips of toes
- Pain is worse at night
43
Typical finding on angiograms in buerger's disease
Corkscrew collaterals = new collateral vessels form to bypass affected arteries
44
Management of buergers disease
- Stop smoking
- IV iloprost (prostacyclin analogue to dilate blood vessels)
45
Age of screening for AAA
Males aged 65
46
AAA screening outcomes
- <3cm = normal
- 3-4.4 = small = rescan 12mnths
- 4.5 - 5.4 = rescan every 3 mnths
- >5cm = 2wk vascular referral
47
When will AAA be referred 2wk
- >=5.5cm
- Symptomatic
- Growth of >1cm a year
48
Management of AAA
Elective endovascular repair (EVAR)
49
Diagnosis of varicose veins
Venous duplex USS = retrograde venous flow.
50
First line investigation for PAD
DUplex USS
51
Interpretation of ABPI in PAD
Looks at SBP in ankle compared to that in arm
>1.3 - calcification of artery (e.g. DM)
1 : normal
0.6-0.9 : claudication (mild PAD)
0.3-0.6 : rest pain (mod-severe)
<0.3 : impending (critical)
52
Define superficial thrombophelbitis
Inflammation of a superficial vein associated with a thrombus. Usually long saphenous vein of the leg
53
when should be measure when suspected superficial thrombophelbitis ?
ABPI to exclude PAD
USS to exlcude DVT
54
Management of superficial thrombophebitis
- Topical NSAIDS if mild, oral if more severe
- Compression stockings.
55
Presentation of neuropathic ulcers
- Over plantar surface of metarsal head and plantar surface of hallux
- Common in diabetics
56
Intermittent claudication affecting the buttock, what vessel
Iliac stenosis
57
Surgical options for intermittent claudication
- Endovascular angioplasty anfd stenting
- Endarterectomy
- Bypass surgery
58
