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Vascular Flashcards

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1
Q

What are indications for amputation? 3Ds

A

Dead limb - gangrene
Deadly limb - wet gangrene, spreading cellulitis
Dead useless limb - gross deformities

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2
Q

What are the benefits of above knee amputation?

A

Quick to do

Heals reliably

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3
Q

What are the potential complications of amputation? (early)

A

Haemorrhage
Ischaemia
Infection
Wound dehiscence

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4
Q

What are the potential complications of amputation? (late)

A

Pain from unresolved infection

Adherent to bone and an amputation neuroma

Phantom limb

Phantom pain

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5
Q

What is aortic dissection?

A

Tearing of intima media

Blood pools in the media layer

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6
Q

How does someone with Aortic dissection present?

A

Tearing chest pain radiating through the back
Tachycardia
Hypotension
New AR murmur

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7
Q

What is a AR murmur?

A

Aortic regurgitation murmur

Valves cannot close and become leaky

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8
Q

Define aortic dissection

A

Injury to the innermost of the aorta allows for blood to flow between the aortic walls forcing them apart

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9
Q

What are the two ways of classifying Aortic Dissection?

A

Stanford (Type A or B)

Debakey (Type I, II and III)

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10
Q

What bedside investigations would you do in aortic dissesction?

A

ECG to exclude other cardiac pathology

A to E assessment

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11
Q

What bloods for possible aortic dissection?

A 
FBC
U&Es 
LFTs
Coag
Lactate
Trop
Group and save
Cross match 10 units of blood
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12
Q

What imaging do you do for aortic dissection?

A

CT with contrast

See the artery with a line going through it

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13
Q

Define acute limb ischaemia

A

Sudden decrease in limb perfusion that threatens the viability of the limb = VASCULAR EMERGENCY

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14
Q

What are the causes of acute limb ischaemia?

A

Embolic
Thrombotic
Traumatic
Stent-related

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15
Q

What are the 6Ps of acute limb ischaemia?

A

pain, pallor, perishingly cold, pulselessness, paresthesia, paralysis

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16
Q

What are the investigations for acute limb ischaemia?

A

ECG to look for AF
Doppler USS

Routine + serum lactate, dying tissue

CT/MR angiogram with contrast
Digital subtraction angiography

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17
Q

What is thrombus association with?

A

AF because of stasis

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18
Q

How do we manage acute limb ischaemia?

A

Referral to tertiary vascular centre

Embolectomy or Thrombolysis

Bypass or angioplasty in long thrombotic occlusions

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19
Q

What is done in prep for surgery for patients with acute limb ischaemia?

A

IV Heparin
IV fluids
NBM

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20
Q

What are the complications of acute limb ischaemia?

A 
Reperfusion injury
Compartment syndrome
Release of substances from damage muscle cells:
K+ --> hyperkalaemia
H+ --> acidosis
Myoglobin can result in AKI
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21
Q

What is chronic limb ischaemia?

A

Symptomatic reduction of blood supply to the limbs
aka
Peripheral arterial disease

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22
Q

What can be caused by chronic limb ischaemia?

A

Intermittent claudications - cramping pain after walking a fixed distance

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23
Q

What defines critical limb ischaemia?

A

ABPI < 0.5

Persistent rest pain

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24
Q

What is the classification of chronic limb ischamia?

A

Stage I - asymptomatic
Stage II - Intermittent claudication
Stage III - Ischaemic rest pain
Stage IV - gangrene

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25
What is ABPI?
Ankle brachial pressure index (ABPI) The ABPI is the ratio of the ankle systolic blood pressure to the brachial systolic blood pressure Normal is 1
26
Why might the ABPI be greater than 1?
Pressure in leg higher than brachial caused by calcification
27
How can we manage chronic limb ischaemia conservatively?
Regular exercise Healthy diet/Weight loss Smoking Sensation
28
How can we manage chronic limb ischaemia medically?
Statin Anti-platlet Optimise diabetes
29
How can we manage chronic limb ischaemia surgically?
Bypass using vein conduit or PTFE OR Angioplasty with/without stenting Amputation
30
What are the main features of an arterial ulcer?
``` Lower legs and tops of feet or toes Painful Symmetrical with well defined border Cool, pale or bluish surrounding skin Loss of leg hair Faint or absent ankle pulses ```
31
Define carotid artery stenosis
Narrowing of the lumen on the carotid artery, most commonly die to atherosclerosis plaque
32
What are the main features of carotid artery stenosis?
``` Previous TIA Amaurosis fugax - black curtain (hypo perfusion of ophthalmic artery) Peripheral vascular disease IHD Valvular disease/replacements Carotid bruit, best heard on expiration ```
33
What are the bedside investigations for carotid artery stenosis?
Urine dip to check for proteinuria | ECG to look for ischemic changes, AF
34
What bloods for carotid artery stenosis?
FBC to look for anaemia U+Es Glucose/HbA1c Lipids
35
What imaging is done in carotid artery stenosis?
Carotid duplex US to assess size and extent of stenosis
36
How would we conservatively manage carotid artery stenosis?
``` Smoking cessation Regular exercise Weight loss SALT referral OT/PT ```
37
How would we medically mange carotid artery stenosis?
Anti-platelet Manage RFs e.g. T2DM or HTN
38
How would we surgically manage carotid artery stenosis?
Assessment for CEA (Carotid Endearcterectomy) - surgical procedure to remove plaque Criteria: acute, non-disabling stroke symptomatic stentosis
39
What are the components of a vascular examination?
``` Inspection - ulcers, paleness Palpation - cap refill, pulses, temp Auscultation - carotid Sensation Buerger's test ```
40
What pulses should we be checking?
``` Temporal Common carotid Brachial Radial Femoral Popliteal Posterior tibialis ```
41
What is Buerger's test?
Measure angle at which limb goes pale when raised | Less than 20 degrees is indicative of chronic limb ischaemia
42
What is peripheral arterial disease?
Atherosclerotic disease affecting the legs Powerful marker of CVD risk
43
How prevalent is PAD?
30% of the adult population
44
How does PAD present?
Claudication Rest pain becomes localised to toes, bad at night Tissue loss Gangrene
45
What differentials should be considered alongside PAD?
Spinal canal stenosis Osteoarthritis Non-atheroscerlotic e.g. entrapment syndromes
46
What are the risk factors for PAD?
Smoking Dyslipidaemia Hypertension Diabetes
47
What exams for PAD?
CV AAA Pulse palpation
48
What investigations for PAD?
Doppler ABPI Toe pressure TCPO2
49
What imaging for PAD?
DUS CTA MRA Intra arterial DSA
50
Describe the natural history of PAD?
50% asympto 40% intermittent claudication 10% critical leg ischaemia 5 year outcomes - 73% stable claudication - 16% worsening claudication - 7% leg bypass surgery - 4% major amputation
51
How do we manage PAD conservatively?
``` Smoking cessation Diabetes control Statin BP control Antiplatelet ``` Improve walking distance
52
How can we improve walking distance in PAD?
Supervised exercise Vasoactive drugs Revascularisation Amputation (last resort)
53
What typically causes embolic acute limb ischaemia?
AF
54
What typically causes thrombotic acute limb ischaemia?
Previous PAD disease | History v important when distinguishing between embolic and thrombotic
55
What percentage of patients will develop diabetic foot ulcer?
25% of those with diabetes
56
Why is DFD so important?
High rates of amputaiton and mortality | Costs NHS more than 1B£ a year
57
How do you manage diabetic foot sepsis?
``` Surgical emergency Sepsis 6 Foot x-ray Bloods Microbiology Emergency debridement ```
58
What is the FAST acronym for stroke?
Face Arms Speech Time
59
What is the investigation pathway for stroke?
``` ECG Duplex CTScan Decision re intervention Rapid intervention for max gain ```
60
What defines a AAA?
Abnormal dilation >50% its normal size
61
What are risk factors for AAA?
Male HTN Smoking Genetics
62
How do AAAs present?
``` Asympto normally OR Pressure Rupture Thrombosis Embolisation ``` Expansile and pulsatile
63
When do we operate on AAAs?
Size > 5.5cm but 5cm threshold for females Increase > 1 cm in a year\ Repair of aorto-iliac disease Informed patient preference
64
What are the two ways of surgically repairing an AAA?
Open | Endovascular
65
How to you choose between open and endovascular?
Low risk - open | High op risk - EVAR
66
What are signs and symptoms of venous disease?
``` Pain Discomfort Heaviness Varicose veins Oedema Skin discolouration (brown) Lipodermatoscelrosis (champagne bottle legs) Ulceration ```
67
What are the RFs for venous disease?
``` Age FH Gender Pregnancy Obesity Reduced mobility at work Smoking Decreased fibre intake and constipation ```
68
What does elevated venous pressure result from?
Muscle pump Valvular reflex in deep and superficial veins Venous obstruction
69
What are the investigations for venous disease?
Duplex US | Venogram
70
What are characteristics of venous ulcers?
Superficial | Wet
71
What is the treatment of venous ulcers?
Compression | and offer surgery to reduce risk of reoccurrence
72
What investigation is done for varicose veins?
DUS
73
What are the indications for treatment for varicose veins?
Bleeding Symptomatic primary or recurrent v. veins Skin changes Superficial vein thrombosis (hard, painful veins) Venous leg ulcer
74
What is the treatment for varicose veins?
Compression stockings Venous ablation - under US guidance, radio frequency probe generates heat (thermal 0 Mechnochemical venous ablation Foam therapy can be used as a part of mechnochemical or by itself
75
What is gangrene?
complication of necrosis characterised by the decay of body tissues can be: - infectious (wet) - ischaemic (dry)
76
What is the most common cause of gangrene?
Critically insufficient blood supply associated with diabetes and smoking
77
What are 1st line investigations for gangrene?
``` FBC (raised WCC) Metabolic panel (Hyponatraemia common) LDH (haemolytic anaemia) Blood cultures if suspected infection CRP ```
78
What is the treatment for necrotising fasciitis?
Intensive supportive care Surgical debridement +/- amputation Local irrigation ABs
79
What is the treatment for ischaemic gangrene?
IV heparine Surgical revascularisation Thrombolytic therapy
80
What is arterial thrombosis?
Blood clot in artery
81
What are the risks of arterial thrombosis?
MI Stroke TIA Critical limb ischaemia
82
What are RFs for atherosclerosis?
getting older smoking an unhealthy diet a lack of exercise being overweight or obese regularly drinking excessive amounts of alcohol other health conditions, including high blood pressure, high cholesterol and diabetes a family history of atherosclerosis being of south Asian, African or African-Caribbean descent
83
What are the treatments for arterial thrombosis?
Throbolytic medication Embolectomy to surgically remove clot Angioplasty to widen affected artery CABG (coronary artery bypass graft to divert blood around blocked artery)

Cardiology (16 decks)

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