Vascular Flashcards

Question

Acute Limb Ischaemia Ix

Answer 1

Blood  FBC, U+E, INR, G+S  CK ECG Imaging  CXR  Duplex doppler

Answer 2

Discuss w senior as time is crucial. NBM  Rehydration: IV fluids  Analgesia: morphine + metoclopramide  Abx: e.g augmentin if signs of infection  Unfractionated heparin IVI: prevent extension Complete occlusion?  Yes: urgent surgery: embolectomy or bypass  No: angiogram + observe for deterioration ``` Angiography  Not if complete occlusion - introduces delay: straight to theatre.  If incomplete occlusion, pre-op angio will guide any distal bypass. ```

Answer 3

Embolectomy  Under LA or GA  Wire fed through embolus  Fogarty catheter fed over the top  Balloon inflated and catheter withdrawn, removing the embolism.  Send embolism for histo (exclude atrial myxoma)  Adequacy confirmed by on-table angiography 2. Thrombolysis  Consider if embolectomy unsuccessful  E.g. local injection of TPA 3. Other options  Emergency reconstruction  Amputation Post-embolectomy  Anticoagulate: heparin IVI → warfarin  ID embolic source: ECG, echo, US aorta, fem and pop ``` Complications >Reperfusion injury  Local swelling → compartment syndrome  Acidosis and arrhythmia 2ndary to ↑K  ARDS  GI oedema → endotoxic shock >Chronic pain syndromes ```

Answer 4

 Emergency reconstruction if complete occlusion  Angiography + angioplasty  Thrombolysis  Amputation

Answer 5

Stroke: sudden neurological deficit of vascular origin lasting >24h TIA: sudden neurological deficit of vascular origin lasting <24h (usually lasts <1h) w complete recovery

Answer 6

Pathogenesis  Turbulent flow → ↓ shear stress @ carotid bifurcation promoting atherosclerosis and plaque formation.  Plaque rupture → complete occlusion or distal emboli  Cause 15-25% of CVA/TIA Presentation  Bruit  CVA/TIA Ix  Duplex carotid Doppler  MRA

Answer 7

Conservative - aspirin/clopidogrel, control RF ``` Surgical Endarterectomy (unblock) Symptomatic (ECST, NASCET)  ≥70% (5% stroke risk per yr)  ≥50% if low risk (<3%, typically <75yrs)  Perform w/i 2wks of presentation ``` Asymptomatic (ACAS, ACST)  ≥60% benefit if low risk

Answer 8

Stroke or death 3% HTN 60% Haematoma MI Nerve Injury - hypoglossal - ipsilateral tongue deviation - great auricular - numb ear lobe - recurrent laryngeal - hoarse voice, bovine cough

Answer 9

less invasive than endarterecrtomy Less invasive: ↓ hospital stay, ↓ infection, ↓ CN injury There is concern over ↑ stroke risk, esp. pts. >70yrs Meta-analysis shows no sig difference in mortality vs. CEA @ 120d Younger pts. have best risk / benefit ratio

Answer 10

Abnormal Dilatation of blood Vessel >50% of its normal diameter (across all layers)

Answer 11

 Dilatation of a blood vessel involving all layers of the wall and is >50% of its normal diameter  Two different morphologies > Fusiform: e.g AAA > Saccular: e.g Berry aneurysm

Answer 12

 Collection of blood around a vessel wall that communicates c¯ the vessel lumen.  Usually iatrogenic: puncture, cannulation

Answer 13

Vessel dilatation caused by blood splaying apart | the media to form a channel w/i the vessel wall.

Answer 14

Congenital  ADPKD → Berry aneurysms  Marfan’s, Ehlers-Danlos ``` Acquired  Atherosclerosis  Trauma: e.g. penetrating trauma  Inflammatory: Takayasu’s aortitis, HSP Infection >Mycotic: SBE >Tertiary syphilis (esp. thoracic) ```

Answer 15

``` Rupture Thrombosis Distal Embolization Pressure - DVT, oesophagus, nutcracker syndrome Fistula (IVC, intestine) ```

Answer 16

Less common than AAA 50% pt w PA also have AAA Presents - v easy palpable popliteal pulse > 50% bilateral > rupture rare > thrombosis + distal embolism main complication - causes acute limb ischaemia Mx Acute - embolectomy or fem-distal bypass Stable - elective grafting + tie off vessel

Answer 17

Dilatation of abdominal aorta to 3+cm 90% infrarenal, 30% involve iliac arteries ``` Present usually ASx (incidental) May > back pain or umbilical pain radiating to groin Acute limb ischaemia Blue toe syndrome (distal embolisation Acute Rupture ```

Answer 18

Examination  Expansile mass just above the umbilicus  Bruits may be heard  Tenderness + shock suggests rupture Ix  AXR: calcification may be seen  Abdo US: screening and monitoring  CT / MRI: gold-standard  Angiography  Won’t show true extent of aneurysm due to endoluminal thrombus.  Useful to delineate relationship of renal arteries

Answer 19

``` Conservative - Manage CV RF esp BP - Trial suggest AAA <5.5cm in maximum diameter can be monitored by US (/CT)  <4cm: yearly monitoring  4-5.5cm: 6 monthly monitoring ``` Screening - UK M offered one time screen at 65

Answer 20

Aim to treat aneurysm before it ruptures.  Elective mortality: 5%  Emergency mortality: 50% Operate when risk of rupture > risk of surgery ``` Indications  Symptomatic (back pain = imminent rupture)  Diameter >5.5cm  Rapidly expanding: >1cm/yr  Causing complications: e.g. emboli ``` Open or EVAR (endovasc aneurysm repair)  EVAR has ↓ perioperative mortality  No ↓ mortality by 5yrs due to fatal endograft failures.  EVAR not better than medical Rx in unfit pts.

Answer 21

Blood splays apart laminar planes to form channel w/i aortic wall Atherosclerosis and HTN cause 90% Minority caused by connective tissue disorder  Marfan’s, Ehlers Danlos  Vitamin C deficiency

Answer 22

Sudden onset, tearing chest pain  Radiates through to the back  Tachycardia and hypertension (primary + sympathetic) ``` Distal Propagation > sequential occlusion of branches  Left hemiplegia  Unequal arm pulses and BP  Paraplegia (anterior spinal A.)  Anuria ``` Proximal propagation  Aortic regurgitation  Tamponade Rupture into pericardial, pleural or peritoneal cavities - commonest cause of death

Answer 23

``` Type A: Proximal  70%  Involves ascending aorta ± descending  Higher mortality due to probable cardiac involvement  Usually require surgery ``` Type B: Distal  30%  Involves descending aorta only: distal to L SC artery  Usually best managed conservatively

Answer 24

ECG - exclude MI TTE/TOE - haemodynamically unstable pts CT MRI - if stable

Answer 25

Resuscitate Investigate  Bloods: x-match 10u, FBC, U+E, clotting, amylase  ECG: 20% show ischaemia due to involvement of the coronary ostia Imaging  CXR  CT/MRI: not if haemodynamically unstable  TOE: can be used if haemodynamically unstable ``` Treat Analgesia ↓SBP (systolic)  Labetalol or esmolol (short t½)  Keep SBP 100-110mmHg ``` Type A: open repair  Acute operative mortality: <25% Type B: conservative initially  Surgery if persistent pain or complications  Consider TEVAR if uncomplicated

Answer 26

Death of tissue from poor vascular supply

Answer 27

Wet - tissue death + infection Dry - tissue death only Pregangrene - Tissue on brink of gangrene Presents black tissues +/- slough May suppuration sepsis

Answer 28

Clostridium perfringes myositis RF- DM, trauma, malignancy ``` Presentation  Toxaemia  Haemolytic jaundice  Oedema  Crepitus from surgical emphysema  Bubbly brown pus ``` Rx  Debridement (may need amputation)  Benzylpenicillin + metronidazole  Hyperbaric O2

Answer 29

Aerobes and anaerobes Fournier's - perineum Meleney's - post op ulceration

Answer 30

Mx - take cultures - debridement (include amputation) Benpen +/- clindamycin

Answer 31

Tortuous, dilated veins of the superficial venous system One-way flow from sup → deep maintained by valves  Valve failure → ↑ pressure in sup veins → varicosity 3 main sites where valve incompetence occurs: SFJ: 3cm below and 3cm lateral to pubic tubercle SPJ: popliteal fossa Perforators: draining GSV  3 medial calf perforators (Cockett’s)  1 medial thigh perforator (Hunter’s)

Answer 32

``` Primary Idiopathic (congenitally weak valves)  Prolonged standing  Pregnancy  Obesity  OCP  FH Congenital valve absence (v. rare) ``` ``` Secondary  Valve destruction → reflux: DVT, thrombophlebitis  Obstruction: DVT, foetus, pelvic mass  Constipation  AVM  Overactive pumps (e.g. cyclists)  Klippel-Trenaunay  PWS, varicose veins, limb hypertrophy ```

Answer 33

``` Sx  Cosmetic defect  Pain, cramping, heaviness  Tingling  Bleeding: may be severe  Swelling ``` Signs  Ulcers: medial malleolus / gaiter area  Oedema  Thrombophlebitis ``` Skin changes  Venous stars  Haemosiderin deposition  Venous eczema  Lipodermatosclerosis (paniculitis)  Atrophie blanche ```

Answer 34

``` Ix Duplex ultrasonography  Anatomy  Presence of incompetence  Caused by obstruction or reflux ``` Surgery: FBC, U+E, clotting, G+S, CXR, ECG ``` Referral Criteria  Bleeding  Pain  Ulceration  Superficial thrombophlebitis  Severe impact on QoL ```

Answer 35

Chronic venous disease  Clinical signs (1-6 + sympto or asympto)  Etiology  Anatomy  Pathophysiology

Answer 36

Treat contributing factors (wt loss, relieve constipation) education - avoid prolonged standing, regular walks Class II Graduated compression stockings (18-24mmHg) - Sx relief + slows progression Skin care - maintain hydration w emollients - treat ulcers rapidly

Answer 37

Indication - small below knee not involving Great Saphenous Vein or Small Saphenous Vein Techniques - LA, GA - Injection sclerotherapy - 1% Na teradecyl sulphate - endovenous laser or radiofrequency Post-op - compression bandage for 24h - compression stockings for 1mo

Answer 38

Indications  SFJ incompetence  Major perforator incompetence  Symptomatic: ulceration, skin changes, pain Procedures  Trendelenberg: saphenofemoral ligation  Small SV ligation: in the popliteal fossa  LSV stripping: no longer performed due to potential for saphenous nerve damage.  Multiple avulsions  Perforator ligation: Cockett’s operation  Subfascial endoscopic perforator surgery (SEPS) Post-op - bandage tightly - elevate 24h - discharged w compression stockings + instructed to walk daily

Answer 39

```  Haematoma (esp. groin)  Wound sepsis  Damage to cutaneous nerve (e.g. long saphenous)  Superficial thrombophlebitis  DVT  Recurrence: may approach 50% ```

Answer 40

Interruption of continuity of epithelial surface Causes - venous (commonest) - arterial - large or small vessel - neuropathic (EtOH, DM) - traumatic (pressure) - systemic - pyoderma gangrenosum etc - neoplastic - SCC

Answer 41

75% Painless, sloping, shallow ulcers Usually on medial melleolus (gaiter area) Assw haemosiderin deposition + lipodermatosclerosis RF - venous insufficiency, varicosities, DVT, obesity

Answer 42

``` 2% Hx of vasculopathy + RF Painful deep punched out lesions Occur at pressure points > heal > tips of and between toes > metatarsal (esp 5th) Other signs of chronic leg ischaemia ```

Answer 43

painless w insensate surrounding skin warm foot w good pulses

Answer 44

Oesteomyelitis Dev SCC in ulcer (Marjolin's ulcer)

Answer 45

ABPI if poss Duplex ultrasonography Biopsy may be neessary (look for malignancy

Answer 46

refer leg ulcer community clinic Focus on preention (graduated compression stockings, venous surgery) Optimise RF -nutrition, smoking ``` Specific Rx - analgesia - bed rest + elevate leg - 4 layer graded bandage (if ABPI >0.8) - Pentoxyfylline PO > microcirculatory blood flow > improves healing rates ``` Other options (no proven benefit) - desloughing (larval therapy, hydrogel) - topical antiseptics - iodine, manuka honey - split thickness skin grafting may be considered

Answer 47

↑ Venous Pressure RHF Venous insufficiency Drugs: e.g. nifedipine ↓ Oncotic Pressure Nephrotic syndrome Hepatic failure Protein losing enteropathy Lymphoedema Myxoedema Hyper- / hypo-thyroidism

Answer 48

Venous insufficiency DVT Infection/inflammation Lymphoedema

Answer 49

Collection of interstitial fluid due to blockage or absence of lymphatics Primary - congen absence of lymphatics - presents - congen from birth, praecox (after birth <35y), tarda (>35y) Milroy's Syndrome - famillial AD subtype of congenital lymphoedema - F>M

Answer 50

FIIT Fibrosis (post radio etc) Infiltration  Ca: prostate, lymphoma  Filariasis: Wuchereria bancrofti Infection - TB Trauma - block dissection of lymphatics

Answer 51

Ix  Doppler US  Lymphoscintigraphy  CT / MRI ``` Mx Conservative  Skin care  Compression stocking  Physio  Treat or prevent comorbid infections ``` Surgical: debulking operation

Vascular Flashcards

(75 cards)