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Flashcards in Vascular Deck (71)
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1

What is a venous thromboembolism

- blood clot develop in your venous circulation
- due to stagnation of blood and hypercoagulable states
- Blood clots can mobilise from the deep veins and travel through the right side of the heart and into the lungs (PE)
- IF pt has a VSD - stroke

2

What are the risk factors for VTE

Immobility
Recent surgery
Long haul flights
Pregnancy
Hormone therapy with oestrogen (COCOP and HRT)
Malignancy
Polycythaemia
Systemic lupus erythematosus

3

what is the Well's score

Predicts risk of DVT and pulmonary embolism
Use online calculators to calculate score

4

What is the presentation of a DVT

Unilateral
Calf/leg swelling (measure circumference of the calf 10cm below the tibial tuberosity, >3cm difference is significant)
Dilated superficial veins
Tenderness to the calf (particularly over the site of the deep veins)
Oedema
Colour changes to the leg

5

What investigations should you do for a DVT

- D-Dimer is sensitive (95%), but not specific
- D-Dimer is positive and Doppler negative, repeat the doppler after 6-8 days
- Confirm the diagnosis with a ultrasound Doppler of the leg
- Patients should have this within 4 hours or receive LMWH whilst waiting
- Both should be negative to exclude a DVT in patients with a high Wells score

6

What other causes other than a DVT can raise a D dimer

pneumonia, DVT, malignancy, rheumatoid arthritis

7

What is the management of DVT

- Analgesia.
- Treatment dose LMWH (i.e. enoxaparin 1.5mg/kg) for >5 days (or until INR 2-3 if on warfarin).
- Long term anticoaguation with a NOAC (first line), warfarin (second line) or LMWH(third line)

8

How long should you continue anti-coagulation for

- 3 months if obvious reversible cause
- Indefinitely if cause unclear / underlying irreversible cause (e.g. cancer) / recurrent VTE

9

How do you prevent a DVT

- assess for VTE risk
- increased risk: prophylaxis if no contraindications renal dose is lower)
- If risk of bleeding, then use compression stockings

10

What is lymphoedema

- chronic oedematous condition secondary to disruption or inadequate lymph drainage of an area
- Can be primary or secondary
- Areas of lymphoedema are prone to infection

11

What is primary lymphoedema

- idiopathic condition usually presenting in the first three decades of life
- It is a result of faulty development of the lymphatic system

12

What is secondary lymphoedema

- due to another cause (e.g. after lymph node clearance for cancer, deep vein thrombosis and obesity)
- Chronic arm lymphoedema is common after axillary node clearance for breast cancer

13

What is the management of lymphoedema

Massage techniques to manually drain the lymphatic system
Compression bandages
Specific exercises
Surgery is rarely used
DO NOT TAKE BLOOD FROM THIS ARM

14

What is a Abdominal Aortic Aneurysm (AAA)

dilated abdominal aorta (increased circumference)

15

What are the RF of a AAA

Same as PVD

16

How is AAA diagnosed

- Palpable expansile pulsation in abdomen when palpated with both hands
- Found incidentally on abdominal Xray
- Diagnosis by ultrasound or angiography (CT or MRI)

17

What is the management of AAA

Treat reversible risk factors
Monitoring size
Treating peripheral arterial disease
Surgical (usually considered >5.5cm)
Endovascular stenting
Laparoscopic repair
Open surgical repair

18

What is the risk of AAA rupture

- increases with the diameter of aneurysm (roughly 5% for 5cm aneurysm, 40% for 8 cm aneurysm).
- Ruptured AAA is very dangerous and has an extremely high mortality (>75%).

19

What is the presentation of a ruptured AAA

- Known AAA or pulsatile mass in abdomen
- Severe abdominal pain (non- specific, possibly radiating to the back or loin)
- Haemodynamic instability (hypotension, tachycardia)

20

What is the management of a AAA rupture

- Moved directly to theatre for surgical repair without imaging

21

What is the management of a AAA rupture

- Moved directly to theatre for surgical repair without imaging if haemodynamically unstable
- CT for confirmation if haemodynamically stable

22

What is an aortic dissection

- A break in the lumen causes blood to flow between the layers of the wall of the aorta
- This creates a false lumen in the aorta (a space where blood is contained within the wall of the aorta
- Most commonly affects around the ascending aorta and aortic arch
- surgical emergency

23

What are the RF of aortic dissection

Same as PVD
Ehlers-Danlos Syndrome
Marfan’s Syndrome

24

What is the presentation of an aortic dissection

Tearing chest pain of sudden onset
Radiating to the back
Hypertension
Hypotension (as the dissection becomes more severe)

25

What investigations should be done if suspecting an aortic dissection

- Troponins: Raised
- CT?MRI angiogram
- ECG: ST depression
- CXR: mediastinum widening
- Bloods, esp cross match

26

What is the management of an aortic dissection

Resuscitation
Urgent vascular input and surgical repair
Manage hypertension (beta blockers)
Urgent surgical stenting or repair (time critical – each passing hour increases mortality)

27

What is carotid artery stenosis

Stenosis of the carotid arteries secondary to atherosclerosis
Diagnosis by carotid ultrasound or angiogram (CT or MRI)

28

what is the presentation of carotid artery stenosis

Asymptomatic
Syncope
TIAs
Cognitive impairment
Carotid bruit

29

What murmur do you typically hear in aortic stenosis

- crescendo decrescendo systolic murmur

30

What is the management of aortic stenosis

Treating modifiable risk factors
Surgery:
Endarterectomy (scraping out the blockage)
Angioplasty and stenting

31

How do arterial ulcers occur

poor blood supply to the skin due to peripheral arterial disease

32

How do venous ulcers occur

due to pooling of blood and waste products in the skin secondary to venous deficiency (varicose veins, DVT, phlebitis etc)

33

WHat type of ulcers can you have

- arterial
- venous
- mixed

34

What is the pathophysiology behind ulcers

- Small wounds (e.g. a tiny cut or pressure sore) cannot heal due to poor blood supply
- It progressively gets larger and more difficult to heal

35

What features suggest an arterial ulcer

Absent pulses
Pallor
Tend to be smaller
More regular boarder
Grey colour due to poor blood supply
Less likely to bleed
More painful than venous ulcers
Pain at night when legs elevated
Pain worse on elevating the leg, improved by hanging

36

What features suggest a venous ulcer

Oedematous flushed skin
Hyperpigmentation to skin
Varicose eczema
Tend to be larger
Irregular boarder
More likely to bleed
Pain relieved by elevation and worse on hanging

37

What is the management of ulcers

- Treating underlying cause (i.e. arterial or venous disease)
- Good wound care
- Antibiotics where infected
- Tissue viability nurse and district nurse input
- Plastic surgery input in severe ulcers
- Skin grafts in severe and appropriate cases

38

How do you ensure good wound care

Debridement
Cleaning
Dressing

39

What is atherosclerosis

chronic inflammation and activation of the immune system in the medium and large artery walls. This cause deposition of lipids in the wall, followed by fibrotic plaques

40

What is the result of development of fibrotic plaques in arterial walls

Stenosis leading to reduced blood flow (e.g. in claudication)
Rupture giving off a thrombus that blocks a distal vessel leading to ischaemia (e.g. in acute coronary syndrome)

41

What are the risk factors of atherosclerosis (PVD)

Older age
Family history
Male
Smoking and alcohol consumption
Poor diet (i.e. high trans-fat and reduced fruit and vegeables and omega 3 consumption)
Low exercise
Obesity
Diabetes

42

What does the end stage of athersclerosis lead to

Angina
Acute Coronary Syndrome
Transient Ischaemic Attacks
Strokes
Peripheral Arterial Disease
Chronic Mesenteric Ischaemia

43

What is peripheral arterial disease

Results from atherosclerosis and narrowing of the arteries supplying the limbs and periphery

44

What is critical limb Ischaemia

end stage of peripheral arterial disease, where there is inadequate supply of blood to a limb to allow it to function normally at rest.

45

What is intermittant claudication

- Crampy, achy pain in the calf muscles associated with muscle fatigue when walking beyond a certain intensity.
- It's a sign of limb ischaemia

46

What are the symptoms of peripheral arterial disease

- Intermittant claudication
- Thigh/buttock back on walking relieved at rest
- Erectile dysfunction
- Pain in one leg
- diminshed pulses

47

What is Leriche’s Syndrome

Associated with occlusion in the distal aorta or proximal common iliac artery
A clinical triad:
Thigh / buttock claudication
Absent femoral pulses
Male impotence

48

Whcih pulses should you check in a vascular exam

Radial
Brachial
Carotid
Aorta
Femoral
Popliteal
Dorsalis Pedis
Femoral

49

What should you check on examination for ? Peripheral arterial disease

- Feel for pulses
- Pallor
Cold
Skin changes (ulceration, hair loss)
Buerger’s Test
You can use a handheld doppler to more accurately assess pulses

50

What investigations should be conducted for peripheral arterial disease

Ankle-Brachial Pressure Index (ABPI)
Arterial Doppler
Angiography (CT or MRI)

51

What is ankle-brachial pressure

The ratio of systolic blood pressure in the ankle (around the lower calf) vs the arm
E.g. an ankle SBP of 80 and an arm SBP of 100 gives a ratio of 0.8

52

What do the results of an ankle-brachial pressure suggest

>0.9 is normal
0.6 – 0.9 is mild disease
0.3 – 0.6 is moderate to severe disease
<0.3 is severe disease to critical ischaemic

53

What are the 6 P's of critical limb Ischaemia

Pain
Pallor
Pulseless
Paralysis
Paraesthesia
Perishing cold

54

What medical treatments can be used to manage the symptoms of intermittent claudication

Atorvastatin 80mg
Clopidogrel 75mg once daily (alternatively aspirin plus dipyridamole)
Naftidrofuryl oxalate (peripheral vasodilator)

55

What surgical treatments can be used to manage the symptoms of intermittent claudication

Angioplasty and stenting
Bypass Surgery

56

What is the management of intermittant claudication

General lifestyle changes to reverse modifiable risk factors (diet, smoking, exercise etc)
Optimise medical treatment of co-morbidities (hypertension, diabetes etc)
Medical Rx
Surgical Rx

57

How do you manage critical limb ischaemia

Urgent referral to vascular team
Analgesia
Urgent revascularisation by
Angioplasty and stenting
Bypass surgery

58

Explain Varicose veins

- Veins contain valves that only allow blood to flow one direction – towards the heart
- In the legs this means that as the leg muscles contract, they squeeze blood upwards against gravity
-When these valves become incompetent, the blood pools (drawn by gravity) in the veins and is not effectively pumped back to the heart
- Varicose veins is when the blood pools into the deep veins so much that it overflows into the superficial veins overloading them
- This leads to dilatation and engorgement of the superficial veins

59

What is venous disease

- varicose veins become leak blood into surrounding tissue due to the increased pressure
- haemoglobin in this blood breaks down to “haemosiderin”, which is deposited around the shins
- This gives a brown discolouration to the lower legs
- This causes the skin to become dry and inflamed. This is called “varicose eczema”
- The skin and soft tissue become fibrotic causing tight, narrowed lower legs. This is called “lipodermatosclerosis”

60

What is lipodermatosclerosis

Severe inflammation of the skin and soft tissue in the lower legs leads to fibrosis which contracts forming a champagne bottle leg

61

What is the presentation of varicose veings

- Cosmetically unappealing dilated superficial leg veins
- Heavy / dragging sensation in the legs
- Muscle cramps
- Complications
- Positive Trendelenburg’s Test

62

What are the complications of venous insufficiency

Ulcers
Infection
Thrombophlebitis and DVT

63

What simple measures can be taken to reduce venous insufficiency

Mobilising
Keep legs elevated when possible to help drainage
Compression stockings

64

What surgical options are there for varicose veins

Endothermal ablation
Sclerotherapy
Stripping (veins are pulled out of the leg)

65

What is endothermal ablation

a catheter is inserted into the vein and radiowaves are used to heat the vein and make it permanently collapse)

66

What is slcerotherapy

an injection into the vein causes it to permanently collapse

67

At what ABPI can you no longer use compression bandages

<0.8

68

What may an ABPI of >1.2 suggest

stiff, calcified arteries, likely T2DM

69

Severe PAD or critical limb ischaemia may be treated by:

angioplasty
stenting
bypass surgery

70

management of PAD

Stop smoking
Supervised exercise program
Atorvostatin 80mg
Clopidogrel 75mg

71

Where do venous ulcers usually start

above the malleolus