Vascular

Question 1

What are varicose veins?

Answer 1

Definition – tortuous, twisted, or lengthened veins that occur as a result of incompetent venous valves allowing blood to flow back away from the heart.

Question 2

What causes varicose veins?

Answer 2

Failure of venous valves aggravated by a sedentary lifestyle
Obesity, pregnancy, and certain occupancies worsen this due to raised intrabdominal pressure.
Females are at high risk as are the elderly

98% primary with no cause
2% secondary to DVT, pelvic tumour and arterio-venous fistulae

Question 3

What are the clinical features of varicose veins?

Answer 3

Poor cosmesis
Aching
Throbbing
Itching 
Heaviness
Tension

Complications 
Skin changes – varicose eczema, haemosiderin deposition (hyperpigmentation) Lipodermatosclerosis (hard/tight skin) and atrophie blanche (hypopigmentation) 
Bleeding 
Superficial thrombophlebitis 
Venous ulceration 
DVT

Question 4

How should varicose veins be investigated?

Answer 4

Always examine standing up and ask about DVT history

Trendelengburg test – to work out where the deep veins are spilling over into superficial
Doppler test – raise leg then lower until superficial veins fill.

Classified using the CEAP classification system.
• Varicose
• Reticular varicose veins
• Telangiectasia

Question 5

What conservative management can be offered for varicose veins?

Answer 5

Does patient want treatment is the first and most important question

Conservative Management
Leg elevation, weight loss, regular exercise, and graduated compressions stockings

Question 6

What are the indications for referral of a patient with varicose veins to secondary care

Answer 6

Indications for referral to secondary care
• Significant/troublesome lower limb symptoms – pain, discomfort or swelling
• Previous bleeding from varicose veins
• Skin changes secondary to chronic venous insufficiency (pigmentation and eczema)
• Superficial thrombophlebitis
• Active or healed venous ulcer

Question 7

How can varicose veins be managed surgically?

Answer 7

Does patient want treatment is the first and most important question

Endothermal ablation using either radiofrequency ablation or endovenous laser treatment
Injection of foam sclerotherapy – irritant foam that causes closure of the vein
Surgery either ligation or stripping

Question 8

What is thrombophlebitis, what causes it and what might happen if its left untreated?

Answer 8

Inflammation of the superficial veins usually along the long saphenous vein of the leg, usually non infective but secondary bacterial infection can occur resulting in septic thrombophlebitis. 20% will have underlying DVT at presentation and 3-4% will progress to a DVT if untreated – this risk of this is proportional to the length of vein affected.

Question 9

How should thrombophlebitis be investigated?

Answer 9

USS to rule out DVT

Question 10

How is thrombophlebitis managed?

Answer 10

Oral NSAIDS

Anticoagulation if suspected DVT or extending towards inguinal junction

Question 11

What are leg ulcers?

Answer 11

Definition – chronic break in the skin of the leg

Question 12

What are the risk factors for venous leg ulcers?

Answer 12

Increased risk with obesity
DVT – causes deep venous insufficiency 
Poor mobility
Varicose veins – causes superficial venous insufficiency 
Older age.

Question 13

What can cause leg ulcers?

Answer 13

Vascular – venous is most common but can also be arterial, vasculitis and lymphatic
Neuropathic – diabetes
Haematological – sickle cell anaemia
Trauma – burns, cold injury, pressure sore and radiation
Neoplastic – basal or squamous cell carcinoma e.g. Marjolin’s ulcers
Others – Sarcoidosis

Question 14

What are the clinical features of venous leg ulcers?

Answer 14

Venous causes are usually found in the foot and mid lower leg region and are flat, wet, and painless also:
•	Sign of venous insufficiency 
•	Oedema 
•	Brown pigmentation 
•	Lipodermatosclerosis 
•	Eczema

Question 15

What is the presentation of arterial leg ulcers?

Answer 15

Arterial causes are generally in the toes and heel and are punched out and painful. There may be areas of gangrene. The leg will feel cold with poor or non-palpable pulses and low ABPI measurements.

Question 16

How do neuropathic ulcers present?

Answer 16

Neuropathic ulcers common occur over plantar surfaces of metatarsal head and plantar surface of the hallux. These occur as a result of pressure.

Question 17

How should leg ulcers be investigated?

Answer 17

ABPI is important – if <0.8 venous ulcers should not be treated with compression bandaging if PAD is present, nor should TED stockings be used.

Doppler USS for presence of reflux
Duplex USS for anatomy/sufficiency

Question 18

How are venous leg ulcers managed and prevented?

Answer 18

Venous Ulcers
Exclude arterial insufficiency and other causes
4 layers compression bandages
If failed to heal after 12 weeks of >10cm^2 then skin grafting may be needed

Prevention
Keep mobile
Surgery to correct superficial venous reflux
Below knee then use class 2 compression hosiery

Question 19

How are neuropathic leg ulcers managed?

Answer 19

Cushioned shoes to reduce callous formation

Treatment or control of underlying cause

Question 20

What are the 3 classifications of peripheral vascular disease?

Answer 20

Intermittent Claudication – aching or burning in the leg muscles following walking which is relieved within minutes of stopping and not present at rest
Critical limb ischaemia – 1 or more of: pain in foot at rest for more than 2 weeks, ulceration and gangrene
Acute limb Ischaemia – previously stable limb with a sudden deterioration in arterial supply resulting in pain at rest and/or features of severe ischaemia of less than 2 weeks duration

Question 21

What causes peripheral vascular disease?

Answer 21

Smoking
High Cholesterol
Hypertension
Diabetes

Question 22

What are the clinical features of peripheral vascular disease?

Answer 22

Hanging legs out of bed at night
Pain on exercising that is relieved with rest
Pain at rest
Pain in the buttocks suggest iliac disease, pain in the calf suggests femoral
Arterial ulceration – punched out
Poor or non-palpable pulses

Question 23

How should suspected peripheral vascular disease be investigated?

Answer 23

FBC, Lipid profile and glucose levels
Thrombophilia screen if < 50yrs
Duplex USS of the arterial anatomy
ABPI (ankle/brachial pressure index) – ratio between leg and arm blood pressure normal = 1, lower BP in the legs suggest stenosis above this level and so peripheral arterial disease.

> 1.2 – may indicate calcified stiff arteries
0.9-1.2 – normal/acceptable
<0.9 – arterial disease
<0.5 – severe arterial disease

MRI/CT angiography should be completed prior to performing any investigations

Question 24

What are the medical management options for peripheral vascular disease?

Answer 24

Cessation of smoking, correction of BP, control of diabetes and weight loss
All patients should be on a statin and clopidogrel
Supervised exercise training should be offered to all patient prior to other interventions

Other drugs – Naftidofurl oxalate (vasodilator) and cilostazol (phosphodiesterase III inhibitor with both antiplatelet and vasodilator effects

Note – do not used compression stocking (TED) for VTE prophylaxis if ABPI <0.8

Question 25

What are the surgical management options for peripheral vascular disease?

Answer 25

Surgical Percutaneous Transluminal Angioplasty Stenting Bi-pass surgery – saphenous vein, cephalic vein or synthetic Amputation in critical limb ischaemia not suitable for other interventions

Question 26

How does critical limb ischaemia present?

Answer 26

- Rest pain especially when sleeping so hang leg off beds and sleep in chair - Buergers test – angling the foot up until blood can’t perfuse when leg dropped back down you get a rapid hyperaemia - Limb will look paradoxically red when ischaemic - Ankle oedema as a result

Question 27

What can cause acute limb ischaemia?

Answer 27

Embolism from AF Thrombosis – atherosclerosis, graft closure etc. Others – dissection, trauma, external compression etc.

Question 28

What are the clinical features of acute limb ischaemia?

Answer 28

6 Ps – pulselessness, painful, pallor, perishingly cold, paraesthesia and paralysis (worse) Absence of previous claudication 0-6 hours white marble limb 6-12 hours mottled limb 12+ hours dead limb

Question 29

How should you investigate an acutely ischaemic limb?

Answer 29

If upon pressing it is purple and blanches you still have time to save it Bloods including group and save Us and Es important to check potassium and CK Lactate Duplex? ECG to ascertain AF or not

Question 30

What is the immediate management of an acutely ischaemic limb?

Answer 30

``` Oxygen through rebreathe mask IV unfractionated heparin Analgesics IV fluids Surgery ```

Question 31

What are the surgical options to manage an acute limb ischaemia?

Answer 31

1. Embolectomy – percutaneous transluminal angioplasty 2. Bypass surgery 3. Amputation After revascularisation – ischaemic reperfusion injury and flushing of inflammatory markers systemically. This can lead to swelling and compartment syndrome causing venous occlusion. So must open up the 4 fascial compartments to prevent. Also be aware of rhabdomyolysis.

Question 32

What is an aneurysm?

Answer 32

Definition – typically involve dilation of all layers of the arterial wall and most occur as a result of degenerative disease. After the age of 50 normal diameter is 1.5cm for females and 1.7 cm for males, anything over 50% of normal is considered an aneurysm so for abdominal aortic aneurysms this is 3cm.

Question 33

What are the risk factors for having aneurysms (and for then rupturing)?

Answer 33

``` Smoking Hypertension Male sex Caucasian Positive family history ```

Question 34

What are the causes of aneurysms?

Answer 34

Congenital – berry aneurysms Degenerative – atheromatous degeneration of the vessel wall – loss of elastin and smooth muscle (smoking and hypertension) Connective tissue disease – Marfan’s and Ehlers Danlos Infective – mycotic aneurysms such as from syphilis or endocarditis Dissection

Question 35

How do unruptured abdominal aortic aneurysms present?

Answer 35

``` Unruptured Often asymptomatic Generally, grow at 0.2-0.8 cm per year Sometimes present with distal embolization Found by accident from imaging ```

Question 36

How do ruptured abdominal aortic aneurysms present?

Answer 36

Ruptured Intermittent or continuous abdominal pain that radiates to the back, iliac fossa or groins Collapse Expansile abdominal mass Shock Pale and unwell looking with a weak and thready pulse Acute abdomen due to blood irritating peritoneum

Question 37

How are suspected ruptured abdominal aortic aneurysms investigated and what other emergencies must be ruled out?

Answer 37

Must rule out MI, Massive PE and acute pancreatitis (Troponin, d-dimer and amylase) Place hand on abdomen and feel for pulsation USS CT scan with contrast

Question 38

How are abdominal aortic aneurysms screened for?

Answer 38

Screening – single Abdominal USS for males aged 65 • <3cm – normal no action required • 3-4.4cm – small aneurysm – rescan every 12 months • 4.5-5.4cm – medium aneurysm – rescan every 3 months • =/>5.5cm large aneurysm – refer within 2 weeks to vascular surgery for intervention

Question 39

How are low risk unruptured aneurysms managed?

Answer 39

Low rupture risk = asymptomatic and < 5.5cm Management – abdominal US surveillance as for screening and optimise cardiovascular risk factors such as smoking, hypertension, cholesterol etc.

Question 40

How are high risk abdominal aortic aneurysms managed?

Answer 40

High rupture risk = symptomatic, >5.5 cm or rapidly enlarging (>1cm/year) Management – refer within 2 weeks for vascular surgery for probable intervention. Usually, intervention involves endovascular repair or open repair if suitable. EVAR – stent placed into the abdominal aorta via the femoral artery to prevent blood collecting in the aneurysm

Question 41

Do patients with abdominal aortic aneurysms have to inform the DVLA about their diagnosis?

Answer 41

Aortic aneurysm of 6cm or more - notify DVLA. Licensing will be permitted subject to annual review. An aortic diameter of 6.5 cm or more disqualifies patients from driving.

Question 42

How can you tell an intrabdominal rupture and a retroperitoneal rupture apart?

Answer 42

Intraperitoneal rupture is immediately fatal as the abdominal cavity has a capacity for 23 litres of fluid and cardiac output is 5l per minute. A retroperitoneal rupture will usually survive to get to hospital as it is a contained leak but will eventually rupture intraperitoneally.

Question 43

What is the immediate management of a ruptured abdominal aortic aneurysm?

Answer 43

1. Contact on call vascular registrar and anaesthetist and initiate major haemorrhage protocol 2. Oxygen 15l non re-breath 3. ECG 4. IV access with 2 large bore cannulas and take bloods – amylase, Hb, crossmatch and group and save 5. Replace blood with blood but maintain BP < 100 systolic 6. Catheterise 7. Only delay for CT or X-ray if stable 8. Give prophylactic co-amoxiclav and take straight to theatre Must be 100% ready when you open the abdomen as the pressure of it acts like a tamponade and bleeding will drastically increase afterwards. Start unfractionated heparin to prevent thrombus formation when clamping aorta

Question 44

What is a pseudoaneurysm?

Answer 44

Aneurysms that only involve the outer layer (adventitia) but which still communicates with the lumen.