Vascular

Question 1

How do venous leg ulcers come about?

Answer 1

• most due to venous hypertension secondary to chronic venous insufficiency
• other: calf pump dysfunction or neuromuscular disorders
• ulcers form due to capillary fibrin cuff or leucocyte sequestration

Question 2

Features of venous insufficiency:

Answer 2

• oedema
• brown pigmentation
• lipodermatosclerosis
• eczema

Question 3

What is venous insufficiency related to?

Answer 3

• deep: previous DVT

- superficial: varicose veins

Question 4

Investigation and management of lower leg ulcers:

Answer 4

• doppler ultrasound looks for presence of reflux and duplex ultrasound looks at anatomy/flow of vein
• 4 layer compression banding after exclusion of arterial disease or surgery
• if failure to heal after 12 weeks or >10cm2 skin grafting

Question 5

What is Marjoiln’s ulcer?

Answer 5

• squamous cell carcinoma
• occurring at sites of chronic inflammation e.g. burns, osteomyelitis after 10-20 years
• mainly lower limb

Question 6

What are arterial ulcers?

Answer 6

• toes and heel
• painful
• areas of gangrene
• cold with no palpable pulses
• low ABPI measurements

Question 7

What are neuropathic ulcers?

Answer 7

• plantar surface of metatarsal head and plantar surface of hallux
• plantar neuropathic ulcer most commonly leads to amputation in diabetics
• due to pressure
• cushioned shoes to reduce callous formation

Question 8

What is pyoderma gangrenosum?

Answer 8

• associated with IBD/RA
• stoma sites
• erythematous nodules or pustules which ulcerate

Question 9

Three patterns of presentation in patients with peripheral arterial disease:

Answer 9

• intermittent claudication
• critical limb ischaemia
• acute limb-threatening ischaemia

Question 10

Features of acute limb-threatening ischaemia:

Answer 10

• pale
• pulseless
• painful
• paralysed
• paraesthetic
• perishing with cold

Question 11

3 features of critical limb ischaemia:

Answer 11

• rest pain in foot for more than 2 weeks
• ulceration
• gangrene

Question 12

ABPI suggestive of critical limb ischaemia:

Answer 12

<0.5

Question 13

Interpretation of ABPI:

Answer 13

1 - normal
0.6-0.9 - claudication
0.3-0.6 - rest pain
<0.3 - impending

Question 14

Features of intermittent claudication:

Answer 14

• aching or burning in leg muscles following walking
• able to walk predictable distance before symptoms
• relieved within minutes of stopping
• not present at rest

Question 15

Assessment intermittent claudication:

Answer 15

• femoral, popliteal, posterior tibialis and dorsalis pedis pulses
• ABPI
• duplex US
• magnetic resonance angiography (MRA) before intervention

Question 16

Management of peripheral arterial disease:

Answer 16

• stop smoking
• treat hypertension, diabetes, obesity
• statin (atorvastatin 80mg)
• clopidofrel
• exercise training
• severe: angioplasty, stenting, bypass surgery, amputation

Question 17

Drugs to use in peripheral arterial disease:

Answer 17

• naftidrofuryl oxalate = vasodilator

- cilostazol: phosphodiesterase III inhibitor with both anti platelet and vasodilator effects

Question 18

What is superficial thrombophlebitis?

Answer 18

• inflammation due to thrombosis of superficial vein
• usually long saphenous vein
• usually non-infective (bacterial can result in septic thrombophlebitis)

Question 19

What is risk of superficial thrombophlebitis related to?

Answer 19

length of vein affected - >5cm likely to have associated DVT

Question 20

Investigations superficial thrombophlebitis:

Answer 20

• ultrasound scan to exclude concurrent DVT
• antiembolism stockings
• consider treatment with prophylactic LMWH for up to 30 days or fondaparinux for 45 days
• if contra, 8-12 days oral NSAIDs

Question 21

What are varicose veins?

Answer 21

• dilated, tortuous, superficial veins
• secondary to incompetent venous valves
• most commonly in legs due to reflux of great saphenous vein and small saphenous vein

Question 22

Risk factors varicose veins:

Answer 22

• age
• female
• pregnancy: uterus causes compression of pelvic veins
• obesity

Question 23

Symptoms varicose veins:

Answer 23

• aching, throbbing, itching
• varicose eczema (venous stasis)
• haemosiderin deposition (hyperpigmentation)
• lipodermatosclerosis (hard tight skin)
• atrophie blanche (hypopigmentation)
• bleeding
• superficial thrombophlebitis
• venous ulceration
• DVT

Question 24

Management varicose veins:

Answer 24

• leg elevation
• weight loss
• exercise
• stockings
• endothermal ablation
• foam sclerotherapy
• surgery (ligation or stripping)

Question 25

Reasons for referral of varicose veins to secondary care:

Answer 25

- significant symptoms - previous bleeding from veins - skin changes secondary to chronic venous insufficiency - superficial thombophlebitis - active or healed venous leg ulcer

Question 26

Cervical rib:

Answer 26

- supernumerary fibrous band arising from 7th vertebra - incidence of 1 in 500 - thoracic outlet syndrome - surgical division of rib - bilateral in 70% - compression of subclavian artery may produce absent radial pulse on examination and positive Adsons test - treatment if evidence of neuromuscular compromise

Question 27

What is subclavian steal syndrome:

Answer 27

- proximal stenotic lesion of subclavian artery - retrograde flow through vertebral or internal thoracic arteries - decreased cerebral blood flow and syncopal symptoms - duplex scan and/or angiogram will delineate lesion and allow treatment to be planned

Question 28

What is Takayasu's arteritis?

Answer 28

- large vessel granulomatous vasculitis - intimal narrowing - young asian females - mild systemic illness, pulses phase with symptoms of vascular insufficiency - treat with systemic steroids

Question 29

What is coarctation of the aorta?

Answer 29

- aortic stenosis at site of ductus arteriosus insertion - most common in boys and Turner's - symptoms of arterial insufficiency such as syncope and claudication - blood pressure mismatch may be seen - angioplasty or surgical resection

Question 30

Axillary/brachial emobolus:

Answer 30

- 50% of upper limb emboli in brachial - 30% axillary - sudden onset: pain, pallor, paresis, pulselessness, paraesthesia - sources: left atrium with cardiac arrhythmia, mural thrombus - cardiac arrhythmias may result in impaired consciousness

Question 31

What are arterial occlusions:

Answer 31

- resulting from atheroma common - trauma may result in vascular changes and long term occlusion but rare - claudication, ulceration, gangrene - may result in subclavian steal syndrome - progressive: development of collaterals, acute ischaemia may occur as result of acute thrombosis

Question 32

What is Adsons test?

Answer 32

- for compression of subclavian artery - lateral flexion of neck away from symptomatic side and traction of symptomatic arm - obliteration of radial pulse