Vascular core conditions Flashcards by Georgia Gadsby

What causes critical limb ischaemia? 6

Obstructive atherosclerotic arterial disease

rarely: 
Vasculitis 
thromboangitis obliterans 
cystic adventitial disease
popliteal entrapment 
trauma

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What causes acute limb ischaemia? 9

Thrombosis at the site of an atherosclerotic stenosis

Cardiac embolisation 
aortic dissection 
aortic embolisation 
graft thrombosis 
thrombosis of a popliteal aneurysm 
trauma 
hypercoaguable state 
air, fat or amniotic fluid embolism

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What are the risk factors for PAD?

smoking
DM
HTN
dyslipidaemia

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What are the signs of acute limb ischaemia? And how long is the onset? 6

6Ps:
pain 
pallor 
pulseless
paraethesia 
paralysis
perishingly cold

Minutes, hours, days

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What are the signs of limb ischaemia due to an embolus?5

Onset: seconds to minutes

ischaemia is usually profound

Skin changes to the feet: fine reticular blanching or mottling in early stages, progressing to coarse fixed mottling

History of claudication

Pulses are usually present in the other leg

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How to you calculate an ABPI? and what do the scores mean?

Highest ankle BP of that leg/ highest BP of both the arms

Normal= 1
claudiation= 0.6-0.9 (0.8 refer to specialist)
Rest pain= 0.3-0.6
Impending gangrene= 0.3 or less

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Aside from ABPI what other investigations can be done in PAD? 4

Duplex ultrasonography- to determine site, severity and length of occluison

MR angiography- may be offered prior to revascularisation

Digital subtraction arteriography- used in endovascular management and surgical planning

Full CV risk assessment

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What medications should be considered in PAD to reduce CV risk factors?

Treat HTN
Statins- reduce risk of CV events and stroke
ACEis can reduce CV morbidity in patients with PAD

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What drugs should be given for symptomatic PAD?

Antiplatelets
aspirin
clopidogrel
aspirin + dipyridamole

generally pick clopidogrel, as although it’s less effective than aspirin it has fewer SE

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What drugs can you give for people with intermittent claudication?

Peripheral vasodilators:

Naftidrifuryl oxalate

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What are the surgical options for PAD?

Percutaneous catheter-directed thrombolytic therapy

surgical embolectomy

endovascular revascularisation- if limb is viable

revascularisation-if the limb is marginally or immediately threatened

amputation

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What are the complications of PAD?

ulceration and gangrene

Multiorgan dysfunction- e.g. AKI or acute lung injury
^ due to release of inflammatory markers and activation of complement cascade in response to ischaemia or reperfusion syndrome

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What is an aneurysm?

An irreversible dilatation of a blood vessel by at least 50% of the normal diameter
affects all 3 layers of the arterial wall

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What causes a pseudo-aneurysm?

Blood leaking through the wall, but it is contained by the adventitia or surrounding pervivascular tissue

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What is the normal diameter of the AA?

~2cm- it increases with age

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What is the diameter of an AAA?

> 3cm

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Where do most AAA arise?

below the level of the renal arteries

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Are AAA more common in F or M?

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Is the risk of rupture of an AAA more common in F or M?

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What causes an aneurysm? 4 (pathophysiology)

degradation of the elastic lamellae
leukocytic infiltrate
enhanced proteolysis
smooth muscle cell loss

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What are the risk factors for the majority of AAAs? 7

Severe atherosclerosis 
FH 
smoking 
age 
HTN 
COPD 
hyperlipidaemia

What are the less common risk factors for AAAs? 9

Trauma

Infection- brucellosis, salmonellosis, TB, HIV

Inflammatory disease- Behcet’s disease, Takayasu’s disease

Connective tissue disorders- Marfan’s, Ehler’s Danlos syndrome type IV

What are the signs and symptoms of an unruptured AAA? 4

Normally incidental finding- asymptomatic

Pain in back, abdomen or groin- due to pressure on nearby structures

Pulsatile abdominal swelling
May cause distal embolisation–> features of limb ischaemia

Uretrohydronephrosis- dilatation of ureter and pelvis of kidney due to obstruction

What is the sign that indicates impending AAA rupture?

Severe lumbar pain of recent onset

What are the features of a ruptured AAA? 8

Should be considered in any Px with hypotension and abnormal abdominal signs pain in abdomen, back or loin- may be sudden and severe Syncope shock collapse Grey Turner's sign- retroperitoneal bleeding Pulsatile mass AA bruit

What tests may be done in suspected AAA? 12

``` FBC clotting screen renal function test LFTs cross-matching if surgery is planned ESR and CRP ECG CXR lung function tests USS- used in initial assessment CT MRI angiography ```

What would a CT scan show in AAA? 4

visceral arterias mural thrombus the crescent sign= blood within the thrombus, may predict imminent rupture para-aortic inflammation

What are the differential diagnoses for AAA?

``` acute gastritis appendicitis diverticulitis cholelithiasis (gallstones) Large/ small bowel obstruction MI peptic ulcer disease ```

What level of monitoring should be done for different sized AAA?

3-4.4cm- annual ultrasound 4.5-5.4- 3 monthly USS >5,5cm- surgery

What are the indications for surgery in AAA? 4

>5.5cm rupture rapid expansion onset of sinister symptoms e.g. back pain, abdominal pain or tenderness

What are the surgical options for AAA?

Surgical open repair- replace aneurysmal section with prosthetic graft Endovascular repair of AAA= EVAR - stent passed through femoral artery

What are the pathophysiological causes of varicose veins?

Incompetent valves --> reflux of blood and increased pressure in the vein distally

What are the risk factors for varicose veins? 6

``` F>M pregnancy age FH Overweight leg trauma ```

Why does pregnancy cause varicose veins?

There is an increase of blood volume --> strain on venous system Hormones--> relaxation of muscular walls of vessles Enlarging uterus--> pressure on the pelvic veins and IVC

What are the signs and symptoms of varicose veins? 5

``` Mostly cosmetic aching legs itching over veins swollen feet and ankles discomfort after prolonged standing ```

What can ease the symptoms of varicose veins?

Leg elevation | compression stockings?

What are the skin complications of varicose veins? 3

Areas of pigmentation Venous eczema Lipodermatosclerosis= hardened, tight red or brown skin which if it's wrapped around the ankle may eventually --> champaign bottle leg

Where are venous ulcers due to varicose veins most commonly seen?

In the ankle (gaiter) area

What is thrombophlebitis?

tender, inflamed varicose veins with overlying redness and heat which feel firm due to thrombus within the vein tend to present acutely

What investigations can be done in varicose veins? 2

Duplex ultrasound Triplex ultrasonography- colour flow imaging: further refinement of the above can sow minor valve leakages and incompetence in small perforator veins

What are the differential diagnoses for varicose veins? 4

Cellulitis Osler-weber-rendu sydnrome superficial phlebitis DVT

How do you manage varicose veins?

``` Lose weight moderate exercise elevate legs when possible avoid standing or sitting for too long compression stockings ```

When should people with varicose veins seek further medical help? 4

If veins are hard or painful There are skin changes A break in the skin that lasts longer than 2 weeks There is bleeding from the varicose veins

When do you refer varicose veins to a vascular service?

They are symptomatic- pain, aching, itchy etc There are skin changes There is superficial vein thrombosis and suspected venous incompetence Venous leg ulcer- that hasn't healed within 2 week, refer within 2 weeks A healed venous leg ulcer

What are the surgical options for varicose veins?

stripping- surgical removal ligation- tying off the vein Foam sclerotherapy Endothermal methods- radio frequency and laser ablation

What are the complications of varicose veins?4

bleeding- rarely occurs, due to trauma of the veins Thrombophlebitis DVT skin damage

Where do the clots causing femoral embolisms usually come from?

the heart

What are the risk factors for femoral embolism?

Age | heart disease

What are the signs and symptoms of a femoral embolism?

``` 6Ps pain pulseless paralysis parasaethesia Pershingly cold pallor ```

What investigations should be done for a suspected femoral embolism?

Doppler USS arteriography= contrast fluid + X-ray- shows location and extent of blockage Examination of heart- to find source of embolus ECG echocardiogram CXR

How do you manage a femoral embolism?

Surgery within 12 hours If there is numbness of paralysis do it within 4-6hours anticoagulants