Vascular Teaching

Question 1

What are the complications of varicose veins?

Answer 1

Phlebitis - 20%
Bleeding - 3%
Skin changes - 25%
Ulcers 5-10%

Question 2

History - varicose veins

Answer 2

Symptoms -
Previous treatment
Medical history inc DVT, diabetes, anticoagulants

Question 3

Physical exam for varicose veins

Answer 3

Site of varicosities
Signs of venous hypertensive complications - eczema, oedema, ulcers, scars from surgery, muscle wasting immobility
Palpate arterial pulses, look for tender and lumpy veins
Control at SFJ/SPJ - supine vs standing
Percuss - tapping test
Auscultation - trial or bruit over SFJ
Auscultation for reflux using hand-held Doppler

Question 4

Key investigation in varicose veins?

Answer 4

Duplex ultrasound scan 
Confirms or establishes source of reflux
Provides a roadmap
Assesses the deep veins
Allows treatment planning and helps guide treatment

Question 5

Colour Doppler - physiology

Answer 5

Question 6

Treatment of varicose veins - conservative

Answer 6

Leg elevation, exercise and weight loss
Compression stockings - difficult for patients to integrate into daily routine but are uncomfortable, lengthy treatment and do not cure the underlying problem
NOT TED stockings
NICE not recommended alone, but in
- pregnancy (40% increase in blood volume)
- pts unsuitable for invasive treatment

Question 7

Truncal varicosities

Answer 7

Question 8

Disconnection procedures for varicose veins

Answer 8

Question 9

Endovenous therapy - laser vs radio frequency in varicose veins

Answer 9

Question 10

Endovenous surgery - radiofrequency ablation

Answer 10

Question 11

Cyanoacrylate embolisation - glue

Varicose vein

Answer 11

Question 12

Venous ulcers - management

Answer 12

Question 13

Assessment of the ulcer

Answer 13

Question 14

Sensible dressing selection

Answer 14

Question 15

Compression therapy - venous ulceration

Answer 15

Question 16

Compression therapy - mechanism of action and art to successful compression??

Answer 16

Question 17

Aetiology of DVT - … triad

Answer 17

Virchow triad

Changes to flow
Changes to blood coaguability
Changes to vessel wall

Question 18

Management of DVT

Answer 18

Prevention is the best management
Risk assess
Periop prophylaxis
Mechanical - TED stocking, early mobilisation, active intermittent mechanical compression
Coaguability - LMWH heparin

Manage DVT itself - anticoagulation, compression hosiery 2 week minimum

Question 19

Role of thrombolysis

Answer 19

catheter directed thrombolysis
- mechanical clot disruption/aspiration, pharmacological lysis agents - e.g. alteplase
Iliofemoral DVT (only)
Venous infaction - beware, persistence of symptoms e.g. swelling

Question 20

Post-thrombotic syndrome

Answer 20

A combination of patient reported symptoms and objective findings such as swelling and skin changes in patients following DVT of the upper or lower extremity
20-50% of patients after symptomatic DVT
5-10% will suffer severe PTS

Question 21

Pathophysiology of PTS and CVI

Answer 21

Question 22

Venous infarction

Answer 22

Question 23

Preventing upper extremity PTS

Answer 23

Question 24

Aneurysm - define

Answer 24

Permanent and irreversible, localised dilation of a blood vessel to at least 50% more than its expected normal diameter

Question 25

Ectasia - define

Answer 25

Permanent and irreversible, localised dilation of less than 50% of the normal diameter

Question 26

Arteriomegaly - what is this ?

Answer 26

Diffuse ectasia involving multiple arterial segments

Question 27

Aetiology of aneurysm

Answer 27

``` Degenerative Familial Vasculitic Connective tissue abnormalities Infected ‘mycotic’ ```

Question 28

Age and gender distribution for aneurysm

Answer 28

More common in men

Question 29

Why Infra-renal aorta?

Answer 29

Question 30

Presentations of AAA

Answer 30

``` Asymptomatic Rupture Compression Embolism Thrombosis Fistulation Infection ```

Question 31

Diagnosis of aneurysms ?

Answer 31

Clinical exam Ultrasound imaging Cross-sectional imaging

Question 32

Diagnosis of aneurysms - asymptomatic?

Answer 32

Ultrasound in asymptomatic individuals - highly reliable, cheap, portable

Question 33

Ruptured AAA

Answer 33

Question 34

Rupture risk - AAA

Answer 34

Question 35

When to treat AAA

Answer 35

Question 36

Screening for AAA

Answer 36

``` Common condition, serious condition Detectable at an asymptomatic stage Reliable test for diagnosis Non-invasive test Inexpensive - £63 per person Men over 65 years target Effective treatment - open and endovascular Better outcome with early treatment ```

Question 37

UK national screening for AAA

Answer 37

Question 38

Open repair vs endovascular repair for AAA

Answer 38

Question 39

EVAR vs OPEN repair?

Answer 39

Question 40

Ischaemia - define

Answer 40

Deficiency in supply of blood flow (perfusion) to the tissue bed

Question 41

Absolute ischaemia - define

Answer 41

Insufficient perfusion to continue normal cellular process - is limb threatening

Question 42

Relative ischaemia - define

Answer 42

Insufficient perfusion to permit full function, ok at rest

Question 43

Acute ischaemia - define

Answer 43

Sudden occurrence of absolute ischaemia - 6PS

Question 44

Chronic ischaemia - define

Answer 44

Established insufficient perfusion > 2 weeks Absolute - critical ischaemia - gangrene, rest pain Relative - depends on need, asymptotic, claudication

Question 45

6 Ps of acute ischaemia

Answer 45

``` A sudden decrease in limb perfusion causing a potential threat to limb viability Pale Painful Pulseless Perishingly cold Paraesthetic Paralysed ```

Question 46

Algorithm for limb ischaemia

Answer 46

Question 47

Acute limb ischaemia - causes

Answer 47

Embolisation - AF, endocarditis, proximal aneurysm Thrombotic - rupture of an atherosclerotic plaque Aneurysm - e.g. popliteal thrombosis Trauma - fracture/dislocation, knife/gunshot wound, IV drug use, iatrogenic

Question 48

Thrombotic disease

Answer 48

Involves acute clot on underlying atherosclerosis Thrombosis can clear acute clot and allow angioplasty/stent of underlying plaque Surgery usually involves bypass

Question 49

Trauma management - limb ischaemia

Answer 49

Question 50

Compartment syndrome

Answer 50

When ischaemia muscle gets re-perfumed Muscle oedema, pressure in compartment increases, causes micro vascular compromise and muscle necrosis Intense pain - especially to passive movement Paraesthesia in feet Lack of pulse is late sign

Question 51

Chronic ischaemia (PVD, PAD, PAOD)

Answer 51

Risk factor mods - smoking, antiplatelets, statin, ACEi, claudication clinic Try not to intervene unless critical = absolute ischaemia

Question 52

Critical ischaemia - treatment options

Answer 52

Angioplasty +/- stent often first option Long segment occlusion, vein conduit - bypass Amputation if tissue loss is advanced, low chance of revascularisation succeeding Palliative if frail and not compos mantis

Question 53

Angioplasty

Answer 53

Seldinger technique Trans-luminal Sub-intimal Technical innovations - crossing devices, debunking, lithoplasty Stent developments - drug elution, covered stents Trials against surgery, favour surgery slightly

Question 54

Bypass surgery - anatomical

Answer 54