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Phase 2 > Vascular > Flashcards

Vascular Flashcards

1
Q

Define TIA

A

Acute loss of focal cerebral function with symptoms lasting for less than 24 hours
No apparent cause other than vascular origin

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2
Q

What % of strokes are caused by ischaemia?

A

80%

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3
Q

What are the potential pathologies of the carotid artery?

A

Carotid thromboembolism
Small vessel disease
Cardiac embolism
Haematological

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4
Q

What are the features of a stroke of carotid origin?

A

Hemisensory or hemimotor deficit
Monolateral blindness
Higher cortical dysfunction e.g. Expressive dysphasia, visuospatial neglect

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5
Q

What are the features of a vertebrobasilar stroke?

A 
Hemisensory or hemimotor deficit
Bilateral motor/sensory
Bilateral blindness
Dysarthria
Veering to one side
Ataxia/unsteadiness
Homonymous hemianopia
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6
Q

What features indicate that the patient has not had a TIA?

A

Isolated diplopia
Isolated vertigo
Isolated dizziness
(pre)syncope

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7
Q

What grade of carotid stenosis requires surgical intervention?

A

High-grade: over 70%

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8
Q

What are the aspects of optimal medical management for carotid artery disease?

A 
Anti platelet
Blood pressure
Statin therapy
Diabetic management
Angina
Lifestyle advice
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9
Q

Describe carotid endarterectomy

A

Carotid artery cut at its bifurcation
Temporary shunt inserted to avoid the surgical site
Plaque removed
Artery sutured

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10
Q

What nerves may be damaged during carotid endarterectomy?

A

Vagus CNX
Hypoglossal CNXII
Ansa (part of cervical plexus)

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11
Q

What are the potential risks of carotid endarterectomy?

A

Stroke (3%)

Nerve damage - especially hypoglossal (3%)

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12
Q

When is surgery used for asymptomatic carotid disease?

A

70-99% stenosis

Otherwise fit males

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13
Q

What are the potential benefits of carotid angioplasty rather than endarterectomy?

A

Less invasive
No neck incision
No risk of cranial nerve injury

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14
Q

Define aneurysm

A

A permanent localised dilatation of an artery

More than 50% of the normal diameter of the artery

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15
Q

Define ectasia

A

Localised area of enlargement in the artery but less than 1.5x

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16
Q

What is a true aneurysm?

A

All 3 layers of the arterial wall involved

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17
Q

What is a false aneurysm?

A

Leakage of blood out of an artery into a cavity surrounded by connective tissue, that is expansile and Pulsatile

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18
Q

Where is the most common site for an abdominal aortic aneurysm?

A

Infra-renal AA

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19
Q

What is the normal diameter of the male abdominal aorta?

A

1.5 - 2 cm

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20
Q

Define an infra-renal AAA

A

Diameter > 3 cm

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21
Q

What % of elderly males have an AAA?

A

5%

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22
Q

At what rate do AAAs commonly expand?

A

10% per year

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23
Q

What factors influence rupture of AAAs?

A

Blood pressure

Smoking

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24
Q

What is the most common presentation of an AAA?

A

Majority are asymptomatic

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25
Q

How does a ruptured AAA present?

A

Triad:
Abdominal pain (epigastric radiating to back, sudden onset)
Pulsatile mass
Hypovolaemic shock - leading to collapse

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26
Q

What are the indications for repair of am AAA?

A

Symptomatic, rapidly expanding, or ruptured

Asymptomatic > 5.5 cm

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27
Q

What is the mortality from ruptured AAAs?

A

Overall 75%

50% make it to hospital, and 50% of these die

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28
Q

What are the complications of open repair of an AAA?

A 
Haemorrhage
Cardiac events
Respiratory complications
Renal failure
Embolism/thrombosis of distal arterial tree
Colonic ischaemia
Death
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29
Q

What are the complications of endovascular repair of an AAA?

A

Graft migration
Fracture of supporting wires
Endoleak
Endotension

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30
Q

Define stroke

A

Acute loss of focal cerebral function, with symptoms lasting longer than 24 hours
No apparent cause other than a vascular origin

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31
Q

How can popliteal aneurysms present?

A 
Asymptomatic
Claudication
Embolisation
Occlusion
Rupture
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32
Q

How do you examine for a popliteal aneurysm?

A

Get patient to relax leg and bend to 45degrees

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33
Q

How do you treat popliteal aneurysms?

A

Hunterian ligation of popliteal aneurysm and bypass surgery

Endovascular stenting

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34
Q

What is the normal range for ABPI?

A

0.9 - 1.3

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35
Q

What is the underlying pathology of intermittent claudication?

A

Atheroma

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36
Q

What are the non-modifiable risk factors for PVD?

A

Age
Male gender
Family history

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37
Q

What are the modifiable risk factors for PVD?

A 
Smoking
Hypertension
High LDLs
High cholesterol
Sedentary lifestyle
Diabetes mellitus
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38
Q

What is intermittent claudication?

A

Pain in the muscles of the lower limb elicited by walking/exercise

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39
Q

What are the characteristics of intermittent claudication pain?

A

Always in the muscles, most commonly calf but sometimes thigh or buttock
Cramp-like pain
Always relieved by rest
Worse going uphill

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40
Q

What causes pain in PVD?

A

Muscle O2 requirement/availability mismatch
Leads to muscle ischaemia
Muscles have to metabolise anaerobically, producing lactate and substance P - cause pain

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41
Q

What are the differential diagnoses of intermittent claudication?

A

Spinal stenosis
Lower limb arthritis
Musculoligamentous strain

42
Q

How does arthritis pain differ from intermittent claudication?

A

Arthritic pain worse going downhill and in the first few steps

43
Q

Where are the majority of atheromatous plaques located in PVD?

A

Superficial femoral artery

44
Q

What is Leriche’s syndrome?

A

Bilateral buttock claudication + erectile failure

Common/internal iliac or distal aorta affected

45
Q

Where do you feel for the common femoral pulse?

A

Mid-inguinal point

46
Q

Where do you feel for the posterior tibial pulse?

A

Behind medial malleolus

47
Q

Where do you feel for the dorsalis pedis pulse?

A

Pull toe up - lateral to flexor hallucis longus tendon

48
Q

What is the conservative management of PVD?

A

Stop smoking
Correct risk factors
Exercise

49
Q

What are the surgical options for intermittent claudication?

A

Angioplasty

Surgical bypass: fempop

50
Q

Why is smoking such a powerful risk factor for PVD?

A

Atherogenic
Increases lipids
Reduces HDLs
Increases platelet adhesion and fibrinogen levels

51
Q

How does exercise rehabilitation help PVD?

A

Optimises collateral blood distribution

Improves capillary perfusion

52
Q

What % of patients with intermittent claudication require surgery?

A

2%

53
Q

What are the features of critical limb ischaemia?

A

Rest pain

Ulceration/gangrene of leg

54
Q

What is sunset foot?

A

Foot is paradoxically red on examination in critical limb ischaemia

55
Q

What is Buergers test?

A

When you lift an ischaemic foot it goes white, showing arterial stenosis

56
Q

How is critical limb ischaemia managed?

A

Optimise medical management
Will need angioplasty or bypass surgery to salvage leg
May need amputation if in a lot of pain and revascularisation not possible

57
Q

What is the course of the long saphenous vein?

A

Begins at medial malleolus
Travels up medial calf
Wiggles round knee then goes straight up the thigh
Joins femoral vein at saphenous opening

58
Q

Where is the saphenous opening?

A

1 inch medial and lower than femoral pulse

59
Q

What are the superficial veins in the lower limb?

A

Superficial saphenous vein

Long saphenous vein

60
Q

What are the deep veins in the lower limb?

A 
Deep femoral (thigh)
Popliteal (calf)
61
Q

Define varicose veins

A

Tortuous, twisted or lengthened veins

62
Q

What are the different types of varicose veins?

A

Trunk
Reticular
Telangiectasia

63
Q

What factors aggravate varicose veins?

A

Obesity
Occupation
Pregnancy

64
Q

What type of varicose veins lead to surgery?

A

Trunk

65
Q

Define Telangiectasia

A

Tiny blood vessels swollen so they become visible

66
Q

What is Virchow’s triad?

A

Stasis
Viscosity
Direct damage to vessel

67
Q

How are varicose veins classified?

A

0 - 6 depending on degree of signs and symptoms

68
Q

What class of varicose veins need treatment?

A

5 or 6

69
Q

What are class 5 varicose veins?

A

Ulcer present

70
Q

What are class 6 varicose veins?

A

Had ulcer but either with treatment/conservative management it resolved

71
Q

What are the symptoms of varicose veins?

A

Heaviness
Tension
Aching
Itching

72
Q

What are the potential complications of varicose veins?

A

Haemorrhage
Thrombophlebitis
Complications from venous hypertension…Oedema, skin pigmentation, varicose eczema, atrophie blanhe, lipodermatosclerosis, venous ulceration

73
Q

What is lipodermatosclerosis?

A

Skin becomes thick and yellowish

74
Q

What are the potential causes of varicose veins?

A

DVT
Pelvic tumours
AV fistulae

75
Q

How do you examine varicose veins?

A

Not distribution of veins with patient standing - long or short saphenous involved?
Tap test
Note whether there are any skin changes
Hand-held Doppler to detect incompetent veins

76
Q

What is the treatment for varicose veins?

A 
Reassurance
Compression hosiery
Surgery
Injection sclerotherapy
Endovenous laser obliteration of long saphenous vein
77
Q

What does varicose veins surgery involve?

A 
Tiny cut made below knee
Cannula put into LSV
Ablate LSV (burn it) using a laser
Means blood returns via the deep venous system which is still competent, rather than the incompetent superficial system
78
Q

What proportion of leg ulcers are venous?

A

80-85%

79
Q

What are the indications than an ulcer is due to arterial pathology?

A

Pale, pulseless, pain, paraesthesia, cold
Muscle wasting
Low ABPI
Gangrene
Medical history and RFs for arterial disease
Sites of high external compression eg metatarsal I and heel

80
Q

Where are arterial ulcers commonly found?

A

Sites of high external compression eg metatarsal I and heel

81
Q

Where are venous ulcers commonly found?

A

Gaiter area - between knee and ankle

82
Q

What are the associated features of venous ulceration?

A 
Varicose eczema
Lipodermatosclerosis
Oedema
Erythema
Itching
Haemosiderin staining
Telangiectasia
Induration (hardening)
Phlebitis
83
Q

What are the causes of leg ulcers?

A

Arterial pathology - atheroclerosis or AV malformation
Vasculitis
Neuropathic
Haematological
Traumatic eg burns, cold injury, radiation
Neoplastic

84
Q

What is the pathophysiology of venous ulceration?

A

Calf muscle pump failure means veins can’t drain blood back to the heart leading to venous hypertension

85
Q

What are the causes of calf muscle pump failure?

A

Failure of calf muscle contraction eg immobility, obesity
Outflow tract obstruction
Deep vein incompetence
Volume overload

86
Q

What must you check before using compression bandages for varicose veins?

A

ABPI > 0.8 safe for 4-layer bandaging

> 0.5 safe for 3-layer bandaging

87
Q

How do you prevent ulcers recurring?

A 
Keep mobile
Surgery to correct superficial venous reflux (varicose veins)
Below knee class 2 compression hosiery
88
Q

What is ischaemic rest pain?

A

Pain in skin due to ischaemic nerve endings

Usually at night as there are no effects of gravity and cardiac output is lower when asleep

89
Q

What artery is stenosis to cause calf pain?

A

Superficial femoral

90
Q

What artery is stenosis to cause thigh or buttock pain?

A

Aorto-iliac stenosis or occlusion

91
Q

What do ulceration and gangrene occur?

A

Insufficient blood to maintain tissue viability

92
Q

What are the trophic changes found with ulceration?

A

Loss of hair
Shiny skin
Muscle wasting
Thickened toenails

93
Q

What causes misleading ABPI results?

A

Diabetes causing calcified vessels

94
Q

What are the indications for varicose vein surgery?

A

Haemorrhage
Venous skin changes
Superficial thrombophlebitis
Aching legs

95
Q

What proportion of claudicants progress to amputation?

A

Stop smoking limb loss at 5y 0%

Continue smoking 10% at 5y

96
Q

What are the clinical features of acute limb ischaemia?

A 
6Ps:
Pain
Pallor
Pulseless
Paraesthesia
Perishingly cold
Paralysis
97
Q

What are the underlying mechanisms for a diabetic foot?

A

Neuropathy
Ischaemia
Infection

98
Q

What is the law of Laplace?

A

The bigger the diameter of an aneurysm, the faster it grows

99
Q

What are the secondary causes of lymphoedema?

A

Malignant obstruction
Surgery
Radiotherapy

100
Q

What are the clinical features of lymphoedema?

A

Painless swelling

Associated with recurrent infection

Phase 2 (21 decks)

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