Vascular Disease Chris Oldfield - PowerPoint Presentation

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Vascular Disease

Chris Oldfield co3917@ic.ac.uk

Menti.com: 3959 1526

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Disclaimer

“MedED does not represent the ICSM Faculty or Student Union. This lecture series has been designed and produced by students. We have made every effort to ensure that the information contained is accurate and in line with Learning Objectives featured on SOFIA, however, this guide should not be used to replace formal ICSM teaching and educational materials.”

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Contents

Varicose Veins

Aortic Dissection

Abdominal Aortic Aneurysm

Ulcers

Peripheral Vascular Disease

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Structure of the Lecture

Signs & Symptoms

Investigations

Management

Background

https://

bestpractice.bmj.com

= Gold standard

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Peripheral Vascular Disease

Peripheral Vascular Disease

Acute

Chronic

Acute limb ischaemia

Critical limb ischaemia

Intermittent claudication

B

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Peripheral Vascular Disease

RFs

Atherosclerosis

Stenosis

Pathophysiology:

Critical limb ischaemia

Intermittent claudication

Pain on exertion

Pain at rest

Acute limb ischaemia

Sudden decrease in limb perfusion

B

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Peripheral Vascular Disease

Critical limb ischaemia

Intermittent claudication

Acute limb ischaemia

P

P

P

P

P

P

ain

ale

erishingly

cold

ulseless

arasthesia

aralysis

Hair loss

Numbness in feet / legs

Brittle, slow-growing toenails

Ulcers

Absent pulses

Atrophic skin

S&S

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Peripheral Vascular Disease

Beurger’s Test:Lie patient flat on bed & lift up leg to 45°

Limb developing pallor indicates arterial insufficiency

<20°is Beurger’s angle and indicates severe limb ischaemiaPatient then swings leg over the bed, reactive hyperaemia is seen

S&S

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Peripheral Vascular Disease

Full cardiovascular risk assessmentBP & HR

Bloods (GBC, fasting glucose, lipids)ECG

Ankle-Brachial Pressure Index (ABPI)Normal range: 0.9  1.2<0.9 abnormal,

<0.5 CLI

Colour duplex ultrasound scan

Magnetic Resonance Angiogram

Ix

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Leriche Syndrome

Leriche Syndrome aka aortoiliac occlusive disease

Sx:Buttock claudication

Impotence Absent / weak distal pulses

Ix

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SBA 1

Mr

X speaks to his GP after noticing some hair loss on his feet and numbness in his toes. The GP finds

Mr X’s ankle-brachial pressure index to be 0.7. What does result suggest?

1.

2

.

3

.

4

.

5

.

No abnormality

Abnormal ABPI, but not yet intermittent claudication

Abnormal ABPI, but not yet critical limb ischaemia

Critical limb ischaemia

Intermittent claudication

Menti.com: 3959 1526

Slide12

SBA 1

Mr

X speaks to his GP after noticing some hair loss on his feet and numbness in his toes. The GP finds

Mr X’s ankle-brachial pressure index to be 0.7. What does result suggest?

1.

2

.

3

.

4

.

5

.

No abnormality

Abnormal ABPI, but not yet intermittent claudication

Abnormal ABPI, but not yet critical limb ischaemia

Critical limb ischaemia

Intermittent claudication

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Ulcers

Venous ulcers

Arterial ulcers

Neuropathic ulcers

B

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Ulcers

S&S

Venous ulcers

Arterial ulcers

Neuropathic ulcers

Appearance:

Punched out

Deeper

than venous ulcer

Distal

(dorsum of foot & between toes)

Well defined edges

Pale base (grey granulation tissue)

Signs:

Hair loss, shiny & pale skin

Calf muscle wasting

Absent pulses

Night pain

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Ulcers

S&S

Venous ulcers

Arterial ulcers

Neuropathic ulcers

Appearance:

Large & shallow

Sloping, less well-defined sides

More proximal than AU (gaiter region)

Other symptoms of venous insufficiency (swelling, itching, aching)

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Ulcers

S&S

Venous ulcers

Arterial ulcers

Neuropathic ulcers

Signs

Stasis eczema

Lipodermatosclerosis

Atrophie

blanche

Hemosiderin deposition

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Ulcers

Venous ulcers

Arterial ulcers

Neuropathic ulcers

Ix

Duplex USS of lower limbs

ABPI

Percutaneous angiography

ECG

Bloods:

Fasting serum lipids

HbA1c

Blood glucose

FBC

Duplex USS of lower limbs

Measure surface area of ulcer

(monitor progression)

ABPI

Swab for microbiology

If signs of infection

Biopsy

If possibility of

Marjolin’s

ulcer

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Ulcers

Venous ulcers

Arterial ulcers

Neuropathic ulcers

Mx

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SBA 2

What sign associated with venous ulcers is shown in the photo below?

1.

2

.

3

.

4

.

5

.

Haemosiderin

deposition

Stasis eczema

Lipodermatosclerosis

Grey-Turner’s Sign

Atrophie

blanche

Menti.com: 3959 1526

Slide20

SBA 2

What sign associated with venous ulcers is shown in the photo below?

1.

2

.

3

.

4

.

5

.

Haemosiderin

deposition

Stasis eczema

Lipodermatosclerosis

Grey-Turner’s Sign

Atrophie

blanche

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Abdominal Aortic Aneurysm

Definition =A localised enlargement of the abdominal aorta where the diameter is >3 cm

or >50% larger than normal diameter.

B

90% occur below renal arteries

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Abdominal Aortic Aneurysm

B

RFs

Screening population = males >65 years old

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Abdominal Aortic Aneurysm

S&S

Unruptured AAA

Ruptured AAA

Usually asymptomatic

Often an incidental finding

May have pain in back, abdomen or groin

Sudden, severe pain in back, abdomen or groin

Syncope

Shock

Signs:

Pulsatile & laterally expansile mass on palpation

Abdominal bruit

Grey-Turner’s sign (ruptured)

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Abdominal Aortic Aneurysm

BloodsFBC, clotting screen, U&Es, LFTs

Cross match in case surgery is neededAbdominal Ultrasound

Can detect presence of AAA but not whether it has ruptured or not CT AngiogramCan detect whether AAA has ruptured Magnetic resonance angiogram

To detect whether AAA has ruptured – if patient has contrast allergy or renal impairment

Ix

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SBA 3

Ms

Y is BIBA to A&E with a suspected abdominal aortic aneurysm, which is confirmed with an initial investigation. Which further investigation is the gold standard in determining whether an abdominal aortic aneurysm has ruptured?

1.

2

.

3

.

4

.

5

.

ABPI

CT angiogram

Abdominal ultrasound

Abdominal x-ray

Magnetic resonance angiogram

Menti.com: 3959 1526

Slide26

SBA 3

Ms

Y is BIBA to A&E with a suspected abdominal aortic aneurysm, which is confirmed with an initial investigation. Which further investigation is the gold standard in determining whether or not an abdominal aortic aneurysm has ruptured?

1.

2

.

3

.

4

.

5

.

ABPI

CT angiogram

Abdominal ultrasound

Abdominal x-ray

Magnetic resonance angiogram

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Aortic Dissection

B

Both ascending & descending aorta

Ascending aorta only

Descending aorta only (above the diaphragm)

Descending aorta only (above and below the diaphragm)

Aortic dissection

=

A condition where a tear in the

aortic intima

allows blood to flow into a new

false channel

in between the inner and outer layers of the tunica media.

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Aortic Dissection

B

RFs

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Aortic Dissection

“Aortic dissection typically presents in men older than 50 years of age, with sudden onset of severe ripping or tearing substernal or interscapular pain.” – BMJ Best Practice

S&S

Symptoms

Signs

Sudden central

tearing pain

, can radiate to the back

Symptoms caused by blockages to branches of the aorta:

Carotid artery

 blackout, dysphasia

Coronary artery  angina

Subclavian artery  LOC

Renal artery  anuria, renal failure

Hypertension

Blood pressure difference between the two arms (>50%)

Murmur on the back

Signs of aortic regurgitation

Signs of connective tissue disease

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Aortic Dissection

Ix

1.

Bloods (FBC, cross match, U&E, LFT, cardiac enzymes)

2.

3.

4.

ECG (often normal)

Chest x-ray

CT angiogram

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Aortic Dissection

Ix

1.

Bloods (FBC, cross match, U&E, LFT, cardiac enzymes)

2.

3.

4.

ECG (often normal)

Chest x-ray

CT angiogram

False lumen

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SBA 4

Mr

Z, a 57-year-old lorry driver who takes crack cocaine at the weekends, arrives at A&E with a ‘really painful tearing feeling’ in his back. An early diastolic murmur is heard over the aortic area and a collapsing pulses is noted on examination. Which of the following murmurs is most likely being described?

1.

2

.

3

.

4

.

5

.

Mitral stenosis

Aortic stenosis

Mitral regurgitation

Tricuspid regurgitation

Aortic regurgitation

Menti.com: 3959 1526

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SBA 4

Mr

Z, a 57-year-old lorry driver who takes crack cocaine at the weekends, arrives at A&E with a ‘really painful tearing feeling’ in his back. An early diastolic murmur is heard over the aortic area and a collapsing pulses is noted on examination. Which of the following murmurs is most likely being described?

1.

2

.

3

.

4

.

5

.

Mitral stenosis

Aortic stenosis

Mitral regurgitation

Tricuspid regurgitation

Aortic regurgitation

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Varicose Veins

B

Definition = subcutaneous,

permanently dilated veins >3 mm in diameter

when measured in a standing position

(most often the

superficial veins of the lower limb

)

RFs

10 – 15% men

20 – 25% women

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Varicose Veins

Causes

Primary

Secondary

Deep vein thrombosis

Venous outflow obstruction

B

Idiopathic valvular incompetence

AV malformations

Pregnancy

Ovarian cysts

Ascites

Pelvic malignancy

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Varicose Veins

S&S

Symptoms

Visible dilation of veins

Leg aching

Worse with prolonged standing

Swelling & itching

Bleeding

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Varicose Veins

S&S

Signs

Veins feel tender or hard

Tap test

Tap VV distally & feel thrill over sapheno-femoral junction

Auscultation for bruits

Trendelenburg test

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Varicose Veins

Ix

Localises the site of valve incompetence

Can be used to exclude DVT

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Varicose Veins

Mx

Conservative

Endovascular treatment

Surgery

Compression stockings

Weight loss, exercise, leg elevation

Lifestyle changes

Radiofrequency ablation

Endovenous

laser ablation

Microinjection scleropathy

Liquid or foam

Stripping of the long saphenous vein

Avulsion of varicosities

Saphenofemoral ligation

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Varicose Veins

Mx

Surgery

Stripping of the long saphenous vein

Avulsion of varicosities

Saphenofemoral ligation

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Varicose Veins

Mx

Sclerotherapy

Venous ulcer

Lipodermatosclerosis

Stasis eczema

Hemosiderin deposition

Complications

Surgery

Skin staining, local scarring

Haemorrhage, infection, recurrence,

paraesthesia

, peroneal nerve injury

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SBA 5

Which of the following signs/symptoms is NOT associated with varicose veins?

1.

2

.

3

.

4

.

5

.

Improvement with prolonged standing

Leg bleeding

Leg itching

Hardening of veins

Leg swelling

Menti.com: 3959 1526

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SBA 5

Which of the following signs/symptoms is NOT associated with varicose veins?

1.

2

.

3

.

4

.

5

.

Improvement with prolonged standing

Leg bleeding

Leg itching

Hardening of veins

Leg swelling

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Covered in this Tutorial

Varicose Veins

Aortic Dissection

Abdominal Aortic Aneurysm

Ulcers

Peripheral Vascular Disease

Acute limb ischaemia

Critical limb ischaemia

Intermittent claudication

Venous ulcers

Arterial ulcers

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Extra SBA 1

Which of the following is NOT used in the treatment of venous ulcers?

1.

2

.

3

.

4

.

5

.

Microinjection sclerotherapy

Moisturising cream

Debridement

Antibiotics

Graded Compression stockings

Menti.com: 3959 1526

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Extra SBA 1

Which of the following is NOT used in the treatment of venous ulcers?

1.

2

.

3

.

4

.

5

.

Microinjection sclerotherapy

Moisturising cream

Debridement

Antibiotics

Graded Compression stockings

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Extra SBA 2

A male patient attends his GP with pain in the buttocks, saying he’s ‘unable to get it up’ anymore. On examination you cannot feel the posterior tibial or dorsalis pedis pulses bilaterally. What imaging would confirm the diagnosis?

1.

2

.

3

.

4

.

5

.

ABPI

CT angiogram

Abdominal ultrasound

Abdominal x-ray

Magnetic resonance angiogram

Menti.com: 3959 1526

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Extra SBA 2

A male patient attends his GP with pain in the buttocks, saying he’s ‘unable to get it up’ anymore. On examination you cannot feel the posterior tibial or dorsalis pedis pulses bilaterally. What imaging would confirm the diagnosis?

1.

2

.

3

.

4

.

5

.

ABPI

CT angiogram

Abdominal ultrasound

Abdominal x-ray

Magnetic resonance angiogram

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Thank you

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