clinical - vascular discussion

VASCULAR

ISCHEMIA

What are causes of chr. ischemia = causes of ischemic ulcer?

Atherosclerosis (commonest cause) – Large vessel ds

Thrombangitis obliterans (Beurger ds) – Large vessel ds

DM – Large (cause atherosclerosis) & Small vessel ds

PAN – Small vessel ds

Rh.Arthritis – Small vessel ds

What are risk factors of ischemia? Smoking-ISHD-DM-HTN-hyperlipidemia

What is presentation of PVD (peripheral vascular disease)= chr. ischemia?

	Claudication pain	Rest pain	Critical ischemia
Site	Aorta & CIA → Buttocks EIA → Thigh Femoral → Calf	Forefoot & Toes	1-Ulcer or gangrene 2-Rest pain > 2ws 3-Ankle pr <50 mmHg
What ↑	Exercise (fixed distance) (d.t. accumulation metab.)	Rest & Sleep (d.t. ↓ COP, V.D. skin bl.v)
What ↓	rest	Walk & hang leg out bed
TTT	Conservative	Angioplasty +/- stent (if short segment)       Bypass Graft (if long segment)       Amputation (if failed)

What is definition of critical ischemia?

European working group definition

1-    presence ofarterial ulcer or gangrene OR

2-    rest pain ≥ 2 weeks relieved only by opioids OR

3-    absolute ankle pr. < 50mmHg

Other features

4-    ABPI < 0.5

5-    Burger vangle < 30^o

Examination

Scars?

Ts Lt to umbilicus: Lumbar sympathectomy or retroperitoneal approach to aorta

Ts (as above) & long. Bilaterally at skin crease: aorto-bifemoral bypass

Long. at skin crease: femoral embolectomy

Long. at skin crease & popliteal fossa: femoro-popliteal bypass with synthetic graft

Multiple scars from skin crease downwards to knee:

      multiple stab avulsion (for V.V.)

or

      femoro-popliteal bypass with vein graft (natural)

Where to feel pulses UL?

Subclavian: just behind mid-clavicle from behind

Axillary: bicepital groove (medial humerus) bimanual

Brachial: med. bicepital aponeurosis

Radial: lat. to FCR- radial bone

Ulnar: lat. to FCU – pisiform bone

Where to feel pulses LL?

AAA: above umbilicus, just Lt midline

Femoral: midinguinal point (midway SP & ASIS) at skin crease

Popliteal: knee 160 degrees (relax muscles) in popliteal fossa (variable site)

Posterior tibial: midway between med. malleolus & tendo-achilis

Dorsalis pedis: lat. to ext. hallucis longus tendon on navicular bone

Commonest sites of leg ischemic ulcers?

1-    heel

2-    head of metatarsals

3-    between toes

4-    sole

Is Burger test practical? NO, now replaced by ABPI (ankle-brachial pr. Index)

Is capillary filling a good test for ischemia? NO, because may be normal due to return of venous blood

How to measure & interpret ABPI?

Measure ankle pr. by cuff above med. malleolus & hear post. Tibial by doppler

Measure brachial pr. By doppler

Divide ankle / brachial pr.

If >1 → DM (rigid vessel wall)

If 0.9 – 1 → normal

If 0.5 -0.9 → chronic ischemia

If < 0.5 → critical ischemia

Why in DM pulse felt till late &ABPI is higher than even Normal >1?

Because of calcification of vessel wall

Diagnosis, D.D. & management

Diagnosis of case of Ischemia? Example,

Color & trophic changes, ulcer with punched out edge, necrotic floor & deep, Beurger angle < 30o, sluggish capi. Circulation, pulses not felt below femoral

→ Critical ischemia LL for ABPI & Angiography

How to diagnose pt. with ischemia?

1-    angiography (goldstandard)- now CT angio.

2-    Duplex (less invasive)

What to do for pt. with only femoral pulse felt? (Common on exam)

Angiography (standard)

Which artery is commonest to be occluded? Superficial femoral

What is ttt of chronic ischemia in most cases ? in most of cases superficial femoral occluded → Femoro-popliteal bypass 

What is value for angiography?

1-    diagnostic: site (aorto-iliac, femoral-popliteal or distal) & extent of thrombus & distal run-off (=good collaterals =good prognosis)

2-    therapeutic: ballon angioplasty +/- stent (if short segment)

What are precautions of angiography in DM pt.?

ensure normal S.Cr., good hydration & non-ionized dye (usually mild renal impairment)

stop metformin (cause lactic acidosis with dye)

What is ttt of ischemia?

Conservative ttt: (if claudication pain)

→ stop smoking, control DM, HTN & hypercholest, regular aspirin 75mg, analgesia acc. to analgesic ladder (paracetamol→NSAIDS oral→IM→oral opioids →IM)

Surgery with conservative ttt: (if claudic. & failed conservative OR critical ischemia OR rest pain)

→ Angioplasty +/- stent (if short segment)

     Bypass Graft (if long segment)

     Amputation (if failed or no distal run-off)

     Lumbar sympathectomy (if ischemic ulcer)

What are contraindications of sympathectomy?

DM (autosympathectomy) & Gangrene

What is ttt of this pt. with clasudication pain & trophic changes?

Conservative ttt

What is ttt of this pt. with ischemic ulcer? 

Angioplasty +/- stent (if short segment)

Bypass Graft (if long segment)

Amputation (if failed)

What are types of bypass grafts?

1-    natural: saphenous v.

2-    synthetic: Dacron or PTFE (Gortex)

D.D. claudication pain?

1- Vascular: PVD or DVT or PTS

2- Neurological: spinal stenosis (spinal claudication) or sciatica

3- Musculoskeletal: pathology of hip, knee orankle (e.g, osteoarthritis)

OSCE advanced Qs

Pathology of ischemia by DM? Mixed

1-      Vasculopathy: Macro- angiopathy & Micro- angiopathy

2-      Periph. Neuropathy:

3-      Inf.: → Macro & Micro- angiopathy

Which type of DM is worest?

IDDM (type I) because:

usually  P.N. (poorvresponse to surg.)

↓ immunity → more inf.

More plat. Aggregation

Ask this pt. with diabetic toe 1 question? Are you on insulin or not?

If on insulin (type I) → amputation (no ischemia but neuropathy=bad prognosis)

If on oral hypoglycemics (type II) → angioplasty (ischemia due to vasculopathy)

What is thoracic outlet syndrome?    ……

What if auscultate over carotid & bruit is heared?

Do duplex if carotid stenosis for intervention → angioplasty or endarterectomy

What is endarterectomy. How it is done?

Done in carotid thrombosis only

Peel Intima & part of media (leave part of media + adventitia)

PTS (Post-Thrombotic syndrome)

Cause PTS? DVT

1-    deep v. system reflux post-DVT (90%)

2-    deep v. system obstruction post-DVT (10%)

Presentation of PTS? pain & Signs chr.venous insuffeciency=chronic skin changes (edema, eczema, hyperpigmentation, lipodermatosclerosis, V.V., venous ulcer)

Ask pt. 2 questions? heparin inj. or oral anticoagulant (=DVT) & operations

Examination

What is lipodermatosclerosis? Skin & SCT Subfascial fibrosis

Ccc of venous ulcer? Floor healthy granulation tissue

                                    Edge sloping (means healing)

Shallow

Area surrounding → signs chr.v. insuffeciency

Diagnosis, D.D. & management

Diagnosis of case PTS? Example,

Edema of Rt LL, dark periphery, purple central area, with multiple ulcers with floor of healthy granulation tissue & sloping edge, also there is a punch of v.v.s

propably a case of PTS.

I would like to examine pulse (to exclude mixed pathology) & ask pt. to stand to examine for v.v. 

How to investigate case venous ulcer or case of PTS or deep system? Duplex

Other rare options (ambulatory venous pr., venography, varicography)

Another method to asses deep system (clinically)?

Perthe’s test or modified perthe’s test (close superficial system by tourniquet & walk or tip toe → pain) (not used because painful)

Role of duplex in PTS?

diagnostic: for deep system patency & competence (exclude DVT which contraindicate surg.) & superficial system SFJ & perforator competence

therapeutic: superficial system (not in PTS)

(it is contraindicated to treat 2ry V.V. (V.V. + prev. DVT) because surgery worsen v.ischemia) So, any case of V.V. + ulcer → do duplex

What are causes of Venous ulcer?

PTS

V.V.

Muscle pump failure (NM ds, stroke, stiff ankle)

Can varicose vein cause this picture (ulcer) without PTS? Yes, severe V.V.

How is treatment different between varicose ulcer due to PTS or 1ry V.V.?

varicose ulcer due to PTS → compression dressing (4 layer bandage)

varicose ulcer due to 1ry V.V. → surgery for v.v.

What is treatment of venous ulcer ?

1- Conservative:

1-  Elevation of leg

2-  Compression bandage (Four-layer bandage)

      & after ulcer healing use G II compression stocking for life (for V.V.)

2- Surgical:  ulcer base excision & skin grafting (after biopsy from edge to exclude marjolin ulcer = SCC)

What are differences between types of ulcers?

	Venous	Ischemic	Neuropathic
Size	large	Small	medium
Site	Gaiter area	Distal & pr. area	Pr. area
Shape	irregular
Edge	sloping	Punched out	Punched out
Surrounding	CVI	Trophic & color changes & lost pulse	Lost sensation

OSCE advanced Qs

What are the 4 layers of 4 layer bandage (not used now)?

1- non-adherent & absorbable (wool)

2- crepe bandage

3- blue line

4- tape (plaster)

Exchange / week

What are results of conservative management for ulcer (4 layer bandage)?

Very good at 3ms→ 50-70% healing & at 12 ms 80-90% healing

What is venous gangrene?

Rare complication of Iliofemoral DVT:

Phlegmasia alba dolens: white leg

Phlegmasia cerula dolens: blue leg

Gangrene: in foot or extend to leg (due to acute ischemia)

What are types granulation tissue?

Healthy: red, not bleed easy, flat & Unhealthy: blue, bleed easy & raised

Varicose Vein

What is pathogenesis V.V.? fibrous tissue invades intima & media & broke ms tone

What are tributaries of Saphenous vein ?

1-      Superficial circumflex iliac

2-      Superficial inferior epigastric

3-      Superficial external pudendal

4-      Deep external pudendal

5-      Antero-lateral & postero-medial veins of the thigh

Examination

What is fegan test (sign)?

palpation of fascial defects

Where is the SFJ (saphenofemoral junction) by doppler?

1 cm below & medial to femoral a. (mid-inguinal point = midway bet. S.P. &ASIS)

OR 4 cm below & lat. to P.T. (1^st prominrnce med. to ing. Lig. Or attachment of adductor longus by abd. & ext.rot. hip)

How to asses SFJ incompetence?

1-    palpation =thrill

2-    tourniquet test

3-    Doppler

How to use Doppler to asses SFJ (saphenofemoral junction) incompetence?

Carried by examiner or in your pocket (not by pt.)

At site of thrill: Locate artery (below skin crease) then vein just below &med. (1cm)

Squeeze quadriceps (punch of veins) or ask pt. to cough

Hear 2^nd sound (bidirectional flow)

How to use Doppler to asses SPJ (sapheno-popliteal j.) incompetence? (rare)

Flex knee (to relax muscles)

Locate artery in midline & vein lies beside artery

Diagnosis, D.D. & management

What is Diagnosis of v.v. case? Example

v.v. at medial side of leg at distribution LSV, pigmentation in gaiter area, no v.v. in course SSV, incompetent SFJ by thrill, tourniquet test & Doppler

V.V. with incompetent SFJ & competent perforators

What are indications of duplex in V.V.? Some surgeons perform it as routine but

history DVT

venous ulcer

recurrent V.V.

pre-operative: for perforators & SPJ (both are variable anatomicaly)

if cannot determine SFJ incompetence

What is role of duplex in V.V.?

3-    diagnostic: for deep system patency & competence (exclude DVT which contraindicate surg.) & Superficial system SFJ & perforator competence

4-    therapeutic: site of perforators & SPJ for surg. (both are variable anatomicaly)

What is treatment of v.v.?

1- Conservative: graduated pr. Compression stockings G II & lifestyle modification (exercise & ↓ weight & ↓ standing)

2- Surgical

1-    Open surgery:

       For LSV →SF Ligation (Trendlenberg oper. (ligate LSV 1 cm from fem. v.)+ Stripping till just below knee (avoid saph.n.) + Multiple avulsions.

       For SSV do SP ligation & avulsion (no stripping to avoid sural inj.)

2-    Injection sclerotherapy (cosmetic) use ethanolamine oleate or sclerovein

3-    injection of foam

4-    Subcutaneous Endosc. Perforator Surg. (SEPS) for severe skin changes or ulcer

5-    Radiofrequency (intraluminal)…. new

6-    Laser (intraluminal)…. New

What is treatment of this case (severe V.V. + SFJ incomp. + perforator incomp.)?

Surgery (skip conservative) ….most of exam cases

Why stripping of LSV till just below knee?

To avoid inj. saphenous v. (near LSV in leg) → parathesia & numbness med. leg

Why no stripping of SSV? To avoid inj. sural n. → parathesia & numbness lat. leg

OSCE advanced Qs

What to tell pt. about his surgery (consent for stripping)?

1-      daycase

2-      no driving 1 wk

3-      may not improve skin changes

4-      may not improve aching pain

5-      risk inj. saphenous or sural n.

6-      risk DVT

7-      risk recurrent vs (20 % at 5 years)

What are common sites for perforators?

Mid-thigh, Above med. malleolus by 2, 4, 6 & Above lat. malleolus by 1, 3, 5 inches

Where is gaiter area? Lower 2/3 of leg

What is Klippel Trenauny syndrome?

Severe V.V. in abnormal site (e.g, lat.thigh)+ giant limb+ portwine stain

AVF

What is diagnosis?

Dilated pulsatile vessels on front of forearm, scar over it, thrill over it,

→ Surgically induced AVF for dialysis +/- venous hypertension

What is AVF ? type of vascular malformation

What is the most dangerous AV malformations? Berry aneurysm → subarachnoid

                                                                                                         hemmorhage

What is its ttt? Transfemoral embolization or coiling

How to access carotid (e.g, transluminal angioplasty)? Transfemoral

Where are the sites of surg. AVF? Start by non-dominant hand & distal first

Radiocephalic

Brachiocephalic

Brachiobasilic (need superficialization)

What are types?

Direct: end to side (better), side to side

Graft: bridge or loop (natural=saphenous or  synthetic graft=PTFE)

How to know dominant artery of hand? Allen test

What to do before AVF? Allen test (in exam done on examiner hand not pt.)

Elevate hand & make a fist

Press to close On site of radial & ulnar artery

Ask pt. to open & close fist many times till hand blanches(evacuate blood)

Release one of them & notice refilling time (usually 6 secs radial)

Compare time of refilling between radial & ulnar, the longer the time the less dependent is the artery

What is usual dominant artery of hand? Ulnar artery

What if radial is the dominant? Do brachiocephalic (instead of radio-cephalic)

Is there is ulno-basilic. Why? NO, because

difficult access of canula (applied from lat. Side)

basilic v. is deep in most of its course

What are complications?

1- Failure (thrombosis)

2- Inf.

3- Rupture & bleeding

4- Steal syndrome (ischemia due to blood stealed to veins) 

      Ttt→ ligation of distal vein

5- high COP HF

What is ttt steal syndrome? ligation of distal vein

OSCE advanced Qs

How to determine degree of shunt & general effect of AVF?

Branham test: measure carotid pulse before & closure fistula by cuff

If pulse ↓ > 10 = general effect (Lt to Rt shunt)

What else you want to do?

Ask about hemodialysis or prev. transplantation

Examine neck for prev. access & abdomen for transplantation scar

What does thrill & needle marks indicate? Functioning AVF

What does pulsation indicate? Distal obstruction

What is Parkes Weber synd.? Multiple AVF + limb hypertrophy

Lyphedema

What is your diagnosis & why? Lymphedema of LL because:

In dorsum of foot

Unhealthy skin (due to recurrent lymphangitis → obstructed lymphatics → ↑ lymphedema)

Preserved ankle crease

+/- Fungal inf. (between toes)

What are causes of lymphedema?

Congenital = Millor’s ds (congenita- precox- tarda)

Acquired: 1- inf. (filariasis = W.Bancrofti)

                 2- trauma

                 3- iatrogenic: after radiotherapy or oper. (block dissection axilla or groin)

                 4- neoplastic

What is the ttt?

Conservative only: leg elevation & foot hygiene & stockings & ttt cellulites (AB)

(Now no role for lymphovenous shunts or debulking)

What are degrees of stockings?

G I (1^st degree): pressure 10 - 20 mmHg → prophylactic against DVT

G II (2^nd degree): pr. 20 - 30 mmHg → ttt V.V.

G III (3^rd degree): pr. 30 – 40 mmHg → ttt lymphedema

What are complic. lymphedema? Lymphangitis (cellulites), tinea pedis, vesicles

D.D. LL edema (Swollen leg)?

A- General causes: Heart failure, Hepatic, Nephrotic, hypoAlb., Hypothyroidism

B- Local causes: Venous: PTS, V.V., klippel trenaunay synd.

Lymphedema

Cong. AVF

Angioedema

What are difference between Venous edema & Lymphedema?

Venous edema: in ankle, unilat.

Lymphedema: in dorsum of foot, preserved crease & bilat.