Vascular – Vascular – Vascular MOZZAR

NO LIST OF DIAGNOSIS PATHO/RISK FACTORS/ CAUSES
1 Lower Extremities ‐ Systemic atherosclerotic process with
Arterial Disease subintimal lipid and fibrous material
(LEAD) accumulation  diffuse stenosis of
peripheral arteries  diminished blood
supply
‐ Risk factors; existing dz (DM, CAD, stroke,
TIA), non‐modifiable (age, gender, FHx),
modifiable (smoking, HTN,
hyperlipidaemia, DM, obesity)
2 Buerger’s disease ‐ Aka thromboangiitis obliterans
‐ Progressive non‐atherosclerotic
segmental inflammatory disease
3 Acute limb ischemia ‐ Sudden decrease in limb perfusion that
threatens viability of limb
‐ Present within 2/52 of acute event
‐ Risk factors; Arterial embolism, Acute
thrombosis, Arterial trauma, Dissecting
aortic aneurysm
‐ Rutherford Criteria for ALI; Stage I (limb
viable), Stage II (limb threatened), Stage III
(non‐viable)
CLINICAL PRESENTATION/ COMPLICATIONS INVESTIGATION
Intermittent claudication – reproducible muscles Classification: Fontaine’s Classification
discomfort, induced by exercise, relieved with rest (Europe) or Rutherford Classification (USA)
CLTI – rest pain, need opioid analgesia, >2 weeks,
gangrene/ ulcers over toes or feet, ABPI ≤0.5 Ankle‐brachial pressure index (>0.9 normal,
0.5‐0.9 occluded, <0.5 critical ischemia rest
Ischemic rest pain – severe pain in distal lower limb, pain)
at rest, at night, wakes pt from sleep, aggravated by Arterial Duplex ultrasound – 1st line imaging for
lifting limb, relieved by dependency, often requires PAD
opioids ‐ Normal; triphasic
‐ Abnormal; biphasic and
Ischemic ulcers – often painful, on tips of toes, bunion monophasic waves
area, over metatarsal heads, lateral malleolus, deep, Basic lab Ix, transcutaneous oxygen pressure
dry, punctate (TcPO2), CT angiogram with iodinated contrast,
MR angiogram with contrast
Stenosis of lower aorta & common iliac – buttock
claudication, impotence Angiogram with digital subtraction – GOLD
Stenosis of external iliac – thigh claudication STANDARD for evaluating arterial tree prior to
Stenosis of superficial femoral – calf claudication revascularization
Foot, leg, arm, or hand claudication Angiography of all 4 limbs – segmental
Progress to calf claudication, eventually ischemic rest occlusions, “skip” lesions, extensive
pain, ulceration on toes, feet, or fingers collateralization “cock‐screw collaterals”
Classic 6 P’s; Pain, paraesthesia, pain, pallor, Biochemical; FBC, RP, GXM, Trop I
perishingly cold, paralysis, pulselessness
Imaging; Duplex ultrasound, CXR/ECG, CT
Pain – acute, start off in distal part, progresses angiogram
proximally
Paraesthesia – progression; light touch  vibration 
proprioception – deep pain  pressure sense
Paralysis – poor prognostic sign. (Initial; heavy limb),
(late irreversible ischaemia; muscle turgidity)
MANAGEMENT
Mx for asymptomatic pt
Best medical therapy – smoking cessation, healthy diet,
exercise, lipid control, HTN control, DM control, single anti‐
platelet therapy
Mx for symptomatic (claudication) pt
Supervised exercise training
Lifelong anti‐platelet drugs – Aspirin 100mg or clopidogrel
75mg
Pharmacological agents to decrease walking impairment –
Cilostazol, naftidrofuryl
Revascularization therapy
Mx of chronic limb ischemia
Endovascular – lower limb angiography, angioplasty KIV
stenting
Open surgical intervention with bypass grafting
Endarterectomy – for severe stenosis of common femoral and
profunda femoris arteries
Mx of gangrenous limb
Infection and pain control
Prompt revascularization
Amputation (dead, damaged, dangerous, damn nuisance)
Smoking cessation
Early anticoagulation – IV heparin bolus 3000‐5000 units (70
units/kg), follow with IV heparin infusion at 1000 units/hr (10‐
15 units/kg/hr), ideal PTT is 2‐2.5 times normal
Measure to improve existing perfusion – keep foot dependent,
avoid pressure to heel, O2 supply, correct hypotension
Surgical emergency requiring active intervention – Emergency
thrombectomy/ embolectomy
KIV fasciotomy to prevent compartment syndrome

[Cx; reperfusion injury, rhabdomyolysis,

4 Carotid disease ‐ Symptomatic carotid stenosis – stenosis in
internal carotid artery leading to
symptoms of amaurosis fugax, TIA,
ipsilateral ischemic stroke
5 Subclavian Steal ‐ Arteriosclerotic stenotic plaque at origin
syndrome of subclavian
6 Aortic dissection ‐ Abnormal blood flow through focal defect
in intima into medial later. Blood return to
true lumen of artery distally or ruptures
externally
‐ Risk factors; advanced age, HTN, smoking,
male, structural abnormalities of aortic
wall, collagen vascular condition
compartment syndrome]
Asymptomatic; carotid bruit
Symptomatic; carotid territory – hemi‐motor/ hemi‐
sensory signs, monocular blindness (amaurosis
fugax), higher cortical dysfunction (ie dysphagia,
visuospatial neglect)
More commonly occurs on left arm
Claudication of arm
Posterior neurologic signs eg hearing loss, tinnitus,
blurred vision, dizziness, vertigo, loss of muscle
coordination, or ataxia, fainting
Anterior chest pain or pain – sudden onset, tearing
sensation, mimicking MI
Abdominal pain – possible mesenteric ischemic
Syncope – cerebrovascular involved
Upper extremity Sx (pain, weakness, paraesthesia) –
subclavian A involved
Lower extremity Sx – iliac/ femoral A involved
Biochemical – FBC, RP, Trop I, coagulation
profile, GXM, ABG/ lactate
Imaging;
‐ ECG – ST, T wave changes
‐ CXR – widened mediastinum,
pleural effusion, abnormal aortic
contour
‐ CT aortogram – GOLD STANDARD
Best medical therapy – BP <140/90, statin Tx, stop smoking,
stop alcohol, exercise, diet modification, reduce weight, anti‐
platelet Tx
Carotid endarterectomy – mostly if pt symptomatic
Bypass graft from common carotid to subclavian artery distal
to stenosis
Main aim; reduces left ventricular pressure while maintaining
adequate distal organ perfusion
Stanford A (surgical emergency) – primary open surgical repair
(repair ascending aorta ± aortic valve replacement)
Stanford B (medical emergency) – IV labetalol to control HR
and produce vasodilation. Require surgery if got Cx
Vascular – Vascular – Vascular
(Marfan’s syndrome, Ehler‐Danlos
syndrome), pregnancy
‐ Stanford Classification; Stanford A (involve
ascending aorta), Stanford B (not involve
ascending aorta)
‐ DeBakey classification
7 Abdominal aortic ‐ Aortic diameter >50% larger (normal
aneurysm ~2cm)
‐ Most AAA develop below renal arteries
(infra‐renal artery)
‐ Risk factors; Modifiable (smoking, HTN),
non‐modifiable (male, FHx, connective
tissue disorder, advanced age, COPD,
hyperhomocysteinemia
8 Chronic Venous ‐ Venous HTN results from obstruction to
Insufficiency (CVI) venous flow (tumour compression,
pregnancy, DVT), dysfunction of venous
valves (varicose veins), or failure of
“venous pump” (dependent on adequate
contraction. Stroke, muscular weakness
can cause failure)
‐ CEAP classification; Clinical, Etiologic,
Anatomic, Pathophysiologic
9 Varicose vein ‐ Dilated tortuous subcutaneous vein that it
≥3mm in diameter measured in upright
position
‐ Risk factors; age, occupation, weight,
posture (crossing legs all time), increased
abdominal pressure (constipation, chronic
cough), pelvic tumour compressing deep
veins, FHx
10 Venous ulcers ‐ Cause; by any cause of CVI
Cx – bleeding, cardiac arrhythmias, neurological
dysfunction, acute renal impairment, multi‐organ
failure
Asymptomatic – found incidentally, pulsatile/
expansile abdominal mass, or on imaging
Classical presentation – hypotension, intense
abdominal pain radiating to back, pulsatile abdominal
mass
Local compression – radicular symptoms in thigh and
groin (nerve root compression), GI, urinary
obstruction
Rupture into IVC – audible abdominal bruit, venous
HTN (swollen cyanotic legs, lower GI bleed,
hematuria)
Distal embolization – intraluminal thrombus 
emboli  ALI or mottling of lower trunk and
extremity
PE; visible pulsation on abdomen, pulsation and mass
in epigastric region felt on deep palpation, mass is
expansile (fingers pushed upwards and outwards)
Venous dilatation – telangiectasias, reticular veins,
varicosities, corona phlebectatica
Oedema – pitting: Hallmark of CVI
Skin changes – hyperpigmentation, phlegmasia alba
dolens, phlegmasia cerulea dolens, atrophie blanche,
venous stasis eczema, lipodermatosclerosis, cellulitis
Venous ulcer formation – typically over medial
malleolus, shallow, flat ulcer, sloping edges, base may
be sloughy or granulating, usually quite moist‐looking
Leg fullness, aching discomfort, heaviness, nocturnal
leg cramps, bursting upon standing
Asymptomatic
Symptomatic – non‐specific pain, tingling, aching,
burning, muscle cramps, swelling, sensation of
throbbing or heaviness, itching skin, restless leg, leg
tiredness, worsen with heat, worsen throughout
course of day, relieved by resting or elevating legs or
wearing elastic stockings
Cx; thrombophlebitis, bleeding, hyperpigmentation,
eczema, ulceration
MOZZAR
‐ 2D echo
Diagnostic imaging Asymptomatic AAA
Ultrasound abdomen – assess size and position No role for surgical repair, ‘best care’ favours surveillance
CT aortogram/ MR aortogram Medical Mx; smoking cessation, optimize BP, statins to reduce
Portable CXR to look for dissection/ aneurysmal growth rates
mediastinal widening Surgical option; Open AAA repair or Endovascular aneurysm
repair
Pre‐operative Ix
FBC, RP, PT/PTT, GXM, ECG Symptomatic AAA
Echocardiogram/ Pulmonary function test Indications; any size painful or tender, any size that is causing
distal embolization
Option; open surgery or endovascular approach
Ruptured AAA
Can rupture anterior into peritoneal cavity or posterolaterally
into retroperitoneal space
Option; open surgery or endovascular approach
Acute Mx; stabilize pt, fluid resuscitation, urgent CT
angiogram, NBM GI decompression with NG tube, open repair,
IV broad spectrum antibiotic, analgesia
Venous duplex ultrasound – evidence of Venous compression therapy using elastic stockings/ wraps
venous reflux, ultrasound features of DVT Laser therapy – endovenous thermal ablation
MR venogram Meds‐ antibiotics
Lab studies; CBC, thrombophilia panel, Surgical treatment – ligation, ambulatory phlebectomy, vein
microbiology bypass, vein valvuloplasty
Non‐surgical treatment – sclerotherapy (chemical ablation)
Weight Mx, leg elevation, exercise, avoid wearing tight
clothing, avoid long standing and sitting
Venous duplex ultrasound Conservative
Indications; recurrent varicose veins, history of Lifestyle changes – decrease time spent standing, weight loss
superficial thrombophlebitis or DVT Graduated compression stockings
Medications eg Daflon
Surgical
Indications; Cx present, Sx (pain, bleeding, thrombophlebitis,
discomfort), cosmesis
Options; endovenous laser/ radio‐frequency ablation of
saphenous vein, US‐guided injection foam sclerotherapy
Exclude infection and other Cx; blood test, Non‐surgical; 4‐layer compression bandage, analgesia,
inflammatory markers, wound swab for gram antibiotics, avoid trauma, rest and elevate leg, compression
stain and culture, X‐ray stockings should be fitted once healed and continued for life
Venous duplex ultrasound Surgical ± endovenous ablation
ABPI
Biopsy venous ulcer if cannot exclude
malignant transformation
Vascular – Vascular – Vascular MOZZAR
11 Deep venous ‐ Formation of a blood clot in the deep veins Unilateral leg pain and swelling DVT Wells’ Score should be calculated: Direct oral anticoagulants* (DOACs) as first line
thrombosis of a limb, most commonly affecting those Other symptoms include low‐grade pyrexia, pitting ‐ Score less than or equal to 1 – DVT is clinically Anticoagulation treatment should be continued for 3 months
of the legs or pelvis oedema, tenderness, or prominent superficial veins unlikely, requires a further D‐dimer test to in those with a provoked DVT, however in those with a
Importantly, 65% of DVTs are asymptomatic exclude proximal DVT and a persistent risk factor or high risk of DVT
‐ Score greater than 1 – DVT is clinically likely recurrence may require lifelong anticoagulation
and a DVT diagnosis should be confirmed via
either a ultrasound scan (more common) or a Mechanical Thromboprophylaxis; Antiembolic stockings (AES),
contrast venography (rarely used) Intermittent pneumatic compression (IPC, more commonly
used in theatre)
Pharmacological Thromboprophylaxis; Low molecular weight
heparin (LMWH), unless poor renal function (eGFR<30) then
consider unfractionated heparin (UFH)
12 Pulmonary ‐ Risk factor; recent surgery, thrombophilia, Dyspnoea, chest pain, palpitation, syncope D‐dimer – if negative, excludes pulmonary Haemodynamic unstable Supportive Tx (O2, fluid challenge,
embolism leg fracture, prolonged bed rest/ reduced Preceding leg pain, cough, haemoptysis, fever, embolism vasopressor adrenaline). Immediate bedside echo. Confirm Dx
mobility, malignancy, pregnancy/ syncope FBC, U&E, Baseline clotting via CTPA. Anticoagulation – IV UFH
postpartum Cyanosis, tachypnoea, tachycardia, raised JVP, pleural ABG Definitive Tx – reperfusion Tx  systemic thrombolysis IV rtPA
rub, pleural effusion, hypotension CXR – dilated pulmonary artery, linear Haemodynamic stable
atelectasis, pleural effusion, reduced vascular Confirm via CTPA (high risk), serum D‐dimer
Cx; pulmonary infarction, pleural effusion, right‐sided markings, wedge‐shaped infarct Anticoagulation – SC LMWH
heart failure, peripheral oedema, massive PE can CTPA – test of choice for high risk pt Long term  Anticoagulation warfarin/DOAC min for 3months
cause lethal Cx like cardiac arrest, circulatory collapse ECG – tachycardia, RBBB, S1Q3T3
and cardiogenic shock