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7 MedEd Vascular Jonny Hodgkinson 12.11.12 1
7 MedEd Vascular Jonny Hodgkinson 12.11.12 1
Contents
Objectives
Understand vascular examination
Describe management of aneurysmal
disease
Discuss the principles of arterial
disease management
Discuss the features and
management of venous disease
Diagnosis lymphoedema
Case 1
65yo Male
PC
sudden onset central abdominal pain
Dizziness
A/w painful right foot
PMHx
HTN, high cholesterol
Smoker 30 pack year history
Case 1
O/E
HR 110, BP 90/60, RR24, 95% on RA,
afebrile
Sweaty, distressed
Diffusely tender abdomen
No pulses on the right distal to
femoral
Ruptured AAA
Surgical emergency
Mortality without surgery 100%; with 50-75%
Rates
Rupture/yr - <4.5cm = 9%; 4.5-7cm = 35%;
>7cm = 75%
Mx
Fluid resus aggrssive + CXM (10 units)
Senior and anaesthetist
If haemodynamically stable CT scan
AAA
Normal diameter 1.5-3cm; Aneurysm
>3cm
95% infra-renal
75% asymptomatic
Incidence 5%
Sex M>F
Case 2
65yo male
PC incidental finding of aneurysm
Asymptomatic
Ix
Imaging CT/USS
Bloods renal function, cholesterol
Work-up ECG, ECHO, lung fn
Stable AAA
Management
Conservative
Watch and wait - <5cm serial USS/CT
Risk factor management
(MASS trial screening beneficial and viable)
Symptomatic aneurysms
>5.5cm
Rapidly expanding - >1cm/year
Complicated by embolism
Stable AAA
Surgical options
Open vs EVAR
EVAR trials
1 lower 30 post-op mortility
2 reduction in aneurysm related mortality but
not all cause
Complications
Haemorrhage, renal failure, embolism, graft
infection/migration, MI/infection, endoleaks
Case 3
65yo male
PC sudden onset left foot pain
HPC
6hr history severe pain on movement
History of intermittent claudication
100yds
PMHx
MI, HTN, Chole, diabetes
Case 3
O/E
Haemodynamically stable
Cold
Mottled & blanching
Absent pulses distal to popliteal
Painful
Motor and sensation intact
Limb ischaemia
Acute (on chronic)
Emobilic (thrombotic)
Chronic
Thrombotic
No claudication
Sudden onset
(sec/min)
Recent MI/AF/AAA
Claudication
Gradual onset (hrs)
Chronic vascular
disease
Thrombolysis
Emergency recon
Amputation (10-20%
mort)
Angioplasty
Emergency recon
Amputation
Management
General analgesia, rehydration, NBM, anti Embolectomy coagulation
Thrombolysis
Limb ischaemia
Complications - Immediate
Reperfusion injury
Compartment syndrome
Renal failure
ARDs/toxic shock
Long-term
Further episodes
Chronic pain syndromes
Pulses
Buergers test/angle
Doppler examination
Triphasic, biphasic, monophasic
STOP SMOKING
Excerise collateralisation
Obesity
Diet
Good BM control in diabetes
Foot care
Treat underlying cardiac disease
Control lipids
Statins
Diabetic control
Reconstructive
Reserved for critical ischaemia
Autologous vs. synthetic
Anatomical vs. extra-anatomical
Endarterectomy femorals
Amputation
Lethal limb
Dead limb
Useless limb
Case 4
Venous disease
Features
Pigmentation/haemosiderosis
Visible veins
Varicose eczema
Lipodermatosclerosis atrophic change
(loss of elasticity)
Ulceration
Atrophy blanch healed ulcers
Venous disease
Pathology
Increased pressure in venous system
Gradually become incompetent
Secondary
Thrombosis
Increased abdominal pressure
pregnancy/masses/ascites/obesity/constipation
AV malformations
Overactive muscle pumps (e.g. cyclists)
Venous disease
Conservative
Rx underlying cause lose wt/constipation
Skin care
Class 2 compression stockings
Surgical
Injection sclerotherapy
Laser/radiofrequency ablation
Trendelenburg procedure high tie and
ligation
+/- phlebectomies
Venous disease
Complications of surgery
Bruising
Infection
Bleeding
Neuropraxia
Recurrence/no improvement in cosmesis
DVT 1/1000
Case 5
Case 6
Lymphoedema
Features
F>M
Peripheral oedema worse on standing
Non-pitting
Hyperkeratosis, fissuring, secondary
infection
Squaring and thickening of nails
Lymphoedema
Abnormal collections of interstitial fluid
Types
Primary congenital absence of lymphatics
Congenital
Praecox Milroys Syndrome - <35 progressive
Tarda - >35
Secondary
Lymphoedema
Treatment
Allow fn and decrease swelling
Conservative
COMPRESSION
Skin care
Physiotherapy
Surgical
Debulking of tumours
Bypass
Omental/mesenteric bridges
Others
Carotid artery disease
15-25% of all CVAs/TIAs
Ix Doppler
Management
Conservative
anti-platelet therapy
Risk factor management
Surgery in asymptomatic disease controversial
Others
Aortic dissection
Split in intima and internal portion of
media allowing blood to enter and extend
proximally and distally
Types
A 70%
Affects arch and ascending aorta
10-20% mortality 100% need surgery
Aortic root replacement
B 30%
Distal to left subclavian
Conservative Mx unless evidence of visceral or limb
ischaemia
Objectives
Understand vascular examination
Describe management of aneurysmal
disease
Discuss the principles of arterial disease
management
Discuss the features and management
of venous disease
Diagnosis lymphoedema
Framework
References