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Dr Sara Beattie-Spanjol sara.beattie-spanjol@nhs.scot.uk Conditions Procedures - AAA - AAA Repair - Aortic Dissection - ABPI - Peripheral Vascular Disease - Amputation - DVT - Revascualrisation Surgery - Varicose Veins - Carotid Endarterectomy - Arterial & Venous Ulcers - GangreneA 52 year old women is in hospital after being admitted for an elective umbilical hernia repair. She has a past medical history of T2DM, was a smoker for 20 years and, IBS. She is 2 days post op. On the morning ward round you notice some erythema of the right clave. On palpation there is mild tenderness. You order a d- dimer which is elevated and a subsequent lower limb USS is performed which confirms a DVT inferior to the saphenous-popliteal junction. What is the most appropriate management for the DVT? a) 6 months Rivaroxaban b) Compression stockings and 3 months Aspirin c) Compression stockings and 6 months Apixaban d) 3 months Apixaban e) 3 months ClopidogrelA 61 year old man is admitted to A&E with sudden onset of a painful, cold right foot. He has a radial pulse of 82bpm that does not have a discernable pattern. An abdominal and cardiac examination find nothing else of note. There are no palpable pedal pulses in the right foot. Ankle doppler signs are absent. An ECG is performed and there are no obvious signs of acute ischemia. What is the most likely diagnosis. a) DVT b) Abdominal Aortic Aneurysm c) Aorto-iliac dissection d) AF e) DVTA 66-year-old male returns to clinic for an abdominal USS. One year ago he attended the 1 off USS Screening for an Abdominal Aortic Aneurysm. He was found to have an asymptomatic aneurysm inferior to the renal arteries that at its widest point measured 3.8 cm in diameter. Today he reports that he remains asymptomatic and it is found to be 4.9cm in diameter. His blood pressure is well controlled Given the above findings what is the most appropriate next step for this patient? a) Follow up Abdominal USS In 1 year b) Follow up Abdominal USS in 3 months and commence atorvastatin OD and Aspirin OD c) Follow up Abdominal USS in 3 months d) Refer to clinic to discuss surgical intervention for AAA management. e) Follow up Abdominal USS In 1 year and commence atorvastatin OD and Aspirin OD Dilation of blood vessel >50% normal diameter >3cm The wall of the artery forms the Other surrounding tissues form the wall of the aneurysm wall of the aneurysm - Femoral Artery - After femoral artery puncture - Blood spills out → haematoma - Eventually surrounding tissue will form wall of haematoma - Different to normal haematoma in that there is still communication between lumen and fluid collection 80% below renal arteries Aortic Root • Atherosclerosis Descending Aorta • Smoking Ascending Aorta • Age • HTN Syndromic • Atherosclerosis • Marfan Syndrome • Hyperlipidemia • Aortitis – Takayasu, Syphilis • Male • Ehlers-Danlos • Cystic Medial Necrosis • FHx • accumulation of basophilic Non-Syndromic substances in media w/ • Other CVS disease • Inflammatory aneurysm IgG4-RD • Bicuspid aortic valve cyst like lesions • Infectious aneurysm • Familial TAA • Trauma• Asymptomatic • Asymptomatic • Symptomatic o Pulsatile abdominal mass on examination o Pressure effect • Symptomatic ▪ back pain / dysphagia / cough o Pressure effect Renal o Aortic Regurgitation (if close to aortic root) ▪ epigastric / back pain Colic ▪ SOB / presyncope / Syncope / Angina/ o Rupture Arrhythmia / Fatigue on exertion ▪ Epigastric pain radiating to back o Asymmetrical brachial/radial/carotid pulse – if ▪ Hypovolemic shock dissection USS ECHO / TOE CT CT CT Angiogram Often seen on AXR as 65 % cases are sufficnetly calcified Screening : 1 off USS Men >65yo USS 3-4.4cm 4.5-5.4cm >5.5cm Follow up scan Follow up scan Surgical Mgx: Surgical REPAIR 1 yr 3 months - Open Aortic Surgery • Ruptured - EVAR Conservative Mgx • Symptomatic Smoking, ETOH, WL • >5.5cm Medical Mgx • >4cm and grown by more than Statins, Aspirin, BP Mgx 1cm in 1 yearA tear in the tunica intima: blood at high pressure creates a false lumen in the tunica media Ascending Aorta Descending Aorta (distal to L Subclavian Origin) S/S Igx Mgx • Tearing chest pain → Radiates to back Bedside • Urgent BP control - BB • Unequal BP in arms • Proximal dissection → Surgery • BP • Weak distal pulses • ECG • Aortic Regurgitation • Neurological symptoms (poor perfusion) Bloods • FBC, U&E, LFT, Lactate • Hemiplegia • G&S / X-Match • Headache • Neck pain Imaging • CXR – Widened mediastinum • CT • MRI • TOE (unstable) Risk Factors S/S • Age >60 • Comorbidities • Asymptomatic • Red • Hospital admission • Erythematous • Systemic Infection • Obesity • Painful • Superficial venous distension • Major pelvic / Abdo surgery • Cancer • Pregnancy • Oestrogen Contraception/HRT • Immobility • Varicose vein phlebitis • HHS (dehydration) ddx • FMHx – 1 Degree relative • Ruptured Baker’s cyst • Thrombophilia • Oedema from other causes • IBD • Cellulitis • Nephrotic syndrome • Surgery Investigations Wells Score 0, 1 ≥ 2 D-dimer USS leg (if not in <4hr interim DOAC) (if not in <4hr interim DOAC + USS <24hr) +ve -ve +ve -ve USS leg Consider other DOAC D-dimer diagnosis Mgx DOAC Provoked –3m Unprovoked – 6m CT AP ?MalignancyRatio of Ankle Systolic BP to Brachial Systolic BP Mild Severe • Claudication • Punched out ischemic ulcers • On Exertion & rest • Gangrene (Infected = Wet Gangrene) • Reduced / absent pulses • Skin atrophy • Hair loss • Cyanosis • Excessive sweating (overactivity of sympathetic nerves) • Erectile dysfunction (distal aortic disease) Investigations Bedside Bloods Imaging Special Tests • BP • FBC • CT Angio • ABPI • ECG • U&E • MR Angio • Vascular Exam • Lipids • DSA – digital o Beuger’s angle <20* • Hba1c subtraction o Leg goes pale/cold/painful • ESR/CRP - arteriography o Increased vascular filling time ?arteritis • Colour duplex >15s – may become hot and red • Plts / clotting imaging • Swab lesions Management Conservative Medical Surgical • WL • Statin • Angioplasty, stenting, bypass, • ETOH • Anti-plt embolectomy • Smoking • Optimise other CVS RF • Amputation • Exercise ACUTE LIMB THREATENING ISCHAEMIA •Pain •Pulseless Critical limb •Pallor - cyanosis / mottling ischaemia •Power loss / Paralysis. •Paraesthesia Intermittent •Perishingly Cold claudication Management Medical Surgical • Prolonged course of Heparin Embolic • IV Heparin infusion • Embolectomy • 02 • Thrombolysis • Regular APTT • Bypass • Thrombolysis • Angioplasty • Bypass Varicose veins arise from incompetent valves that allow blood flow from the deep venous system into the superficial venous system → venous HTN and dilation of superficial veins Primary idiopathic 2* to • DVT • Pelvic Mass (pregnancy / fibroids/ ovarian masses) • AV Malformation Management Conservative Surgical S/S Investigations • NICE Criteria • WL 1. Symptomatic • Aching • Exercise 2. Lower limb skin changes • Itching GOLD STANDARD • Avoiding RF 3. Superficial vein thrombosis • Compression stockings – Check ABPI 4. Venous leg ulcer • Skin changes DUPLEX USS (<0.8 contraindicated) • Ulceration • Thrombophlebitis • Vein ligation, stripping and avulsion • Foam sclerotherapy • Thermal ablation Arterial Venous Neuropathic • Small deep incisions • Venous insufficiency Peripheral neuropathy • Well defined borders • Irregular boarders →DM / B12 def • Necrotic base • Granulating base • Painless • At sites of trauma / pressure areas • Variable in size • (no healing → little granulation tissue) Impaired venous return --> trapping WBC → • Punched out lesions activation → release of inflammatory mediators → • Pressure points Decreased arterial bloods flow → poor perfusion → poor healing/necrosis • May be associated glove and stocking distribution poor healing neuropathy Associated w/ PVD • Warm feet & good pulses • ABPI • ABPI • Thorough neurological exam • Duplex USS • Duplex USS • HbA1c / Random BG • CT Angio • Swab - ?Abx • B12 levels • MR Angio • Young pt – thrombophilia & vasculitis screening • Micro swab • XR - ?osteomyelitis Conservative • Compression bandaging • Diabetic foot clinic - Lifestyle: ETOH, Exercise, WL , Smoking cessation • ABPI must be >0.6 • Optimise diabetes control • Treat Varicose Veins --> prevents recurrence • Diet / exercise Medical • Regular Chiropody - Statin - Anti plt - Optimize BP and blood glucose control Surgical - Angioplasty - Bypast grafting Causes: • Infection • Injury • Chronic disease Blood supply to tissue is cut off – area Bacteria invade tissue. Area may swell, becomes dry, shrinks and black drain fluid, smell bad. Management S/S • Antibiotics • Cold / numbness in area • Pain • Surgical debridement • Redness / Swelling around wound • Maggot debridement • Exudate • Hyperbaric oxygen therapy • Pyrexial → Sepsis • Vascular surgery • ConfusionA 52 year old women is in hospital after being admitted for an elective umbilical hernia repair. She has a past medical history of T2DM, was a smoker for 20 years and, IBS. She is 2 days post op. On the morning ward round you notice some erythema of the right clave. On palpation there is mild tenderness. You order a d- dimer which is elevated and a subsequent lower limb USS is performed which confirms a DVT inferior to the saphenous-popliteal junction. What is the most appropriate management for the DVT? a) 6 months Rivaroxaban b) Compression stockings and 3 months Aspirin c) Compression stockings and 6 months Apixaban d) 3 months Apixaban e) 3 months ClopidogrelA 52 year old women is in hospital after being admitted for an elective umbilical hernia repair. She has a past medical history of T2DM, was a smoker for 20 years and, IBS. She is 2 days post op. On the morning ward round you notice some erythema of the right clave. On palpation there is mild tenderness. You order a d- dimer which is elevated and a subsequent lower limb USS is performed which confirms a DVT inferior to the saphenous-popliteal junction. What is the most appropriate management for the DVT? The correct answer is 3 months of Apixaban. 3 months of a DOAC are prescribed in cases of a a) 6 months Rivaroxaban provoked DVT. b) Compression stockings and 3 months Aspirin Examples of things that can provoke a DVT include: c) Compression stockings and 6 months Apixaban surgery, hospital admission, pregnancy, immobility. d) 3 months Apixaban Dabigatran is the only DOAC with a reversal agent. e) 3 months Clopidogrel When starting a patient on a DOAC they should always be counselled on the risks of taking it.A 61 year old man is admitted to A&E with sudden onset of a painful, cold right foot. He explains that the pain came on suddenly about an hour ago. He has a radial pulse of 82bpm that does not have a discernable pattern. He appears short of breath; his oxygen saturations are 98% on room air. An abdominal and cardiac examination find nothing else of note. There are no palpable pedal pulses in the right foot. Ankle doppler signs are absent. An ECG is performed and there are no obvious signs of acute ischemia. What is the most likely diagnosis. a) DVT b) Abdominal Aortic Aneurysm c) Aorto-iliac dissection d) AF e) DVTA 61 year old man is admitted to A&E with sudden onset of a painful, cold right foot. He explains that the pain came on suddenly about an hour ago. He has a radial pulse of 82bpm that does not have a discernable pattern. He appears short of breath; his oxygen saturations are 98% on room air. An abdominal and cardiac examination find nothing else of note. There are no palpable pedal pulses in the right foot. Ankle doppler signs are absent. An ECG is performed and there are no obvious signs of acute ischemia. What is the most likely diagnosis. The correct answer is d, AF. a) DVT is an unlikely cause of acute lower limb ischemia. But may occur if the DVT embolises a) DVT and passes through a patent foramen ovlae to enter the arterial circulation b) Abdominal Aortic Aneurysm c) Aorto-iliac dissection b) Given that he the pt is able to talk and has a hr 82bpm it would be consistent with that fact that this is not a ruptured AAA and the Abdo exam showed nil of note/. d) AF c) Dissection would likely present with tearing like pain e) MI d) The irregularly irregular pulse is typical of AF. This presentation suggests an embolic event that occluded the right lower limb arterial flow. e)There were no findings on the ECG that would suggest that this is an MI and there was no noted chest pain.A 66-year-old male returns to clinic for an abdominal USS. One year ago he attended the 1 off USS Screening for an Abdominal Aortic Aneurysm. He was found to have an asymptomatic aneurysm inferior to the renal arteries that at its widest point measured 3.8 cm in diameter. Today he reports that he remains asymptomatic and it is found to be 4.9cm in diameter. His blood pressure is well controlled Given the above findings what is the most appropriate next step for this patient? a) Follow up Abdominal USS In 1 year b) Follow up Abdominal USS in 3 months and commence atorvastatin OD and Aspirin OD c) Follow up Abdominal USS in 3 months d) Refer to clinic to discuss surgical intervention for AAA management. e) Follow up Abdominal USS In 1 year and commence atorvastatin OD and Aspirin ODA 66-year-old male returns to clinic for an abdominal USS. One year ago he attended the 1 off USS Screening for an Abdominal Aortic Aneurysm. He was found to have an asymptomatic aneurysm inferior to the renal arteries that at its widest point measured 3.8 cm in diameter. Today he reports that he remains asymptomatic and it is found to be 4.9cm in diameter. His blood pressure is well controlled Given the above findings what is the most appropriate next step for this patient? a) Follow up Abdominal USS In 1 year b) Follow up Abdominal USS in 3 months and commence atorvastatin OD and Aspirin OD c) Follow up Abdominal USS in 3 months d) Refer to clinic to discuss surgical intervention for AAA management. e) Follow up Abdominal USS In 1 year and commence atorvastatin OD and Aspirin ODA 66-year-old male returns to clinic for an abdominal USS. One year ago he attended the 1 off USS Screening for an Abdominal Aortic Aneurysm. He was found to have an asymptomatic aneurysm inferior to the renal arteries that at its widest point measured 3.8 cm in diameter. Today he reports that he remains asymptomatic and it is found to be 4.9cm in diameter. His blood pressure is well controlled Given the above findings what is the most appropriate next step for this patient?PLEASE FILL IN THE FEEDBACK FORM!