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My email address: sr1220@ic.ac.uk Sl ide s ba se d of f: C hri s Ol df iel d Vascular Disease Shruti Rajendra MedEd Y3 Written Exam Lectures 2025Contents Peripheral Vascular Disease Ulcers Abdominal Aortic Aneurysm Aortic Dissection Varicose Veins Gangrene Deep Vein Thrombosis B PeripheralVascularDisease Peripheral Vascular Disease Acute Chronic Acute limb ischaemia Intermittent Critical limb claudication ischaemia B PeripheralVascularDisease Acute limb ischaemia Sudden decrease in limb perfusion Intermittent claudication RFs Pain on exertion Critical limb ischaemia Pain at rest Pathophysiology: Atherosclerosis Stenosis S&S PeripheralVascularDisease Acute limb ischaemia Intermittent Critical limb claudication ischaemia P ain P ale Hair loss Numbness in feet or legs P ulseless P aralysis Brittle, slow-growing toenails Ulcers P arasthesia Absent pulses P erishingly cold Atrophic skin S&S PeripheralVascularDisease Buerger’s Test: • Lie patient flat on bed & lift up leg to 45° • Limb developing pallor indicates arterial insufficiency • <20 degrees indicates severe limb ischaemia • Patient then swings leg over the bed, reactive hyperaemia is seen Ix PeripheralVascularDisease • Full cardiovascular risk assessment ➢BP and HR ➢Bloods (complete blood count (CBC), fasting glucose, lipids) ➢ECG • Ankle-Brachial Pressure Index (ABPI) ➢Normal range: 0.9 - 1.2 ➢<0.9 = abnormal; <0.5 = critical limb ischaemia • Colour duplex ultrasound scan • Magnetic resonance angiogram Ix LericheSyndrome • Leriche Syndrome (ie. aortoiliac occlusive disease) • Affects the aortic bifurcation point • Symptoms are: ➢Buttock claudication ➢Impotence ➢Absent or weak distal pulsesSBA1 Mr X speaks to his GP after noticing some hair loss on his feet and pressure index to be 0.7. What does result suggest?chial Abnormal ABPI, but not yet intermittent claudication 1. 2. Abnormal ABPI, but not yet critical limb ischaemia 3. Intermittent claudication 4. Critical limb ischaemia 5. No abnormalitySBA1 Mr X speaks to his GP after noticing some hair loss on his feet andpressure index to be 0.7. What does result suggest?achial Abnormal ABPI, but not yet intermittent claudication 1. 2. Abnormal ABPI, but not yet critical limb ischaemia 3. Intermittent claudication 4. Critical limb ischaemia 5. No abnormality B Ulcers Arterial ulcers Venous ulcers Neuropathic ulcers S&S Ulcers Arterial ulcers Appearance: • Punched out • Deeper than venous ulcer • Distal (dorsum of foot and between toes) • Well defined edges • Pale base (grey granulation tissue) Signs: • Hair loss, with shiny and pale skin • Calf muscle wasting • Absent pulses • Night painUlcers S&S Venous ulcers Appearance: • Large and shallow • Sloping, with less well-defined sides • Found in gaiter region (ie. more proximal than arterial ulcers) • Other symptoms of venous insufficiency (eg. swelling, itching, aching) S&S Ulcers Signs of venous ulcers Stasis eczema Lipodermatosclerosis Atrophie blanche Hemosiderin deposition Ix Ulcers Arterial ulcers • Duplex USS of lower limbs • ABPI • Percutaneous angiography • ECG Venous ulcers • Bloods: ➢ Fasting • Duplex USS of lower limbs serum lipids • Measure surface area of ulcer (to monitor the ➢ HbA1c progression) ➢ Blood • ABPI glucose • Swab for microbiology – if signs of infection ➢ FBC • Biopsy – if possibility of Marjolin’s ulcerUlcers Mx Venous ulcers Graded compression stockings Debridement & cleaning Antibiotics (if infected) Moisturising creamSBA2 What sign associated with venous ulcers is shown in the photo below? Stasis eczema 1. 2. Lipodermatosclerosis 3. Atrophie blanche 4. Grey-Turner’s Sign 5. Haemosiderin depositionSBA2 What sign associated with venous ulcers is shown in the photo below? 1. Stasis eczema 2. Lipodermatosclerosis 3. Atrophie blanche 4. Grey-Turner’s Sign 5. Haemosiderin deposition AbdominalAorticAneurysm B Definition = A localised enlargement of the abdominal aorta where the diameter is >3cm or >50% larger than normal diameter. 90% occur below renal arteries B AbdominalAorticAneurysm RFs Screening population = males >65 years old S&S AbdominalAorticAneurysm Unruptured AAA Ruptured AAA Usually asymptomatic Sudden, severe pain in back, abdomen or groin Often an incidental finding Syncope May have pain in back, Shock abdomen or groin Signs: Pulsatile and laterally expansile mass on palpation Abdominal bruit Grey-Turner’s sign (ruptured) Ix AbdominalAorticAneurysm • Bloods ➢FBC, clotting screen, U&Es, LFTs ➢Cross match in case surgery is needed • Abdominal Ultrasound ➢Can detect presence of AAA but not whether it has ruptured or not • CT angiogram ultrasound ➢Can detect whether AAA has ruptured • Magnetic resonance angiogram ➢To detect whether AAA has ruptured if the patient has contrast allergy or renal impairmentSBA3 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. CT angiogram Abdominal ultrasound 2. 3. Magnetic resonance angiogram 4. Abdominal x-ray 5. ABPISBA3 Ms Y is BIBA to A&E with a suspected abdominal aortic aneurysm, which is confirmed with an initial investigation. Wwhether or not an abdominal aortic aneurysm has ruptured?ining CT angiogram 1. 2. Abdominal ultrasound 3. Magnetic resonance angiogram 4. Abdominal x-ray 5. ABPI B AorticDissection 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. Ascending aorta only Descending aorta only (above the diaphragm) Both ascending and descending aorta Descending aorta only (above and below the diaphragm) B AorticDissection RFs S&S AorticDissection “Aortic dissection typically presents in men older than 50 years of age, with sudden onset of severe ripping or tearing substernal or interscapular pain.” Symptoms Signs • Sudden central tearing pain, can radiate • Hypertension to the back • Blood pressure difference • Symptoms caused by blockages to between the two arms branches of the aorta: (>50%) ➢ Carotid artery → blackout, dysphasia • Murmur on the back ➢ Coronary artery → angina • Signs of aortic regurgitation ➢ Subclavian artery → loss of • Signs of connective tissue consciousness disease ➢ Renal artery → anuria, renal failure Ix AorticDissection Bloods (FBC, cross match, U&E, LFT, cardiac enzymes) 1. 2. ECG (often normal) 3. Chest x-ray 4. CT angiogram Ix AorticDissection 1. Bloods (FBC, cross match, U&E, LFT, cardiac enzymes) ECG (often normal) False lumen 2. 3. Chest x-ray 4. CT angiogramSBA4 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. The consultant asks you to come to listen to the murmur. Given the most likely diagnosis, which of the following is true of the murmur that you would hear? 1. It is heard loudest over the mitral area It can be accentuated by asking the patient to lie down on their left side 2. 3. It is described as a decrescendo murmur 4. It is best heard using the bell of the stethoscope 5. It can sometimes radiate to the carotid arteriesSBA4 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. The consultant asks you to come to listen to the murmur. Given the most likely diagnosis, which of the following is true of the murmur that you would hear? 1. Heard loudest over the mitral area It can be accentuated by asking the patient to lie down on their left side 2. 3. It is described as a decrescendo murmur 4. It is best heard using the bell of the stethoscope 5. It can sometimes radiate to the carotid arteries VaricoseVeins 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 B VaricoseVeins Causes Primary Secondary Idiopathic valvular Venous outflow Deep vein AV incompetence obstruction thrombosis malformations Pregnancy Ascites Ovarian cysts Pelvic malignancy S&S VaricoseVeins Symptoms Visible dilation of veins Leg aching Worse with prolonged standing Swelling and itching Bleeding S&S VaricoseVeins Signs Veins feel tender or hard Tap test Tap varicose veins distally and feel thrill over sapheno-femoral junction Auscultation for bruits Trendelenburg test Ix VaricoseVeins • Localises the site of valve incompetence • Can be used to exclude DVT Mx VaricoseVeins Endovascular Conservative Surgery treatment Compression stockings Radiofrequency ablation Stripping of the long saphenous vein Lifestyle changes Endovenous laser ablation Weight loss, exercise, Saphenofemoral ligation leg elevation Microinjection scleropathy Liquid or foam Avulsion of varicosities Mx VaricoseVeins Surgery Stripping of the long saphenous vein Saphenofemoral ligation Avulsion of varicosities Mx VaricoseVeins Complications Venous ulcer Stasis eczema Lipodermatosclerosisemosiderin deposition Sclerotherapy Skin staining, local scarring Surgery Haemorrhage, infection, recurrence, paraesthesia, peroneal nerve injurySBA5 Which of the following signs/symptoms is NOT associated with varicose veins? Saphenofemoral incompetence 1. 2. Symptoms worse whilst standing 3. Venous ulcers 4. Pain on palpation of the vein 5. Rapid filling of the vein whilst putting on the tourniquet during Trendelenburg testSBA5 Which of the following signs/symptoms is NOT associated with varicose veins? 1. Saphenofemoral incompetence 2. Symptoms worse whilst standing 3. Venous ulcers 4. Pain on palpation of the vein 5. Rapid filling of the vein whilst putting on the tourniquet during Trendelenburg test B Gangrene Definition = tissue necrosis; either wet with superimposed infection, dry or gas gangrene Caused by tissue ischaemia and infarction or physical trauma Gas gangrene is caused by Clostridium Perfringens RFs PVD Gangrene S&S Painful, black tissue Often affects extremities & areas of high pressure Dry Wet Gas B DeepVeinThrombosis RFs DeepVeinThrombosis S&S Erythema Warmth Painless Varicosities Swollen limbDeepVeinThrombosis S&S Homan’s sign Ix DeepVeinThrombosis Doppler ultrasound Impedence phlethysmography D-dimer has strong NPV ECG, CXR & ABG (if PE suspected) DeepVeinThrombosis Mx Anticoagulation DOACs (eg. apixaban, rivaroxaban) – clinical practice Continue for 3 months or LMWH Compression stockings Prevention Advise physical activity and mobilisationExtraSBA1 Which of the following is NOT used in the treatment of venous ulcers? 1. Moisturising cream 2. Debridement 3. Graded Compression stockings 4. Antibiotics 5. Microinjection sclerotherapyExtraSBA1 Which of the following is NOT used in the treatment of venous ulcers? 1. Moisturising cream 2. Debridement 3. Graded Compression stockings 4. Antibiotics 5. Microinjection sclerotherapyExtraSBA2 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. CT angiogram Abdominal ultrasound 2. 3. Magnetic resonance angiogram 4. Abdominal x-ray 5. ABPIExtraSBA2 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 posimaging would confirm the diagnosis?es bilaterally. What 1. CT angiogram 2. Abdominal ultrasound 3. Magnetic resonance angiogram 4. Abdominal x-ray 5. ABPIFeedback