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Yep. Like when you said my name is Sarah, I'm an F two. I am currently working in Edinburgh. Um, so I'll pop up my slides. But, um, and I think we should show everything. I can't see anyone. Um, and I can't see the chat. So the way that we'll do it is we'll just go through the lecture and if you've got any questions, I'll, um, just like pop in the question like what it's relevant to and then I'll answer them at the end. Um, but yeah, like I said, I'm, I'm currently enough to currently working a psych job and working in Edinburgh. So that's my email, my work email on the screen. So if anyone has any questions, I think you guys have probably like, ranked your, are ranking your, like oral preferences now. But if anyone has any questions about, um, working in Scotland, I'm more than happy to answer those. Um, I'm applying for co surgical training. And so hopefully this, um, this will be helpful. It's basically going to go through all of the Sophia vascular conditions that you have and then all of the, um, like investigations and like procedures. I think they're called, um, that you need to know. Um, it basically gives you just like, not, well, it gives you the minimum of everything that you need to know and how it kind of ends up being like clinically applicable. So hopefully quite like high yield, I won't go through everything on the slides and, but, um, lots of pictures and things. So hopefully you can just use it for your revision. Um, so the way that it is going to go is we'll do all of the conditions first and then the procedures kind of like come into the stuff that I talk about and we'll start off with basically three B so you don't need to put them in the chat. Um, but if you commit to an answer, write it down and we won't go through the answers. Now we'll do them at the end, but I'll just give you a couple of minutes for each of them, um, to have a little read and then commit to commit to one. and then we'll go through the answers at the end and hopefully things will be a bit clearer. Um, so this one is a 52 year old woman is in hospital after being admitted for an elective umbilical hernia repair. She's got a past medical history of type two diabetes. She was a smoker for 20 years and she's got IBS, she's day two POSTOP on the morning ward and you notice some erythema of her right calf, um, on palpation, there's tenderness you do ad dier, which is elevated and then you also do a lower limb ultrasound, which confirms that she's got a DVT. And what is the most appropriate management for a DVT in this case? So give me just a couple of minutes to commit to something. Ok. I'll just give you a couple more secs and then we'll move on. Cool. Ok. So number two is um a 61 year old man who's admitted to Ed with sudden onset um, pain in his right foot, which is cold. He's got a radial pulse of 82 BPM. That doesn't have a discernible pattern. Um, an ABDO and a cardio exam finds nothing else of note. There's no palpable pedal pulse in his right foot. Um, an ankle Doppler is done and signs are absent. An ECG is performed and there are no signs of any acute ischemic changes. Uh What do you think is the most likely diagnosis? Ok. I'll just give you a couple more seconds. Ok. And then this is the last one. So, um a 66 year old male returned to clinic for an ABDO ultrasound. Um One year ago, he attended the One off ultrasound screening clinic for um abdominal aortic aneurysms. He was found to have found to have an asymptomatic aneurysm inferior to the renal arteries. Um That at its widest point was 3.8 centimeters in diameter. Today, he reports that he remains asymptomatic from it and it's found to be 4.9 centimeters in diameter. His BP is well controlled. Given the above findings. What is the most appropriate next step for this patient? So, have a read of the options. Commit to one. Even if you don't know, guess because if it ends up being wrong, you'll remember as being wrong and you'll remember the right one. So I'll give you like 30 seconds and then we'll move on. Cool. Ok. So, um, like I said, I'm not going to give you any answers. Now, we'll come back to them at the very, very end. So hopefully some things will come up that will basically answer the things in this. Um, ok, so we'll go through it by presentation. So we'll start off with aortic aneurysms. So, with regards to aneurysm, you've got two different types, you've got true aneurysms and you've got pseudoaneurysms. So true aneurysms are ones where the wall of the artery forms the wall of the aneurysm. So you basically get a weak weakening at some point in the endothelium of the vessels and you basically end up with blood, pushing it out. So you either get secular ones which are kind of like little berries on the side or fusiform ones, which is where you basically just get an expansion of the entire vessel in both directions. You don't need to know like the two different types of them, um like for finals or for working really, unless you become a vascular edge, but just to kind of be aware of that. And then you have pseudoaneurysms, which are basically what happens when you have a break in the wall of the blood vessel. And then blood starts leaking through that gap. And it's the surrounding tissue around where the, where it's bleeding that creates essentially the wall of the pseudoaneurysm. So if you have a little, look at this picture here, you can see this kind of lump on this person's wrist. I expect this person has had an ABG done. But um um you basically like it's pretty self explanatory. You create a wall in the vessel and eventually, basically the pressure from the surrounding structures will keep that blood in place. So the difference between it being a pseudoaneurysm and it being a hematoma, which is just a bruise is that in a pseudoaneurysm, you've got, you've got communication between the aneurysm and the vessel. So blood will come out and back into it. Whereas with a hematoma, you basically just got leaking of blood into the surrounding tissue which causes a bruise. Um So definitions, you classified as an aneurysm if it's basically more than 50% of its normal diameter or if it's um greater than three centimeters um in the aorta. Ok. Um So you've got th thoracic and abdominal aneurysms. So 80% of your abdominal of your aneurysms occur basically in the abdominal aorta. And then your thoracic ones are split where most of them are the ascending and then the other half of the um thoracic ones are in the descending aorta. So things that you're gonna want to like times when you're going to think about. Ok. Could this be a thoracic aneurysm is when people have connective tissue disorders? So things like Marfan's and Ehlers Danlos Syndrome, you get disruption in the connective tissues which then basically leads to aneurysms forming because the walls of the vessels aren't as strong as they used to be. And then you've got ones that are caused by non syndromic things. So if you've got a bypass aortic valve, um so basically, self aortic valve has two rather than it being three, it's got two valves in it and it basically causes a disruption in your vasculature. Um and then familial T ta. So things that run in families, um descending aortic aneurysms, things that contribute to this. The two main ones are atherosclerosis. So basically build up of um of stuff in vessels which causes weakening essentially. And then you get aneurysms as a result, you can get infected causes so a um aortitis. So, inflammation of the wall which causes it to weaken and then you've got cystic medial necrosis, which basically you get kind of like an accumulation of inflammatory cells which then causes kind of like cyst like lesions because you've got lots of inflammatory cells turning up, you get an inflammatory process, it causes damage to the surrounding structures and then that basically makes the wall weaker and then it kind of expands and then obviously, trauma, don't worry about knowing like different things that are contributing to it. It's just kind of like good to kind of think about it. If it comes up in an SBA like this person happens to have this. How can it maybe, But why might you consider an aneurysm as a, a differential? And then like I said, 80% of the aneurysms are um below the renal arteries. And you've got like your main things that are contributing towards it. So, like um cardiovascular risk factors are smoking, hypertension, increased lipids, males, family history of it, other cardiovascular diseases, etcetera, etcetera. Ok. So, symptoms of things. So your thoracic aneurysms can be asymptomatic. Um and they can also be symptomatic. So, if you've got basically an expansion of um the blood vessels in the um yeah, in the um thoracic cavity, it can cause pressure on surrounding structures. So you can get back pain, you can get like dysphasia, you can get cough, anything that's like causing pressure on any of the surrounding structures. If it's going so far back that it's just disrupting where the heart attaches to the um ascending aorta, it can cause um damage to your aortic valve. So it can cause aortic regurge. Um and then um it can also depending on kind of like how it's affecting the other blood vessels. Um, it can also cause um, variations in your pulses. So, let's say it's affecting some of the branches or that come off the aorta, it means different amounts of blood could go to one side of, um, basically the branches off the top of the aorta compared to the other. And investigations that you're gonna wanna do are, um, an echo or a CT and thoracic aortic aneurysms are usually looked after by cardiothoracic um your abdominal aneurysm. So if they're asymptomatic, the patient won't really feel anything. But things that you might feel on examination is if you've got pulsatile abdominal mass, you have to press pretty hard to be able to feel, feel that. Um and then same again, if you've got an expanding mass in someone's abdomen, it's going to cause pressure on surrounding things. So, epigastric pain, back pain, um if it ruptures, that's really bad. So, epigastric pain that's radiating to the back. Also, if your aorta ruptures, you're going to become horribly hemodynamically unstable. So the blood pressures are going to be really low, they're going to be tachycardic, they're going to be passing out, they're going to feel dizzy. So, major emergency, um and things that you're going to do are ultrasound scans, CT CT angio. Um But incidentally, a lot of abdominal aortic aneurysms are actually found on chest, um abdo X rays because so much of the, the vasculature is calcified. You can kind of pick up where they are expanded when you can see them. Um, things to consider if someone does come in with like tummy pain is, oh, I've got pain in my back. Um, you might think it's renal colic as well. So just kind of like when you're actually being an F one, aortic aneurysms are not as common as you, like, think, um, you get more people coming in with renal colic than you do with AAA. So just similar things that present in similar ways that you have to consider and then how do you manage it? So everyone that's male, over 65 years old gets offered a once off ultrasound scan. Um And then depending on the size of the aneurysm, if it's picked up, determines what they do afterwards. So if it's 3 to 4.4 centimeters, they get another follow up scan in a year. If it's between 4.5 and 5.4 they get another scan in three months. And if it's over 5.5 that's when you do surgical intervention for it. And if you're following them up in three months, you're gonna stress like conservative and medical management. So smoking, alcohol, weight loss, improve their diet, reduce their salt, um medical things. So, statins, aspirin, manage their BP, things that will basically cause less stress on that aneurysm. Um Obviously, if anyone has got any of these problems and they've got an aneurysm that's smaller, you're going to tell them to do that as well. Um, times when you do a surgical repair is when something is ruptured. If it's symptomatic, if it's more than 5.5 centimeters, like in this flow chart, if it's more than four centimeters and it's grown by more than one centimeter in a year. So, that's kind of an important one. So, it's ok. Well, it's not necessarily OK, that it's big, but the thing that's gonna worry you if it's big and it's getting bigger at a faster rate. Um So yes, aortic aneurysms, that's pretty much it. Next one, aortic dissection. So an aortic dissection is a tear in the tunica intima and the blood at high pressure creates a false lumen in the tunica media. So you basically create a false lumen. So you make like a, you make like a slip road or you make like a hard shoulder basically to your blood vessel. Um Type A is in the ascending aorta and type B is in the descending aorta, descending aorta is anything after the left subclavian artery? Ok. That's it. You don't need to know any more details. It's either type A or Type B ascending or descending and just know when it comes descending. Um signs and symptoms of someone that's presenting with an aortic dissection. They've got unequal blood pressures in their arm. So let's say I know I've come back, but let's say I don't know if you can see my mouth, but I'll try to explain it. Let's say you've got um uh um an ascending aortic aneurysm got lots of blood coming out basically here into the side of the blood vessel. So less of it is actually going to be getting into this vessel up here to go off into this branch. So as soon as you've got kind of like a disruption in the normal flow of blood. Its end destination also gets disrupted. So you're gonna get manifestations of that. So you can get unequal blood pressures in arms, weak distal pulses, um aortic regurgitation. So like I said, again, if this is happening kind of further back, closer to the aortic valve, it can cause damage in your aortic valve, which like other things, if you get issues with your valves, it can predispose you to heart failure. So you might think about other symptoms that the person might present with that are actually secondary to this first problem. Um Neurological symptoms, um headaches, reduced blood supply, causing hemiplegia, neck pain. Um like I said, basically, if blood is not going where it should be and it's going into a different cavity, the end destination of it isn't going to get as much perfusion as it should um investigations that you want to do. So, bedside bloods and imaging is a good way of thinking about it and it's, it's like I know I used to like say that at, at med school. But then when you're actually working, it actually ends up being like a really good way of thinking about stuff. So you're going to do their BP, do an ECG If someone has got tearing chest pain that's radiating to their back, you've got to exclude that. They are not having an M I um do a set of blood. So FP CSE N FT S do a lactate and lactate particularly important because if you're getting less perfusion to your end organs, your lactate is gonna go up, do a group and save in a cross match. That will make you sound quite good. I think if you say that in an osk because it shows that you're thinking, hey, this person has had an aortic dissection and they're going to have to end up going to theater if you said I'll do a group and save in a cross match before they become really hemodynamically unstable when it's really difficult to get bloods of them. It shows that you're forward thinking. Um imaging chest X rays classically shows a widened mediastinum CT MRI or you do uh a transesophageal echo. If they are unstable, someone's really hemodynamically unstable. The chances of you getting them in a CT scan are pretty low. But surgeons also hate taking people to theater without having any form of imaging. So they'll do, they'll do a um an echo. Um You're gonna wanna control their BP if this is happening and then if it's a proximal dissection, so closer to the heart you're gonna operate on it. Um Yeah, that's pretty much it for that one. Um Next one is DVT, which in practice just comes up all the time. So, swelling of the leg, um uh under the DVT because blood basically cannot drain as easily because there's a blockage in it. So all of the, there's blood that should be coming out of the leg, going up, up into the body, um, can't, it's blocked. So you basically have a backlog of blood and it causes things to swell underneath it. Ok. So risk factors if you're over 60 if you're comorbid, um, if you're in the hospital a lot, so you're immobile. If you've got a systemic infection, having an infection makes you hyper coag coag. I can never say it. It makes you coagulate more. Um, if you're obese, um, if you've had pelvic or abdominal surgery, if you've got cancer, if you're pregnant, if you're on the pill, if you're immobile, if you've got uh varicose vein phlebitis. So, if the surrounding vessels are inflamed, um HHS. So, um, if you're really dehydrated, secondary to your diabetes, if you've got a family history of it, if you've got a thrombophilia, so you're more prone to clotting. Um I don't actually know why IBD is a risk factor if I'm really honest. Um I just kind of remembered it. Nephrotic syndrome. I also don't know the answer to that one either. Um, I just memorized those two and if you've had surgery, so, basically that pretty much covers almost all of the population. Um, so people might be an asymptomatic but very rarely will this manifest if someone is not really symptomatic of it. So, red erythematous, hot legs, they are painful. You can see sort of like superficial veins that distended. Um, other things to consider as well are ruptured Baker's cysts. I've never seen that. Um edema from other causes. So maybe if they've got heart failure, but then if it's red and hot and swollen, um not really that consistent if they've got cellulitis. So very often you get the cellulitis versus DVT um dilemma because it's not uncommon that like you get tracking of cellulitis up someone's calf. Um And I literally had this exact presentation cellulitis versus DVT, like the final patient that clocked on my nights last week. Um at which point you do a wells score. So, um if they score zero or one, you do a ddimer. Um If they score more than two, you do an ultrasound of their legs, ok? Um Get MD CALC, it's a great app. It's got every single scoring system on there. So use that. So if you've scored zero or one and you're doing a ddimer and it's positive you're then gonna go and do an ultrasound to see if there is or isn't a clot there if it's negative, you're gonna think about something else. If they've scored highly enough to basically entitle themselves to an ultrasound and then it's positive for a DVT, you're gonna give them a DA and if it's negative you go kind of back here and you do a ddimer. OK? Um This is basically the um scoring system for wells, OK? An alternative diagnosis is as likely as a DVT this one down here that gives you minus two. That's the one where you're having to make a bit of clinical judgment. So for example, someone scratched their leg or been bitten by something and their legs got really hot and red. That might be a cellulitis rather than a DVT. And if the clinical picture fits more to that, that's when you kind of use, you just, you have to make a bit of a judgment and say, ok, fine, something else is as likely as a DVT, ok? Um If you're treating them with a doac, um you're gonna give them either three or six months so provoked. If something is causing them to have DVT and if it's unprovoked, you're gonna give them longer because you can't find a reason why. Ok. Um When people have unprovoked DVTs, you're also going to think in the back of your head is actually something that we're missing that's causing these DVTs. So you might do a CT Abdel S to exclude that they haven't got some cancer that you don't know about because cancers make you hypercoagulable, etcetera right there. OK. And then just be mindful when you're reviewing somebody that's got a DVT ask them about shortness of breath, chest pain, pleuritic, chest pain, dizziness. Are they tachycardic? Could this DVT have turned into a little pe OK. Um And then this is basically just a flow chart um about it kind of puts everything in the previous slide into one slide. I'm not going to go through it. You can have a look at it. Um And I'll send whoever the slide so you can just kind of use them. It's quite helpful for actually just like applying to clinical scenarios. Um How are we getting on for time? Ok. Um Let's talk about ABP. So, um your ankle brachial pressure index. So it's a ratio basically your systolic BP in your ankle versus your brachial systolic BP. So the way that it works is um, you take the BP of someone's arm and you take the BP of someone's ankle. If so the the top number comes from the ankle and the bottom number comes from the arm. So if the top number, so around the ankle is a small systolic BP, it means you've got worse peripheral vascularization. If the BP is lower, it means less blood is getting there. So your systolic BP is lower. If your brachial BP is normal, you've basically got a small number divided by a normal number, which is going to give you a small number compared to if your BP in your ankle was normal because you've not got peripheral vascular disease and the BP in your arm is normal. You're just going to do a normal number, divide by a normal number. So it will give you a normal result. Ok. So that's why if you calculate an ABPI and you get a small number and you've got arterial disease, ok? You've got peripheral vascular disease. Um So what is it? Peripheral vascular disease is basically when you get a build up of plaques in your peripheral vasculature. So it's going to be secondary to like atherosclerosis, high cholesterol, et cetera, et cetera. Ok? You um occlude the air, you the airway, you occlude the vessel, the amount of blood that gets through is less. So your BP gets less going through the amount of blood actually getting to the muscles in the legs is less. So you've just got peripheral vascular disease because you've got less blood getting to the muscles, it's gonna start to hurt. So you get claudication. So, claudication is painful muscles on movement. So the more you move, the more you exert your muscles, the higher the oxygen demand is if you've got peripheral vascular disease with a rubbish, blood supply, your muscles are gonna start to hurt earlier when there's not enough oxygen being supplied to them via blood. Ok? Um, things like if you, if your peripheral vascular disease gets severe and you're gonna get ulcers, you're gonna get gangrene, the pulses in your foot are gonna get worse because you've just got less blood getting there. Your skin is gonna start to get worse. The hair is gonna fall out, the foot is gonna look pale and very niche. You get excessive sweating because your sympathetic nervous system gets activated more. Um, and a very like common one, erectile dysfunction. If it's in like peripheral like distal aortic disease, it's supply it like has an effect on the blood vessel supplying like the lower abdomen, um and genitals and things. Ok. So investigations that you're gonna do. So bedside bloods imaging and then special tests. So bedside things like with all cardiovascular stuff, BP, ecg do a vascular exam, see if they're positive for bur um burgers angle. Um If the leg goes pale, cold and painful, that's concerning um if they are vascular filling time. So if they cap refill, you give the finger a foot a squeeze and the amount of time it takes the blood to get back is more than 15 seconds. Um Yeah, it then in reaction to that becomes hot and red when the blood kind of rushes back in. Ok. Um If you've got any lesions in your feet, your you should swab them just to exclude that. There's not like it's not actually like an external infection, bloods that you're gonna do um full blood count using these um lipids, um HBA1C because people that have vascular disease often have diabetes. Um do an ESR or CRP to see whether they've got any like inflammation of the blood vessels. Um and then also do platelets and clotting. So you'll do a coag um if they've got like elevated platelets that like it might be like, it might actually be a little clot or something like that. Um Imaging is basically angio. So you either do a CT angio or an Mr angio, which is an MRI angio and you put contrast into the vessels and you see how well it gets to places, um distal subtraction, arteriography. So like fancy ways that radiologist look at vessels um and Dulic scans. So ultrasounds that like light up with color based on if it's arterial or venous supply to places and then you're going to do an ABPI, which is what we talked about in the last ways that you're going to manage peripheral vascular disease. So always structure answers, conservative, medical or surgical, conservative things, weight loss, alcohol, smoking, exercise, same as with all the other vascular problems, medical stuff, statins, antiplatelets, optimize all of their cardiovascular risk factors. So if they've got high BP, if they've got high cholesterol, if they diabetic, like help like fix everything else around it and this will improve. And then if they continue to have really bad peripheral vascular disease, which isn't really uncommon because people are not always compliant with these like conservative or medical treatment. You're going to do an angioplasty, you're going to either do stenting or you're going to do a bypass or an embolectomy. So you are basically going to do something to get rid of that occlusion. So you're either going to get it out, press it out to the side, put a vessel around it or take out the embolus. It's not uncommon with really bad vascular disease that you have to cut someone's leg off either. Um Cool. Ok. So, um I think we're making our way through. Um It pretty, pretty well. I don't think there's too many things left. So, um acute limb ischemia, um I'll actually give you like an example of this after I've talked about it. But you've kind of got your levels of um how extreme someone's peripheral vascular disease disease is. So, if they've got intermittent claudication, it hurts a bit when they're walking a lot, that's your lowest level. You got up to critical limb ischemia. So the occlusion is getting worse. And then your worst thing is your acute limb threatening ischemia. So when you've got a full blockage of a vessel and you're not getting a blood supply to the limb, which is your six ps. So it's painful, pulseless pa. So it's, it's, it's cyanotic and you've lost power in it, which is quite extreme. You're getting paresthesia. So, pins and needles and it's perishing cold. Ok. Um, times when this comes up, um, is, you've got an old lady on a Jerry's ward who's got really cold legs. Um, and you put socks on her, you put blankets on her, I think she's just older. She's got bad circulation but actually she's been sat there with a, um, critical limb ischemia for a fair few days and it's really not that uncommon for stuff like that to happen in hospital when someone notices a bit of a problem. And then you kind of like think, oh it's, it's nothing really much but sometimes it just takes kind of like coming in from like you come in at the beginning of a shift and you think, OK, no, this, this limb actually looks pretty bad. So like it's not always someone coming into ed my legs really sore, like wailing in pain. Like it can come up quite like s two ways that you manage acute limb ischemia. So medical ways you give them a heparin infusion, you can give them oxygen as well. So make sure their saturations are up so that they're perfusing as well as possible. Um And you regularly check their APTT, so regularly check their clotting if you need surgical intervention. So like you won't be making these decisions and I doubt you'll be asked to a question about the like which specific management would you do in finals? This is the point at which you ring the vascular reg and the vascular reg makes a decision about it, but it's still good to know um if it's embolic. So um it's come from somewhere, you can basically take it out or thromb it or dissolve it or bypass it. So go around it. So you can, it can either be embolic. So it's come from somewhere or it's thrombotic. It's basically a clot that has been made there. Ok? And that's causing your acute limb ischemia. Um Fine. Next thing, varicose veins. So, um varicose veins arise from incompetent valves in your deep venous system. Well, incompetent valves that basically allow blood to go from the deep venous system into the superficial venous system. So, blood coming from deeper to shallower. Ok? Um As a result, blood basically backs up and you get venous hypertension because your valves are incompetent. The blood is not getting out and your vessels dilate. Um So you either have primary varicose veins or you've got secondary varicose veins. So primary ones are where you just have varicose veins of their own accord. Secondary is when it's happening as a result of something. So someone's had a DVT which has caused the blockage. Someone's got a massive pelvic mass which is impeding blood, getting back out of the legs up to the heart. So if you're pregnant, if you've got fibroids, if you've got an ovarian mass, if you've got ascites, that's putting a lot of pressure on vessels. Um or if you've got arteriovenous malformations bump, that's been so signs and symptoms, it's sore and it's itchy. You're getting a build up of dirty blood, which basically causes that your skin will change. You'll get ulcers and with a build up of dirty blood with dirty stuff in it, it's going to cause inflammation of the surrounding blood vessels. So you're going to get thrombophlebitis so you can get inflammation of your surrounding vessels. Your gold standard investigation is a duplex ultrasound scan. So it's just an ultrasound scan that basically picks up like arterial and venous blood basically. And the way that you manage it is conservative or surgical, you've also got medical in the, in the middle. So like you give people analgesia and stuff, but conservative stuff is weight loss exercise, avoid risk factors, compression stockings. So, um getting people to wear Ted stockings, um and then your surgical management is um if you have these four things. So, um they're symptomatic, they've got skin changes, they've got um superficial vein thrombosis. So their superficial veins are getting a bit blocked. Um and they're getting ulcers. So at that point, you're basically gonna, they either basically pull the veins out or they fill them with foam or they like burn them with ablation. Um But the that kind of stuff isn't gonna come up in finals. It's very niche that's decided by a vascular consultant or a reg like how they manage their varicose pains. Um OK. This slide looks quite like content heavy. So I probably won't go through it in a lot of detail. Um And in the interest of time, but types of ulcers that you definitely will get asked about um are arterial venous and neuropathic. So um arterial ulcers, the the pathophysiology is basically, you've got decreased arterial blood flow, which basically causes poor perfusion, which causes any little ulcer that is formed to heal poorly. Ok. They are small, they are deep, they are well defined. Um And it's at site of trauma. So where little things have happened. Um, your venous ulcers are basically venous insufficiency. So you've got dirty blood staying in your legs, it causes inflammation in surrounding vessels or, and you get a little nick somewhere and the amount of like you've got dirty blood and not fresh blood with good um immunological things in it coming, coming in to fix it. So you've got your impaired venous return your white blood cells stay trapped, they activate things and that causes more inflammatory mediators to be released and it basically causes necrosis of your wound. Neuropathic ulcers are secondary to diabetes and B12 deficiency, um, neuropathic ulcers secondary to diabetes come up all the time. Ok? Um So I'm not gonna go through all of the like investigations and the management of them. I'll leave them there for you to have a little look at, but it's basically just one table that tells you what you do to each for each of them. Ok, pictures and how they look different arterial ones that you can see. They're like really quite fresh and like very easily defined, especially that second picture, venous ones just look a bit grotty and a bit kind of like spread out and your neuropathic ones look very like bye. Kind of like punctured but quite clean around the edges when you're in like a practical thing. Whenever people have ulcers like this, refer them to tissue viability nurses who are great at basically recommending the right dressings and creams and stuff. Very rarely when old people come in with ulcers. Do they ever get fixed? They just go home and the district nurses come in and check on them and change their dressings and stuff like that. Once you've got to this point, it's like it takes forever to get rid of them. Ok. Um So yeah, just have a little look at that table. Um It's all summarized quite nicely. Um, gangrene. So you've got two different types of gangrene. You've got dry and wet, dry is basically when you've got impaired blood supply to the tissue. So it becomes um dry shrinks, it's black and it falls off, which is quite often what they let happen. Wet gangrene is basically when you get infection of the tissue and then you get swelling, you've got lots of fluid, it stinks. Um and it's basically an active infection. So you can't just leave that you need to operate on that and get rid of it otherwise you can become septic and die. Um, so you need to, if it's dry, you can let it fall off. If it, if it's, if it's wet and infected, you need to get rid of it. Um, so things that you're gonna look out for if the area is cold, it's painful, it's red, it's swollen. Um, if it's infected, they might be septic. So they've got temperature, their BP is low. They're tachycardic, they're confused. Um And then obviously you're gonna manage it. So if there's any sign of infection, give them antibiotics, you're going to debride it, maggot debridement. Actually, really quite common. You get maggots in little tea bags and you put them on, on stuff and the maggots just eat things and it keeps the wounds really clean. Um hyperbaric oxygen therapy and obviously vascular surgery. But yeah, just be mindful of like little foot ulcers and stuff like that when old people become delirious and they don't look like they've got uti they not look like they've got a hap or anything. Make sure you check their skin because their skin is like skin is always a massive cause of sepsis or confusion. Ok? I appreciate. I have spoken at you for quite a long time. So last three sides and then I'm done and then we'll have a look at the questions. Let's just go through the questions that I gave you, um, at the beginning. So this lady, she was 52 came in for an elective, um, hernia repair. She had type two diabetes. She was a smoker. She had IBS. She's day two POSTOP. She noticed erythema on her right calf. Um, it was tender, her D dier was up and you did an ultrasound. She got a DVT, right. Um, so three months of Apixaban. Ok. Three months of Apixaban in this case because it's a provoked DVT. She's had surgery, she's in hospital, so she's immobile. Um, other things to consider like we said, if she's pregnant, if they're immobile at home as well. Um I've written here because this is from last year. The Batran is the only Dirk with a reversal agent. Um, this is not true anymore. They actually do have a reversal agent for Dox. However, it is only licensed if people are actively bleeding. Um, so let's say someone comes in, they're on AP band, they've had their last dose at 7 p.m. for something. Um, and you need to do a procedure like you need to put a chest drain in. Um, but you know, putting a chest drain in, I don't know, let's say they've got pneumothorax or something will cause them to bleed lots. You can't give them the reversal agent prophylactically for that. You can only give the reversal agent if they're actively bleeding. So, um, it's actually come up a few times on, on like on patients that I've reviewed. So, um, that's new and only recent. Um, obviously your job with an F one will, like any junior is basically when you start someone on, you need to counsel them on them. So you need to talk to them about it, increase their risks of bleeding. Don't go doing any extreme sports or like standing on chairs if they hit their head, come into hospital, um, if they cut themselves, they will bleed more. So you have to go through a whole list of things when you're an F one, when someone gets started on AP, number two is a 61 year old man admitted to A&E with a painful cold right foot. It came on suddenly he's got a heart rate of 82 and he's got a regular radial pulse, he's short of breath. Um His oxygen sats are 98. Um His other examination is fine. He's not got pulse in his right foot. Um The Doppler didn't show any blood supply and his ecg um is OK. So no ischemic changes. So the little nuance here is that he's got an irregular radial pulse. So he's got af so things that you've got to be mindful of is people that have af the reason why you put people on a on anticoagulants is to stop little emboli flying off because they've got an irregular heart rate. So, therefore, blood becomes static at the wrong times in the heart and then it contracts and it fires off a little embolus, which we always worry about it going into someone's brain and giving them a stroke. But you also have to think about it flying off somewhere else and causing a little blockage. Ok. So this man's got ischemic foot secondary to a little blockage because he's got AF, which isn't treated. Ok. So it's not a DVT because, um, that's not a likely cause of an acute lower limb ischemia. Ok. Um It may occur if your DVT embolize and passes through your heart through a form of, of valley into your arterial circulation. But that's a lot of ifs so common things are common. Um It's not a AAA because he's able to talk, his BP is his heart rate is 82. He, he looks like end of the bed hemodynamically stable. OK? And you can't feel anything in his tummy on an ABDO exam. Um Dissection would likely present with like chest pain, not foot pain. Um Your irregularly irregular pulse is typical of AF so this, like I said, it's suggest an embolic event. Um and it's not going to be an M because his ECG shows no ischemic changes. However, sometimes people have silent MS so you don't get ECG changes but you get chest pain. Um And at that point, you put in a cardio review for the next morning. Um Final one is um your 66 year old man that's come back to clinic after they found a abdominal aneurysm of 3.8 centimeters on him last year. This year, it's now 4.9. So the nuance here is, it's increased by more than one centimeter in one year and it's above four centimeters. So when it increases by more than one centimeter in one year, you're gonna discuss surgical intervention for a AAA management. Ok. So more than four centimeters and he's gone up by more than one centimeter in one year. OK? Um Fab that's everything from me. So if you guys wouldn't mind scanning my QR code and just filling out, I think it's four multiple choice questions. Um A little bit of feedback is really helpful. Um And then I'll leave it up on the screen for a little bit and um I'll exit and I'll go into teams to look at any questions. But if anyone has got any questions in the meantime and wants to unmute, that's also cool. I'll just leave it on the screen for like 20 more seconds. If you could give some feedback, that'd be grand. Uh Yeah, I had a question. Yeah, I had a question. Yeah, go ahead. Um So for aortic dissection, the management is like, if there's like proximal dissection, then you have surgery. So if it's like sort of more distal dissection, then what would be the management? Is it just B control at that point? So it, so, so I can't give you a very accurate answer to that. So um are you won't have to know that for um finals. My understanding is, is if it's more distal, it's like further into basically the thoracic cavity. So it depends, I think cardiothoracic basically make decision on like how accessible it is. Um And how um whether it's operable or not. Um Lots of these things are emergency situations like if they happen overnight, the consultant has to come in and stuff like that. So if it's more distal, I think, I think it's basically a discussion about whether surgery will actually work because it's like in quite a difficult place. Um But um, that's like a cardiothoracic decision and you won't get a question about that in finals, but from my year of F one, that's kind of my interpretation of it. All right. Thank you. No worries. Um Right. I'll come out of this and go back into teams. Oh, someone's put on nice. Um, um, someone's put the thing in there. Oh, and you guys answered the questions? That's grand. Um Cool. Does anyone have any other questions? I have a question. Yes. Go ahead. So, with um, critical limb ischemia and acute limb ischemia, was it just that acute, is worse and critical or is critical, been going on longer and acute the first time? This is a good question and I literally had this exact conversation with someone today at work. So, critical limb ischemia is critical limb ischemia is like when well, we'll do it this way. Acute limb ischemia is basically when you no longer have any blood supply to your foot. Critical limb ischemia is on the way to that. Ok. So your acute, your acute limb ischemia would present with basically like all six of your kind of like three ps. Your critical limb ischemia is basically when your peripheral vascular disease is getting bad. So it's, it's not kind of like this is for this one. This is for this one, it's kind of like a gradient. So it's, it, I can't say exactly like which one when you would say it this or that, but you'd know when it's the worst one basically is what I'm trying to say. Ok, so like if um it was the first time they ever had any symptoms and they came in with um like four of the six ps, is that acute limb ischemia or is that um critical? But that would be acute? Well, it's not like it isn't like whether you meet all six. Like if, if you basically got four of the six, you're on your way to getting all six in essence, aren't you? Um It's gonna get worse. Um Like practically what you would do at that point, like let's say you reviewed someone with a leg like that, you'd, you'd refer to vascular, you'd, you'd offer a vascular review either way. Um I II don't know if I've answered your question. So on the way, it's like there's no, there's no signs of like um lack of blood supply and critical limb ischemia. Um So it will be so like lack of blood, like you will have impaired blood supply. So like their, their foot will be like colder, it might be harder to feel a pulse. So like you might be able to feel it a little bit and like, not um not like another time or like someone else might be able to feel it. So it's, it's like, or like if someone has critical limb ischemia, they'll um they're on their way to getting acute limb ischemia, right? So it's like a gradient of things. So if, if you're seeing any of these kind of six symptoms um that are not like hugely isolated one from like one from another, you'd get like, you'd get like you either get the med or you get vas or somebody to review it in terms of a question in terms of like an SBA question in um like finals. Um They won't get you to differentiate between the two of them. Ok. It, it's way too nuance. It's way too niche. Cool, thanks. No worries. Um Someone said is chronic limb ischemia. Um dr due to um peripheral vascular disease. Um Yeah. So chronic, basically, your chronic limb ischemia is basically long, long, like, well, hold on chro chro chronic limb ischemia is you can't have chro if you've got an ischemic leg. It like it's ischemic then like ischemic means like no blood supply then. So you wouldn't have like chronic limb ischemia. Um Are you may be asking is critical limb ischemia due to peripheral vascular disease? If that is the question, then yes, that can definitely be one of the things that contributes towards it. Oh, sorry. Thank you so much. That was really good. And um you went through all of essentially all of vascular in such a short amount of time. So I was really appreciated. Thank you. No worries. What I'll do is do you, shall I email the slides to you and then you can send them out? Yeah, yeah. So um I'll just give you my email over text and then um you can send them to me and I will distribute them. Ok. That's grand. Thanks so much for having me. Yeah. Thank thanks everyone for coming as well. Cheers. Thanks. Bye.