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But there's a clear aneurysm in this patient's abdomen, you can see the clear lumen with the bright contrast running through the aorta. Um And then that ballooning that you see around sort of L3 L4 L5 level of the abdomen, um is the actual aneurysm itself and you see the, the darker contrast um associated with the ballooning. This is all just con uh congested blood that's clotted and swollen and then there's a slight rim you can see on the outside of the aneurysm, which is basically just calcification that often occurs. Um So this is obviously a, a reasonably large um AAA OK, leaving on talking about the first question. So Freddie should be able to release um the poll into the chat. So if you could just answer on that, that would be great. I'll give you a couple of minutes. So the question, the ultrasound scan in an a 4.3 centimeter abdominal aortic aneurism, what is the next appropriate stage of management? So I'll give you a couple of minutes and then we'll go from, sir. Fine. So that, that, so 54% of you put B which is a free monthly ultrasound, um, followed by 27th that put C which is an annual ultrasound, um, which is the correct answer in the snoring. It's good just to have a basic understanding of the um abdominal aortic aneurysm screening program in the UK, I'll discuss it a bit later on, but basically any patient that has um, an asymptomatic uh ASM picked up on screening ultrasound that's between uh 3 to 4.4 centimeters. Um It's just basically monitored with annual ultrasound scans. Um Any greater they need um more frequent imaging or potentially a referral to vascular surgery. But I'll discuss the details in the next few slides. Aneurysm just the definite and dilatation of the blood vessel by more than 50% of its down, obviously, they can occur in a lot of different places. Um But the aorta is, is, is one of the most common locations. So specifically for the aorta, um an to diagnose an aneurysm, it has to have a down to greater than three centimeters pores is generally unknown. Um There's a lot of different potential um causes such as atherosclerosis. Um infections, sometimes patients can get infected aneurysms, um sometimes they're linked to connective tissue diseases such as others Danlos, um or certain arteries and inflammatory diseases and can even occur secondary to trauma. Um The sort of risk factors that you look for in these patients are similar for a lot of different vascular conditions. So, um and they link with all the cardiovascular conditions as well. So obviously, smoking, high BP, high cholesterol, um family history being male, um dramatically increases your risk. So screening is actually only offered to males in the UK and obviously in age as well. Interestingly, diabetes is a protective factor for this disease. So reduces your risk. Um The reason for this is completely unknown. Um It's just one of these medical mysteries that maybe actually be able to establish exactly why this this happens. So when looking at aneurysms will boost them up, obviously into how these things are ruptured and unruptured. So we'll just start off with the unruptured, um, aneurysm so often can be asymptomatic and it's just picked up either incidentally on scans done for other symptoms, um or on uh the screening program I've discussed before. They can cause um quite severe abdominal pain. Uh think of it radiating through to the back and the loins, um they can cause limb ischemia. So the aneurysm itself um can be a source of emboli that can um break off an aneurysm and spread to the distal arteries down towards the lower limb and therefore, presents with limb ischemia. Um in some cases, they can present as aortoenteric fistulas. So that would present with like a gi bleed like picture that would only be picked up on CT scan. Um And then also, um just the episodes alone are also a a uh a symptom of um an unruptured AAA, they can be quite sinister in a presentation and it can be quite difficult to pick up in the emergency department. So, if just, if you have any suspicion, um, of a AAA, you should just do some more investigations, certainly, if they have risk factors for it. I mean, obviously, uh, on examination, patient might have a large pulsatile abdominal mass, but this all isn't always the case. Um, uh, and sometimes you can't actually palpate that in the abdomen. It might be quite tender as well around that area. I in the outpatient setting, the first line method of of imaging would be an ultrasound. Um And then once this is confirmed that there is an aneurysm, they then conduct a CTA autom which is basically just a angiogram of the aorta. So using contrast, um but they only do the CTA autom if the diameter is greater than 5.5 centimeters on the ultrasound. Um and it basically just provides more anatomical detail for things like surgical planning. Um in the uh in in the emergency department, ultrasound scans are also quite useful patients presenting with um nonspecific abdominal pain where there's quite a uh a lot of different differentials and they're quite unstable. A point of care. Ultrasound can be quite useful. Um If the uh operators are available um in the department, an abdominal X ray isn't particularly useful, it won't show much at all. Um That is uh with the exception of some cases where there is um significant calcification of the um aortic wall that I was discussing before. And sometimes this can show up on an abdominal X ray. But it's not an investigation. We need use to rule out a, an aneurysm by any means. Dim just shows basically how an aortoenteric fistula forms between the aneurysm and the bowel as well. So, in terms of meaning, um so there is this national um abdominal AAA screening program for offered to all men in their 65th year of life um in and in fact, have quite a significant reduction in aneurysm related mortality. So, about 50% in the UK. So it's a very stressful screening program. Um 1.1% of those seen are, are diagnosed with AAA S with 0.3% of those being over 5.5 centimeters. So it picks up a small number, like percentage wise. Actually, that's quite a large um population. Um uh amongst the UK. Um, men detected uh with a 3 to 5 years, um just having surveillance scans before reaching any threshold sort of vascular referral or repair or anything like that. So it's often managed in the, in the community. Um and also in like unfit elderly patients, aortas might actually be left until uh six centimeters before considering uh repair or intervention due to the risks of mortality associated with the surgery. Um, if the uh aorta is greater than 6.5 centimeters, then the D VA will need to be informed. So that sometimes comes up in exams as well. Um Alongside all of the epilepsy guidelines and things like that. So just in summary, 3 to 4.4 centimeters um annual ultrasound and anything less than less, they won't need any further imaging. 4.5 to 5.4 centimeter. You need three monthly, the ultrasounds 5.5 centimeter or, and they're greater than one centimeter year or they're very symptomatic, they need to refer to vascular surgery for consideration of that. Um So, in terms of management, so in the non emergency setting, obviously, medical management is important. So reducing risk factors such as uh smoking cessation, uh lowering BP Gatins. So 80 mg um and also antiplatelets and weight loss as well. Um There's various methods for active uh repair of the aorta. It depends on the anatomy and a, a number of other factors. So, in terms of open repair, it's conducted via a midline laparotomy where they open the abdomen um or they do a long transverse incision, um they expose aorta, they clamp it approximately um and then also distally as well by the iliac arteries and then remove the segment and replace it with a graft. Basically, the endovascular repair um is all done via IR in collaboration with vascular surgeons. Um And this is basically where they introduce a graft endovascularly through the femoral arteries. Um via inserting a cat into the femoral arteries. Um And then they fix the stent within the uh inside of the aneurysm. You can see it clearly in figure four. It has a bit of an advantage over the open repair. Obviously, the the the hospital hospital stays are reduced in this scenario and actually has a lower 40 day mortality, but actually in the long run, um over a number of years has a higher rate of reintervention. Um and rupture and it can often develop what we call an endoleak um where the uh blood leaks around the graft back into the aneurysm. Um And this is quite common with uh ears. So it, they only require uh fairly regular CTA autos to monitor uh kind of um open repair a just to the complexity of, of the repairs. Um So, you know, there's so many different um uh arteries coming off the off to the the renal arteries, the mesenteric, but, you know, the celiac axis that can also be involved in the aneurysm or be occluded um from the aneurysm. But uh the graft repair often doesn't just um encompass the aorta itself, but also the vessels that come off the aorta. So in terms of the rupture, really unlikely, um this is pretty much the extreme of surgical amount that, that, that you'll ever see. So eight, because 85% of patients die before actually reaching hospital in this scenario, again, can present with severe abdominal and back pain, simply uh vomiting and then a postal mass um in the abdomen often uh uh this is very hemorrhagic shock. So they're very tachycardic and very hypotensive. Um and the the key methods of management is obviously your at assessment in any acute scenario, focusing on getting early um for cannula access um ideally to cital fossor, um then resuscitating with blood products um and fluids. Initially when these aren't available, we, we try and aim for something called permissive permissive hypotension. So, rather than just pumping them for the fluids and increasing their BP too high. We aim for a systolic of 90 to 100. Um This is basically because this is enough to sustain perfusion to the brain um and prevent complications from that side of things, but anything higher than this can actually exacerbate the bleeding from the aorta um and make the patient more unstable. So, hence, they aim for that, that slightly lower threshold. Um Obviously oxygen and then they're referred for urgent surgical repair. Sometimes it can be done um via endovascular procedures even in cases of ruptured AAA where there's just small leaks. Um but often they require urgent open surgical repair. So, question. So a 68 year old gentleman presents to the ed with a six hour history of sudden onset tearing chest pain, getting through to his back has a past medical history of hyperlipidemia and hypertension for which he takes atorvastatin and amLODIPine, other than the tachycardia, his obs and all A CTA autom is conducted, which demonstrates a Stanford B aortic dissection with no evidence of any other vessel involvement. So which of the following is the most appropriate first line method of management for this patient. So give you a couple of minutes again, fine. So the majority of the people will put IV labetalol uh which is the correct answer in this scenario And we'll go into exactly why. But basically the reason for using IV labetalol is basically related to the um type of aortic standard of B type aortic dissection and other than slight tachycardia, the patient's stable. So they don't need any urgent surgical repair. But we'll go into the specific classifications of dissection and how we manage them on the sorry per section. Um in a in the intimal lining of the aortic wall, splitting the tunica intima and tunica Comey apart as seen um in figure seven, uh these tears can progress often distally or approximately or both from the point of origin. So they can be anterograde or retrograde dissections acute when diagnosed over less than 14 days or clinic. If the patient has had symptoms for longer than this, often, those retrograde dissections that extend back towards the heart can um over the uh aortic arch and down to the uh send aorta uh actually affect the aortic valve root complications such as a prolapsed valve, um bleeding into the pericardium and actually cardiac ARDS, patients can be quite unwell. Um in terms of the risk factors, very similar to aneurysm. So, uh hypertension atherosclerosis being male. Again, um lots of different connective tissue diseases classically in exams, they'll talk about Marfan syndrome or S dan loss. Um And also you're at risk if you have a bypass of the aortic valve as well. Your textbooks say states that the features of presentations are classically tearing chest pain, radiating through to the central back. Um But often cases are a lot more subtle than this. Um And don't present with this classic tearing sensation. Um They might have signs of end organ damage. So again, these can present with unexplained syncope episodes. Um They might have palpitations. Um They might be tachycardic and hypotensive on their ops if they're particularly unstable. Um in terms of uh and damage, we think of reduce uh you can get paraplegia, lower limb ischemia again. Um and also confusion, confusion and deteriorating consciousness in these aortic discuss about the classification. Um They probably basically anatomically based on two systems that are used. So the Stanford is the uh important one when we talk about the initial management of these sections. So a type A Stanford classification dissection involves the ascending aorta and can propagate to the aortic arch and sending aorta. So if it involves the ascending aorta, then it's a type A um uh Stanford uh dissection if it doesn't involve the ascending aorta but instead occurs in any other part of the aortic or actual descending aorta. Then it's the type B standard classification. Um and these uh ones which were discussed in the uh previous question, the Daba classification just basically class uh classifies them in more detail. So type one originating in the ascending aorta and propagates to at least to the aortic arch. Type two S can be um ascending aorta and does not extend any further beyond the aortic arch. And these are quite classically for hypertensive elderly patients and then type which um actually originates distal to the subclavian artery in the descending aorta. So free A extends distal to the diaphragm and free b um uh uh sorry, uh free A extends uh no, no further than the diaphragm and then extends distally beyond the, the diaphragm. So, more extensive to uh based are important. Uh And these are also important as um aortic dissections can affect the arterial to the different um intraabdominal organs. So it can cause a ais derangement of liver function. Um A troponin, uh it can also be quite useful um uh often is elevated in these sort of scenarios and a coagulation. Um And two, we say is obviously important because the patient might need surgery. Generally. Um four units of packed red blood cells need to be cross matched prior to a dissection patient going to the theater. An ECG might show some signs of ST elevation in the inferior leads um when there's uh a dissection of the aortic root involving the right coronary artery. Um And an echocardiogram is particularly useful when looking for signs of any tampon art, if they have muffled heart sounds or anything like that on examination CT angiogram, CTA autom um is basically the first time method of investigation as seen in figure nine. And what you see in these scenarios in this um axial image is uh a false lumen, which is basically the darker area labeled by L where blood collects between the intima and media. And then the true lumen is the more opacified region labeled TL in terms of their management. Again, at assessment, prioritizing high flow oxygen IV access just like uh aneurysms, cautious uh resuscitation needs to be conducted. So uh in contrast to aneurysms, which uh we aim uh 90 to 100 um these dice be kept below 100 and 10 systolics again to maintain cerebral perfusion, um type a dissection and for type a dissections rate of mortality. So 1% mortality um of when they present. So they'll need um urgent cardiothoracic review and potentially repair uh when they release, they basically uh they remove the uh aortic arch and replace it with a synthetic graft and any additional branches of the aortic arch that require reimplantation with a graft onto as well. Um Often it's a stage procedure involving nu numerous operations over a number of days. Um in cases where there's quite long type that in a lot of vessels, type B, um are uh generally less complicated, managed medically initially with uh initial uh high control of BP. So we give IV labetalol and while the patient is an inpatient to control their BP, just because uh uncontrolled hypertension can lead to pro of dissection itself. And then they're given oral antihypertensives before they're discharged. Um We aim to uh in the acute setting. The repair isn't conducted um due to the risk of retrograde dissection in these type B dissections. So it's uh if they are repaired, they're conducted in an elective setting. Um, surgery uh is conducted if there's complications such as ruptured renal vi or vein uh arteries or there's limb ischemia. Um or if there's refractory P control hypertension figure 10 just shows basically a type a dissection repair fine. So, moving on to the next question, um It's a lady to her worsening right calf pain. It was initially only associated with walking over the last two months. Even her at rest being particularly bad at night whilst lying in bed, not relieved by leaning forward, however, is relieved by hanging her leather bed. She also has a black wet fifth toe that has gradually worsened over a similar time period. On examination, she has a gangrenous toe on her right foot, dorsalis, p posterior tibial pulses are absent on palpitation. She has an ap of normal. So what is the most likely diagnosis. So the majority of people put the critical Democrat ischemia, which is uh the correct answer scenario. So in order to answer questions, you basically have a good understanding of uh limb ischem in the spectrum for fracture suggesting this. Uh so I just having some connection issues. Oh, fine, I think I'm back fine, fine. So, um on vascular claudication. So vascular claudication is also called chron limb ischemia and it's on the same spectrum of disease as critical limb ischemia. However, it's less severe. Um Basically, the patient initially was describing vascular cla when she described uh right calf pain associated with the walking. But as it's progressed to rest pain, it's more suggestive of critical limb pressing ischemia, acute limb pressing ischemia ischemia, although can have an associated long history of symptoms. Um in cases of acute on chronic limb ischemia. Um patients usually presents with the five ps we'll discuss in the later slide. Um The neurogenic claudication is obviously quite an important differential in patients presenting with that initial claudication like symptoms, the pain in the legs whilst walking. The reason why I put in the scenario that it's not relieved by leaning forward is that um a neurogenic claudication, which is basically just where there's spinal stenosis and compression of some of the nerves and the spinal cord. Um leaning forward, such as they say classically leaning forward onto a shopping trolley whilst walking around the supermarket, actually relieves the patient's sym symptoms as it opens up the spinal canal. Um But it's not really the scripted of, of that in this scenario, especially with the other vascular factors and the A VP of NAT 0.4 which we were discussed earlier. Um So we'll move on. So, chronic limb ischemia is a symptomatic reduction in blood flow to the lower limb. Often can cause uh called vascular claudication. Typically caused by atherosis sometimes by vasculitis. Um and mostly affect lower limbs, although can affect the upper limbs causes a cramping like uh calf pain or thigh pain or buttock pain. In some scenarios, walking distance is what we call the claw, the cane. Um This is then also relieved by rest. Uh as this progresses, it can lead to critical lymph resting ischemia, which was described in the scenario before. So this is basically an advanced form of chronic limb ischemia characterized by um this similar um pain in the leg. Uh actually at rest as well. Um For the last two weeks, it's typically worse at night when lying flat because your legs are up and gravity isn't helping with the blood flow, but it's relieved when patients hang their leg out of the bed. So if you walk around a vascular wall with a lot of patients with ischemic limbs, a lot of them just hang their, their affected leg out of the bed because it helps improve their pain. Um It's uh so you have to have ischemic rest pain for more than two weeks. Presence of ischemic lesions or gangrene like this patient has uh or an ABP of less than naught 0.5 which this patient had as well. Acute limb ischemia is a sudden recent limb perfusion that threatens limb vi viability. And the risk factors are all similar to other vascular conditions um and similar across all of these limb ischemia uh conditions. So, there are a number of signs associated with limb ischemia to look for on a peripheral vascular examination. Early signs might just be some hair loss um on the lower limb or thick nails. Uh I often have absent DP or PT pulses um which are often quite hard to palpate even in healthy individuals. So it can be quite difficult to tell. Um as the legs is to become critical limb threatening ischemia, the foot may become very cold, develop some ulceration in gangrene as well. And then we do burger's test as well, which is kind of seen represented in figure 11. So basically, you lie the patient flat so high, raise their legs until they become pale and then gradually lower them until the color returns. And then you note the angle at which the color returns and this is the burger's angle if less than 20 degrees, indicates quite severe ischemia. And then when the feet are to the uh side of the bed and the patient sits up, they become quite, quite red and this is what we call reactive hyperemia and supports the diagnosis of peripheral arterial disease. So, investigating this and ABP rate pressure is first line form to get limb ischemia. So basically dividing the angle systolic BP by the brachial systolic BP. In uh figure 12, most accurately done using a Doppler machine um to, to actually identify the the the BP as seen in the diagram after a ultrasound was conducted at a whole which measures basically blood flow at different parts of the leg through the arteries to map the anatomical location of any of narrowings or occlusions. And it's a fairly accurate and sensitive method of assessment. And then if uh the ischemic uh areas I, then we can conduct CT angiogram or Mr angiogram in severe disease as the gold standard method of investigation to diagnose and surgically plan. Um for the sorry management cardio modification is key to lifestyle advice such as cessation exercises. Um optimizing the medical treatment again, starting them on 18 mg of statin if they can tolerate anti plates, ideally clopidogrel and also uh optimizing their diabetic control course of ischemia is quite variable. Most patients symptoms improve with lifestyle changes and medical management alone, but they can obviously progress. It's important to encourage walking. Um because this stimulates the uh development of new blood, fresh uh vessels and collateral circulation which can help to improve the patient's symptoms. So, exercise programs are used quite a lot indications for surgery, uh include where conservative treatments failed, all the signs of critical and pressing ischemia. And there's various methods that we do. So we can conduct angioplasty, um, which basically just involves, uh, again, a procedure done ir under local anesthetic or a catheter is inserted to the femoral artery. And then a balloon is inflated by whether the stenosis of the arteries occurred to open the blood vessel up. And often the stents placed over this to keep the patency of the blood vessel. Uh However, uh this often fails with time. Uh although it can relieve patients symptoms for a number of years, often the um atherosclerosis across the artery continues and may need further management. But this is why bypass grafting is often used as a good option. So basically, just bypassing the arterial blockage with either a vein graft or graft. Uh particularly useful in diffuse disease where patients have a narrowing of the artery all the way along the lower limb. And then uh final line sort of management for these patients. If they have like severe gangrenous uh lesions with um uh lots of ulceration and they're very septic, then we can conduct amputation as well. Um And the level of this depends on the degree of ischemia, acute limb threatening ischemia, increased fusion, threatening limb can be caused by complete or even partial occlusion. And the rapid ischemia and poor function within ours can be split into three main groups. In terms of the cause. So, embolization is the most common cause where from the uh where an er emboli from a proximal source travels distally to occlude the artery. Um and common sources of these emboli are AAA S as discussed before. Uh AF heart valves will have a mural thrombus, postmyocardial infarction, throm thrombosis in situ basically just where a atherosclerotic plaque has just ruptured and the thrombus has formed plaques cap and patients often get acute on chronic uh limb threatening ischemia in this scenario. And then obviously, trauma can cause this as well if there's any injury to any um arteries of the lower limb classically presenting with your six. So uh all sudden onset. So pain, pallor, pulselessness, paresthesia, feeling perishing cold with early and often a degree of paralysis at advanced stages. Um If there's a normal post uh contralateral limb, then this is quite a sensitive sign that there's an embolic source of the patient's uh symptoms because the other leg isn't affected. Uh You don't really need to know the details of it. It helps with the management. So the Ruford classification is basically just a way to categorize the severity of the acute limb ischemia based presence of sensory deficits, findings on arterial and venous Doppler uh investigations. A lactate is particularly useful because it will tell us about the degree of ischemia ongoing in the leg from the fia screen, particularly in those on the 50 without any known risk factors to rule out other causes of the acute limb pressing ischemia and obviously groups as well. An ECG can be useful to identify af as a potential cause of a source of the emboli. And then a Doppler ultrasound of both limbs is the initial form of investigation, followed by a CT angiogram, much like the chronic limb ischemia. So it's a irreversible damage can occur within six hours. So initially, you start patients with all patients on IV Heparin. So basically prevent the clot progression further down the leg. And um the reason why we use IV Heparin is because its effects are very quick. Uh And also when you stop the infusion, for example, if a patient is going to theater, the half life is, is is uh is very quick. So they can go straight to theater or, or very soon after stopping the he they can go to theater um in some patients with Rutherford one and two A uh classification uh symptoms, they respond well to I Heparin alone and may actually just be monitored and not need any further intervention. But any anyone with Ruford two B classification or more needs surgery uh to try and resolve their ischemia. So there's so many different forms of um uh surgery to resolve acutely impressing ischemia. And a lot of it's based on the cause. So for embolic causes, we can conduct an embolectomy, which basically just involves inserting what's called a fogarty ca which is seen in figure 16, um it into the artery uh under local anesthetic. Um you pass it, pass the clots and then inflate the balloon. Um and then you pull back the catheter and then the clot should hopefully come with it and you can extract the clot. Um directly local in arterial thrombolysis is another option. So it basically just involves uh administering thrombolysis medication directly in the arteries in an attempt to break it down. And then obviously, bypass surgery is a, is a, is another option as well in more advanced disease for thrombotic disease. Um uh angioplasty can often be conducted as discussed before and then again, local intra arterial thrombolysis and bypass surgery. Bypass surgery is used a lot more in thrombotic disease because the the extent of uh vascular stenosis throughout the whole lower limb means that um uh you can't just focus uh target it with just a sim simple uh angioplasty of a small lesion because it extends through the whole limb. So you have to bypass the whole vessel itself if left, the leg can become quite hard, non blanching. And the amputation is often required in, in uh where there's non viable limbs basically to prevent like sepsis and further complications. Long term management in patients that have recovered includes reducing cardiovascular risk and active platelets again. Um And most patients should be started on aspirin or clopidogrel immediately after surgery. Patients need HD level care cos there's numerous complications that can actually say we think of compartment syndrome, which I think was discussed in a previous orthopedic talk um which is quite common after reperfusion of the lower limb after it's become ischemic. Um so often patients actually have fasciotomies done in theater at the time of vascular repair to try and prevent this, which have gradually closed over time. And then ischemic refusion syndrome, which is basically just the release of substances such electrolytes from damaged muscle cells such as potassium or hydrogen ions that can cause a lot of electrolytes abnormalities and acidosis. So, they require a lot of regular medical monitoring as well. Right briefly to, to uh touching on peripheral aneurysms, they don't come, come up as much is important to know about. Um So uh peripheral aneurysm, just an aneurysm affecting any of the peripheral arteries, around 70 to 80% of them are actually popliteal. Um So in the back of the knee, um and their ati is similar to AAA S. So trauma, infection, connective tissue diseases and inflammatory disorders. Um such as Takayasu Aortitis can be predisposed to this. Often. They're an incidental finding just on another uh on act scan that's been conducted. Um but they can present with simply unthreatening. Ischemia can produce uh an bolic, uh they can produce emboli which eventually can occlude arteries. It can cause extensive bruising if they are ruptured and can present with a postal mass investigations. First line again, is your ultrasound duplex and and then act or MRI and GEO to further classify the, the uh aneurysm itself, management is generally via a um, stent insertion or we can open ligate the aneurysm as seen in figure 17, where they basically bypass the aneurysm and then directly resect it from the artery. Um uh or, or they can be if they're not particularly symptomatic and they're not large. So next fashion, an 88 year old male with a past medical history of diabetes sent to his GP with a one month history of a painful wet ulcer with irregular borders on the medial aspect of his lower leg, brachial pressure index of naught 0.9. So it is the first line method of manage management for this patient's condition fine. So the majority of people were put managing, which is of course, of course, the correct answer. So this is a venous ulcer seen in the picture here. These are 80% of lowering ulcers um that present to general practice. Uh they can be more and they can be mixed venous arterial. So the main method of management is basically uh comparing um as long as there's no evidence that there's any arterial disease associated with the ulcer. So we do A BPS before we start managing and we give this with regular dressing changes. Um typically. So, angioplasty and stenting is a method of management, obviously for arterial disease. So, isn't the correct answer? Um The referral to diabetic foot clinic is not really uh classical of a, a diabetic ulcer in description and not the correct location. So this wouldn't be required venous stripping uh if there's associated parks to the er, but that's not described in this scenario. Um and bypass grafting again is a method of management for uh arterial disease. So, is incorrect in this scenario. Sorry, I just got an ambulance again. So the of venous disease is just secondary to venous insufficiency and uh incompetence however, can occur due to venous outflow obstruction such as in patients where they have large abdominal masses, including the eye el or even in pregnant patients as well. Risk factors include age uh history of venous thrombus, emem or va veins and obesity as well. Classically present as the shallow painful ulcers with irregular borders in the gator region of the ankle are seen in the diaphragm with signs of venous insufficiency that we'll discuss about. Uh in the next slide. Uh The initial investigation is a duplex ultrasound and is important just to rule out our disease because giving a patient compression, managing of arterial disease is obviously contraindicated. Uh and then culturing the wound if there's any signs of infection management involves leg elevation exercise, compression, managing and they might need antibiotics. If there's signs of any infection, dressing and emergence are quite key and good wound care is key for for these patients often requiring changes to their dressings around 22 to 3 times. A week. Here are just some classic venous eczema seen in figure uh he staining which is this darkened staining on the lower ankle seen in 20 then lipodermatosclerosis, which is also referred to as the inverted champagne bottle sign because of the appearance of the the narrow ankle and the large calf. Um looking like an inverted champagne bottle bottle arterial to reduce blood arterial blood flow to the leading to poor perfusion and poor healing and causes the ulcer. Risk factors include known peripheral arterial disease, smoking, diabetes, hypertension, and high cholesterol. Uh classically as seen in figure 22 presented with this punched out appearance of a well fine border um and it's not seem particularly well in this image but often might have a darkened necrotic base. Uh indicating ischemia often that sites sort of trauma and pressure areas. Uh The initial er method of investigation is an ankle breaker, pressure index, duplex, ultrasound and A CT angiogram or M RM to evaluate for the arterial anatomy generally. Um on the scenario. But uh after these patients, the urgent vascular review because they often present with signs of critical limb threatening ischemia was can be managed conservatively with lifestyle changes, smoking cessation. Um again, like any vascular disease, starting them on statins and clopidogrel and optimizing their blood glucose. And any non healing ulcers might be offered angioplasty in an attempt to try and improve perfusion and healing of the area or maybe even stenting or bypass grafting as well. So, and then our last ulcer that we're gonna be talking about is these neuropathic ulcers. Uh basically secondary to peripheral neuropathy, most commonly type two diabetes or to diabetes, basically caused by loss of protective sensation in the foot, leading to repetitive stress and unnoticed injuries, um to the foot causing chest ulcers, um, pen ulcers because they can't feel secondary to theopathy. Often vascular disease, exacerbates all issues and reduces healing. Risk factors include any sort of condition associated with peripheral neuropathy such as B12 deficiency or diabetes. They might present with symptoms of peripheral neural feet and numbness, the lower limb burning or tingling of the lower limb and muscle wasting as well. Um And they typically have this, it again, a similar punch out appearance but over directly over uh areas, pressure areas at the bottom of the foot such as uh where the metatarsal heads are as seen in figure 23 here or the heel possibly as well. Uh It's important to get HBA1C and B12 levels um to look for any exacerbating features. Um an ABP ra duplex swab and x-ray in some scenarios. So, if you are concerned that the patient might have Osteomyelitis as well, management is uh requires a full M ET approach. So first line always refer the clinic to optimize their blood glucose control. Um and also review the ulcer itself where they'll be seen by vasa. Um typically uh need regular chop to make sure. Uh and also uh that the need to wear, advice on wearing good footwear to prevent any further ulceration forming. Uh Any signs of infection might require, typically, we use flucloxacillin. Um And then there might need debridement or amputation depending on the degree of the ulcer foot is just basically a complication of neuropathic ulcers, uh sorry, associated with peripheral neuropathy and also often neuropathic ulcers as well. It's basically just where there's loss of joint sensation in the foot leading to continue unnoticed trauma and deformity forms because of this. And this basically just pre exposes you to neuropathic ulcer formation and you get that rocker bottom. So as seen in diagram F figure, um and you can see why that would predispose to neuropathic ulcer formation. Um The management typically is completely offloading the foot and sometimes immobilize a cast, an orthopedic with you and they might consider surgery for this fine. So on our last note, GP with dilated superficial veins across his leg associated with some localized tenderness on examination, lodge, torturous congested veins noticed across both his legs associated with hemosiderin staining and venous eczema. He is diagnosed as having varicose veins. So, what is the first time method of, of investigation for this patient's condition? Right. So 75% of people do that, which is the correct answer. And so this is the first time direct imaging arterial would be useful because there's no obvious arterial disease. The CV might be conducted if the patient is with surgery. But isn't the first time that it may be. Yeah. So veins is taught, vein caused by valvular incompetence. Basically causes congestion of the superficial, um, veins of the lower limb leads to venous tension and subsequent dilatation surrounding skin changes uh around the veins. Most commonly primary, primary idiopathic in nature, but can be secondary to patients that have had quite significant uh deep vein thromboses in the past or if they have venous outflow destruction, like discussed before from large pelvic masses such as fibroids, um uh or in pregnancy as well, typically presents initially just with cosmetic issues, but in severe cases can become more symptomatic with aching itching, sometimes they can bleed if they're not. Um And also there's skin lesions associated with venous insufficiency as discussed before. Uh the initial investigation uh is duplex ultrasound of the of the venous system management is often conservative initially. Um just depends on the degree of the patient's symptoms. So, uh conservative advice includes uh advising the patient to avoid prolonged standing weight loss and also increasing exercise because increasing exercise um basically increases uh muscle contraction in the lower limbs which helps aid with uh venous blood flow back to the heart and reduce the congestion in the system. Um Compression stockings are the first line method of management as well. Um and are up to date by GPS, obviously, obviously, once um uh any arterial disease has uh is, is, is not suggested in the this presentation A BPI is normal. So, however, if the patient does present with symptoms such as pain, has associated skin changes, venous insufficiency, skin changes or has any leg ulcers. And they need to refer to vascular services for consideration of surgical repair and there's loads of different forms of surgical repair again for these patients. Um So thermal ablation is one option as seen in figure 25. Basically, they insert a catheter and heat the vein from the inside which causes irreversible damage to the vein causing fibrosis and then closure of the vein lumen. So, reducing the dilatation in the leg foam, sclerotherapy is another option. Um So that's just basically involving the sclerosing agent directly into the varicus vein causing an inflammatory response, which again closes off the vein and reduces the dilatation. And then vein ligation um is another method basically involving uh making an incision in the groin, identifying the vein that is responsible for um the uh congestion in the veins and then tying it off and potentially stripping it away as well. Um And this is often used in quite severe cases. So, thank you very much for listening. Um I think instead of using the QR uh should be some way to give feedback uh in the app. Is that right for you? Yeah. So I'll send the feedback form again. It's in the chat. OK. So we're going out. Um And give us any feedback and then we'll send slides to your email. Um Once you've done that over the next few days. Thanks very much for listening. By all means, come back next week for our breast.