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Flashcards in Vascular Deck (30)
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1
Q

Tx/prevention of Post surgery DVT

A

Stop COCP 4 weeks pre op

Mobilize as early as possible

Immobilised patients should have heparin

At risk patients should have support hosiery or intermittent pneumatic pressure until 16 hours post op

2
Q

Tx of known DVT

A

LMWH
Stop when INR 2-3

DOAC (1st line) or Warfarin if contraindicated
3 months if DVT is post op
6 months if no precipitating cause
Lifelong if there is known thrombophilia or recurrent DVT

Anticoagulation failure to prevent a PE may indicate an IVC filter, which would stop and thrombi making their way to the lungs

3
Q

Tx of a PE

A

Major/minor treat as DVT

Massive 
A-E resus 
IV morphine + antiemetic  
LMWH  
SBP >90 = warfarin  
SBP <90 = vasopressors + thrombolysis (alteplase/streptokinase)
4
Q

Lifestyle interventions for high blood pressure

A

Lifestyle intervention

Weight loss

Decrease alcohol, sodium, caffeine,

Stop smoking

5
Q

when do you start pharmocological management for hypertension

A

Start in all of those with stage 2 (>140/90)

Start in those under 80 with stage 1 HTN (120-139/0-89) and one of the following:

>20% 10 year CV risk  
Other comorbidities  
Renal disease  
Known CV disease 
Organ disease  `
6
Q

Target Blood pressures in hypertension

A

Clinic:
<140/90
<150/90 if 80 or above
<130/80 if diabetic

<135/85 or 145/85 if Ambulatory

7
Q

What is the pharmocological management of hypertension

A

1st line: ACEIs (<55, non black, high renin), CCBs (>55, black, low renin)
ACEis can be swapped for ARBs if adverse reaction

2nd line: ACEi + CCB

3rd line: +loopdiuretic

4th: spironlactone if K+ <4.5, or thiazide like diuretic, BB or alpha blocker (if CCB is dihydropiridine) if K+ >4.5

8
Q

Tx of hyperlipidaemia

A
  1. lifestyle advice
  2. statins
  3. Ezetimibe
  4. Cholestyramine or PCSK9 inhibitor (alirocumab)
  5. fibrates - used for familial disease or with comorbin hypertriglycerideaemia
9
Q

side effects of ace inhibitors

A

dry cough (10%)

hyperkalaemia

worsened renal function (up to 30% rise in creatinine allowed)

first dose hypotension

10
Q

contraindications for ace inhibitors

A

renal artery stenosis

11
Q

side effects of CCBs

A

Peripheral oedema

Postural hypotension

Reflex tachycardia

12
Q

what qRISK score indicates atorvostatin prescription

A

> 10%

13
Q

counselling points for statins

A

Nausea

Headache

Muscle pain

Always report muscle pain as rarely rhabdomyolysis occurs

14
Q

Tx for unruptured unprotected AAA

A

<5.5cm
Treat with regular USS
Modify risk factors (HTN)
75% will progress to requiring surgery with no risk factor modification

> 5.5cm
Think about surgery
Risk of rupture in AAAs >6cm goes from 1% to 25%

Expansion >1cm in a year
Surgery

Symptomatic aneurysms
Surgery

Surgery = EVAR

15
Q

major risk in EVAR surgery

A

kidney injury - contrast used is nephrotoxic and there is often ischaemia as the aorta is clamped

16
Q

Tx of popliteal aneurysms

A

Femoral to distal popliteal bypass grafts

Intravascular thrombolysis or embolectomy may occur at the time of the surgery for distal emboli

17
Q

Tx of aortic dissection

A

A-E resus
Urgent cardiothoracic advice

Patients managed on ITU
BP controlled to keep around 100
IV esmolol

Type A dissection (involves ascending aorta)
Patients are considered for surgery if fit enough due to risk of tamponade
Surgery is grafting of the aortic root
High operative mortality

Type B dissection (descending only)
Medical management if there are no complications

18
Q

complications of aortic dissection

A

tamponade

spreading dissection affecting a major artery:
Coronary arteries = MI
Brachiocephalic trunks = CNS issues with unequal arm pulses
Renal arteries = haematuria, AKI, anuria
SMA/IMA = mesenteric ischaemia
Iliac arteries = acute lower limb ischaemia

19
Q

Treatment for chronic peripheral arterial disease

A
ABPI >0.6 - conservative management 
weight loss
stop smoking
exercise to point of claudication (improves collatorals) 
raise heel - reduces calf work
foot care 
optimise BP and Diabetes if present
Clopidorel + atorvostatin 

ABPI <0.6 - surgical management
mild-moderate disease - percutaneous transluminal angioplasty
severe - surgical reconstruction/bypass

if surgery not possible - sympathectomy helps w pain

amputation is last resort, for intractible pain and septicaemia/gangrene

20
Q

what has been shown to improve phantom limb pain in amputation

A

preoperative gabapentin

mirror therapy

21
Q

how long do you have to re-establish flow in an acutely ischaemic limb

A

6 hours

22
Q

Tx of acute arterial occlusive disease of peripheral limbs

A

A-E resus

IV heparin to prevent clot formation

Assessment of limb
Blood starting to come back via collaterals indicates the use of thrombolysis over surgery
No blood supply + neurological changes = urgent surgery indicates

Urgent CT angiogram
Can differentiate between thrombotic/embolic causes

Embolus management
Open embolectomy
Performed using a fogarty catheter
There may be some local thromboylsis if the clot has propogated beyond the original embolus

Investigation into the underlying cause

Thrombus management
Thrombolysis to restore patency
Interval angioplasty to treat underlying disease

Last resort = amputation
Only undertaken in threatened limbs where the patient is not able to undergo operative intervention
Also done if the leg is not viable

23
Q

what indicates a non-viable limb in acute arterial occlusive disease

A

fixed staining (no blanching) and rigid muscles

24
Q

management of reynauds

A

Keep extremities warm

Heated gloves

Stop smoking and stop exacerbating drugs
B blockers
OCP

Nifedipine is the first line medical therapy, 2nd line includes:
Losartan
Prazocin
Fluoxetine

Sympathomimectomy may provide symptomatic relief for those with severe disease but it will be short lived

25
Q

management of thoracic outlet syndrome

A

Surgery
Excision of surgical rib/often first rib also
Grafting of the post stenotic aneurysm

26
Q

when should you treat varicose veins

A

Grossly dilated/symptomatic veins

Haemorrhage

Skin changes

Incompetent perforator veins (can be treated minimally)

27
Q

Tx for Varicose veins

A

Lifestyle advice
Avoid prolonged standing
Regular exercise
Lose weight

Graded compression stockings
Minor varicosities
Elderly and unfit

Endothermal ablation
Often treatment of choice
Laser fibre passed along vein under ultrasound guidance and fired to cause a thrombosis

Sclerotherapy
For cosmetically undesirable superficial varicosities
Chemical sclerosant is injected into an empty vein and then compression bandages are used for 2 weeks to allow fibrosis to occur

Surgery
Gold standard but indications are under scrutiny
Disconnects saphenous vein from deep femoral veins
Incompetent perforators are ligated also

28
Q

complications of untreated varicose veins

A

haemorrhage

phlebitis

29
Q

treatment for deep venous insufficiency

A

there is none

30
Q

management of chronic lymphedema

A

Elevation

Compression stockings

Physical massage

Long term Abx for recurrent cellulitis