Vascular

Vascular

Acute Arterial
1. 6 P's
  1. Pulseless
    1. Score 0
  2. Pain (exacerbated by movement)
  3. Pallor (cyanotic blotches)
  4. Paraesthesia (1-3 hours after onset, sensory nerve ischaemia)
  5. Paralysis (6hours)
  6. Poikothermia
2. Categories
  1. 1- Viable (No motor or sensory loss, clearly audible Doppler signals)
  2. 2- Threatened limb (Audible venous but no arterial on Doppler) A - prompt treatment minimal sensory loss, no motor loss. B - require immediate treatment - muscle weakness, sensory loss more than toes
  3. 3- Irreversible damage - amputation
3. Reperfusion
  1. Results from muscle hypoxia & associated metabolic changes. It is an accumulation of potassium, lactic acid & cellular enzymes which causes a fall in the local Ph (these conditions are a risk for cardiac depression & dysrhythmia. The products of muscle breakdown (myoglobulin) is associated with renal damage - need to monitor electrolytes & urinary output closely.
4. Assessments
  1. Pulse level indicates level of occlusion
  2. Segmental arterial pressures (Vascular team)
  3. ABPI
  4. Angiography (Gold Standard)
    1. Needle inserted in to the femoral artery & a radio-opaque dye is injected just proximal to the occlusion. It can be used to locate occlusions & stenotic vessels & to determine whether a collateral circulation has been established. Helps to determine most appropriate vascular procedure
  5. Duplex Ultrasound (Radiology)
5. Management
  1. Identify the cause (intrinsic embolus/thrombus etc), if extrinsic remove cause (A&E vasc team)
  2. Categorise it, Grade 1,2A, 2B or 3? Use 6Ps
  3. Refer to A&E & Vascular team for assessments
  4. Thrombolysis (IV heparin)<14 days. Peripheral arterial surgery >14 days -bypass/stents
Chronic Arterial
1. Assessments
  1. ABPI
    1. Record systolic pressure at arm, record systolic pressure at tibial, divide reading of ankle by arm
    2. 0-0.5 = pre gangrenous unlikely to heal
    3. 0.5-0.75 = severe arterial obstruction present
    4. 0.75-0.98 = some arterial obstruction present
    5. 0.98-1.31 = Normal
  2. Buerger's test
    1. Elevate limb until the plantar aspect of the foot turns pale (1m), if limb rapidly loses pallor suggests widespread insufficency
    2. Lower limb in to dependency and note how long it takes for the colour to return
    3. 15 seconds = normal
      1. 20 Seconds = arterial deficiency
        40 seconds = severe arterial deficiency
  3. Doppler
    1. triphasic = normal, biphasic = arterial impairment, monophasic = severe impairment/ AV shunting
  4. Allan's test
    1. Elevate limb & compress DP/PT, maintain pressure & lower limb, rapid return indicates sufficient supply via other artery
2. Intermittent claudication
  1. MGT - improved nutrition, smoking cessation, increase exercise (Referall to self help)
    1. Pharmacological = asprin, antihypertensives and statins (GP Referral)
      1. Surgical referral to vasc = angioplasty, endarterectomy, arterial bypass
  2. 60% reduction of atrial lumen
3. Rest Pain
  1. Same as intermittent claudication
  2. 70-80% reduction of arterial lumen due to atheromatous activity leading to insufficient o2 delivery to tissues while at rest
Acute Venous
1. Risk factors
  1. older age
  2. Surgery, inactivity, immobilisation, paraplegia
  3. Cancers
  4. Pregnancy, combined oral contraceptive pill
  5. Anti-phospholipid, inflammatory disease
  6. Obesity
  7. Infection
  8. Nephrotic syndrome
  9. IV drug use
  10. Thrombophilia
2. Differential diagnosis
  1. Phlebitis
  2. Cellulitis
  3. Acute ischemia
  4. Baker's cyst rupture
  5. Muscle/tendon tears
3. Diagnosis
  1. D-dimer test - specialised blood test used to detect small fragments of broken off clot (95% sensitive, 50% specific)
  2. Unilateral leg pain, swelling, tenderness, increased temperature, pitting odema and prominent superficial veins
  3. Pulmonary embolism
    1. Breathlessness, chest pain, collapse, tachycardia, hypotension, hypoxia, cyanosis, risk factors
  4. Wells score > refer for venous ultrasound to confirm if likely
4. Treatment
  1. Treated with therapeutic doses of LDWH until diagnosis unlikely/anticoagulant therapy has been established
    1. After first episode, treatment with a vitamin k antagonist should be initated
      1. Target INR should be 2.5. 3.5 will be considered if there is a recurrent episode during 2.5
        Graduated elastic compression stockings should be worn for 2 years post DVT to reduce the risk of post-phelbitic syndrome
        Be aware of bleeding risk in this patient group
  2. IV unfractioned heparin in certain circumstances
Chronic Venous
1. Pathology: Vascular incompetence of veins resulting in o2 desaturation of haemoglobin
2. Management
  1. Raising lower legs while sitting/during periods of rest
  2. Regular stretching exercises of lower limb
  3. Revision of pharmacological management
  4. Support stockings
    1. Class I: 20-30mmHg aching, swelling small varicose vein changes
      1. Class II: 30-40mmHg, symptomatic varicose veins, chronic venous insufficiency, post ulcer
        Class III: 40-50mmHg Chronic venous insufficiency, post ulcer, lymphodema
        Class IV: 50-60mmHg, same as III
  5. Venous ulceration
    1. Simple non-adherent dressings are recommended in the mgt
      1. High compression multicomponent bandaging should be routinely used for the treatment of leg ulcers
        Referral to specialised leg ulcer clinics
3. Presentation
  1. Presentation - unilateral suggestive of CVI, if bilateral suggestive of congestive heart failure
  2. Pain: Aching tired heavy legs, night cramps
  3. Veins: Bulbous & Tortious due to varicosities
  4. Warm lower limb
  5. Gravitational oedema
  6. Colour: cyanotic, bhaemosiderin pigmentation, telangestasia
  7. Tissues: Varicose eczema with impaired wound healing
  8. No neurological deficit in acute & chronic VI

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