27- Vascular Explains Flashcards
1
Q
What conditions are associated with ejection systolic murmurs?
A
Aortic stenosis, pulmonary stenosis, hypertrophic obstructive cardiomyopathy (HOCM), atrial septal defect (ASD), and Tetralogy of Fallot
2
Q
What conditions are associated with pan-systolic murmurs?
A
Mitral regurgitation, tricuspid regurgitation, and ventricular septal defect (VSD)
2
Q
What conditions are associated with late systolic murmurs?
A
Mitral valve prolapse and coarctation of the aorta
3
Q
What conditions are associated with early diastolic murmurs?
A
Aortic regurgitation and Graham-Steel murmur (pulmonary regurgitation)
4
Q
What conditions are associated with mid diastolic murmurs?
A
Mitral stenosis
5
Q
What condition is associated with Austin-Flint murmur?
A
Severe aortic regurgitation
6
Q
What is the long saphenous vein used for in bypass surgery?
A
It can be harvested for bypass surgery as a graft to bypass blocked coronary arteries.
7
Q
What is a treatment option for varicose veins with saphenofemoral junction incompetence?
A
The long saphenous vein can be removed as a treatment for varicose veins with saphenofemoral junction incompetence.
8
Q
Where does the long saphenous vein originate?
A
It originates at the 1st digit, where the dorsal vein merges with the dorsal venous arch of the foot.
9
Q
What path does the long saphenous vein take in the leg?
A
It passes anterior to the medial malleolus, runs up the medial side of the leg, and at the knee, it runs over the posterior border of the medial epicondyle of the femur bone. It then passes laterally to lie on the anterior surface of the thigh before entering an opening in the fascia lata called the saphenous opening.
10
Q
Where does the long saphenous vein join with the femoral vein?
A
It joins with the femoral vein in the region of the femoral triangle at the saphenofemoral junction.
11
Q
What are the tributaries of the long saphenous vein?
A
The tributaries include the medial marginal vein, superficial epigastric vein, superficial iliac circumflex vein, and superficial external pudendal veins.
12
Q
Where does the short saphenous vein originate?
A
It originates at the 5th digit, where the dorsal vein merges with the dorsal venous arch of the foot, which attaches to the great saphenous vein.
13
Q
What path does the short saphenous vein take in the leg?
A
It passes around the lateral aspect of the foot (inferior and posterior to the lateral malleolus) and runs along the posterior aspect of the leg, alongside the sural nerve. It then passes between the heads of the gastrocnemius muscle.
14
Q
Where does the short saphenous vein drain into?
A
It drains into the popliteal vein, approximately at or above the level of the knee joint.
15
Q
When are amputations indicated for the affected limb?
A
Amputations are indicated when the affected limb is dead and non-viable, posing a major threat to life, or deemed useless where a prosthesis would be preferable.
16
Q
In what cases is orthopaedic surgery likely to perform an amputation?
A
Orthopaedic surgery may consider amputation as a last resort when limb salvage has failed, and the limb is non-functional to the point where mobility would be best achieved with a prosthesis. This includes cases of chronic fracture non-union or significant limb shortening following trauma.
17
Q
When would a primary amputation be preferable following major trauma?
A
A primary amputation would be preferable in cases of open fracture with major distal neurovascular compromise and other life-threatening injuries present.
18
Q
What is the most prevalent cause for amputations in vascular surgery?
A
The most prevalent cause for amputations in vascular surgery is diabetic foot sepsis, which can rapidly spread in the presence of established peripheral vascular disease.
19
Q
What is the main concern in vascular surgery prior to performing an amputation?
A
The main concern in vascular surgery is optimizing vascular inflow before the amputation. The more distal the planned amputation, the more crucial this becomes.
20
Q
When would an amputation be required following an embolic event?
A
If an embolic event has occurred and revascularization has not been successful in time, resulting in fixed mottling of the limb, an amputation will be necessary.
21
Q
What are the main categories of lower limb amputations?
A
The main categories of lower limb amputations include pelvic disarticulation (hindquarter), above knee amputation, Gritti Stokes (through knee amputation), below knee amputation (using either Skew or Burgess flaps), Syme’s amputation (through ankle), and amputations of mid foot and digits.
22
Q
What factors are considered when choosing a level of amputation?
A
The level of amputation is chosen based on the disease process being treated, desired functional outcome, and the patient’s co-morbidities.
23
Q
What are the advantages of above knee amputations?
A
Above knee amputations are quick to perform, heal reliably, and patients regain their general health quickly. However, many patients over the age of 70 may not be able to walk on an above knee prosthesis.
23
What are the considerations for below knee amputations?
Below knee amputations are technically more challenging to perform and heal less reliably compared to above knee amputations. However, many more patients are able to walk using a below knee prosthesis. Skew flaps or Burgess long posterior flap are commonly used in below knee amputations, with skew flaps resulting in a less bulky limb that is easier to attach a prosthesis to.
24
What type of flaps are used in above knee amputations?
Above knee amputations use equal anterior-posterior flaps.
25
Are there circumstances when above knee amputation may be preferred over below knee amputation?
Yes, in cases such as fixed flexion deformities of the lower limb, where little functional benefit would be gained from below knee amputation surgery, an above knee option may be preferable.
26
What are the indications for surgery to revascularize the lower limb in peripheral vascular disease?
The indications for surgery to revascularize the lower limb in peripheral vascular disease include intermittent claudication, critical ischemia, ulceration, and gangrene. Intermittent claudication that is not disabling may be a relative indication, while the other complaints are often absolute indications, depending on the patient's frailty.
27
What are the methods used for assessing peripheral vascular disease?
Peripheral vascular disease can be assessed through clinical examination, ankle brachial pressure index measurement, duplex arterial ultrasound, and, in some cases, angiography (standard, CT, or MRI) if intervention is being considered.
28
What is angioplasty and when is it performed?
Angioplasty is a procedure performed to treat peripheral vascular disease. It is successful when the artery is accessible, the lesion is relatively short, and there is reasonable distal vessel runoff. Longer lesions may require sub-intimal angioplasty.
29
When is surgery considered for peripheral vascular disease?
Surgery is considered when attempts at angioplasty have failed or are unsuitable. Surgery involves bypassing the affected arterial segment by using a graft to run from above the disease to below the disease. Good runoff, similar to angioplasty, improves the outcome.
30
What is the preferred conduit for bypass surgery in the superficial femoral artery to above knee popliteal region?
In the ideal scenario, vein (either in situ or reversed long saphenous vein) is used as a conduit. However, prosthetic material can also be used with reasonable 5-year patency rates. Some surgeons may prefer using prosthetic material to preserve vein for future procedures. Both techniques generally have excellent outcomes if there is satisfactory run-off.
31
What is the general procedure for bypass surgery?
The artery is dissected out, IV heparin (3,000 units) is given, and then the vessels are cross-clamped. A longitudinal arteriotomy is made, and the graft is cut to size and tunneled to the arteriotomy sites. The anastomosis to the femoral artery is usually performed using a 5/0 'double-ended' Prolene suture, and the distal anastomosis is typically done using a 6/0 'double-ended' Prolene suture.
32
What are some considerations for femoro-distal bypass surgery?
Femoro-distal bypass surgery is more time-consuming, technically challenging, and has higher failure rates compared to other bypass procedures. In elderly diabetic patients with poor run-off, primary amputation may be a safer and more effective option. It is not recommended to perform this type of surgery in patients who are wheelchair-bound. Vein is preferred over polytetrafluoroethylene (PTFE) for femoro-distal bypasses, as it provides superior outcomes.
33
What are some important rules to follow in bypass surgery?
Vein mapping is done first to assess the availability of suitable vein for the conduit. Using PTFE for the distal anastomosis can lead to early graft occlusion and failure due to sub-intimal hyperplasia. Attaching vein to the end of a PTFE graft for the distal anastomosis, known as a 'vein boot' or Miller Cuff, is associated with better patency rates than using PTFE alone. Remember that the more distal the arterial anastomosis, the lower the success rate.
34
What causes lymphoedema?
Lymphoedema is caused by impaired lymphatic drainage in the presence of normal capillary function.
35
What are the characteristic features of lymphoedema?
Lymphoedema causes the accumulation of protein-rich fluid, subdermal fibrosis, and dermal thickening. Fluid is typically confined to the epifascial space (skin and subcutaneous tissues), and muscle compartments are usually free of edema. Unlike other forms of edema, lymphoedema involves the foot, and there may be a 'buffalo hump' on the dorsum of the foot. The skin cannot be pinched due to subcutaneous fibrosis.
36
What are the causes of primary lymphoedema?
Primary lymphoedema can be categorized based on age of onset. For individuals under 1 year, it is usually sporadic or associated with Milroy's disease. Onset between 1-35 years is also often sporadic or related to Meige's disease. Onset after the age of 35 is referred to as Tarda.
37
What are the causes of secondary lymphoedema?
Secondary lymphoedema can be caused by bacterial, fungal, or parasitic infections (such as filariasis), lymphatic malignancy, radiotherapy to lymph nodes, surgical resection of lymph nodes, deep vein thrombosis (DVT), or thrombophlebitis.
38
What are the indications for surgery in lymphoedema?
Surgery may be indicated in cases of marked disability or deformity caused by limb swelling. It is also suitable for lymphoedema caused by proximal lymphatic obstruction with patent distal lymphatics that can undergo a lymphatic drainage procedure. Additionally, surgery may be considered for lymphocutaneous fistulae and megalymphatics.
39
What is the Homans operation?
The Homans operation is a surgical procedure aimed at reducing limb circumference in lymphoedema. Skin flaps are raised, and the underlying tissue is excised, typically resulting in a one-third reduction in limb size. This procedure requires the overlying skin to be in good condition.
40
What is the Charles operation?
The Charles operation involves the excision of all skin and subcutaneous tissue around the calf down to the deep fascia in cases where the overlying skin is not in good condition. Split skin grafts are then placed over the site. The Charles operation typically results in a larger reduction in size compared to the Homans procedure.
41
What is a lymphovenous anastomosis?
A lymphovenous anastomosis is a surgical procedure where identifiable lymphatics are connected to subdermal venules. This procedure is usually indicated in about 2% of patients with proximal lymphatic obstruction and normal distal lymphatics.
42
What is the ankle-brachial pressure index (ABPI)?
The ankle-brachial pressure index (ABPI) is a commonly performed vascular investigation. It is calculated by dividing the lower limb pressure by the highest upper limb pressure.
43
What are the results and their interpretations for ABPI?
ABPI results and their interpretations are as follows:
- 1.2 or greater: Usually due to vessel calcification.
- 1.0-1.2: Normal.
- 0.8-1.0: Minor stenotic lesion. Initiate risk factor management.
- 0.50-0.8: Moderate stenotic lesion. Consider duplex scanning and continue risk factor management. Avoid tight compression bandages if mixed ulcers are present.
- 0.3-0.5: Likely significant stenosis. Duplex scanning is needed to delineate lesions. Compression bandaging is contraindicated.
- Less than 0.3: Indicative of critical ischemia. Urgent detailed imaging is required.
- 1.2 or greater: Usually due to vessel calcification.
- 1.0-1.2: Normal.
- 0.8-1.0: Minor stenotic lesion. Initiate risk factor management.
- 0.50-0.8: Moderate stenotic lesion. Consider duplex scanning and continue risk factor management. Avoid tight compression bandages if mixed ulcers are present.
- 0.3-0.5: Likely significant stenosis. Duplex scanning is needed to delineate lesions. Compression bandaging is contraindicated.
- Less than 0.3: Indicative of critical ischemia. Urgent detailed imaging is required.
44
What are some key questions to consider when evaluating groin lumps?
When evaluating groin lumps, consider the following key questions:
- Is there a cough impulse?
- Is it pulsatile and expansile (to distinguish between false and true aneurysm)?
- Are both testes intra scrotal?
- Are there any lesions in the legs, such as malignancy or infections (possibly lymph nodes)?
- Have you examined the ano rectum, as anal cancer may metastasize to the groin?
- Is the lump soft, small, and very superficial (possibly a lipoma)?
- Is there a cough impulse?
- Is it pulsatile and expansile (to distinguish between false and true aneurysm)?
- Are both testes intra scrotal?
- Are there any lesions in the legs, such as malignancy or infections (possibly lymph nodes)?
- Have you examined the ano rectum, as anal cancer may metastasize to the groin?
- Is the lump soft, small, and very superficial (possibly a lipoma)?
45
What are some common causes of groin masses?
Common causes of groin masses include herniae, lipomas, lymph nodes, undescended testis, femoral aneurysm, and saphena varix (which is more of a swelling than a mass).
46
What are some key questions to consider when evaluating scrotal lumps?
When evaluating scrotal lumps, consider the following key questions:
- Is the lump entirely intra scrotal?
- Does it transilluminate (possibly a hydrocele)?
- Is there a cough impulse (possibly a hernia)?
- Is the lump entirely intra scrotal?
- Does it transilluminate (possibly a hydrocele)?
- Is there a cough impulse (possibly a hernia)?
47
What is the recommended next investigation when the diagnosis is not clear clinically?
When the diagnosis is not clear clinically, an ultrasound scan is often the most convenient next investigation.
48
What is chronic venous insufficiency (CVI)?
Chronic venous insufficiency is a series of tissue changes that occur due to pooling of blood in the extremities and associated venous hypertension resulting from incompetent deep vein valves. It can range from a minor cosmetic problem to ulceration and disability.
49
What are varicose veins?
Varicose veins are saccular dilations of veins. They occur due to localized weakness in the vein wall, leading to dilatation and reflux of blood caused by non-union of valve cusps.
50
What are the typical symptoms of varicose veins?
Typical symptoms of varicose veins include cosmetic appearance, aching, ankle swelling that worsens as the day progresses, episodic thrombophlebitis, bleeding, and itching.
51
What are the typical symptoms of chronic venous insufficiency?
Typical symptoms of chronic venous insufficiency include dependent leg pain, prominent leg swelling, edema extending beyond the ankle, and venous stasis ulcers.
52
What are the characteristics of a typical venous stasis ulcer?
A typical venous stasis ulcer is located above the medial malleolus and has an indolent appearance with basal granulation tissue, variable scarring, non-ischemic edges, and haemosiderin deposition in the gaiter area (and also lipodermatosclerosis).
53
What are some differential diagnoses for chronic venous insufficiency and varicose veins?
Differential diagnoses include lower limb arterial disease, Marjolins ulcer, claudication, spinal stenosis, and swelling due to medical causes such as congestive heart failure. Physical examination and ankle-brachial pressure index measurement can help exclude these differentials.
54
What are the key aspects to examine when evaluating chronic venous insufficiency and varicose veins?
When examining chronic venous insufficiency and varicose veins, assess for a dilated short saphenous vein in the popliteal fossa and palpate for saphena varix medial to the femoral artery. Perform the Brodie-Trendelenburg test to assess the level of incompetence and use Perthes' walking test to evaluate if the deep venous system is competent.
55
What are the recommended investigations for chronic venous insufficiency and varicose veins?
The recommended investigations include a Doppler exam to assess for venous reflux and detect retrograde flow as a biphasic signal. A duplex scan is also performed to ensure a patent deep venous system, especially in cases of deep vein thrombosis (DVT) or trauma.
56
What is the importance of a Doppler assessment in the evaluation of chronic venous insufficiency and varicose veins?
A Doppler assessment helps assess for venous reflux and classifies patients as having uncomplicated varicose veins or varicose veins with associated chronic venous insufficiency. It is particularly important to investigate a history of previous thrombotic events (DVT/lower limb fracture) and perform a duplex scan in patients with such a history or evidence of chronic venous insufficiency.
57
What is the recommended treatment for minor varicose veins without complications?
For minor varicose veins without complications, reassurance and cosmetic therapy are typically sufficient.
58
What are the treatment options for symptomatic uncomplicated varicose veins without deep venous insufficiency?
Treatment options for symptomatic uncomplicated varicose veins without deep venous insufficiency include endothermal ablation, foam sclerotherapy, saphenofemoral/popliteal disconnection, stripping and avulsions, and the use of compression stockings.
59
What is the recommended therapy for varicose veins with skin changes?
For varicose veins with skin changes, the recommended therapy is the same as for symptomatic uncomplicated varicose veins. However, the use of compression stockings is essential, with a minimum requirement of formal class I stockings.
60
What is the recommended therapy for chronic venous insufficiency or venous ulcers?
The recommended therapy for chronic venous insufficiency or venous ulcers is the use of class 2-3 compression stockings, ensuring there is no arterial disease present.
61
What is the recommended application of compression stockings for chronic venous insufficiency and varicose veins?
Formal compression stockings, usually class II or III, are commonly used. Patients who have suffered ulceration should wear compression stockings long-term. If ulceration is present and established saphenofemoral reflux is present, surgical intervention should be considered for durable relief of symptoms, either initially or after ulcer healing.
62
What are the minimally invasive treatment options for chronic venous insufficiency and varicose veins?
Injection sclerotherapy with 5% Ethanolamine oleate is a commonly used option. Foam sclerotherapy is also increasingly popular, although transient blindness has been reported as a rare side effect. Endovenous laser therapy is another minimally invasive option.
63
What is the current best practice guidance in the United Kingdom for the treatment of varicose veins?
According to the National Institute of Clinical Excellence (NICE) guidance, for patients with symptomatic varicose veins, the first-line procedure of choice should be endothermal ablation. If this is not available or unsuitable, foam sclerotherapy is recommended as the second-line option. Surgery is currently considered the third-line treatment option.
64
What are the surgical procedures for chronic venous insufficiency and varicose veins?
Surgical procedures include sapheno-femoral or sapheno-popliteal ligation, stripping, and multiple phlebectomies. In the case of the long saphenous vein (LSV), sapheno-femoral or sapheno-popliteal ligation is performed. The vein can also be stripped to the level of the knee or upper calf, although there is an increased risk of saphenous neuralgia if it is stripped more distally.
65
What is the Trendelenburg procedure for chronic venous insufficiency and varicose veins?
The Trendelenburg procedure involves the ligation of the sapheno-femoral junction. The patient's head is tilted 15 degrees and the legs are abducted. An oblique incision is made 1cm medial to the artery, and tributaries such as the superficial circumflex iliac vein, superficial inferior epigastric vein, and superficial and deep external pudendal vein are ligated. The saphenous vein is then stripped to the level of the knee or upper calf. It is important to note that there is an increased risk of saphenous neuralgia if the vein is stripped more distally.
66
What is the simplest and commonly used investigation for assessing venous junctional incompetence?
A Doppler assessment is the simplest and commonly used investigation for assessing venous junctional incompetence. It involves the patient standing and manual compression of the limb distal to the junction of interest. Normal flow should occur in one direction only, while reverse flow indicates junctional incompetence.
67
What are venograms and duplex scans used for in the assessment of venous disease?
Venograms are historically used for obtaining structural venous information, but they are invasive and rarely required in modern clinical practice. The most helpful test for assessing venous disease is a venous duplex scan. It provides information about flow and vessel characteristics, and it is also useful in providing vein maps for bypass surgery.
68
What is the ankle-brachial pressure index (ABPI) measurement used for?
The ABPI measurement is an important investigation to assess the severity of flow compromise in arterial disease. It classifies the severity of the flow compromise. However, in individuals with calcified vessels, such as diabetics, false readings may occur, so results in these cases should be interpreted with caution.
69
What provides reassurance of a healthy vessel during auscultation?
Triphasic signals provide reassurance of a healthy vessel.
70
What does a monophasic signal during auscultation of a vessel indicate?
A monophasic signal is associated with a proximal stenosis and reduction in flow.
71
What information can be obtained from an arterial duplex scan?
Similar to the assessment of veins, an arterial duplex scan provides information about arterial patency and flow patterns. Skilled operators can also gain insights into the state of proximal vessels that are anatomically inaccessible to duplex, such as iliac vessels. The assessment of distal flow patterns is crucial.
72
What is the conventional angiogram used for in assessing arteries?
A conventional angiogram, involving vessel puncture and catheter angiography, is considered the gold standard method for assessing arteries. It provides high-quality information about arterial status. However, it carries the risks of contrast toxicity and vessel damage. Severely calcified vessels may pose challenges, and a remote access site, such as the brachial artery, may be used. This technique is particularly useful for providing a distal arterial roadmap prior to femoro-distal bypass.
73
What information can be obtained from CT angiography in arterial disease assessment?
CT angiography provides a considerable amount of structural and flow information. It is particularly useful in the setting of gastrointestinal bleeding and can be rapidly performed by a non-vascular radiologist. However, it lacks the capability for endovascular intervention and does not provide high enough resolution for distal arterial surgery.
74
What are the advantages of magnetic resonance angiography (MRA) in arterial disease assessment?
MRA is a non-invasive method that does not use nephrotoxic contrast. It avoids the risks associated with contrast use. However, movement artifact can be a problem in some sites, and distal arterial resolution is not perfect.
75
What is the most common cause of acute limb ischaemia?
Thrombosis of a pre-existing site of atherosclerosis is the most common cause of acute limb ischaemia.
76
What are the clinical appearances of acute limb ischaemia based on the time elapsed since onset?
Less than 6 hours: White leg; 6-12 hours: Mottled limb with blanching on pressure; More than 12-24 hours: Fixed mottling.
76
Which type of aneurysm poses the greatest threat to the limb when it undergoes acute thrombosis?
Acute thrombosis of popliteal aneurysms poses the greatest threat to the limb.
77
What is the appropriate treatment for acute limb ischaemia based on the clinical picture?
White leg with sensorimotor deficit: Surgery and embolectomy; Dusky leg, mild anesthesia: Angiography; Fixed mottling: Primary amputation.
78
What is the role of thrombolysis in the management of acute limb ischaemia?
Intra-arterial thrombolysis is better than peripheral thrombolysis and is mainly indicated in acute on chronic thrombosis. However, it should be avoided if within 2 months of a stroke or 2 weeks of surgery. Aspiration of clot may improve the success rate if the thrombosis is large.
79
What preparations should be made for surgery in the management of acute limb ischaemia?
Both groins should be prepared, and a transverse arteriotomy is easier to close. If poor inflow persists, iliac trawl should be considered. If this fails, a femoro-femoral cross over or axillo-femoral cross over may be necessary. A check angiogram should be performed on the operating table and prior to closure. Systemic heparinization should follow surgery. Fasciotomy should be considered if the time between onset and surgery exceeds 6 hours.
80
What are the two types of abdominal aortic aneurysms?
Abdominal aortic aneurysms can occur as either true or false aneurysms. True aneurysms involve all three layers of the arterial wall, while false aneurysms are formed by a single layer of fibrous tissue.
81
Who is most commonly affected by abdominal aortic aneurysms?
Abdominal aortic aneurysms are most commonly found in elderly men.
82
What is the approximate incidence of true abdominal aortic aneurysms?
True abdominal aortic aneurysms have an approximate incidence of 0.06 per 1000 people.
83
What is the main cause of abdominal aortic aneurysms?
The main cause of abdominal aortic aneurysms is standard arterial disease, which is commonly seen in individuals who are hypertensive and have a history of smoking. Other patients, such as those with connective tissue diseases like Marfan's, may also develop aneurysms.
84
What is the recommended threshold for surgical intervention in abdominal aortic aneurysms?
Most vascular surgeons recommend surgery once the aneurysm reaches a size of 5.5cm to 6cm. This threshold is based on the risk of rupture, as aneurysms measuring over 7cm have a significantly higher risk compared to those measuring less than 4cm.
85
What imaging technique is commonly used to assess anatomy and plan treatment for abdominal aortic aneurysms?
CT scanning of the chest, abdomen, and pelvis is commonly performed to assess the anatomy and plan treatment for abdominal aortic aneurysms.
86
What is the significance of calcification in the walls of an abdominal aortic aneurysm?
Calcification in the walls of an abdominal aortic aneurysm may facilitate identification on plain x-rays.
87
What are the indications for surgery in abdominal aortic aneurysms?
Symptomatic aneurysms, increasing size above 5.5cm if asymptomatic, and rupture are indications for surgery in abdominal aortic aneurysms.
87
What is the mortality rate for untreated symptomatic aneurysms?
Untreated symptomatic aneurysms have an 80% annual mortality rate.
88
What are the potential complications following abdominal aortic aneurysm repair surgery?
Complications following abdominal aortic aneurysm repair surgery include embolic events such as gut and foot infarcts, cardiac complications due to premorbid states and re-perfusion injury, wound problems, and later risks related to graft such as infection and aorto-enteric fistula.
89
What is the mortality rate for ruptured abdominal aortic aneurysms without surgery?
Ruptured abdominal aortic aneurysms have a 100% mortality rate without surgery.
90
What are the steps involved in abdominal aortic aneurysm repair surgery?
The steps involved in abdominal aortic aneurysm repair surgery include general anesthesia, invasive monitoring, midline or transverse incision, mobilization of bowel and distal duodenum, dissection of the aneurysm neck and base, systemic heparinization, cross clamp placement, longitudinal aortotomy, atherectomy, management of back bleeding, graft insertion, suturing with appropriate materials, removal of clamps, ensuring hemostasis, closure of aneurysm sac, closure of abdominal wall, and skin closure.
91
What is the management approach for ruptured AAA?
In patients with symptoms of rupture, prompt laparotomy is ideal. For patients with vague symptoms and hemodynamic stability, a CT scan is performed to determine if rupture has occurred. The most common rupture site is retroperitoneal. Hemodynamic stability is maintained with a target blood pressure of 100mmHg.
92
What are the special groups of patients requiring a different approach in abdominal aortic aneurysm surgery?
Special groups include patients with supra renal AAA and ruptured AAA.
92
What is the risk associated with supra renal AAA surgery?
Supra renal AAA surgery carries a higher risk of complications and renal failure due to the requirement of a supra renal clamp.
93
What is the role of EVAR in abdominal aortic aneurysm repair?
EVAR, or endovascular aortic aneurysm repair, is an alternative procedure offered to select patients. It involves the joint work of surgeons and radiologists. EVAR is suitable for aneurysms with features such as a long neck, straight iliac vessels, and healthy groin vessels. Fenestrated grafts can be used for supra renal AAA treatment.
94
What are the steps involved in EVAR?
EVAR is performed under general anesthesia in either the radiology suite or the theater. Bilateral groin incisions are made, and the common femoral artery is dissected out. Heparinization is administered, followed by arteriotomy and insertion of a guide wire. The arteriotomy is dilated, and the EVAR device is inserted. Once in a satisfactory position, it is released. The arteriotomy is closed once a check angiogram confirms good position and no endoleak.
95
What are the potential complications associated with EVAR?
Complications of EVAR include endoleaks, which can be Type I or Type 2 depending on the site. These may require re-intervention, and all EVAR patients require follow-up.
96
What are the main causes of venous leg ulcers?
Venous leg ulcers are primarily caused by venous hypertension due to chronic venous insufficiency. Other causes include calf pump dysfunction or neuromuscular disorders.
97
How do ulcers form in venous leg ulcers?
Ulcers form due to capillary fibrin cuff or leucocyte sequestration.
98
Where are venous leg ulcers typically located?
Venous leg ulcers are located above the ankle and are usually painless.
99
What are the features of venous insufficiency associated with leg ulcers?
Features of venous insufficiency include edema, brown pigmentation, lipodermatosclerosis, and eczema.
100
What is the difference between deep venous insufficiency and superficial venous insufficiency?
Deep venous insufficiency is related to previous deep vein thrombosis (DVT), while superficial venous insufficiency is associated with varicose veins.
101
What is the management approach for venous leg ulcers?
The management of venous leg ulcers involves 4-layer compression bandaging after ruling out arterial disease or considering surgery. Skin grafting may be required if the ulcers fail to heal after 12 weeks or if they are larger than 10cm.
102
What diagnostic tests are used for venous leg ulcers?
Doppler ultrasound is used to assess the presence of reflux, while duplex ultrasound evaluates the anatomy and flow of the vein.
103
What are the characteristics of arterial ulcers?
Arterial ulcers occur on the toes and heel, are painful, and may exhibit areas of gangrene. They are associated with cold extremities and no palpable pulses. Low ankle-brachial pressure index (ABPI) measurements are observed.
104
Where are neuropathic ulcers commonly found?
Neuropathic ulcers are commonly found over the plantar surface of the metatarsal head and the plantar surface of the hallux.
105
What is the most common cause of amputation in diabetic patients?
The plantar neuropathic ulcer is the condition that most commonly leads to amputation in diabetic patients.
106
What conditions are associated with pyoderma gangrenosum?
Pyoderma gangrenosum is associated with inflammatory bowel disease, rheumatoid arthritis, and can occur at stoma sites. It presents as erythematous nodules or pustules that ulcerate.
107
What is the management approach for neuropathic ulcers?
The management of neuropathic ulcers includes the use of cushioned shoes to reduce callus formation.
108
What is the primary cause of mesenteric ischaemia?
Mesenteric ischaemia is primarily caused by arterial embolism, resulting in colon infarction.
109
Which areas of the colon are more likely to be affected by mesenteric ischaemia?
Mesenteric ischaemia is more likely to occur in areas such as the splenic flexure, which are located at the borders of the territory supplied by the superior and inferior mesenteric arteries.
109
What are the serological tests that may be abnormal in acute mesenteric embolus?
In acute mesenteric embolus, serological tests such as white cell count (WCC), lactate, and amylase may all be abnormal, particularly in established disease. However, these tests can be normal in the early phases.
109
What are the symptoms of acute mesenteric embolus?
Acute mesenteric embolus presents with sudden onset abdominal pain, profuse diarrhea, and may be associated with vomiting. Rapid clinical deterioration is observed.
109
What are the types of mesenteric vessel disease?
The types of mesenteric vessel disease include acute mesenteric embolus, acute on chronic mesenteric ischaemia, mesenteric vein thrombosis, and low flow mesenteric infarction.
110
What are the symptoms of acute on chronic mesenteric ischaemia?
Acute on chronic mesenteric ischaemia is characterized by a longer prodromal history, postprandial abdominal discomfort, and weight loss. Patients usually present with an acute on chronic event, and symptoms may resemble those of ischaemic colitis.
111
What is the typical history of mesenteric vein thrombosis?
Mesenteric vein thrombosis usually has a history over weeks. Overt abdominal signs and symptoms will not occur until venous thrombosis has reached a stage where arterial inflow is compromised. Thrombophilia accounts for 60% of cases.
111
What is low flow mesenteric infarction?
Low flow mesenteric infarction occurs in patients with multiple comorbidities, in whom mesenteric perfusion is significantly compromised by overuse of inotropes or background cardiovascular compromise. This leads to inadequate bowel perfusion and infarction from the mucosa outwards.
112
What are the serological tests used for diagnosing mesenteric vessel disease?
Serological tests such as white cell count (WCC), lactate, C-reactive protein (CRP), and amylase can be used, but they may be normal in early disease.
113
What is the cornerstone for diagnosing both arterial and venous mesenteric disease?
The cornerstone for diagnosis is CT angiography scanning in the arterial phase with thin slices (<5mm). Venous phase contrast is not helpful.
114
When is SMA duplex ultrasound useful in evaluating mesenteric vessel disease?
SMA duplex ultrasound is useful in evaluating proximal SMA disease in patients with chronic mesenteric ischaemia.
115
Why is MRI of limited use in diagnosing mesenteric vessel disease?
MRI is of limited use due to gut peristalsis and movement artifact.
116
What is the management approach for mesenteric vessel disease with overt signs of peritonism?
In cases with overt signs of peritonism, laparotomy is performed.
117
How is mesenteric vein thrombosis managed if there are no signs of peritonism?
If there are no signs of peritonism, medical management with intravenous heparin is initiated for mesenteric vein thrombosis.
118
What is the recommended approach in cases of mesenteric vessel disease with necrotic bowel?
Limited resection of frankly necrotic bowel is performed with the intention of relooking laparotomy at 24-48 hours. Urgent bowel revascularization is done either via endovascular (preferred) or surgical methods.
119
What is the prognosis for mesenteric vessel disease?
The overall prognosis is poor. The best outlook is seen in cases of acute ischaemia from an embolic event where surgery occurs within 12 hours, with a survival rate of around 50%. Treatment delay reduces the survival rate to 30%. Other conditions associated with mesenteric vessel disease have worse survival figures.
120
Is upper limb arterial disease more or less common than lower limb arterial disease?
Upper limb arterial disease is less common than lower limb arterial disease.
120
What are the possible causes of upper limb circulation impairment?
Upper limb circulation may be affected by embolic events, stenotic lesions (internal and extrinsic), inflammatory disorders, and venous diseases.
121
How does the anatomy of collateral circulation impact disease presentation in the subclavian and axillary artery region?
In the subclavian and axillary artery region, collateral vessels passing around the shoulder joint may provide pathways for flow if the main vessels are stenotic or occluded.
122
What happens to collateral flow during periods of increased metabolic demand?
During periods of increased metabolic demand, collateral flow may not be sufficient, leading to diminished flow in the vertebral arteries. This can result in diminished flow to the brain and neurological symptoms like syncope.
123
What are the features of axillary/brachial embolus?
Axillary/brachial embolus presents with sudden onset symptoms including pain, pallor, paresis, pulselessness, and paraesthesia. It is mainly sourced from the left atrium with cardiac arrhythmia, particularly atrial fibrillation (AF), and mural thrombus.
124
What are the common causes of arterial occlusions in the upper limb?
The most common cause of arterial occlusions in the upper limb is atheroma. Trauma may also result in vascular changes and long-term occlusion, but it is rare.
125
What are the possible features of arterial occlusions in the upper limb?
Features of arterial occlusions in the upper limb may include claudication, ulceration, and gangrene. Proximally sited lesions can lead to subclavian steal syndrome. The progressive nature of the disease allows the development of collaterals, but acute thrombosis can cause acute ischemia.
126
Who does Raynaud's disease primarily affect?
Raynaud's disease primarily affects young females.
127
Which body parts are usually affected by Raynaud's disease?
Raynaud's disease usually affects the hands more than the feet.
128
What color changes occur in the digits during a Raynaud's episode?
During a Raynaud's episode, the digits go through a sequence of color changes: white → blue → red.
128
What is the recommended treatment for Raynaud's disease?
The treatment for Raynaud's disease involves the use of calcium antagonists.
129
What are the common symptoms of upper limb venous thrombosis?
Gradual onset of upper limb swelling and discomfort. Sensation and motor function remain normal.
129
What conditions can complicate or contribute to upper limb venous thrombosis?
Upper limb venous thrombosis may complicate pre-existing malignancy, especially breast cancer, or arise as a result of repetitive use of the limb in tasks such as painting a ceiling.
130
How is upper limb venous thrombosis diagnosed?
Upper limb venous thrombosis is diagnosed using duplex ultrasound.
131
What is the recommended treatment for upper limb venous thrombosis?
The treatment for upper limb venous thrombosis involves anticoagulation therapy.
132
What is the incidence of cervical rib?
The incidence of cervical rib is approximately 0.2-0.4%.
132
What is a cervical rib?
A cervical rib is an anomalous fibrous band that often originates from the C7 vertebra and may arc towards, but rarely reaches, the sternum.
133
When does cervical rib typically present?
Congenital cases of cervical rib may present around the third decade, while some cases are reported to occur following trauma.
134
What are the common clinical findings associated with cervical rib?
Cervical rib is often bilateral in up to 70% of cases. Compression of the subclavian artery may result in an absent radial pulse and a positive Adson's test (lateral flexion of the neck away from the symptomatic side and traction of the symptomatic arm, leading to the obliteration of the radial pulse).
134
What is the recommended treatment for cervical rib?
Treatment for cervical rib is typically undertaken when there is evidence of neurovascular compromise. The traditional operative method for excision is a transaxillary approach.
135
Where does the left subclavian artery originate from?
The left subclavian artery comes directly off the arch of the aorta.
136
Where does the right subclavian artery arise from?
The right subclavian artery arises from the brachiocephalic artery (trunk) when it bifurcates into the subclavian and the right common carotid artery.
137
What is the path of the subclavian artery?
The subclavian artery travels laterally, passing between the anterior and middle scalene muscles, deep to scalenus anterior and anterior to scalenus medius. It becomes the axillary artery as it crosses the lateral border of the first rib. At this point, it is superficial and within the subclavian triangle.
138
What are the indications for cardiopulmonary bypass surgery?
Indications for cardiopulmonary bypass surgery include left main stem stenosis or equivalent (proximal LAD and proximal circumflex), triple vessel disease, diffuse disease unsuitable for PCI, and high-risk patients with severe ventricular dysfunction or diabetes mellitus.
139
What are the conduits commonly used for bypass during cardiopulmonary bypass surgery?
Common conduits used for bypass during cardiopulmonary bypass surgery include the internal mammary artery, radial artery harvested from the forearm, and reversed long saphenous vein grafts.
139
What are the steps involved in the technique of cardiopulmonary bypass?
The steps involved in the technique of cardiopulmonary bypass include general anesthesia, placement of central and arterial lines, midline sternotomy or left sub mammary incision, dissection of the aortic root and pericardium, inspection of the heart, and the use of a cardiopulmonary bypass circuit.
140
What are the branches of the subclavian artery?
The branches of the subclavian artery include the vertebral artery, internal thoracic artery, thyrocervical trunk, costocervical trunk, and dorsal scapular artery.
141
What are some potential complications associated with cardiopulmonary bypass surgery?
Potential complications of cardiopulmonary bypass surgery include post perfusion syndrome (transient cognitive impairment), non-union of the sternum, myocardial infarction, late graft stenosis, acute renal failure, stroke, and gastrointestinal complications.
141
How is perioperative risk quantified in cardiopulmonary bypass surgery?
Perioperative risk in cardiopulmonary bypass surgery is quantified using the Parsonnet and Euroscores, and unit outcomes are audited using this data.
142
Which extremity is most commonly affected by Klippel-Trenaunay-Weber syndrome?
The leg is the most common site followed by the arms, the trunk, and rarely the head and the neck.
143
What is an atypical case of Klippel-Trenaunay syndrome?
An atypical case of Klippel-Trenaunay syndrome refers to cases where port-wine stains (capillary port wine type) may be absent. These cases are very rare and may be classified as 'atypical Klippel-Trenaunay syndrome'.
144
What are the signs and symptoms of Klippel-Trenaunay syndrome?
The signs and symptoms of Klippel-Trenaunay syndrome include one or more distinctive port-wine stains with sharp borders, varicose veins, hypertrophy of bony and soft tissues (which can lead to local gigantism or shrinking), and an improperly developed lymphatic system.
145
What is another name for the adductor canal?
The adductor canal is also called Hunter's or subsartorial canal.
146
Which vessels can be affected by Klippel-Trenaunay syndrome?
Klippel-Trenaunay syndrome can affect blood vessels, lymph vessels, or both. Most commonly, the condition presents with a mixture of the two. Those with venous involvement may experience increased pain and complications.
147
Where is the adductor canal located in the thigh?
The adductor canal is located immediately distal to the apex of the femoral triangle, lying in the middle third of the thigh.
148
What are the borders of the adductor canal?
The adductor canal is bordered laterally by the vastus medialis muscle and the saphenous nerve. Posteriorly, it is bordered by the adductor longus, adductor magnus, and the superficial femoral artery. The roof of the adductor canal is formed by the sartorius muscle and the superficial femoral vein.
149
What is a common symptom associated with Takayasu's arteritis?
A common symptom associated with Takayasu's arteritis is an absent limb pulse.
149
What structures are found within the adductor canal?
Within the adductor canal, you can find the saphenous nerve, superficial femoral artery, and superficial femoral vein. Additionally, the adductor longus and adductor magnus muscles are located posteriorly to the canal.
150
Who is more commonly affected by Takayasu's arteritis?
Takayasu's arteritis is more common in females and Asian people.
151
What is Takayasu's arteritis?
Takayasu's arteritis is a type of large vessel vasculitis that typically causes occlusion of the aorta.
152
What is an association of Takayasu's arteritis?
Takayasu's arteritis is associated with renal artery stenosis.
153
What is the management approach for Takayasu's arteritis?
The management of Takayasu's arteritis often involves the use of steroids.
153
What are the survival rates for patients with aortic dissection if no treatment is received?
Approximately 33% of patients with aortic dissection die within the first 24 hours, and 50% die within 48 hours if no treatment is received.
154
What is the relative frequency of aortic dissection compared to rupture of the abdominal aorta?
Aortic dissection is more common than rupture of the abdominal aorta.
155
What is a common risk factor associated with aortic dissection?
Aortic dissection is commonly associated with hypertension.
156
Where is the most common site of aortic dissection?
The most common site of aortic dissection is within 10 centimeters of the aortic valve, accounting for approximately 90% of cases.
157
What are the features of aortic dissection?
The features of aortic dissection include a tear in the intimal layer, followed by the formation and propagation of a subintimal hematoma. Cystic medial necrosis, often seen in Marfan's syndrome, may also be present.
158
What are the two classification systems used for aortic dissection?
The two classification systems used for aortic dissection are the Stanford Classification and the DeBakey classification.
159
What are the clinical features of aortic dissection?
Clinical features of aortic dissection include tearing, sudden onset chest pain (which can be painless in 10% of cases), hypertension or hypotension, a blood pressure difference greater than 20 mm Hg between the arms, and neurologic deficits in 20% of cases.
160
What imaging modalities are used to investigate aortic dissection?
Imaging modalities used to investigate aortic dissection include chest X-ray (which may show a widened mediastinum, abnormal aortic knob, ring sign, and deviation of the trachea/oesophagus), CT angiography of the thoracic aorta, MRI angiography, and conventional angiography (though it is now rarely used diagnostically).
160
What is the management approach for aortic dissection?
The management of aortic dissection involves the use of beta-blockers to achieve a target heart rate of 60-80 bpm and a systolic blood pressure of 100-120 mm Hg. For type A dissections, aortic root replacement is the standard of care.
161
What is an anastomosis?
An anastomosis refers to the restoration of luminal continuity and is commonly performed in both abdominal and vascular surgery.
162
What are the three criteria for an anastomosis to heal successfully?
The three criteria for an anastomosis to heal successfully are: adequate blood supply, mucosal apposition, and minimal tension.
163
Which types of anastomoses are more prone to leakage?
Oesophageal and rectal anastomoses are more prone to leakage, with reported leak rates following surgery as high as 20%.
163
What is the primary factor that determines the success of an anastomosis?
The attention to surgical technique is more important than the method chosen for anastomosis. A well-constructed hand-sewn anastomosis is less prone to leakage than a poorly constructed stapled anastomosis.
164
What should be done if an anastomosis appears unsafe?
If an anastomosis appears unsafe, it may be best not to construct one at all. In colonic surgery, this often involves bringing out an end colostomy. In more complex situations like oesophageal surgery, colonic interposition may be required.
165
What type of suture material is recommended for vascular anastomoses?
Non-absorbable monofilament suture, such as Polypropylene, is recommended for vascular anastomoses.
166
What type of needle should be used for vascular anastomoses?
A round-bodied needle should be used for vascular anastomoses.
167
What is the correct suture size for a distal arterial bypass?
For a distal arterial bypass, the correct suture size is typically 6/0 prolene.
168
What is the recommended suture technique for vascular anastomoses?
The suture should be continuous and from the inside to the outside of the artery to avoid raising an intimal flap.
169
What is the incidence of cervical ribs?
The incidence of cervical ribs is approximately 0.2-0.4%.
170
What is the composition of cervical ribs?
Cervical ribs consist of an anomalous fibrous band that often originates from the C7 vertebra and may arc towards, but rarely reach, the sternum.
171
When do congenital cases of cervical ribs typically present?
Congenital cases of cervical ribs usually present around the third decade of life. However, some cases have been reported to occur following trauma.
172
What is the bilateral occurrence rate of cervical ribs?
Cervical ribs are bilateral in up to 70% of cases.
173
What clinical examination finding may indicate compression of the subclavian artery due to cervical ribs?
Compression of the subclavian artery may produce an absent radial pulse on clinical examination. This can be further confirmed with a positive Adsons test, which involves lateral flexion of the neck towards the symptomatic side and traction of the symptomatic arm, resulting in the obliteration of the radial pulse.
174
When is treatment for cervical ribs typically undertaken?
Treatment for cervical ribs is most commonly undertaken when there is evidence of neurovascular compromise.
175
What is the traditional approach for treating cervical ribs?
The traditional approach for treating cervical ribs is a transaxillary approach.
176
What is the incidence of axillary vein thrombosis compared to all deep venous thrombosis cases?
Axillary vein thrombosis accounts for approximately 1-2% of all deep venous thrombosis cases.
176
What are the primary causes of axillary vein thrombosis?
The primary causes of axillary vein thrombosis are trauma, thoracic outlet obstruction, or repeated effort in a dominant arm, typically seen in young active individuals.
177
What are the secondary causes of axillary vein thrombosis?
Secondary causes of axillary vein thrombosis include central line insertion, malignancy, and pacemakers.
178
What are the clinical features of axillary vein thrombosis?
The clinical features of axillary vein thrombosis include pain and swelling (non-pitting), numbness, discolouration (mottling, dusky), congested veins, and presence of pulses.
179
What investigations are commonly performed for axillary vein thrombosis?
Investigations for axillary vein thrombosis may include FBC (viscosity, platelet function), clotting studies, liver function tests, D-dimer, duplex scan (investigation of choice), and CT scan for thoracic outlet obstruction.
180
What are the treatment options for axillary vein thrombosis?
Treatment options for axillary vein thrombosis may include local catheter-directed tissue plasminogen activator (TPA), heparin, and warfarin.
180
How does heparin work?
Heparin causes the formation of complexes between antithrombin and activated thrombin/factors 7, 9, 10, 11, and 12.
181
What are the advantages of low molecular weight heparin (LMWH)?
The advantages of LMWH include better bioavailability, lower risk of bleeding, longer half-life, little effect on APTT (activated partial thromboplastin time) at prophylactic dosages, and a reduced risk of heparin-induced thrombocytopenia (HIT).
181
What are the complications associated with heparin use?
Complications of heparin use include bleeding, osteoporosis, heparin-induced thrombocytopenia (HIT) occurring 5-14 days after the first exposure, and anaphylaxis.
182
When is unfractionated heparin preferred over LMWH?
In surgical patients who may require a rapid return to the operating theatre, administration of unfractionated heparin is preferred. This is because LMWH has a longer duration of action and is harder to reverse.
183
What percentage of head and neck paragangliomas do carotid body tumors typically account for?
Carotid body tumors typically account for around 60% of head and neck paragangliomas.
184
What is the typical age range for individuals with carotid body tumors?
Carotid body tumors are usually tumors of middle age.
185
What percentage of carotid body tumors are bilateral?
Approximately 5% of carotid body tumors are bilateral.
185
What percentage of carotid body tumors are malignant?
Around 5% of carotid body tumors are malignant.
186
Are carotid body tumors commonly associated with MEN II or neurofibromatosis type I disease complexes?
Carotid body tumors are rarely found as part of the MEN II or neurofibromatosis type I disease complexes.
187
How do carotid body tumors typically present?
Carotid body tumors typically present as an asymptomatic neck mass in the anterior triangle of the neck.
188
What is the growth rate of carotid body tumors?
Carotid body tumors are typically slow-growing lesions.
189
What imaging modality is used to visualize carotid body tumors?
Carotid body tumors can be readily imaged using duplex ultrasonography, and CT angiography may be helpful in some cases.
190
What is the primary treatment for carotid body tumors?
The primary treatment for carotid body tumors is surgical resection, which is preceded by embolization in selected cases.
191
What are the different types of carotid body tumors?
Carotid body tumors can be classified as sporadic (85% of cases), familial (seen in around 10% of cases, usually in younger patients), or hyperplastic (seen in individuals at high altitude or with COPD).
