27- Vascular Explains Flashcards
What conditions are associated with ejection systolic murmurs?
Aortic stenosis, pulmonary stenosis, hypertrophic obstructive cardiomyopathy (HOCM), atrial septal defect (ASD), and Tetralogy of Fallot
What conditions are associated with pan-systolic murmurs?
Mitral regurgitation, tricuspid regurgitation, and ventricular septal defect (VSD)
What conditions are associated with late systolic murmurs?
Mitral valve prolapse and coarctation of the aorta
What conditions are associated with early diastolic murmurs?
Aortic regurgitation and Graham-Steel murmur (pulmonary regurgitation)
What conditions are associated with mid diastolic murmurs?
Mitral stenosis
What condition is associated with Austin-Flint murmur?
Severe aortic regurgitation
What is the long saphenous vein used for in bypass surgery?
It can be harvested for bypass surgery as a graft to bypass blocked coronary arteries.
What is a treatment option for varicose veins with saphenofemoral junction incompetence?
The long saphenous vein can be removed as a treatment for varicose veins with saphenofemoral junction incompetence.
Where does the long saphenous vein originate?
It originates at the 1st digit, where the dorsal vein merges with the dorsal venous arch of the foot.
What path does the long saphenous vein take in the leg?
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.
Where does the long saphenous vein join with the femoral vein?
It joins with the femoral vein in the region of the femoral triangle at the saphenofemoral junction.
What are the tributaries of the long saphenous vein?
The tributaries include the medial marginal vein, superficial epigastric vein, superficial iliac circumflex vein, and superficial external pudendal veins.
Where does the short saphenous vein originate?
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.
What path does the short saphenous vein take in the leg?
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.
Where does the short saphenous vein drain into?
It drains into the popliteal vein, approximately at or above the level of the knee joint.
When are amputations indicated for the affected limb?
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.
In what cases is orthopaedic surgery likely to perform an amputation?
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.
When would a primary amputation be preferable following major trauma?
A primary amputation would be preferable in cases of open fracture with major distal neurovascular compromise and other life-threatening injuries present.
What is the most prevalent cause for amputations in vascular surgery?
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.
What is the main concern in vascular surgery prior to performing an amputation?
The main concern in vascular surgery is optimizing vascular inflow before the amputation. The more distal the planned amputation, the more crucial this becomes.
When would an amputation be required following an embolic event?
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.
What are the main categories of lower limb amputations?
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.
What factors are considered when choosing a level of amputation?
The level of amputation is chosen based on the disease process being treated, desired functional outcome, and the patient’s co-morbidities.
What are the advantages of above knee amputations?
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.
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.
What type of flaps are used in above knee amputations?
Above knee amputations use equal anterior-posterior flaps.
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.
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.
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.
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.
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.
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.
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.
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.
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.
What causes lymphoedema?
Lymphoedema is caused by impaired lymphatic drainage in the presence of normal capillary function.
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.
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.
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.
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.
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.
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.
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.
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.
What are the results and their interpretations for ABPI?
ABPI results and their interpretations are as follows:<br></br>- 1.2 or greater: Usually due to vessel calcification.<br></br>- 1.0-1.2: Normal.<br></br>- 0.8-1.0: Minor stenotic lesion. Initiate risk factor management.<br></br>- 0.50-0.8: Moderate stenotic lesion. Consider duplex scanning and continue risk factor management. Avoid tight compression bandages if mixed ulcers are present.<br></br>- 0.3-0.5: Likely significant stenosis. Duplex scanning is needed to delineate lesions. Compression bandaging is contraindicated.<br></br>- Less than 0.3: Indicative of critical ischemia. Urgent detailed imaging is required.
What are some key questions to consider when evaluating groin lumps?
When evaluating groin lumps, consider the following key questions:<br></br>- Is there a cough impulse?<br></br>- Is it pulsatile and expansile (to distinguish between false and true aneurysm)?<br></br>- Are both testes intra scrotal?<br></br>- Are there any lesions in the legs, such as malignancy or infections (possibly lymph nodes)?<br></br>- Have you examined the ano rectum, as anal cancer may metastasize to the groin?<br></br>- Is the lump soft, small, and very superficial (possibly a lipoma)?
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).
What are some key questions to consider when evaluating scrotal lumps?
When evaluating scrotal lumps, consider the following key questions:<br></br>- Is the lump entirely intra scrotal?<br></br>- Does it transilluminate (possibly a hydrocele)?<br></br>- Is there a cough impulse (possibly a hernia)?
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.
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.
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.
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.
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.
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).
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.
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.
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.
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.
What is the recommended treatment for minor varicose veins without complications?
For minor varicose veins without complications, reassurance and cosmetic therapy are typically sufficient.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
What provides reassurance of a healthy vessel during auscultation?
Triphasic signals provide reassurance of a healthy vessel.
What does a monophasic signal during auscultation of a vessel indicate?
A monophasic signal is associated with a proximal stenosis and reduction in flow.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Who is most commonly affected by abdominal aortic aneurysms?
Abdominal aortic aneurysms are most commonly found in elderly men.
What is the approximate incidence of true abdominal aortic aneurysms?
True abdominal aortic aneurysms have an approximate incidence of 0.06 per 1000 people.
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.
