Adult Health: Surgery Flashcards
Vascular Surgery
A question asking a patient with accidental finding of 2.2cm splenic artery aneurysm,what to do?
A. 6 monthly follow up w ults
B. Reassure
C. refere for angio something like that
C. Refer for angio.
NCBI:
Ideal diangostic imaging: CT Scan with IV contrast especially for small SAA/assesing anatomy. If patient has chronic renal insufficiency: MRI.
Contrast angiography - most specific test to idnetify SAA, can also be therapeutic. (SAA = Splenic Artery Aneurysm)
Management:
There is increased risk of aneurysmal rupture, thus intervention when:
* **Aneurysm >2cm diameter **
* Symptomatic patients (vague epigastric/LUQ pain radiating towards left shoulder. Can also be GI hemorrage + hemetemsis or hematochezia)
* Women of childbearing years
* Concomitant pregnancy
* Cirrhotic patients planning to undergo orthotopic liver transplant/portovenous shunting procedure
Approach:
1) Gold standard: Open surgical intervention. Laparatomy when already ruptured + control of hemorrhage with ligation of aneurysm. Try to preserve spleen.
2) Endovascular approach. True aneurysm: stent graft. Sacular aneurysm: coiling technique. Pseudoaneruysm: embolization with liquid embolizing agent. Avoid distal splenic embolization.
3) Minimally invasive laparoscopic : elective splenic aneurysm repair. Includes: ligation of mid-splenic artery (staple/clip) to splenectomy alone for distal SAAs. Suitable for pregnant patients.
From radiopedia:
Follow-up for incidentally detected splenic artery aneurysm:
* less than 2cm:
1. spontaenous rupture is rare
2. 1 year follow up if no risk factors. Can be extended if there are other comorbidities.
- 2cm or more
1. endovascular therapy should be considered
2. Coil embolization for larger aneurysms
ALARM and MUST INVESTIGATE
* rapidly increasing size
* presence in premenopausal women
* cirrhosis
* symptomatic aneurysm
Vascular Surgery
Treatment femoral aneurism after puncture. Immediate treatment?
A. Compression Trombin Ini
B. FEP
A. Compression thrombin injection. Preferably we compress first, and then decide based on patient’s condition.
FROM RACGP
Femoral puncture pseuodaneurysms can be treated conservatively when less than 2 cm and in the absence of therapeutic anticoagulation.
Larger pseudoaneurysms from a femoral puncture and anastomotic or traumatic pseudoaneurysms should be repaired.
Treatment options consist of ultrasound guided compression or thrombin injection for smaller aneurysms, or open surgical repair with debridement and local repair or a bypass.
In some patients, covered stenting from the contralateral limb has been used successfully.
FROM NCBI
Iatrogenic pseudoaneurysm (IPA) - forms when arterial puncture site fails to seal and forms a pulsatile haematoma.
PSAs (femoral pseudoaneurysm) are the most common complication that results after percutaneous procedures performed by a cardiologist, interventional radiologist, or vascular surgeon. Incidence has been reported from 0.5% to up to 9% in some series. There are other rare causes such as surgical intervention or blunt and penetrating trauma. There are a few case reports which have reported femoral artery PSA due to slipped capital femoral epiphysis treatment. However, percutaneous interventions are the leading cause of PSA formation
Imaging:
- INITIAL: Duplex Ultrasound (to-and-fro flow between arterial lumen & femoral artery)
- If surgical intervention planned, CT Angiography
Without treatment –> COMPLICATIONS INCLUDE THROMBOSIS OF VENOUS & ARTERIAL AREAS, EMBOLIZATION (if this happens, bust use Fogarthy catheter)
If its true aneurysm -> DO NOT REPAIR! Must resect and insert prosthetic graft
OPTIONS FOR TREATMENT
1) Open surgical repair
- When AV fistula exist
- Ongoing haemodynamic instability (pt unstable)
- Limb ischemia
Upon haemorrhagic shock:
1) DIGITAL COMPRESS OF BLEEDING SITE!
2) Vascular control
3) Primary arteriography
If primary repair fails -> vein graft to reconstruct system
2) Ultrasound Compression
- To visualize neck of PSA
- Apply pressure until neck is occluded
- Avoid compression of femoral artery!
- PSA considered successfully treated when neck is <2 cm
2) Ultrasound thrombin injection
- Can be performed bedside, local anaesthesia
- PSA: must be long neck, narrow, easily seen on U/S.
- About 0.1ml thrombin increments injected into sac until thrombosis is achieved
- Neck anatomy must be adequate
3) Endovascular treatment (EG: Cone embolization, covered stent deployment)
Complications:
- failure of treatment
- PSA formation (contralateral groin is used for access)
- Coil embolization
- Covered stent deployment
Source: NCBI, RACGP https://www.racgp.org.au/afp/2013/june/non-aortic-aneurysms
Vascular Surgery
Picture CT angio (right common iliac stenosis), clinical feature of this, What to do
A. IV heparin
B. Stent arteria
B. Stent arteria
If patient already developed CLI symptoms (rest pain, ischemia, gangrene) then must send for revascularisation.
If low risk patient -> send for open surgery otherwise, send for revascularization (ballon angioplasty/atherectomy, etc)
COMMON ILIAC STENOSIS
Symptoms:
- Lower back, hip, buttock or thigh claudication defining the proximal claudication
- Fatigue, discomfort or pain in specific muscle groups by IIA druing effort, due to exercies-induced ischemia
- Relieved by rest
- Functional impairment
○ Walking impairment -> work disability
○ Sexual impairment -> erectile dysfunction
**Diagnosis: **
- Dupplex Ultrasound as initial; other option: CTA/MRA (must assess renal function first, as cannot be used)
- Gold standard for diagnosis of IIAS is digital subtraction angiography
Management:
- Goals are:
○ Decrease occurrence of CVD & prevent death
○ Reduce limb symptoms, improve exercise capacity, improve QOL
○ Prevent/lessen disability or progression to limb loss
- Lifestyle modifications
○ Smoking cessation - improve walking distance, doubles 5-year survival rate, reduce post-op complications
- Exercise and Diet
○ Beneficial even among asymptomatic PAD patients - this is cardioprotective
○ Similar & longer lasting than endovascualr interventions
○ Walk until pain occur, rest until it subside, and then repeat to a cycle of 30 minutes, until it reaches 60 mins per day, with 4 - 5 times per week
○ Diet: low salt, low fat, moderate sugar
○ Healthy weight to be achieved as obesity: complication is PAD
- **Pharmacotherapy **
○ Antiplatelet agents (weigh for bleeding complications!!) Clopidogrel > aspirin to reduce combined risk of ischemic stroke, MI, vascular death Single agent is recommended either aspirin OR clopidogrel
○ Lipid-lowering agent (simvastatin) improve pain-free walking distance and total CV event
○ Cliostazol (phosphodiesterase 3 inhibitor) - for improvement of walking distance [low level evidence]
○ ACE-inhibitor ramipril also improve walking distance
§ No evidence for Beta-blockers. Only for cardio-protection
○ CCB protective as well.
○ Good glycemic control & CVD risk control
- Surgical Intervention
○ Indications to refer to vascular surgeon
* Uncertain diagnosis
* CLI evident by rest pain, ischemic ulceration or gangrene
* Claudication symptoms limit work or lifestyle + no improvement despite exercise program/RF modification and medical management after 4 -6 months
* Consideration of interventional management is appropriate by patient/practicioner
○ CLI of rest pain, tissue loss, gangrene Need revascularisation to prevent lim bloss
○ Options: endovascular angioplasty/stenting
○ Options: open surgical reconstruction by peripheral bypass
○ Options: endarterectomy
○ Choices depend on anatomic location of stenotic/occlusive disease & patient’s comorbidities
**Endovascular therapy** Endovascular therapy has grown rapidly over the past few decades. In Australia, 70% of peripheral artery surgery in 2015 was endovascular, and the percentage continues to increase. Performing an endovascular procedure as the first-line revascularisation intervention is associated with increased survival and limb-salvage when compared with open surgery. In recent years, the disease complexity treated with endovascular surgery has improved as a result of advances in intervention techniques. Vascular surgeons employ a range of interventions, from balloon angioplasty or stenting to highly complex endovascular reconstructions that include atherectomy, or drug-eluting devices. The anatomical location of atherosclerotic lesions influences suitability for endovascular therapy, and it is important to recognise that some patients are best treated with open surgery.
Open surgery
Traditional methods of open surgery still have an important role in the treatment of PAD. For patients with lower operative risk, peripheral bypass with autologous vein offers superior long-term patency when compared with endovascular treatment.26 Additionally, for patients who have failed endovascular procedures, open surgery is critical for revascularisation and limb salvage.
