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Vascular surgery > Aortic aneurysm, acute and chronic ischaemia > Flashcards

Aortic aneurysm, acute and chronic ischaemia Flashcards

1
Q

what is an abdominal aortic aneurysm?

A

a permanent pathological dilation of the aorta with a diameter >1.5x the expected anterior posterior diameter of that segment.

most commonly adopted threshold is >3cm

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2
Q

where are most AAA’s located ?

A

90% below the level of the renal arteries

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3
Q

what are the S&S of AAA?

A

asymptomatic

palpable, pulsatile, expansile abdominal mass

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4
Q

how are suspected AAA’s investigated?

A

abdo US

follow up CT scan with contrast if >5.5cm

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5
Q

how are AAA’s managed ?

A
  1. 0 – 4.4cm: yearly ultrasound
  2. 5 – 5.4cm: 3-monthly ultrasound

Medical

  • Smoking cessation
  • Improve blood pressure control
  • Commence statin and aspirin therapy
  • Weight loss and increased exercise

Surgical
- Open repair involves a midline laparotomy or long transverse incision, exposing the aorta, and clamping the aorta proximally and the iliac arteries distally, before the segment is then removed and replaced with a prosthetic graft

  • Endovascular repair involves introducing a graft via the femoral arteries and fixing the stent across the aneurysm
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6
Q

what are the S&S of a ruptured AAA?

A

sudden, severe onset epigastic pain and/or back/loin pain

sudden collapse

Hx of AAA

rapid onset hypotension, pain and sweating

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7
Q

what is the emergency management of ruptured AAA?

A 
call for senior and anaesthetist
permissive hypotension 
IV access, cross match, order FFP and platelets 
modest analgesia (morphine 5-10mg) 
straight to threatre 
ABx prophylaxis 
aortic cross clamping 
distal anastamoses
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8
Q

what causes acute limb ischaemia?

A

acute thrombosis in vessel with pre-existing atherosclerosis (60%)

Emboli (30%)

rare causes

  • aortic dissection
  • intra arterial drug use
  • trauma
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9
Q

what are the S&S of acute limb ischaemia ?

A 
Pain 
Pallor 
Pulselessness 
Paraesthesia 
Paralysis 
Perishingly cold
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10
Q

How is acute limb ischaemia classified?

A

The Rutherford classification

Stage 1 = limb not immediately threatened

     - no sensory loss or muscle weakness 
     - pedal and popliteal arteries audible on doppler

Stage 2a = limb marginally threatened

      - minimal sensory loss, no muscle weakness
      - popliteal arteries audible, pedal not

Stage 2b = limb immediately threatened

       - pain at rest, moderate muscle weakness 
       - popliteal audible, pedal not

Stage 3 = limb irreversibly damaged

       - profound pain, muscle paralysis 
       - popliteal and pedal inaudible
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11
Q

what are the InV done in acute limb ischaemia?

A 
Duplex/doppler US 
ECG - look for AF 
Basic bloods 
Lactate - assess ischaemia 
CT/MR angiography to guide revascularisation
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12
Q

what is the management of acute limb ischaemia ?

A

initial

  • emergency assessment by vascular surgeon
  • systemic anticoagulation with heparin
  • paracetamol and morphine

Surgical

  • revascularisation via thrombectomy or embolectomy. Percutaneous catheter directed thrombolysis. Bypass graft surgery
  • amputation
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13
Q

what are the complications of acute limb ischaemia ?

A

death in 15-20%

Reperfusion injury

  • compartment syndrome (due to oedema)
  • hyperkalaemia (due to K+ release)
  • systemic acidosis from H+ release
  • AKI

Peripheral nerve injury (leading to chronic neuropathic pain)

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14
Q

what is compartment syndrome?

A

Compartment syndrome is a pathological condition characterised by elevated interstitial pressure in a closed osteofascial compartment that results in microvascular compromise (restriction of capillary blood flow)

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15
Q

what causes compartment syndrome?

A

Elevated interstitial pressure in a closed osteofascial compartment may be secondary to several different factors. Haemorrhage within the compartment or direct trauma to the muscles with subsequent oedema can lead to increased pressure to above the capillary level, which restricts capillary flow. This results in tissue necrosis secondary to oxygen deprivation.

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16
Q

what are the S&S of compartment syndrome?

A

pain (out of proportion)

muscle tightness

paraesthesia

pulselessness, pallor and paralysis

17
Q

what InV are done in compartment syndrome?

A

compartment pressure measurement

  • intra-compartment pressure of >30mmHg
  • delta pressure <30mmHg

serum creatinine kinase eleavted

urine myoglobin elevated

18
Q

what is the treatment of compartment syndrome?

A

dressing release
morphine
fasciotomy
amputation

19
Q

what is chronic limb ischaemia?

A

peripheral arterial disease that results in symptomatic reduced blood supply to the limbs

typically caused by atherosclerosis and affects the lower limbs

20
Q

how is lower limb ischaemia classified?

A

the Fontaine classification

I = asymptomatic 
II = intermittent claudication 
III = rest pain 
IV = ulcers/gangrene
21
Q

what are the risk factors for chronic limb ischaemia?

A

smoking
DM
HTN
hyperlipidaemia

22
Q

what are the clinical features of chronic limb ischaemia?

A

intermittent claudication

  • calf pain on exertion
  • worse on sitting/lying and eleviated by standing

ischaemic lesions or gangrene

pale and cold limbs

weak or absent pulses

limb hair loss, skin changes and thickened nails

23
Q

what are the differentials of chronic limb ischaemia?

A

spinal stenosis (neurogenic claudication)

Nerve root compression (sciatica)

Acute limb ischaemia

24
Q

what is chronic limb ischaemia investigated?

A

ABPI

  • Normal = >0.9
  • Mild = 0.8-0.9
  • Moderate = >0.5-0.8
  • Severe = <0.5

Buerger’s test
- angle less than 20 degrees = severe ischaemia

Doppler US

CT/MR angiogram

FBC, lipids and glucose

25
Q

what are the drawbacks of ABPI?

A

calcifications of arteries can give falsely high ABPI

26
Q

how is chronic limb ischaemia managed?

A

lifestyle advice

  • smoking cessation
  • exercise (helps form collaterals)
  • decrease weight, low fat diet

Statin

antiplatelet

angioplasty and stenting

Bypass grafting

Amputation (for gangrenous)

27
Q

what are the complications of chronic limb ischaemia?

A

sepsis (secondary to infected gangrene)

Acute-on-chronic ischaemia

amputation

death in critical limb ischaemia

Vascular surgery (2 decks)

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