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Ciculation and lymphatic systems Flashcards

1
Q

Signs of chronic venous insufficiency

A

L - lipodermatosclerosis
E - eczema
G - gaps in the skin (ulceration)
S - swelling

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2
Q

Indications for preoperative Duplex USS of varicose veins?

A
  • DVT history
  • signs of chronic venous insufficiency
  • recurrent varicose veins
  • to clarify SSV or LSV incompetency
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3
Q

Varicose veins treatment

A

Conservative
- education (avoid prolonged standing and elevate legs)
- grade II graduated elastic compression stockings
- weight loss, regular exercise
Endovascular
- sclerotherapy - 1% sodium tetradecyl sulphate (liquid or foam)
- radiofrequency ablation (catheter in vein and heated to 120C)
- Endovascular ablation
Surgical
- Trendelenburg procedure (saphenofemoral ligation)
- multiple avulsons
- strippling from groin to upper calf
(post op - bandage tightly and elevate for 24 hours)

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4
Q

Syndrome associated with varicose veins

A 
Kippel-Trenaunay-Weber syndrome
- varicose veins
- port wine stains
- bony + soft tissue hypertrophy of limbs
- significant oedema
Parkes-Weber syndrome
- multiple AV fistulae
- limb hypertrophy
- can lead to high output cardiac failure
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5
Q

Venous ulcer causes

A

Deep venous insufficiency

  • Valvular disease: varicose veins, deep vein reflux, communicating vein reflux
  • Outflow tract obstruction: post-DVT
  • Muscle pump failure: primary (stroke, neuromuscular disease), secondary (musculoskeletal pathology/ankle injury)
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6
Q

Venous ulcer treatment

A

Non-surgical: 50-70% healed at 3mths, 80-90% at 12mths
- avoid trauma
- four-layer compression bandaging
- rest and leg elevation
- once healed, grade II compression stockings for life
Surgical
- if ulcer fails to heal, exclude other causes +/- biopsy
- debridement + split skin graft
- if due to primary varicose veins, treat them

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7
Q

Four-layer compression bandaging layers

A
  • non-adherent dressing over ulcer plus wool bandage
  • crepe bandage
  • blue-line bandage
  • adhesive bandage to prevent other layers slipping
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8
Q

How to measure ABPI

A
  • inflate cuff over upper arm, measure systolic pressure with doppler at brachial artery
  • inflate cuff over calf, measure systolic pressure with doppler at dorsalis pedis
  • find doppler sound, inflate cuff till disappears, slowly deflate till sound restarts = sys pressure
  • ankle/brachial = ABPI
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9
Q

Significance of ABPI

A

normal = 1
claudication 0.6-0.9
rest pain 0.3-0.6
impending gangrene 0.3 or less

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10
Q

What foot pathology are diabetics prone to?

A
  • diabetic neuropathy
  • peripheral occlusive arterial disease
  • Charcot neuroarthropathy
  • osteomyelitis
  • foot ulceration
    Can lead to amputation
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11
Q

Aetiology of diabetic foot ulcers

A
  • neuropathic (45-60%)
  • ischaemic (10%)
  • mixed neuroischaemic (25-45%)
    Diabetic neuropathy is due to (1) microvascular disease leading to nerve hypoxia, and/or (2) direct effects of hyperglycaemia on neuronal metabolism
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12
Q

Why might ABPI be normal/higher in diabetics?

A

Calcification of the walls of the vessels - prevents cuff compressing vessels = abnormally high ABPI.
Also seen in CRF

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13
Q

Differences in peripheral vascular disease in diabetics?

A
  • Intra-arterial digital subtraction angiography indicated earlier.
  • Aggressive treatment of infections
  • Meticulous foot care + chiropodist
  • Sepsis treated with surgical debridement
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14
Q

Are their any problems with diabetics undergoing angiography?

A
  • if renal impairment, can be dramatically worsened by intra-arterial contrast
  • well-hydrate patients with IV fluids peri-procedure
  • stop metformin
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15
Q

Indications for amputation

A

4 D’s

  • Dead (ischaemic): PVD, thromboangitis obliterans, AV fistulae
  • Damaged (trauma): unsalvageable limb, burns, frostbite
  • Dangerous (malignancy): bone, soft tissue
  • Damn nuisance (infection/neuropathy): osteomyelitis, nec fasc, charcot neuropathy
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16
Q

Complications of amputations

A 
Patients often have other medical problems which increases risk. Operative mortality 20%, 1 year 50%
Early
- psychological + social
- haematoma + infection
- DVT + PE
- phatom limb pain
- skin necrosis
Late
- osteomyelitis
- stump ulceration
- stump neuroma
- fixed flexion deformity
- difficulty mobilising
- spurs + osteophyte formation
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17
Q

Intermittent claudication differential

A

Leg pain can be dividied into:

  • Musculoskeletal: specific joint pathology e.g. OA
  • Neurological: spinal stenosis (leading to spinal claudication)
  • Vascular: intermittent claudication, DVT
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18
Q

Why do patients with rest pain typically get more severe pain at night?

A

Reduction in perfusion due to:

  • reduced effect of gravity lying down
  • reduced cardiac output at night
  • dilation of skin vessels due to warm bedding
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19
Q

In which patients are AAA most common

A
  • men
  • > 60
  • smokers
  • hypertensives
  • family history
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20
Q

Who should have AAA’s repaired?

A
  • symptomatic aneurysms (back pain, tenderness, distal embolic events, rupture/leak)
  • asymptomatic (>5.5 cm diameter, increase >1 cm per year)
  • 10% risk of rupture per year for aneurysm >5.5cm
21
Q

Alternative to open AAA repair?

A

Endovascular repair is equivalent to open repair for overall survival but has higher rate of secondary interventions. Good for high operative risk patients as less invasive

22
Q

Screening for AAA

A

One-time USS for men >65
Re-screen
3.0-4.4cm yearly
4.5-5.4cm 3monthly

23
Q

Investigations for carotid bruit

A
  • Urinalysis: protein
  • ECG: AF, ischaemia, LVH
  • Bloods: FBC, U+Es, glucose, lipids
  • Carotid duplex scan
  • Carotid angiography (2% stroke risk)
  • MRA
  • Echo
  • CT/MRI brain: looking for old infarcts
24
Q

Consequence of carotid stenosis?

A

85% stokes thromboembolic caused by artherosclerosis at carotid bifurcation

25
Which patients are considered for carotid endarterectomy?
- symptomatic carotid stenosis 70-99% - consider in patients with 50-70% stenosis - no evidence in asymptomatic patients or stenosis
26
What would you warn patient of in consenting them for an endarterectomy?
- advantages are a 6 fold reduction in stroke at 3 years - operative risk of stroke is 2%, mortality 1% - specific risks include: haematoma, hypoglossal nerve injury, numbness of ipsilateral earlobe
27
How do patients with popliteal aneurysms present?
- 80% of all non-aortic aneurysms - lump behind knee - 50% present with distal limb ischaemia from thrombosis or embolism - may present with acute ischaemic leg
28
When and how are popliteal aneurysms treated?
- symptomatic aneurysms - if contain thrombus - >2cm Repaired by excision bypass (with graft), or resection and anastomosis (Hunter's ligation)
29
Causes of ischaemic ulcers
``` Large vessel - atherosclerosis - thromboangiitis obliterans Small vessel - DM - polyarteritis nodosa - RA ```
30
Treatment of ischaemic ulcers
``` Analgesia - very painful - WHO analgesic ladder, combinations given regularly in variety of formulations Risk-factor modification - stop smoking - good DM control - optimize lipids Symptom modification - avoid drugs e.g. beta blockers - low-dose aspirin - iv prostaglandins (anti-platelet, vasodilators) - lumbar sympathectomy (reduces vascoconstriction) ```
31
Causes of gangrene
- diabetes (commonest) - embolus + thrombus - Raynaud's syndrome - thromboangiitis obliterans - ergot poisoning - vessel injury due to extreme cold, heat, trauma, pressure - drugs e.g. warfarin
32
What is Fournier's gangrene
- rare necrotising subcutaneous infection involving the scrotum, penis and perineum - scrotum is red and swollen with crepitus on palpation
33
Raynaud's terminology
``` Phenomenon = characteristic cold-induced changes Disease = primary occurring in isolation Syndrome = secondary associated with other diseases ```
34
Pathogenesis of Raynauld's
Either: normal vessels, over-active alpha receptors = abnormal smooth muscle contraction (Primary) OR: fixed obstruction in vessel wall, reduces distal flow (Secondary)
35
Raynaud's secondary causes
- Blood disordersL polycythaemia - Arterial: atherosclerosis, thromboangiitis obliterans - Drugs: beta-blockers, COCP - CTD: RA, SLE, scleroderma, PAN - Trauma: vibration injury
36
Raynauld's treatment
``` Conservative - gloves + warm pads in winter - remove predisposing drugs - smoking cessation Medical - CCB: nifedipine - Prostacyclin analgues - Alpha-blockers - 5HT anatagonists Surgical - cervical sympathectomy - amputation if digits threatened by gangrene ```
37
Causes of neuropathic ulcers
``` Any cause of peripheral neuropathy Systemic disease - Diabetes - Vasculitis (SLE) - Hypothyroidism - Vit B12 deficiency Drugs and toxins - Amiodarone, metronidazole - Alcohol Infections: TB, leprosy, HIV Paraneoplastic Idiopathic ```
38
Differential of swollen legs
- Central: RHF, hypoalbuminaeia, nephrotic syndrome, hypothyroidism - Peripheral causes: venous disease: DVT, Klippel-Trenaunay syndrome, chronic venous insufficiency - Rare causes: angio-oedema, AV malformations (Parkes-Weber), hemi-hypertrophy
39
Causes of lymphoedma
``` Primary = congential = Milroy's disease (F:M = 3:1) Secondary: - Malignancy: lymph node infiltration - Infection: filiaris, TB - Iatrogenic: post-surgery, radiotherapy ```
40
Lymphoedema treatment
Non-surgical - grade III compression stocking - intermittent pneumatic compression device - treat any cellulitis - elevate leg as much as possible, good foot care Surgical - direct lymphovenous anastomosis - small intestine submucosal plexus implantation can 'replace' a lymph node as forms new connections with distal lymphatics - debulking of subcutaneous tissue +/- skin
41
Hyperhidrosis differential
- anxiety - hyperthryoidism - phaeochromocytoma - hyperhidrosis erythematosus traumatica: vibration causes excess sweating, occupational
42
Hyperhidrosis treatment
- Reassurance - Aluminium hexachloride for axillary - Excise axillary hair-bearing skin and/or intradermal Botox - Cervical sympathectomy (T2-4) for palmar - Lumbar sympathectomy for plantar
43
Side effects of cervcal sympathectomy
- Excessive dryness of skin - Compensatory sweating around trunk - Horner's syndrome (rare) - Pneumothorax/haemothorax - GA risks
44
Difference between false and true aneurysm
Aneurysm = abnormal dilation of blood vessel True involves all layers of arterial wall False follows partial laceration of vessel wall causing blood to leak into surrounding tissues False aneurysm = pulsating haematoma
45
Causes of false aneurysm
- Traumatic | - Iatrogenic: post angiography, post bypass surgery
46
False aneurysm treatment
- USS compression - Thrombin injection - Surgical repair - Observation and review
47
Leriche's syndrome
Buttock claudication +/- impotence | stenosis at aortic bifurcation
48
Buerger's disease
Thromboangiitis obliterans | In young/heavy smokers
49
Define varicose veins
Long, tortuous and dilated veins of superficial venous system

Surgery (10 decks)

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