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Year 3 Surgery > General Surgery (Vascular Surgery) > Flashcards

General Surgery (Vascular Surgery) Flashcards

1
Q

Define Abdominal Aortic Aneurysm

A

Abnormal dilation of Abdominal Aorta by more than 50% (ie dilation greater than 3cm)

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2
Q

Give 4 causes of AAA

A

Atherosclerosis
Trauma
Infection
CT Disease

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3
Q

Describe four clinical features of AAA

A

Abdominal Pain
Back/Loin Pain
Distal Embolisation (blue toe)
Pulsatile Abdominal Mass

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4
Q

How would you investigate AAA

A

Ultrasound
CT with Contrast

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5
Q

What is the AAA screening tool

A

Abdominal USS for all men in their 65th year

If 3-4.4cm then yearly USS
If 4.5-5.4 then 3 monthly USS

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6
Q

Describe the medical management of AAA

A

Monitoring with Ultrasounds
Reduce Risk Factors
Atorvastatin and 75mg Clopidogrel

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7
Q

When is surgery for AAA considered?

A

AAA>5.5cm
Expanding more at a rate of more than 1cm a year
Symptomatic AAA (if otherwise fit)

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8
Q

Describe the two surgical options for AAA

A

Open Repair - Midline laparotomy, clamping proximally and iliac arteries distally, segment removed and replaced with graft

Endovascular Repair - Introducing graft via femoral arteries

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9
Q

Give three complications of AAA

A

Embolisation
Aortoduodenal Fistula
Rupture

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10
Q

What is the AAA rupture triad?

A

Pulsatile Abdo Mass
Hypotension
Back/Flank Pain

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11
Q

How would you manage an AAA rupture

A

IV Fluids and circulatory support (try to keep systolic under 100mmHg to prevent dislodging clots)

If unstable - Immediate open surgical repair
If stable - CT Angiogram Pre-Op

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12
Q

What is an Aortic Dissection?

A

Tear in the intimal layer of aortic wall, causing blood to flow between Tunica Intima and Tunica Media

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13
Q

Describe the two different types of Aortic Dissection progression

A

Anterograde - Towards Iliac Arteries
Retrograde - Towards Aortic Valve

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14
Q

Describe the Stanford Classification of Aortic Dissection

A

Group A - Ascending Aorta
Group B - Descending Aorta

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15
Q

Describe the DeBakey Classification of Aortic Dissection

A

I - Ascending Aorta to arch (atleast)
II - Confined to Ascending Aorta
III - Originates distal to subclavian in descending
IIIa - Extends distally to diaphragm
IIIb - Extends beyond diaphragm (encompassing AA)

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16
Q

What are the clinical features of an Aortic Dissection?

A

Tearing chest pain radiating to the back
Tachycardia
Hypotension
Aortic Regurg

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17
Q

How would you image Aortic Dissections?

A

CT Angiogram
TOE

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18
Q

How would you manage Aortic Dissections?

A

Both types require O2 and IV Fluids (only enough to maintain cerebral perfusion)

Type A - Immediate transfer to cardiothoracic centre and graft
Type B - Medical management with IV Beta Blovkers, surgery if ischaemia/rupture or uncontrolled

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19
Q

Thoracic Aneurysms are less common than Abdominal Aneurysms but have a high mortality. How do they present?

A

Often incidental finding
Ascending Aorta - Anterior Chest Pain
Aortic Arch - Neck Pain
Descending Aorta - Pain between scapulae

May get secondary compression symptoms

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20
Q

How would you image a suspected Thoracic Aneurysm?

A

CT chest with contrast
TOE

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21
Q

What is Acute Limb Ischaemia?

A

Sudden decrease in limb perfusion that threatens limb viability (doesn’t have to be a complete occlusion)

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22
Q

Give 3 underlying causes of Acute Limb Ischaemia

A

Embolisation
Thrombosis In-situ
Trauma

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23
Q

Using the 6P’s, describe the clinical features of Acute Limb Ischaemia

A

Pain
Pallor
Pulselessness
Paraesthesia
Paralysis
Perishingly Cold

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24
Q

How are Acute Limb Ischaemias classified?

A

Using the Rutherford Classification

Parameters include Prognosis, Sensory Loss, Motor Deficit, Arterial Doppler, Venous Doppler

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25
Q

Give four investigations for Acute Limb Ischaemia

A

Routine bloods (inc serum lactate and thrombophilia screen)
ECG
Doppler USS
CT Angiography

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26
Q

What is the initial management of Acute Limb Ischaemia?

A

High Flow O2
IV Access
Heparin bolus then heparin infusion

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27
Q

What is the conservative management of Acute Limb Ischaemia?

A

Prolonged course of Heparin and monitoring of APTT

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28
Q

Describe the surgical management of Acute Limb Ischaemia

A

Embolic Cause - Embolectomy, Bypass
Thrombotic Cause - Angioplasty, Bypass

Amputation

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29
Q

What is Chronic Limb Ischaemia?

A

Peripheral arterial disease resulting in symptomatic reduced blood supply
Typically caused by atherosclerosis and affects lower limbs

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30
Q

What are the four clinical stages of Chronic Limb Ischaemia?

A

I - Asymptomatic
II - Intermittent Claudication
III - Ischaemic Rest Pain
IV - Ulceration/Gangrene

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31
Q

Describe the Buerger’s Test

A

Lay the patient supine, and raise the affected leg until pale, and hen lower to normal
Buerger’s Angle of less than 20 degrees indicates severe limb ischaemia

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32
Q

What is Leriche Syndrome?

A

A form of Peripheral Arterial Disease specifically affecting the aortic bifurcation
Presents with buttock/thigh pain and associated erectile dysfunction

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33
Q

What is Critical Limb Ischaemia?

A

Advanced form of Chronic Limb Ischaemia

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34
Q

How does Critical Limb Ischaemia present?

A

Ischaemic Rest Pain for longer than two weeks
Presence of Ischaemic Lesions/Gangrene
ABPI<0.5
Limb Hair Loss
Thickened Nails

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35
Q

Describe the medical treatment of Chronic Limb Ischaemia

A

80mg OD Atorvastatin
75mg Clopidogrel
Optimising diabetes control

36
Q

Describe the surgical options to treat Chronic Limb Ischaemia

A

Angioplasty (with or without stenting)
Bypass Grafting (in diffuse disease or in younger patients)
Amputations

37
Q

What is Acute Mesenteric Ischaemia?

A

Sudden decrease in blood supply to the bowel (resulting in ischaemia, and if not treated - gangrene and death)

38
Q

Describe the aetiology of Acute Mesenteric Ischaemia

A

Thrombus In Situ (AMAT)
Embolism (AMAE)
Non Occlusive Cause (NOMI)
Venous Occlusion and Congestion (MVT)

39
Q

How does AMI present?

A

Generalised abdominal pain out of proportion to clinical findings
Associated nausea and vomiting
Remember if late stage - may present as perforation

40
Q

After an initial CXR to rule out bowel perforation, what imaging could you use for AMI?

A

CT with IV contrast

Oedematous and then bowel wall enhancement

41
Q

What lab investigations could you do for a suspected AMI?

A

ABG (Assesses levels of acidosis)
Bloods - FBC, U&Es, Clotting

42
Q

After initial treatment with IV fluids/Abx, describe the two possible definitive managements of AMI

A

Excision of necrotic/non viable bowel (loop or end stoma - risk of short gut syndrome)
Revascularisation of bowel (via removal of embolus)

43
Q

What is Chronic Mesenteric Ischaemia?

A

Reduced blood supply to the bowel which gradually deteriorates over time as a result of atherosclerosis in Coeliac trunk/SMA/IMA
Due to collateral supply, two branches have to be occluded to be symptomatic

44
Q

Describe three clinical features of Chronic Mesenteric Ischaemia

A

Post Prandial Pain (10mins - 4hrs after eating)
Weight Loss
Concurrent Vascular Comorbidities

45
Q

What is the gold stanard investigation for suspected Chronic Mesenteric Ischaemia?

A

CT Angiography

46
Q

How is Chronic Mesenteric Ischaemia managed?

A

Modify risk factors
Surgery - Mesenteric Angioplasty/Stenting/Bypass

47
Q

Where is the most common site for Peripheral Aneurysms?

A

Popliteal Artery

48
Q

Describe three possible presentations of Peripheral Popliteal Aneurysms

A

Acute Limb Ischaemia (if embolus)
Intermittent Claudiation
Compression Symptoms

49
Q

How would you investigate a suspected Popliteal Aneurysm?

A

Ultrasound Scan first to rule out Baker’s Cyst/Lymphadenopathy

CT Angiography

50
Q

Femoral Aneurysms are typically Pseudoaneurysms, give two causes

A

Patient Self Injecting
Percutaneous Vascular Injections

51
Q

Describe two possible clinical features of Femoral Aneurysms

A

May just be a painless groin swelling
Varying degrees of intermittent claudication

52
Q

What is the most common Visceral Aneurysm?

A

Splenic Aneurysm

53
Q

Name two other types of Visceral Aneurysm

A

Hepatic
Renal

54
Q

What is the mainstay of treatment of Visceral Aneurysms?

A

Endovascular Repair

55
Q

What are Varicose Veins?

A

Tortuous dilated segments of veins associated with vascular incompetence

56
Q

Describe the pathophysiology of Varicose Veins

A

Incompetent valves permit blood flow from deep to superficial veins resulting in venous hypertension and dilation

57
Q

98% of Varicose Veins are Idiopathic. State some secondary causes

A

DVT
Pelvic Masses
AV Malformation

58
Q

Give 3 risk factors for Varicose Veins

A

Prolonged Standing
Obesity
Pregnancy

59
Q

Name two veins commonly implicated in Varicose Veins

A

Great Saphenous Vein
Short Saphenous Vein

60
Q

Describe three clinical presentations of Varicose Veins

A

Aching
Itching
Venous Insuffiency

61
Q

How are Varicose Veins investigated?

A

Duplex Ultrasound

62
Q

What are the NICE criteria for surgical management of Varicose Veins

A

Symptomatic
Lower Limb Skin Changes (Eczema/Pigmentation)
Superficial Vein Thrombosis
Venous Leg Ulcer

63
Q

Describe the three surgical managements of Varicose Veins

A
  • Ligation and stripping
  • Foam Sclerotherapy (sclerosing agent creates inflammatory response which closes off vein)
    Thermal Ablation (Causes irreversible damage which closes off vein)
64
Q

Define Venous Insufficiency

A

Deep Venous Insufficiency is the failure of the venous system, characterised by valvular reflux/venous hypertension/obstruction
Similar pathophysiology to Variose Veins except in the deep veins

65
Q

State the two types of Venous Insufficiency

A

Primary - Underlying defect to vein wall/valvular component
Secondary - Trauma/Venous Outflow Obstruction

66
Q

Describe four clinical features of Venous Insufficiency

A

Chronically swollen limbs which can suddenly become aching/pruritic/painful
Varicose Eczema
Haemosiderin Staining
Lipodermatosclerosis (Inverted Champagne Bottles)

67
Q

How does Venous Claudication present?

A

Bursting pain and tightness on walking
Resolved by leg elevation

68
Q

State two investigations for Venous Insufficiency

A

Doppler USS
ABPI

69
Q

Describe four management principles of Venous Insufficiency

A

Foot Stockings
Analgesia
Venous Ulcer - Four layer bandage
Deep Venous Stenting

70
Q

What is Thoracic Outlet Syndrome?

A

Clinical features that arise from compression of NVB within the thoracic outlet
Can be divided into neurological, venous and arterial

71
Q

Give 3 causes of Thoracic Outlet Syndrome

A

Rib Anomalies
Muscular Anomalies
Repetitive Stress

72
Q

Give a presenting feature of each arterial, venous and nervous TOS

A

Arterial - Claudication
Venous - DVT
Nervous - Brachial Plexus Palsy

73
Q

What is Subclavian Steal Syndrome?

A

Syncope or Neurological Deficit when blood supply to the affected arm is increased through exercise, secondary to stenosing lesion/occlusion in Subclavian Artery

74
Q

Describe the pathophysiology in Subclavian Steal Syndrome

A

To compensate for the reduced blood supply to the limb, blood is drawn from the collateral circulation, reducing flow in the vertebral arteries and hence reducing cerebral perfusion

75
Q

Subclavian Steal Syndrome can be investigated with Doppler USS, however a CT Scan is used for risk scoring. Explain the level of risk in terms of direction of blood flow

A

Pre-Subclavian Steal - Reduced anterograde flow in Vertebral Arteries
Intermittent Alternating - antero in diastolic, Retrograde flow in systolic
Advanced - Permanent retrograde

76
Q

Describe the management of Subclavian Steal Syndrome

A

Antiplatelets and Statins
Endovascular/Bypass Repair

77
Q

Why does Atherosclerosis commonly occur at the bifurcation of Carotid?

A

Turbulent Flow (Virchow’s Triad)

78
Q

What is Carotid Endarterectomy?

A

Risk reduction surgery to remove plaque if narrowing is greater than 50%

79
Q

Give 3 risk factors for Carotid Artery Dissection

A

Men<50
Marfans
Trauma (lateral rotation and hyperextension, crushing it between skull and C2)

80
Q

Give 4 presenting symptoms of Carotid Artery Dissection

A

Ipsilateral Headache/Neck Pain
Horners
III/IV/VI Palsy
Stroke/TIA

81
Q

How would you manage a Carotid Artery Dissection?

A

Anticoagulate and aim to recanalise the clot
If this fails then consider stent

82
Q

What is the INR target for first presentation DVT/PE and recurrent DVT/PE respectively?

A

First Presentation - 2-3
Recurrent - 3.5

83
Q

What is an important side effect of heparin

A

Heparin induced thrombocytopenia

Measure platelets before starting

84
Q

Describe the DVLA rules regarding AAA

A

HGV - unable to drive from 5.5cm

Car - notify DVLA at 6cm, stop driving at 6.5cm

85
Q

How many units of blood should you cross match in ruptured AAA?

A

6

Year 3 Surgery (11 decks)

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