General Surgery (Vascular Surgery) Flashcards
Define Abdominal Aortic Aneurysm
Abnormal dilation of Abdominal Aorta by more than 50% (ie dilation greater than 3cm)
Give 4 causes of AAA
Atherosclerosis
Trauma
Infection
CT Disease
Describe four clinical features of AAA
Abdominal Pain
Back/Loin Pain
Distal Embolisation (blue toe)
Pulsatile Abdominal Mass
How would you investigate AAA
Ultrasound
CT with Contrast
What is the AAA screening tool
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
Describe the medical management of AAA
Monitoring with Ultrasounds
Reduce Risk Factors
Atorvastatin and 75mg Clopidogrel
When is surgery for AAA considered?
AAA>5.5cm
Expanding more at a rate of more than 1cm a year
Symptomatic AAA (if otherwise fit)
Describe the two surgical options for AAA
Open Repair - Midline laparotomy, clamping proximally and iliac arteries distally, segment removed and replaced with graft
Endovascular Repair - Introducing graft via femoral arteries
Give three complications of AAA
Embolisation
Aortoduodenal Fistula
Rupture
What is the AAA rupture triad?
Pulsatile Abdo Mass
Hypotension
Back/Flank Pain
How would you manage an AAA rupture
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
What is an Aortic Dissection?
Tear in the intimal layer of aortic wall, causing blood to flow between Tunica Intima and Tunica Media
Describe the two different types of Aortic Dissection progression
Anterograde - Towards Iliac Arteries
Retrograde - Towards Aortic Valve
Describe the Stanford Classification of Aortic Dissection
Group A - Ascending Aorta
Group B - Descending Aorta
Describe the DeBakey Classification of Aortic Dissection
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)
What are the clinical features of an Aortic Dissection?
Tearing chest pain radiating to the back
Tachycardia
Hypotension
Aortic Regurg
How would you image Aortic Dissections?
CT Angiogram
TOE
How would you manage Aortic Dissections?
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
Thoracic Aneurysms are less common than Abdominal Aneurysms but have a high mortality. How do they present?
Often incidental finding
Ascending Aorta - Anterior Chest Pain
Aortic Arch - Neck Pain
Descending Aorta - Pain between scapulae
May get secondary compression symptoms
How would you image a suspected Thoracic Aneurysm?
CT chest with contrast
TOE
What is Acute Limb Ischaemia?
Sudden decrease in limb perfusion that threatens limb viability (doesn’t have to be a complete occlusion)
Give 3 underlying causes of Acute Limb Ischaemia
Embolisation
Thrombosis In-situ
Trauma
Using the 6P’s, describe the clinical features of Acute Limb Ischaemia
Pain
Pallor
Pulselessness
Paraesthesia
Paralysis
Perishingly Cold
How are Acute Limb Ischaemias classified?
Using the Rutherford Classification
Parameters include Prognosis, Sensory Loss, Motor Deficit, Arterial Doppler, Venous Doppler
Give four investigations for Acute Limb Ischaemia
Routine bloods (inc serum lactate and thrombophilia screen)
ECG
Doppler USS
CT Angiography
What is the initial management of Acute Limb Ischaemia?
High Flow O2
IV Access
Heparin bolus then heparin infusion
What is the conservative management of Acute Limb Ischaemia?
Prolonged course of Heparin and monitoring of APTT
Describe the surgical management of Acute Limb Ischaemia
Embolic Cause - Embolectomy, Bypass
Thrombotic Cause - Angioplasty, Bypass
Amputation
What is Chronic Limb Ischaemia?
Peripheral arterial disease resulting in symptomatic reduced blood supply
Typically caused by atherosclerosis and affects lower limbs
What are the four clinical stages of Chronic Limb Ischaemia?
I - Asymptomatic
II - Intermittent Claudication
III - Ischaemic Rest Pain
IV - Ulceration/Gangrene
Describe the Buerger’s Test
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
What is Leriche Syndrome?
A form of Peripheral Arterial Disease specifically affecting the aortic bifurcation
Presents with buttock/thigh pain and associated erectile dysfunction
What is Critical Limb Ischaemia?
Advanced form of Chronic Limb Ischaemia
How does Critical Limb Ischaemia present?
Ischaemic Rest Pain for longer than two weeks
Presence of Ischaemic Lesions/Gangrene
ABPI<0.5
Limb Hair Loss
Thickened Nails
Describe the medical treatment of Chronic Limb Ischaemia
80mg OD Atorvastatin
75mg Clopidogrel
Optimising diabetes control
Describe the surgical options to treat Chronic Limb Ischaemia
Angioplasty (with or without stenting)
Bypass Grafting (in diffuse disease or in younger patients)
Amputations
What is Acute Mesenteric Ischaemia?
Sudden decrease in blood supply to the bowel (resulting in ischaemia, and if not treated - gangrene and death)
Describe the aetiology of Acute Mesenteric Ischaemia
Thrombus In Situ (AMAT)
Embolism (AMAE)
Non Occlusive Cause (NOMI)
Venous Occlusion and Congestion (MVT)
How does AMI present?
Generalised abdominal pain out of proportion to clinical findings
Associated nausea and vomiting
Remember if late stage - may present as perforation
After an initial CXR to rule out bowel perforation, what imaging could you use for AMI?
CT with IV contrast
Oedematous and then bowel wall enhancement
What lab investigations could you do for a suspected AMI?
ABG (Assesses levels of acidosis)
Bloods - FBC, U&Es, Clotting
After initial treatment with IV fluids/Abx, describe the two possible definitive managements of AMI
Excision of necrotic/non viable bowel (loop or end stoma - risk of short gut syndrome)
Revascularisation of bowel (via removal of embolus)
What is Chronic Mesenteric Ischaemia?
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
Describe three clinical features of Chronic Mesenteric Ischaemia
Post Prandial Pain (10mins - 4hrs after eating)
Weight Loss
Concurrent Vascular Comorbidities
What is the gold stanard investigation for suspected Chronic Mesenteric Ischaemia?
CT Angiography
How is Chronic Mesenteric Ischaemia managed?
Modify risk factors
Surgery - Mesenteric Angioplasty/Stenting/Bypass
Where is the most common site for Peripheral Aneurysms?
Popliteal Artery
Describe three possible presentations of Peripheral Popliteal Aneurysms
Acute Limb Ischaemia (if embolus)
Intermittent Claudiation
Compression Symptoms
How would you investigate a suspected Popliteal Aneurysm?
Ultrasound Scan first to rule out Baker’s Cyst/Lymphadenopathy
CT Angiography
Femoral Aneurysms are typically Pseudoaneurysms, give two causes
Patient Self Injecting
Percutaneous Vascular Injections
Describe two possible clinical features of Femoral Aneurysms
May just be a painless groin swelling
Varying degrees of intermittent claudication
What is the most common Visceral Aneurysm?
Splenic Aneurysm
Name two other types of Visceral Aneurysm
Hepatic
Renal
What is the mainstay of treatment of Visceral Aneurysms?
Endovascular Repair
What are Varicose Veins?
Tortuous dilated segments of veins associated with vascular incompetence
Describe the pathophysiology of Varicose Veins
Incompetent valves permit blood flow from deep to superficial veins resulting in venous hypertension and dilation
98% of Varicose Veins are Idiopathic. State some secondary causes
DVT
Pelvic Masses
AV Malformation
Give 3 risk factors for Varicose Veins
Prolonged Standing
Obesity
Pregnancy
Name two veins commonly implicated in Varicose Veins
Great Saphenous Vein
Short Saphenous Vein
Describe three clinical presentations of Varicose Veins
Aching
Itching
Venous Insuffiency
How are Varicose Veins investigated?
Duplex Ultrasound
What are the NICE criteria for surgical management of Varicose Veins
Symptomatic
Lower Limb Skin Changes (Eczema/Pigmentation)
Superficial Vein Thrombosis
Venous Leg Ulcer
Describe the three surgical managements of Varicose Veins
- Ligation and stripping
- Foam Sclerotherapy (sclerosing agent creates inflammatory response which closes off vein)
Thermal Ablation (Causes irreversible damage which closes off vein)
Define Venous Insufficiency
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
State the two types of Venous Insufficiency
Primary - Underlying defect to vein wall/valvular component
Secondary - Trauma/Venous Outflow Obstruction
Describe four clinical features of Venous Insufficiency
Chronically swollen limbs which can suddenly become aching/pruritic/painful
Varicose Eczema
Haemosiderin Staining
Lipodermatosclerosis (Inverted Champagne Bottles)
How does Venous Claudication present?
Bursting pain and tightness on walking
Resolved by leg elevation
State two investigations for Venous Insufficiency
Doppler USS
ABPI
Describe four management principles of Venous Insufficiency
Foot Stockings
Analgesia
Venous Ulcer - Four layer bandage
Deep Venous Stenting
What is Thoracic Outlet Syndrome?
Clinical features that arise from compression of NVB within the thoracic outlet
Can be divided into neurological, venous and arterial
Give 3 causes of Thoracic Outlet Syndrome
Rib Anomalies
Muscular Anomalies
Repetitive Stress
Give a presenting feature of each arterial, venous and nervous TOS
Arterial - Claudication
Venous - DVT
Nervous - Brachial Plexus Palsy
What is Subclavian Steal Syndrome?
Syncope or Neurological Deficit when blood supply to the affected arm is increased through exercise, secondary to stenosing lesion/occlusion in Subclavian Artery
Describe the pathophysiology in Subclavian Steal Syndrome
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
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
Pre-Subclavian Steal - Reduced anterograde flow in Vertebral Arteries
Intermittent Alternating - antero in diastolic, Retrograde flow in systolic
Advanced - Permanent retrograde
Describe the management of Subclavian Steal Syndrome
Antiplatelets and Statins
Endovascular/Bypass Repair
Why does Atherosclerosis commonly occur at the bifurcation of Carotid?
Turbulent Flow (Virchow’s Triad)
What is Carotid Endarterectomy?
Risk reduction surgery to remove plaque if narrowing is greater than 50%
Give 3 risk factors for Carotid Artery Dissection
Men<50
Marfans
Trauma (lateral rotation and hyperextension, crushing it between skull and C2)
Give 4 presenting symptoms of Carotid Artery Dissection
Ipsilateral Headache/Neck Pain
Horners
III/IV/VI Palsy
Stroke/TIA
How would you manage a Carotid Artery Dissection?
Anticoagulate and aim to recanalise the clot
If this fails then consider stent
What is the INR target for first presentation DVT/PE and recurrent DVT/PE respectively?
First Presentation - 2-3
Recurrent - 3.5
What is an important side effect of heparin
Heparin induced thrombocytopenia
Measure platelets before starting
Describe the DVLA rules regarding AAA
HGV - unable to drive from 5.5cm
Car - notify DVLA at 6cm, stop driving at 6.5cm
How many units of blood should you cross match in ruptured AAA?
6
