General Vascular Surgery Flashcards
Define a normal ABPI measurement
0.9-1.3
A ptnt has IC, experiencing a cramping pain in his calf muscles on walking, what else might he suffer from if the arterial occlusion is located at the bifurcation of the aorta?
erectile dysfunction (impotence)
why might a ptnt with IC also notice a numbness and paraesthesia in the skin of the foot at the same time as muscle pain begins?
muscle pain due to inadequate blood supply so blood shunted from skin to muscle.
why in some ptnts with IC does following a decrease in the walking distance before becoming static, the walking distance actually increases with symptom remission?
development of a collateral circulation
differentials for IC?
osteoarthritis
spinal stenosis
venous claudication
prolapsed IV disc
define varicose veins
saccular dilatations of veins that are often tortuous
why does pregnancy predispose to varicose vein?
elevated progesterone leads to smooth muscle relaxation and venous distension
also, iliac veins compressed by gravid uterus
causes of secondary varicose veins?
post-thrombotic damage
pelvic tumours
acquired AV fistulae
congenital venous anomalies e.g. CG valvular agenesis
how does varicose process progress?
starts in distal veins and ascends proximally
commonest symptoms of varicose veins?
unsightliness
aching
mild ankle oedema
complications of varicose veins?
venous ulceration, calf pump failure syndrome- pigmentation, eczema, lipodermatosclerosis
haemorrhage
superficial thrombophlebitis
test useful for demonstrating origin of a varicose vein?
percussion test
system of origin of varicose veins can be demonstrated with tourniquet test, but insensitive compared to duplex scanning.
how is presence of valvular incompetence in vein being examined demonstrated?
cough impulse test
investigation required for varicose veins?
duplex USS
tment of varicose veins in ptnts unsuitable for surgery and pregnant women?
compression stocking
why is long saphenous vein not stripped much below the knee in saphenofemoral ligation?
to reduce risk of damaging saphenous nerve
where is thrombosis frequently initiated?
in vein valve sinuses of the soleal plexuses
clinical features of DVT?
limb swelling pain tenderness erythema dilated superficial veins
how might leg appear following an extensive iliofemoral thrombosis?
swollen white leg= phlegmasia alba dolens, or blue leg= phlegmasia cerulea dolens
differentials for DVT?
cellulitis lymphoedema torn calf musscles calf haematoma ruptured baker's cyst
DVT investigations?
ascending venography
colour duplex USS- but relatively insensitive in detecting below knee thromboses
what can be used to detect reduced venous capacitance after a thrombosis?
plethysmography
PE clinical features?
dyspnoea
haemoptysis
pleuritic chest pain
sudden death as interruption of venous return to L heart
gold standard investigation for PE?
CTPA: CT pulmonary angiogram
contraindicated in significant renal disease due to use of IV contrast, and in pregnancy due to risk of radiation exposure- in these circumstances consider V/Q perfusion scan- this is NOT useful if preexisting lung disease.
evidence of PE on chest radiograph?
hilar enlargement
consolidation
pleural effusion- homogenous white opacification with meniscus sign
oligaemia-reduction in b.volume in peripheral circulation
what tment may be given if recurrent PE in face of adequate anticoagulation?
filter insertion
below or above knee amputations preferable?
below- so knee intact, making subsequent mobility and prosthetic limb use much better.
indications for amputations?
end-stage unreconstructable atherosclerotic disease diabetic microangiopathy and infection emboli trauma infection e.g. NF, gas gangrene. septic arthritis-S.aureus, osteomyelitis bony malignancy malformations intractable ulceration painful paralysed limbs
amputation complications?
wound infection too long or too short bony spurs stump neuroma phantom pain muscle herniation DVT
type of foot amputation often necessary in diabetic infection?
ad hoc foot amputation= non-viable tissue excised and deep infection drained
heel and other weight-bearing areas retained if possible
wound may be closed with primary suture or skin grafting
define an aneurysm
a localised permanent dilatation of an artery of >50% of the normal diameter or 1.5 times normal diameter.
types of true aneurysms?
fusiform
saccular
RFs for aneurysms?
same as for atherosclerosis- smoking, hyperlipidaemia, hypertension, male, older age, FH BUT NOT DM.
smoking, male, FH= most important
causes of aneurysms other than atherosclerosis?
trauma- pseudoaneurysm/false aneurysm e.g. stab wound
infection e.g. mycotic in endocarditis, syphilis
CT disorders e.g. Marfans, Ehlers-Danlos
inflammatory
common surgery now for AAAs of a diameter of 5.5cm or more?
endovascular aneurysm repair- stent inserted via femoral artery
appropriate for aneurysms below origin of renal arteries so adequate length of normal aorta for endograft attachment without blood leakage.
advantages of EVAR?
no abdominal incision
no aortic cross clamping
improved CR, renal and GI function
reduced hospital stay
disadvantages of EVAR?
endoleaks- continued perfusion of aneurysm sac
movment of stent- this can cause limb ischaemia
failure of stent
thromboembolic complications
