SURG: Vascular Flashcards
1
Q
Screening for AAA?
A
Single abdominal ultrasound for males aged 65:
- <3cm = normal, no further action
- 3-4.4cm = small aneurysm, rescan every 12m
- 4.5-5.4 = medium aneurysm, rescan every 3m
- > 5.5 = large aneurysm, refer <2w to vascular surgery for intervention
2
Q
Management of AAA?
A
> > Symptomatic, aortic diameter >=5.5cm or rapidly enlarging (>1cm/year)
> > Treat with elective endovascular repair (EVAR) or open repair if unsuitable
3
Q
Investigations for ruptured AAA?
A
- Screen with USS
- Gold standard CT angiogram
- Haemodynamically unstable = clinical diagnosis, not stable enough for CT etc to confirm > should be taken straight to theatre
4
Q
Management of ruptured AAA?
A
Open repair:
- Suitable for any shape of aneurysm
- Requires GA and laparotomy - not suitable if patient has poor baseline
- Requires cross-clamping the aorta - not suitable if significant cardiac disease history
EVAR:
- LA and groin incisions - suitable if frail
- No need to occlude aorta - suitable if cardiac disease
- Only suitable for AAAs not involving the renal arteries
- Requires large quantities of radiological contrast - not suitable for patients with significant renal impairment
Palliative:
- Midazolam for agitation
- Haloperidol for nausea
- Morphine for pain
- Syringe driver is an option to help control symptoms at this point
5
Q
Interpretation of ABPI?
A
- > 1.2 = may indicate calcified, stiff arteries (advanced age or PAD)
- 1.0-1.2 = normal
- 0.9-1.0 = acceptable
- <0.9 = likely PAD
- Values <0.5 indicate severe disease which should be referred urgently
6
Q
Clinical features of venous ulcer?
A
- Oedema
- Brown pigmentation
- Lipodermatosclerosis
- Eczema
- Location above the ankle
- Painless
7
Q
Clinical features of arterial ulcer?
A
- Occur on the toes and heel
- Typically have a ‘deep, punched-out’ appearance
- Painful
- There may be areas of gangrene
- Cold with no palpable pulses
- Low ABPI measurements
8
Q
Clinical features of neuropathic ulcers?
A
- Commonly over plantar surface of metatarsal head and plantar surface of hallux
- The plantar neuropathic ulcer is the condition that most commonly leads to amputation in diabetic patients
- Due to pressure
- Management includes cushioned shoes to reduce callous formation
9
Q
Causes of carotid artery dissection?
A
- Direct neck trauma - often from motor vehicle accidents or strangulation.
- Spontaneous - often associated with structural defects in the arterial wall, e.g. Ehlers-Danlos syndrome type IV or Marfan syndrome, or conditions causing systemic inflammation e.g. arteritis
- Iatrogenic - arising from medical procedures like catheter angiography, carotid endarterectomy, or chiropractic manipulation of the neck.
- Others - physical activities causing hyperextension or rotation of the neck such as yoga, coughing, vomiting, or childbirth
10
Q
Clinical features of carotid artery dissection?
A
- Headache - usually unilateral, severe and of a gradual onset
- Partial Horner’s syndrome (ptosis and miosis)
- Pulsatile tinnitus
- Unilateral neck pain
- Transient monocular blindness
- Cranial nerve palsy - most commonly cranial nerves IX to XII
- Signs of stroke - hemiplegia, hemisensory loss, vascular bruits
11
Q
Investigations for carotid artery dissection?
A
- Screening - carotid USS
- Diagnosis - MRA (narrowing or vessel occlusion, ‘string sign’) and fat suppression MRI (double-lumen sign)
CT can be used
12
Q
Management of carotid artery dissection?
A
Antiplatelet medications such as aspirin:
- Used in traumatic cases
- Specifically preferred in intracranial carotid dissections and extensive infarcts
Anticoagulation with warfarin and heparin:
- Used to prevent progression of neurological symptoms
- Only given after intracerebral haemorrhage ruled out using CT
- Contraindications include intracranial dissection and extensive infarcts
Thrombolysis:
- Used <3hrs of presentation
- Used in patients with stroke caused by spontaneous extracranial dissection
- Contraindications include intracranial dissection and involvement of the aorta due to the risk of aortic rupture
Endovascular interventions e.g. stenting and surgery:
- Beneficial in internal carotid dissection and concurrent proximal intracranial occlusion
- Urgent surgical interventions used in patients who present with SAH
- Surgery can also be performed in symptomatic aneurysmal dilatation and chronic carotid dissections
- Medical management first line due to risks involved in surgery
13
Q
Features of acute limb-threatening ischaemia?
A
1 or more of the 6 P’s
- pale
- pulseless
- painful
- paralysed
- paraesthetic
- ‘perishing with cold’
14
Q
Investigations for acute limb-threatening ischaemia?
A
- Handheld arterial Doppler examination
- If Doppler signals present > ABPI
- Imaging - angiography or duplex ultrasound
15
Q
Management of acute limb-threatening ischaemia?
A
Initial management:
- ABC approach
- analgesia: IV opioids are often used
- IV unfractionated heparin to prevent thrombus propagation, particularly if the patient is not suitable for immediate surgery
- vascular review
Definitive management:
- intra-arterial thrombolysis
- surgical embolectomy
- angioplasty
- bypass surgery
- amputation: for patients with irreversible ischaemia
16
Q
Clinical features of critical limb ischaemia?
A
1 or more of:
- rest pain in foot for more than 2 weeks
- non-healing wounds
- ulceration
- gangrene
- patients often report hanging their legs out of bed at night to ease the pain
- ABPI <0.5
17
Q
Clinical features of intermittent claudication?
A
- aching or burning in the leg muscles following walking
- patients can typically walk for a predictable distance before the symptoms start
- usually relieved within minutes of stopping
- not present at rest
18
Q
Investigations for intermittent claudication?
A
- check the femoral, popliteal, posterior tibialis and dorsalis pedis pulses
- check ABPI
- duplex ultrasound is the first line investigation
- magnetic resonance angiography (MRA) should be performed prior to any intervention
19
Q
Management of PAD?
A
General:
- Stop smoking
- Manage HTN, diabetes, obesity
- Supervised exercise programme
Pharmacological:
- ALL = statin + clopidogrel
- Naftidrofuryl oxalate - vasodilator, sometimes used for patients with poor quality of life
- Cilostazol - both antiplatelet and vasodilator effects (not recommended by NICE)
Severe PAD or critical limb ischaemia may be treated by:
- Endovascular revascularization - percutaenous transluminal angioplasty +/- stent placement, typically used for short segment stenosis (e.g. < 10 cm), aortic iliac disease and high-risk patients
- Surgical revascularization - surgical bypass with an autologous vein or prosthetic material, endarterectomy, open surgical techniques typically used for long segment lesions (> 10 cm), multifocal lesions, lesions of common femoral artery and purely infrapopliteal disease
- Amputation reserved for patients with critical limb ischaemia not suitable for other interventions
20
Q
Clinical features of superficial thrombophlebitis?
A
- Erythema - follows course of involved vein and may be linear or patchy in distribution
- Tenderness - along inflamed vein, may be exacerbated upon palpation or movement of affected limb
- Warmth of affected area
- Oedema in surrounding tissue
- Induration and Cord-like Vein
- Palpable Venous Nodules
- Pruritus around site of inflammation
- Varicosities - frequently occurs in presence of pre-existing varicose veins, may be visible as tortuous and dilated vessels
21
Q
Management of superficial thrombophlebitis?
A
- Anti-embolism stockings
- Consider treatment with prophylactic doses of LMWH for up to 30 days or fondaparinux for 45 days.
- If LMWH is contraindicated, 8-12 days of oral NSAIDS should be offered.
22
Q
Clinical features of varicose veins?
A
- aching, throbbing, itching
- varicose eczema (also known as venous stasis)
- haemosiderin deposition → hyperpigmentation
- lipodermatosclerosis → hard/tight skin
- atrophie blanche → hypopigmentation
- bleeding
- superficial thrombophlebitis
- venous ulceration
- deep vein thrombosis
23
Q
Management of varicose veins?
A
Conservative:
- leg elevation
- weight loss
- regular exercise
- graduated compression stockings
Reasons for referral to secondary care:
- significant/troublesome lower limb symptoms e.g. pain, discomfort or swelling
- previous bleeding from varicose veins
- skin changes secondary to chronic venous insufficiency (e.g. pigmentation and eczema)
- superficial thrombophlebitis
- an active or healed venous leg ulcer
Possible treatments:
- endothermal ablation: using either radiofrequency ablation or endovenous laser treatment
- foam sclerotherapy: irritant foam → inflammatory response → closure of the vein
- surgery: either ligation or stripping
24
Q
A
