Surgery Flashcards
What medical co-morbidities should be managed carefully to minimise risk of atherosclerosis?
diabetes
hypertension
CKD
Inflammatory conditions such as rheumatoid arthritis
Atypical antipsychotic medications
what are the end-results of atherosclerosis?
angina
MI
TIA
stroke
peripheral arterial disease
chronic mesenteric ischaemia
what are the features of critical limb ischaemia?
Pain
Pallor
Pulseless
Paralysis
Paraesthesia
Perishingly cold
critical limb ischaemia typically causes burning pain that is worse at night when the leg is raised, as gravity no longer helps to pull blood into the foot
What is Leriche syndrome?
occlusion in the distal aorta or proximal common iliac artery presenting with a triad of:
- thigh/buttock pain
- absent femoral pulses
- male impotence
What is the Buerger’s test?
used to assess for peripheral arterial disease in the leg
patient lies on their back. Lift their leg to an angle of 45 degrees at the hip - hold them there for 1-2 minutes, looking for pallor - pallor indicates the arterial supply is not adequate to overcome gravity, suggesting PAD.
Buerger’s angle refers to angle at which leg is pale due to inadequate blood supply e.g. a buerger’s angle of 30 means leg will go pale when lifted to 30 degs
2nd part involves sitting pt up with their legs hanging over the side of the bed - blood will flow back into the legs assisted by gravity. In a healthy pt the legs will remain a normal pink colour - in a patient with PAD they will go:
blue initially as the ischaemic tissues deoxygenates the blood
dark red after a short time due to vasodilation in response to waste products of anaerobic respiration
dark red colour is referred to as rubor
what are features of arterial ulcers?
smaller than venous ulcers
deeper than venous ulcers
have well defined borders
have a “punched out” appearance
occur peripherally e,.g. on toes
have reduced bleeding
are painful
What are the features of venous ulcers?
caused by impaired drainage and pooling of blood in the legs
occurs after minor injury to the leg
larger than arterial ulcers
more superficial than arterial ulcers
have irregular, gently sloping borders
affect the gaiter area of the leg - mid-calf down to ankle
less painful than arterial ulcers
occur with other signs of chronic venous insufficiency e.g. haemosiderin staining and venous eczema
What are the features of venous ulcers?
caused by impaired drainage and pooling of blood in the legs
occurs after minor injury to the leg
larger than arterial ulcers
more superficial than arterial ulcers
have irregular, gently sloping borders
affect the gaiter area of the leg - mid-calf down to ankle
less painful than arterial ulcers
occur with other signs of chronic venous insufficiency e.g. haemosiderin staining and venous eczema
what is the management of intermittent claudication?
- lifestyle changes: required to manage modifiable risk factors e.g. stop smoking, optimise medical treatment of co-morbidities
exercise training
medical treatment: atorvastatin 80mg, clopidogrel 75mg
surgical options: endovascular angioplasty and stenting, endarterectomy - cutting vessel open and removing atheromatous plaque, bypass - using graft to bypass blockage
what is the management of critical limb ischaemia?
require urgent referral to the vascular team - require analgesia to monitor pain
urgent revascularisation can be achieved by:
- endovascular angioplasty and stenting
- endarterectomy
- bypass surgery
- amputation of limb if not possible to restore blood supply
what is the management of acute limb ischaemia?
urgent referral to on-call vascular team for assessment:
endovascular thrombosis - inserting catheter through arterial system to apply thrombolysis directly into clot
endovascular thrombectomy - inserting catheter through arterial system and removing thrombus by aspiration or mechanical devices
surgical thrombectomy - cutting open vessel and removing thrombus
endarterectomy
bypass surgery
amputation of limb if not possible to restore blood supply
in acute limb ischaemia what features are suggestive of thrombus formation?
pre-existing claudication with sudden deterioration
no obvious source of emboli
reduced or absent pulses in contralateral limb
evidence of widespread vascular disease
in acute limb ischaemia what features are suggestive of embolus formation i.e. secondary to AF?
sudden onset of painful leg - <24 hours
no history of claudication
clinically obvious source of embolus e.g. AF, recent MI
no evidence of peripheral vascular disease
evidence of proximal aneurysm
what thrombophilias predispose people to forming blood clots?
antiphospholipid syndrome
factor v leiden
protein c or s deficiency
hyperhomocysteinaemia
prothrombin gene variant
activated protein c resistance
what calf size is significant for dvt?
more than 3 cm difference between calves is significant
To examine for leg swelling, measure the circumference of the calf 10cm below the tibial tuberosity
