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cfb practicals > Surgery Clinical Demonstration: Peripheral Vascular System > Flashcards

Surgery Clinical Demonstration: Peripheral Vascular System Flashcards

1
Q

General examination

A
  • Supine

- Exposed lower limbs from groin to toes

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2
Q

Arterial Occlusive Disease

A

Questions to ask:

  1. Arterial Occlusive Disease?
  2. Acute / Chronic
  3. Severity
  4. Location of occlusion
  5. Why
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3
Q

***Acute obstruction of Arteries

A

記: 6P

  1. Pain
  2. Paralysis / weakness
  3. Pallor
  4. Paresthesia / numbness
  5. Pulseless
  6. Perishing coldness
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4
Q

***Chronic obstruction of Arteries

A

記: 皮肉痹痛

  1. ***Intermittent claudication
  2. Rest pain
  3. ***Tissue loss
    - ulcers / gangrene
  4. ***Skin changes
    - loss of hair
    - poor condition of nails
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5
Q

History

A
  1. DM
  2. Hypertension / other heart disease
  3. Clotting disorder
    - any anticoagulant drugs
  4. Family history of CVS disease
  5. Smoking
  6. Previous treatment
  7. Present symptom
    - Intermittent claudication
    - Rest pain
    - Ulcers / gangrene
  8. Duration
  9. Progression
  10. Aggravation and relief
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6
Q

Inspection

A
  1. Colour
    - pallor
    - redness
    - blue discolouration
  2. Hair loss
    - dorsum of toes
  3. Condition of nails
  4. Ulceration
    - size
    - edge
    - surface
  5. Swelling
  6. Presence of gangrene
    - dry / wet (infection)
    - over pressure area
    - heel, medial + lateral malleoli
    - between toes
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7
Q

Palpation

A
  1. Pulse
    - Presence / Absence
    - Rate
    - Rhythm
    - Consistency
    - Strength / Volume
    - Compare L/R
    - Femoral pulse —> halfway between ASIS + pubic symphysis
    - Popliteal pulse —> relaxed + slightly flex knee, against femoral condyle
    - Dorsalis pedis pulse —> lateral to extensor hallucis longus tendon
    - Posterior tibial pulse —> posterior to medial malleoli
  2. Capillary refilling time
    - press on big toes and release
    - ***<2 sec to refill
  3. Venous refilling time
  4. Skin temperature
    - cooler limb: peripheral arterial insufficiency
  5. Sensation
  6. Motor function
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8
Q

Auscultation

A

Bruit —> Stenosis (use diaphragm)

  • Bruit
  • Adductor canal
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9
Q

Investigations of Arterial Occlusive Disease

A
  1. Ankle-Brachial Index (ABI)
    - Ankle systolic pressure (use doppler to measure posterior tibial pulse) / Arm systolic pressure
    —> Normal: 1
    —> Asymptomatic: 0.8
    —> Claudication: 0.5-0.6
    —> Tissue loss: 0.3-0.4 (30-40 mmHg)
    Use:
    —> Assess severity
    —> Monitor treatment effect by measuring ABI before + after surgery
    —> Follow-up use
  2. USG Duplex
    - Confirm obstruction
    - Bloodflow (whether turbulence presence)
    - Waveform
    —> Good: Triphasic
    —> Bad: Monophasic
    - Velocity
  3. Treadmill exercise
    - Do ABI again —> ↓ ABI confirms peripheral arterial insufficiency
  4. Arteriography
    - seldom done, indicated only when surgery is planned
    - NOT for diagnosis
    - CT / MRI
  5. Buerger’s test
    Elevation pallor:
    Buerger’s angle: Angle to which the leg has to be raised before it becomes pale
    Normal circulation: Toes and sole of the foot stay pink, even when the limb is raised by 90 degrees
    Ischaemic leg: Elevation to 15 degrees / 30 degrees for 30 to 60 seconds may cause pallor
    Severe ischaemia: Vascular angle < 20 degrees

Rubor of dependency:
Sitting position
Normal circulation: foot will quickly return to pink colour.
Peripheral artery disease: return to pink colour more slowly + pass through normal pinkness to a red-range colouring (rubor - redness) (i.e. Sunset foot, ∵ dilatation of the arterioles to rid the metabolic waste that has built up in a reactive hyperaemia) —> return to normal colour finally

(Pitfalls of ABI: (from web)

  • Severely calcified non-compressible artery may give falsely elevated reading
  • ABI may be normal in patients with moderate stenosis of aorta-iliac artery
  • ABI may be normal if sufficient collateral circulation present)
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10
Q

Venous problems

A

Venous Occlusion + Valvular Incompetence

Superficial veins (Long / Short saphenous):

  1. Varicose veins
    - prominent, tortuous, dilated
  2. Pain
    - distension of veins
    - ***thrombophlebitis
  3. Bleeding
    - profuse if injured large varix

Deep veins (Femoral vein and veins above):

  1. Swelling
    - ***pitting edema due to blocked vein
  2. Pain
    - blockage by thrombus
  3. Venous ulceration
    - if blockage unrelieved
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11
Q

Inspection of varicose veins

A
  1. Degree and distribution
    - site of valvular incompetence —> Trendelenburg test (***Tourniquet test) / Doppler examination
  2. Swelling
    - edema
  3. **Redness over veins
    - indicate **    thrombophlebitis —> inflammation
  4. Ulceration
    - site
    - edge
    - base
  5. Pigmentation
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12
Q

Palpation of varicose veins

A
  1. Edema
    - pitting
    - brawny (non-pitting) if chronic
  2. Tenderness
  3. ***Sapheno-femoral incompetence: Palpable thrill after Valsalva Manoeuvre Cough
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13
Q

Investigations of Varicose veins

A
  1. Tourniquet examination / Trendelenburg test
    - Only doable in gross varicose veins
    - Lie patient down —> observe + describe venous changes and course —> elevate leg —> empty the veins against gravity —> tie tourniquet below SFJ —> stand up —> look + palpate veins
    —> if veins still visible —> indicate valve incompetence in lower level
    —> if veins not visible —> indicate SFJ incompetence
    - Examine axial + perforators
  2. USG Duplex
    - Squeeze calf then release —> whooshing noise
    - Axial reflux (i.e. Great saphenous veins)
    - Perforator location
    —> showing ***bidirectional flow of blood / from deep —> superficial
    —> indicate reflux
  3. Venous Duplex
    - Less compressible vein by probe
    - Lose phasic variation of bloodflow on USG
    - Less good augmentation of flow by compression of vein
  4. Venogram
    - contrast to show filling defect
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14
Q

Treatment of varicose veins

A

Compression stockings

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15
Q

Revision: Venous system

A
  • Long saphenous system: anterior to medial malleolus, run medial of leg, drain via ***Saphenous opening (2cm lateral + below pubic tubercle)
  • Small saphenous system: lateral of leg —> back of calf —> Popliteal
  • Communicating vein system

Divided into (被deep fascia隔開):

  1. Deep veins
    - travel with arteries with same name
    - drain deeper structures (e.g. muscles, bones, joints)
    - found deep to muscles
    - usually paired when accompanying medium sized arteries (    Venae comitantes)
    - valves present
  2. Superficial veins
    - run in superficial fascia (superficial to muscle)
    - drain SC tissue
    - externally visible
    - communicate with deep veins at regular intervals by **Perforating / Communicating veins (pierce **deep fascia)
    - valves present to direct blood from superficial to deep vein —> systemic veins
    - Clinically important: Venipuncture, Transfusion
    - Prone to Varicosities (lower limb)
Lower limb venous blood flow:
Superficial veins
—> Deep veins
—> Femoral vein
—> External iliac vein
—> Common iliac vein
—> IVC
—> RA
  1. Dorsal venous arch (foot dorsum)
  2. Great saphenous vein (medial)
    - from medial arch (***2/3 cm anterior to medial malleolus: accessible for venous cutdowns) —> medial leg —> behind knee —> medial thigh —> Saphenous opening (in deep fascia of thigh, 3/4 cm lateral and below pubic tubercle) —> Femoral vein
    - used as graft in coronary bypass surgery
  3. Small saphenous vein (back)
    - from lateral arch —> back of leg —> Popliteal vein at popliteal fossa

Blood flow:
Dorsal venous network (plantar arch)
1. Great saphenous vein —(Saphenous opening)—> Femoral vein
2. Small saphenous vein —> Popliteal vein —> Femoral vein

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cfb practicals (24 decks)

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