Surgery: Vasc Flashcards
Atherosclerosis RFs
Elderly Male FHx HTN Diabetes Hyperlipidaemia Smoker
How does PAD px? (3)
Claudication: pain and cramping in the calf after a certain distance
Critical Limb Ischaemia: rest pain, night pain, tissue loss
Acute Limb Ischaemia: sudden onset <2wks, 6P’s
What is Leriche syndrome? (3)
Internal iliac vasc def: buttock claudication, impotence, reduced pulses
Ddx of claudication ie pain when you walk (2)
Spinal stenosis + post thrombotic syndrome
What is the perfusion pressure in critical limb ischaemia?
<40mmHg
Which of the 6P’s of ALI comes on early and starts to worry you?
Paraesthesia
How does the ABPI relate to PAD px?
- 7-0.9: claudication
- 4-0.7: critical limb ischaemia
<0.4: acute limb ischaemia
Why can reperfusing the leg be life threatening?
Cardiac arrest, VF, VT
What is the arterial blood supply to the lower leg?
Popliteal -> Anterior Tibial + Tibioperoneal Trunk -> Posterior Tibial + Peroneal
What are important components of your clerking when a pt presents w leg pain?
Timing, RFs, DHx, prev scars
Where do you amputate up to?
The level where there’s most blood supply ie dead foot below knee and dead ankle above knee
What is the surface anatomy landmark for the femoral artery?
The mid-inguinal point ie half way b/w ASIS + pubic symphysis
What is Buerger’s angle + test?
The angle at which the raised leg becomes pale where <20° is severe
If you get reactive hyperaemia seen as a sunset foot when the pt sits following the leg raise the test is pos
What are the two shapes of true aneurysms?
Fusiform + Saccular
Who is screened for AAA?
Single USS for males >65yrs
Ddx of left sided loin to groin back pain (2)
AAA + Renal Colic
When do you operate on an AAA?
2wk referral to vasc surgery for EVAR/open repair if: sx, >5.5cm, expansion rate >1cm per annum
What is the mortality rate for an emergency AAA repair?
Half will make it into hospital and half will make it out
What is the f/u for open vs EVAR?
Open - once at 5yrs vs EVAR - yearly
Aortic Dissection: Type A vs B
A: before left subclavian
B: beyond left subclavian
Mx of Aortic Dissection
Med: invasive bp monitoring + IV beta blockers and analgesia
Surg: gold standard for type A under cardiothoracics and if rupture, uncontrolled pain or malperfusion of aortic branches or lower extremities then also required for type B under vascular surgeons
What is the consequence of aiming for a SBP <120 when mx dissection?
Oliguric
Def of Oliguria
UO <0.5ml/kg/hr
What is the risk of a long segment of phlebitis or if it’s close to groin?
DVT
What is phlegmasia?
Extensive DVT preventing superficial venous system from draining causing painful oedema and may lead to arterial ischaemia and venous gangrene
What is phlegmasia a/w?
Underlying malignancy + hypercoagulability
What can you give a large proximal DVT within 2wks?
Thrombolysis vs after 2wks too high risk of post thrombotic syndrome
Which pts would you consider a venous bypass in?
Unable to live their life due to recurrent ulceration and pain
Ulcers: Venous v Arterial v Neuropathic - Background, Description, Location
Venous: chronic venous insufficiency, shallow flat margins w exudate, medial malleolus / gaiter region
Arterial: PAD, painful deep punched out w necrotic tissue, lateral malleolus / feet
Neuropathic: diabetics, deep insensate surrounded by callus, planter aspect of foot
What is Marjolin’s ulcer?
Aggressive SCC due to chronic ulceration/burns/osteomyelitis that becomes neoplastic w rolled edges
How often do you rescan a AAA b/w 3-5.4cm?
3-4.4cm every 12m + 4.5-5.4cm every 3m
What is the workup for intermittent claudication?
Hx, check lower limb pulses, ABPI, duplex US, MRA prior to any intervention
Mx of PAD
Consv: stop smoking, exercise training, tx comorbidities
Med: atorvastatin 80mg + clopidogrel 75mg
Surg: angioplasty, stenting, bypass
Mx of Superficial Thrombophlebitis
Perform USS to exclude concurrent DVT, if ABPI >0.8 compression stockings, LMWH 30d or oral NSAIDs 8-12d
Mx of ALI
Surg intervention within 6hrs to revascularise the leg
Dx of Critical Limb Ischaemia
> =1: rest pain in foot >2wks, ulceration, gangrene
When would an ABPI be >1.2?
Usually in type two diabetics due to vessel calcification
RFs for AAA
Smoking
HTN
Syphilis
CTD
What is the biggest risk factor for ALI in pts w/o any prev claudication?
Embolus>Thrombus: AF
What are the classic skin changes of chronic venous insufficiency and a/w venous ulcers?
Eczema
Oedema
Haemosiderin
Lipodermatosclerosis
Mx of Venous Ulcers
Conserv: four layer compression banding after exclusion of arterial disease
Surg: skin grafting if >10cm^2 or fail to heal after 12wks
Mx of Neuropathic Ulcers
Conserv: cushioned shoes to red callous formation
Surg: likely to lead to amputation
What may a cervical rib cause?
Thoracic Outlet Syndrome
What is subclavian steal syndrome?
Stenosis/occlusion of subclavian artery proximal to origin of vertebral artery resulting in retrograde flow and sx of CNS vascular insufficiency
What are the branches off the arch of aorta?
L/R Coronary Arteries
Brachiocephalic: R Subclavian Artery + R Common Carotid
L Common Carotid: external + internal
L Subclavian Artery: vertebral, internal thoracic, thyrocervical trunk, costocervical trunk, axillary
What is Takayasu’s arteritis? Px? Tx?
Large vessel granulomatous vasculitis in young asian females resulting in intimal narrowing
Px w features of mild systemic illness and then pulseless phase w sx of vascular insufficiency
Tx w systemic steroids
What are the classical findings in aortic coarctation?
A/w congenital heart defect
Px w syncope, angina pectoris, leg claudication
Weak arm pulses, radiofemoral delay, BP mismatch, low ABPI
How is ABPI derived?
Ankle/Branchial
Ddx for Rib Notching: Inferior + Superior
Inferior: enlargement of structure in subcostal groove - aortic coarctation, Takayasu arteritis, Blalock-Taussig shunt, SVC obstruction, schwannoma, neurofibroma
Superior: disturbance of osteob/clastic activity - oesteogenesis imperfecta, hyperparathyroidism, intercostal muscle stress
What does the urgency of tx for an aortic coarctation depend on?
Presence of congestive cardiac failure
What is Roesler sign?
Inferior Rib Notching
Why do you get inferior rib notching in long standing aortic coarctation?
The intercostal collateral vessels dilate to try and bypass the coarctation and supply the descending aorta
What does Adson’s test and Wright’s test assess?
Presence of thoracic outlet syndrome
Adson’s: monitor radial pulse as pt extends arm backwards, turns their head toward sx side, takes deep breath and holds
Wright’s: monitor radial pulse and sx onset during abduct and ext rotation of arm for one min then hyperabduct
Tx of Raynaud’s Disease: white -> blue -> red
CCB
Why is the IMA not usually revascularised during AAA tx?
The cross over supply from the SMA and rectal arteries
What are specific risks to an EVAR?
Ischaemia, Leak, Reop
What are the specific risks to an open AAA repair?
Ischaemia, ED, Incisional Hernia
How do you listen for bruits in the neck?
Ask the pt to breathe all the way in, out, hold
Top half of a vasc exam px
The pt appears well at rest w no peripheral stigmata of chronic disease
His fingers are nicotine stained
He is not tachycardic w a regular rhythm and no radio-radial delay
You have indicated he is normotensive
There is a full complement of supra-aortic pulses w no bruits
I always perform a full examination of the pre-cordium in my normal practice
What is the cause of radio-radial and radio-femoral delay?
Radio-Radial: type A aortic dissection
Radio-Femoral: coarctation of the aorta
What do you do next after the popliteal pulse is felt?
Check it’s not expansile + state it’s prominent which may be normal but you’d get a duplex to see if it’s aneurysmal
Where should you palpate next if there’s an absent dorsalis pedis pulse?
Anterior to the lateral malleolus in case there’s a dominant peroneal artery
What special tests would you perform for the vasc lower limb?
Buerger’s Angle, Test, ABPI
Raise both feet and look for angle foot goes white
Swing leg over side of bed, let them hang down, look for the ischaemic foot turning brick red
What does a positive Buerger’s test indicate?
Sig arterial disease of lower limb
What are the typical ABPI values?
Normal: 0.8-1
Claudication: 0.6-1
Critical Ischaemia: <0.6
Why could you end up w an abnormally high ABPI in diabetics?
The arteries have calcified and resist the pressure cuff
Bottom half of a vasc exam px
O/e of LLs there were no obvious scars or ulceration
There was no difference in temperature b/w the LLs
The pt had bilateral and equal femoral pulses w no radio-femoral delay
There was palpable popliteal pulses and a full complement of pedal pulses
I detected no bruits on ausc, Buerger’s test was negative, I would like to perform ABPIs on both sides
What are the reasons for a scar suggest of a bypass? (3)
Trauma
Occlusion
Aneurysm
Which vein is most commonly used for autologous grafts?
Long Saphenous Vein: SFJ 2cm lateral and inferior to pubic tubercle down to in front of the medial malleolus
Where can the posterior tibial pulse be felt?
Just behind and slightly below the medial malleolus
What are the key qs in a claudication hx?
No rest pain, clarify exactly how far they can walk, how long they have to rest for following the pain before it subsides
What tells you where the stenosis is?
Sx + Pulse Pattern
What tests can you do for claudication?
Exercise treadmill ABPIs, duplex, angiography
What are pts w claudication at high risk of developing?
MI, CVA, Renal Failure: therefore must stop smoking, start a structured exercise programme, have strict mx of BP and diabetes, be on an antiplatelet and statin
Def of Critical Ischaemia
All three of:
- Rest pain or tissue loss ie ulceration/necrosis
- Greater than 2wks duration
- Ankle pressure of <40mmHg
What are the comps of an aneurysm? (5)
Rupture Thrombosis Embolism Pressure Fistula
What are the comps of varicose veins? (7)
Swelling Bleeding Eczema Haemosiderin Thrombophlebitis Lipodermatosclerosis Venous Ulceration
What are the typical sx of varicose veins?
Asx, aesthetic complaints, pain on standing worse at the end of the day, itching, restless legs, night cramps
Tx of Varicose Veins
Tx if sev impact on QALY, painful, bleeding, thrombophlebitis, ulceration
Consrv: optimise wt, avoid prolonged standing, elevate legs, reg walks, compression stockings
Surgical: minimally invasive ablation or injection sclerotherapy and or open surgery eg saphenofemoral ligation and stripping
Thoracic Outlet Syndrome
Compressed b/w first rib, scalenus anterior and clavicle
Venous: upper limb DVT and long term swelling
Arterial: Raynaud’s, claudication, embolisation
Neuro: pain + radiculopathy
Ix w duplex of arms down and up, nerve conduction studies, MRA/MRV/MRI
Tx w thrombolysis and removal of the first rib
What are the 2° causes of Raynaud’s?
Vasospasm -> Deoxygenation -> Reperfusion
Use of vibrating tools, atherosclerosis, scleroderma, SLE, polyarteritis nodosa, cold agglutinin disease, drugs
What are the causes of unilateral leg swelling?
- Trauma
- Cancer
- Venous
- Lympathic: 1° milroy’s disease, in gravida, tarda + 2° surg, radiotherapy, chemotherapy, TB, filariasis, cancer
What should you check if you suspect AV malformation?
Pulsatile
Compressible
Auscultate
Doppler
What are the indications for a carotid endartectomy?
There’s >=70% stenosis AND ipsilateral hemisphere sx of TIA, well recovered stroke, amaurosis fugax
What is the Fontaine classification for PAD?
- Asx
- Intermittent Claudication
- Ischaemic Rest Pain
- Ulceration/Gangrene
When does compartment syndrome occur?
After direct trauma (fractured tibia), from pressure effects (rhabdomyolysis following prolonged immobility) & as a complication of revascularising an ischaemic limb
What is Morton’s neuroma?
A condition causing metatarsal pain due to inflammation around the plantar nerve
What is tabes dorsalis?
A feature of quaternary syphilis that may present with numb legs and a neuropathic type pain
What are the six P’s of an acutely ischaemic limb?
Pale Pulseless Painful Paralysed Paraesthetic Perishingly ❄️
What are signs of chronic ischaemia?
Hairless skin, ulcers, lipodermatosclerosis
List four emergency treatments for ALI
Surgical embolectomy, endarterectomy, intraarterial thrombolysis, intravenous heparin
What indicates irreversible limb ischaemia?
Fixed skin mottling
Why should you never rewarm the limb?
It enhances tissue damage
What are the absolute contraindications for thrombolysis in MI and ALI?
Non-viable limb (irreversible ischaemic change – insensate/fixed skin mottling) Internal bleeding Suspected aortic dissection Prolonged or traumatic CPR Previous allergic reaction Heavy vaginal bleeding Pregnancy or < 18 wks postnatal Acute pancreatitis Severe liver disease Active lung disease with cavitation Oesophageal varices Recent trauma or surgery (< 2 wks) Recent head trauma Cerebral neoplasm Recent haemorrhagic stroke Severe hypertension (>200/120 mmHg)
What are the relative contraindications for thrombolysis in MI and ALI?
History of severe hypertension Peptic ulcer History of CVA Bleeding diathesis Anticoagulants
How might an aortic aneurysm px?
Lower limb purpura
At what size does the risk of aortic aneurysm rupture increase sharply?
> 6cm
What is the SBP aim during fluid resus for aortic aneurysm rupture?
<100mmHg to prevent rebleeding
Most common site of varicose veins?
The long or short saphenous veins
Patho of varicose veins
Incompetent valves
Varicose veins affecting the long saphenous
Groin to medial aspect of lower leg
Varicose veins affecting the short saphenous
Popliteal fossa to lateral malleolus
Which tests assess incompetence of varicose veins?
Tourniquet, Trendelenburg, Doppler
Tx of varicose veins
Graduated compression stockings & interventional (surgery, sclerotherapy, endovenous ablation)
Surgical indications for varicose veins
NB: aiming to red any comps
Oedema, skin changes, venous eczema and ulceration
NB: non-specific sx may not be helped by tx
When would you perform a Duplex US before surgery?
Recurrent varicose veins, prev hx of DVT & uncertain distribution
Aortic aneurysm haemo stable vs unstable
If haemodynamically stable send for CT to evaluate aorta and retroperitoneum vs unstable straight to theatre
Immediate mx of ruptured AAA
A-E, administer O2, two large bore IV cannulae, take blood (FBC, U&Es, clotting, crossmatch 6U), give 1L normal saline/Hartmanns to keep SBP ~100mmHg, inform vascular surgeon, insert catheter
What is often the first sign of an AAA?
Lower back pain due to the pressure effect on the spine
NB: can cause pain anywhere in the abdomen & even mimic renal calculi
Which line is NOT for resus
A central line as its length means it has high resistance
Surgical options for repairing an AAA
Endovascular aneurysm repair (EVAR) & open midline laparotomy
Elderly male, loin to groin pain, no hx of kidney stones
Think AAA
At what level does the aorta bifurcate
L4 @ umbilicus
An expansile mass felt below the umbilicus
An iliac aneurysm
At what size is an elective repair generally regarded as being required
> 5.5cm (if below observed w serial US)
Drugs to avoid in pts w peripheral vascular disease
ACEi and beta blockers
Vasc SVR
Pain Itch Bleeding Swelling Ulcers Skin Changes
RFs for Varicose Veins
Age
Female
Pregnancy
Obesity
Sx for Varicose Veins
Aching
Throbbing
Itching
Comps for Varicose Veins
Skin Changes Bleeding Superficial Thombophlebitis Venous Ulceration DVT
Mx for Varicose Veins
Consv: leg elevation, wt loss, regular exercise, graduated compression stockings
Surg: refer if any comp -> endothermal ablation, foam sclerotherapy, ligation/stripping
Tx of Restless Leg Syndrome
Ropinirole
Aortic Dissection Mx
CT, Labetolol, Morphine
Type A: refer to cardiothoracics
Type B: BP control + stent
