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Year 6 - Surgery > Surgery: Vasc > Flashcards

Surgery: Vasc Flashcards

1
Q

Atherosclerosis RFs

A 
Elderly
Male
FHx
HTN
Diabetes
Hyperlipidaemia
Smoker
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2
Q

How does PAD px? (3)

A

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

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3
Q

What is Leriche syndrome? (3)

A

Internal iliac vasc def: buttock claudication, impotence, reduced pulses

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4
Q

Ddx of claudication ie pain when you walk (2)

A

Spinal stenosis + post thrombotic syndrome

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5
Q

What is the perfusion pressure in critical limb ischaemia?

A

<40mmHg

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6
Q

Which of the 6P’s of ALI comes on early and starts to worry you?

A

Paraesthesia

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7
Q

How does the ABPI relate to PAD px?

A
  1. 7-0.9: claudication
  2. 4-0.7: critical limb ischaemia

<0.4: acute limb ischaemia

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8
Q

Why can reperfusing the leg be life threatening?

A

Cardiac arrest, VF, VT

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9
Q

What is the arterial blood supply to the lower leg?

A

Popliteal -> Anterior Tibial + Tibioperoneal Trunk -> Posterior Tibial + Peroneal

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10
Q

What are important components of your clerking when a pt presents w leg pain?

A

Timing, RFs, DHx, prev scars

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11
Q

Where do you amputate up to?

A

The level where there’s most blood supply ie dead foot below knee and dead ankle above knee

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12
Q

What is the surface anatomy landmark for the femoral artery?

A

The mid-inguinal point ie half way b/w ASIS + pubic symphysis

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13
Q

What is Buerger’s angle + test?

A

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

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14
Q

What are the two shapes of true aneurysms?

A

Fusiform + Saccular

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15
Q

Who is screened for AAA?

A

Single USS for males >65yrs

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16
Q

Ddx of left sided loin to groin back pain (2)

A

AAA + Renal Colic

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17
Q

When do you operate on an AAA?

A

2wk referral to vasc surgery for EVAR/open repair if: sx, >5.5cm, expansion rate >1cm per annum

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18
Q

What is the mortality rate for an emergency AAA repair?

A

Half will make it into hospital and half will make it out

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19
Q

What is the f/u for open vs EVAR?

A

Open - once at 5yrs vs EVAR - yearly

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20
Q

Aortic Dissection: Type A vs B

A

A: before left subclavian

B: beyond left subclavian

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22
Q

Mx of Aortic Dissection

A

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

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23
Q

What is the consequence of aiming for a SBP <120 when mx dissection?

A

Oliguric

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24
Q

Def of Oliguria

A

UO <0.5ml/kg/hr

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25
Q

What is the risk of a long segment of phlebitis or if it’s close to groin?

A

DVT

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26
Q

What is phlegmasia?

A

Extensive DVT preventing superficial venous system from draining causing painful oedema and may lead to arterial ischaemia and venous gangrene

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27
Q

What is phlegmasia a/w?

A

Underlying malignancy + hypercoagulability

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28
Q

What can you give a large proximal DVT within 2wks?

A

Thrombolysis vs after 2wks too high risk of post thrombotic syndrome

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29
Q

Which pts would you consider a venous bypass in?

A

Unable to live their life due to recurrent ulceration and pain

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30
Q

Ulcers: Venous v Arterial v Neuropathic - Background, Description, Location

A

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

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31
Q

What is Marjolin’s ulcer?

A

Aggressive SCC due to chronic ulceration/burns/osteomyelitis that becomes neoplastic w rolled edges

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32
Q

How often do you rescan a AAA b/w 3-5.4cm?

A

3-4.4cm every 12m + 4.5-5.4cm every 3m

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33
Q

What is the workup for intermittent claudication?

A

Hx, check lower limb pulses, ABPI, duplex US, MRA prior to any intervention

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34
Q

Mx of PAD

A

Consv: stop smoking, exercise training, tx comorbidities

Med: atorvastatin 80mg + clopidogrel 75mg

Surg: angioplasty, stenting, bypass

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35
Q

Mx of Superficial Thrombophlebitis

A

Perform USS to exclude concurrent DVT, if ABPI >0.8 compression stockings, LMWH 30d or oral NSAIDs 8-12d

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36
Q

Mx of ALI

A

Surg intervention within 6hrs to revascularise the leg

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37
Q

Dx of Critical Limb Ischaemia

A

> =1: rest pain in foot >2wks, ulceration, gangrene

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38
Q

When would an ABPI be >1.2?

A

Usually in type two diabetics due to vessel calcification

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39
Q

RFs for AAA

A

Smoking
HTN
Syphilis
CTD

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40
Q

What is the biggest risk factor for ALI in pts w/o any prev claudication?

A

Embolus>Thrombus: AF

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41
Q

What are the classic skin changes of chronic venous insufficiency and a/w venous ulcers?

A

Eczema
Oedema
Haemosiderin
Lipodermatosclerosis

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42
Q

Mx of Venous Ulcers

A

Conserv: four layer compression banding after exclusion of arterial disease

Surg: skin grafting if >10cm^2 or fail to heal after 12wks

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43
Q

Mx of Neuropathic Ulcers

A

Conserv: cushioned shoes to red callous formation

Surg: likely to lead to amputation

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44
Q

What may a cervical rib cause?

A

Thoracic Outlet Syndrome

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45
Q

What is subclavian steal syndrome?

A

Stenosis/occlusion of subclavian artery proximal to origin of vertebral artery resulting in retrograde flow and sx of CNS vascular insufficiency

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46
Q

What are the branches off the arch of aorta?

A

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

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47
Q

What is Takayasu’s arteritis? Px? Tx?

A

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

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48
Q

What are the classical findings in aortic coarctation?

A

A/w congenital heart defect

Px w syncope, angina pectoris, leg claudication

Weak arm pulses, radiofemoral delay, BP mismatch, low ABPI

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49
Q

How is ABPI derived?

A

Ankle/Branchial

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50
Q

Ddx for Rib Notching: Inferior + Superior

A

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

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51
Q

What does the urgency of tx for an aortic coarctation depend on?

A

Presence of congestive cardiac failure

52
Q

What is Roesler sign?

A

Inferior Rib Notching

53
Q

Why do you get inferior rib notching in long standing aortic coarctation?

A

The intercostal collateral vessels dilate to try and bypass the coarctation and supply the descending aorta

54
Q

What does Adson’s test and Wright’s test assess?

A

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

55
Q

Tx of Raynaud’s Disease: white -> blue -> red

A

CCB

56
Q

Why is the IMA not usually revascularised during AAA tx?

A

The cross over supply from the SMA and rectal arteries

57
Q

What are specific risks to an EVAR?

A

Ischaemia, Leak, Reop

58
Q

What are the specific risks to an open AAA repair?

A

Ischaemia, ED, Incisional Hernia

59
Q

How do you listen for bruits in the neck?

A

Ask the pt to breathe all the way in, out, hold

60
Q

Top half of a vasc exam px

A

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

61
Q

What is the cause of radio-radial and radio-femoral delay?

A

Radio-Radial: type A aortic dissection

Radio-Femoral: coarctation of the aorta

62
Q

What do you do next after the popliteal pulse is felt?

A

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

63
Q

Where should you palpate next if there’s an absent dorsalis pedis pulse?

A

Anterior to the lateral malleolus in case there’s a dominant peroneal artery

64
Q

What special tests would you perform for the vasc lower limb?

A

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

65
Q

What does a positive Buerger’s test indicate?

A

Sig arterial disease of lower limb

66
Q

What are the typical ABPI values?

A

Normal: 0.8-1
Claudication: 0.6-1
Critical Ischaemia: <0.6

67
Q

Why could you end up w an abnormally high ABPI in diabetics?

A

The arteries have calcified and resist the pressure cuff

68
Q

Bottom half of a vasc exam px

A

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

69
Q

What are the reasons for a scar suggest of a bypass? (3)

A

Trauma
Occlusion
Aneurysm

70
Q

Which vein is most commonly used for autologous grafts?

A

Long Saphenous Vein: SFJ 2cm lateral and inferior to pubic tubercle down to in front of the medial malleolus

71
Q

Where can the posterior tibial pulse be felt?

A

Just behind and slightly below the medial malleolus

72
Q

What are the key qs in a claudication hx?

A

No rest pain, clarify exactly how far they can walk, how long they have to rest for following the pain before it subsides

73
Q

What tells you where the stenosis is?

A

Sx + Pulse Pattern

74
Q

What tests can you do for claudication?

A

Exercise treadmill ABPIs, duplex, angiography

75
Q

What are pts w claudication at high risk of developing?

A

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

76
Q

Def of Critical Ischaemia

A

All three of:

  1. Rest pain or tissue loss ie ulceration/necrosis
  2. Greater than 2wks duration
  3. Ankle pressure of <40mmHg
77
Q

What are the comps of an aneurysm? (5)

A 
Rupture
Thrombosis
Embolism
Pressure
Fistula
78
Q

What are the comps of varicose veins? (7)

A 
Swelling
Bleeding
Eczema
Haemosiderin
Thrombophlebitis
Lipodermatosclerosis
Venous Ulceration
79
Q

What are the typical sx of varicose veins?

A

Asx, aesthetic complaints, pain on standing worse at the end of the day, itching, restless legs, night cramps

80
Q

Tx of Varicose Veins

A

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

81
Q

Thoracic Outlet Syndrome

A

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

82
Q

What are the 2° causes of Raynaud’s?

A

Vasospasm -> Deoxygenation -> Reperfusion

Use of vibrating tools, atherosclerosis, scleroderma, SLE, polyarteritis nodosa, cold agglutinin disease, drugs

83
Q

What are the causes of unilateral leg swelling?

A
  1. Trauma
  2. Cancer
  3. Venous
  4. Lympathic: 1° milroy’s disease, in gravida, tarda + 2° surg, radiotherapy, chemotherapy, TB, filariasis, cancer
84
Q

What should you check if you suspect AV malformation?

A

Pulsatile
Compressible
Auscultate
Doppler

85
Q

What are the indications for a carotid endartectomy?

A

There’s >=70% stenosis AND ipsilateral hemisphere sx of TIA, well recovered stroke, amaurosis fugax

86
Q

What is the Fontaine classification for PAD?

A
  1. Asx
  2. Intermittent Claudication
  3. Ischaemic Rest Pain
  4. Ulceration/Gangrene
87
Q

When does compartment syndrome occur?

A

After direct trauma (fractured tibia), from pressure effects (rhabdomyolysis following prolonged immobility) & as a complication of revascularising an ischaemic limb

88
Q

What is Morton’s neuroma?

A

A condition causing metatarsal pain due to inflammation around the plantar nerve

89
Q

What is tabes dorsalis?

A

A feature of quaternary syphilis that may present with numb legs and a neuropathic type pain

90
Q

What are the six P’s of an acutely ischaemic limb?

A 
Pale
Pulseless
Painful
Paralysed
Paraesthetic
Perishingly ❄️
91
Q

What are signs of chronic ischaemia?

A

Hairless skin, ulcers, lipodermatosclerosis

92
Q

List four emergency treatments for ALI

A

Surgical embolectomy, endarterectomy, intraarterial thrombolysis, intravenous heparin

93
Q

What indicates irreversible limb ischaemia?

A

Fixed skin mottling

94
Q

Why should you never rewarm the limb?

A

It enhances tissue damage

95
Q

What are the absolute contraindications for thrombolysis in MI and ALI?

A 
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)
96
Q

What are the relative contraindications for thrombolysis in MI and ALI?

A 
History of severe hypertension
Peptic ulcer
History of CVA
Bleeding diathesis
Anticoagulants
97
Q

How might an aortic aneurysm px?

A

Lower limb purpura

98
Q

At what size does the risk of aortic aneurysm rupture increase sharply?

A

> 6cm

99
Q

What is the SBP aim during fluid resus for aortic aneurysm rupture?

A

<100mmHg to prevent rebleeding

100
Q

Most common site of varicose veins?

A

The long or short saphenous veins

101
Q

Patho of varicose veins

A

Incompetent valves

102
Q

Varicose veins affecting the long saphenous

A

Groin to medial aspect of lower leg

103
Q

Varicose veins affecting the short saphenous

A

Popliteal fossa to lateral malleolus

104
Q

Which tests assess incompetence of varicose veins?

A

Tourniquet, Trendelenburg, Doppler

105
Q

Tx of varicose veins

A

Graduated compression stockings & interventional (surgery, sclerotherapy, endovenous ablation)

106
Q

Surgical indications for varicose veins

NB: aiming to red any comps

A

Oedema, skin changes, venous eczema and ulceration

NB: non-specific sx may not be helped by tx

107
Q

When would you perform a Duplex US before surgery?

A

Recurrent varicose veins, prev hx of DVT & uncertain distribution

108
Q

Aortic aneurysm haemo stable vs unstable

A

If haemodynamically stable send for CT to evaluate aorta and retroperitoneum vs unstable straight to theatre

109
Q

Immediate mx of ruptured AAA

A

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

110
Q

What is often the first sign of an AAA?

A

Lower back pain due to the pressure effect on the spine

NB: can cause pain anywhere in the abdomen & even mimic renal calculi

111
Q

Which line is NOT for resus

A

A central line as its length means it has high resistance

112
Q

Surgical options for repairing an AAA

A

Endovascular aneurysm repair (EVAR) & open midline laparotomy

113
Q

Elderly male, loin to groin pain, no hx of kidney stones

A

Think AAA

114
Q

At what level does the aorta bifurcate

A

L4 @ umbilicus

115
Q

An expansile mass felt below the umbilicus

A

An iliac aneurysm

116
Q

At what size is an elective repair generally regarded as being required

A

> 5.5cm (if below observed w serial US)

117
Q

Drugs to avoid in pts w peripheral vascular disease

A

ACEi and beta blockers

118
Q

Vasc SVR

A 
Pain
Itch
Bleeding
Swelling
Ulcers
Skin Changes
119
Q

RFs for Varicose Veins

A

Age
Female
Pregnancy
Obesity

120
Q

Sx for Varicose Veins

A

Aching
Throbbing
Itching

121
Q

Comps for Varicose Veins

A 
Skin Changes
Bleeding
Superficial Thombophlebitis
Venous Ulceration
DVT
122
Q

Mx for Varicose Veins

A

Consv: leg elevation, wt loss, regular exercise, graduated compression stockings

Surg: refer if any comp -> endothermal ablation, foam sclerotherapy, ligation/stripping

123
Q

Tx of Restless Leg Syndrome

A

Ropinirole

124
Q

Aortic Dissection Mx

A

CT, Labetolol, Morphine

Type A: refer to cardiothoracics

Type B: BP control + stent

Year 6 - Surgery (6 decks)

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