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Surgery - Vascular Flashcards

1
Q

What is an aortic dissection?

A

Tear in the tunica intima

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2
Q

What is the biggest RF for aortic dissection?

A

HTN

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3
Q

Recall 2 ways in which aortic dissection can be classified and what these entail

A

Stanford classification
- Type A is in ascending aorta, type B is in descending aorta

De Bakey classification
Type 1 originates in ascending aorta but extends to arch and possibly beyond
Type 2 is confined to the ascending aorta
Type 3 originates in the descending aorta

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4
Q

How should aortic dissection be managed?

A

Aortic root replacement surgery

Bed rest and beta blockers

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5
Q

What are the main symptoms of aortic dissection?

A

Tearing chest pain, radiates to back, 20mmHg BP difference between arms
Possible Horner’s

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6
Q

How should aortic dissection be imaged?

A

If stable –> CT CAP

If unstable –> TOE/TTE (transoesophageal echo/ transthoracic echo)

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7
Q

In which type of aortic dissection is surgery not indicated?

A

Descending

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8
Q

What are the 3 subtypes of peripheral artery disease?

A
  1. Intermittent claudication
  2. Critical limb ischaemia
  3. Acute limb-threatening ischaemia
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9
Q

How can you differentiate between critical and acute limb-threatening limb ischaemia clinically?

A

Onset
CLI = >2 weeks
ALI = <2 weeks

Colour:
CLI = pink
ALI = marble white
nb. can’t find info on how this works in non-white skin tones

Temp:
CLI: warm
ALI: cold

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10
Q

What are the 6 Ps of acute limb ischaemia?

A 
Pain
Perishingly cold 
Pallor 
Pulseless
Paralysis 
Paraesthesia
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11
Q

What is the expected ankle arterial pressure in critical limb ischaemia?

A

<40mmHg

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12
Q

What are the causes of limb ischaemia?

A 
TRIED to walk: 
Thromboangiitis obliterans 
Raynaud's 
Injury 
Embolism/thrombosis 
Diabetes
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13
Q

How should ischaemic limb be investigated?

A

1st: ABPI
2nd: duplex USS
3rd: MRA/CTA

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14
Q

What ABPI result is indicative of critical limb ischaemia?

A

<0.5

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15
Q

At what ABPI would you refer to vascular surgeons?

A

<0.8 or >1.3

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16
Q

How should asymptomatic limb ischaemia/intemittent claudication be managed?

A

Conservative: (WL, quit smoking etc)
Medical: statin + anti-platelet (1st line is atorvastatin 80mg + clopidogrel 75mg)
Rarely used - naftidrofuryl oxalate (vasodilator)

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17
Q

How is critical limb ischaemia managed?

A

1st: Angioplasty, stenting, bypass, embolectomy
2nd: Amputation

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18
Q

What are the indications for amputation in critical limb ischaemia?

A

Dead (eg severe PAD/ thromboangiitis obliterans)
Dangerous (sepsis, NF)
Damaged (trauma, burns, frostbite)
Darned nuisance (pain, neurological damage)

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19
Q

What is thromboangiitis obliterans also known as?

A

Buerger’s disease

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20
Q

What is thromboangiitis obliterans?

A

A smoking-related condition that results in thrombosis in small and medium-sized arteries, and less commonly veins
Ends of digits look all necrotic and nasty

21
Q

Recall 2 classification systems used to classify limb ischaemia

A

Fontaine

Rutherford

22
Q

What are the 3 stages of venous insufficiency?

A
  • Phlegmasia alba dolens (white leg)
  • Phlegmasia cerulea dolens (blue/red leg)
  • Gangrene (secondary to acute ischaemia)
23
Q

How can venous insufficiency be managed?

A

Conservative: compression bandages (ABPI >0.8 required)
Surgical: grafts

24
Q

What % of varicose veins are primary?

A

95%

25
Q

How should varicose veins be investigated?

A

Cough impulse (should be neg in varicose pathology)
Tap test - tap proximally and feel for an impulse distally
Tourniquet test

26
Q

How is the tourniquet test for varicose veins performed?

A

Patient supine, elevate legs, milk veins
Apply tourniquet high to compress saphenofemoral junction
Stand patient
Repeat distally until controlled filling
Controlled filling = distal veins do not fill
Uncontrolled filling = distal veins full - meaning there is an incompetent valve below the tourniquet

27
Q

How can varicose veins be managed?

A

Conservative: WL, avoid prologed standing, compression stockings, emollients

Medical: injection sclerotherapy, radiofrequency ablation

Surgical: various types of ligation

28
Q

What investigations should be done in suspected DVT?

A

First do a Well’s score
If 2 or more –> USS leg
If 0 or 1 –> D-dimer within 4 hours –> USS if pos, other diagnosis if neg

If DVT is confirmed and unprovoked do a CT AP to help identify possible malignancy

29
Q

How should DVT be managed?

A

DOAC (if renal impairment –> LMWH + warfarin)

30
Q

Recall the components of the Wells score

A

Mnemonic: DVT SCORES
DVT previous [+1]
Veins - superficial collateral [+1]
Three cm difference in calf diameter [+1]

Static (paralysis/paresis/plaster immobilisation) [+1]
Cancer (active within 6 months) [+1]
Oedema (pitting, confined to the symptomatic leg) [+1]
Recently bedridden for 3 days [+1]
Entire leg swollen [+1]
Something else equally likely [-2]

31
Q

What is the most common site of superficial thrombophlebitis?

A

Saphenous vein

32
Q

What are the symptoms of superficial thrombophlebitis?

A

Palpable/nodular cord
Inflammation
Varicose veins

33
Q

How should superficial thrombophlebitis be investigated?

A

Doppler USS

34
Q

How should superficial thrombophlebitis be managed?

A 
Compression stockings + 
1st line = NSAIDs
2nd line (if SVT >5cm long/<5cm from SFJ) = DOAC
3rd line = varicose vein surgery
35
Q

How should venous ulcers be investigated?

A

Doppler USS, ABPI (to exclude arterial)

36
Q

How should venous ulcers be managed?

A

1st - graded compression stockings

2nd line - skin grafting (if not resolved in 12w or area >10cm^2)

37
Q

Where do arterial ulcers typically appear?

A

Toes and heel

38
Q

How should arterial ulcers be managed?

A

Pain mx
IV prostaglandins
RF modification
Chemical lumbar sympathectomy

39
Q

Where do neuropathic ulcers typically appear?

A

Over plantar surface of metatarsal head and plantar surface of hallux

40
Q

How can neuropathic ulcers be managed?

A

Cushioned shoes to reduce callous formation

41
Q

How should popliteal aneurysms be managed?

A

If stable: femoral-distal bypass

If acute: embolectomy +/- femoral-distal bypass

42
Q

What is an abdominal aortic aneurysm?

A

DIlation of the abdominal aorta to >50% of normal diameter/ 3cm, involving all layers of the endothelium

43
Q

What are the 2 types of AAA?

A

Fusiform (equally round)

Saccular (outpouching)

44
Q

What is the process for AAA screening?

A 
In males >65y --> single abdominal USS
If AAA: 
3-4.5cm --> f/u scan in 12m
4.5-5.5cm --> f/u scan in 3m
>5.5cm --> 2ww to vascular
45
Q

What is the elective operation used for AAA repair?

A

EVAR

If particularly young you can do an open replacement - has longer recovery time but lower chance of further procedures

46
Q

What are the complications of AAA?

A

Rupture
Embolism (trash foot)
Thrombus
Fistulation

47
Q

What is the 1st line treatment for SVCO?

A

Dexamethosone

48
Q

How should stridor due to SVCO be managed?

A

Intubation –> endovascular stenting

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