Surgery - Vascular Flashcards
What is carotid artery disease? (pathophys)
Build up of atherosclerotic plaque in one or both common and internal carotid arteries.
- Starts off as a fatty streak
- accumualtes a lipid core and fibrous cap
- turbulent flow at bifurcation of carotid artery predisposes to this process
What are the classifications of carotid artery disease?
Mild stenosis is <50% reduction in diameter
Moderate = 50-69% reduction
Severe = 70-99% reduction
Total = 100% reduction
What are some risk factors for carotid artery disease?
The usual = over 65, smoking, htn, hyperhcolesterolaemia, obesity, DM, CVS disease, fhx of cvs disease
how does carotid artery disease present?
Typically asymptomatic (especially if unialteral) due to collateral supply from contralateral internal carotid artery and also vertebral arteries via circle of willis.
Otherwise can be a focal neuro deficit eg stroke or tia
Stroke from ICA = anterior circulation infarct
How would you investigate and manage carotid artery disease?
Investigate
- urgent non contrast CT head
- CT head contrast angiography
- bloods (fbc, u&es, clotting, lipids, glucose)
- Afterwards, screen carotids for disease precipitating the presentation eg. Carotid artery duplex US scan and CT angiography
Acute Management
- high flow o2, ensure blood glucose optimised
- Ischaemic stroke = IV alteplase in 4.5 hours, 300mg aspirin, thrombectomy, etc
- Haemorrhagic stroke = correct htn, correct coagulopathy, neurosurgery etc
Long term management
- dual antiplatelets = aspirin and clopidogrel
- statins = high dose atorvastatin
- htn and dm control
- stop smoking!!!!
- exercise and weight loss plan
- refer to SALT for dysphagia or dysphasia
- physio and OT input
- Carotid endarterectomy if carotid stenosis 50-99%
What is the spectrum of peripheral vascular disease?
Intermittent claudication –> critical limb ischaemia
What are risk factors for peripheral vascular disease?
- smoking!!!!
- hypercholesterolaemia/ hyperlipidaemia
- HTN
- DM
- FHx of cardiovascular disease
- cardiac disease
- cerebrovascular disease
What is intermittent claudication?
- pain in the lower limb muscles elicited by walking
- typically calf muscles as the superficial femoral artery (add canal region) is most often affected
- pain relieved rapidly by rest (even while standing)
- The pain is due to the build up of anaerobic metabolites and pain producing chemicals (Substance P) in the muscle due to inadequate arterial supply
How would you investigate Peripheral Vascular disease?
Investigate:
- bloods
- routine, lactate for level of ischaemia, etc
- Thrombophilia screen if <50y/o with no risk factors
- Group and save
-
Ankle Brachial Pressure Index (arterial disease <0.9, normal is >1.1)
- this may be falsely high in people with calcified vessels like in dm, renal failure, elderly
- Exercise test for claudication + palpable peripheral pulses
- resting and post exercise ABPI
- a drop after exercise indicates PVD
- Arterial duplex scan
- Doppler US for Critical Limb Ischaemia
- CT Angiogram
How would you manage intermittent claudication?
- risk factors = smoking cessation, reduce cholesterols (statin), treat htn, treat DM
- Regular exercise
- antiplatelet therapy = 75mg clopidogrel
- Angioplasty if significantly affecting QOL
- Surgical bypass if angioplasty unsuccessful
What is acute limb ischaemia?
A sudden decrease in limb perfusion resuting in a threat to viability of the limb.
Presents as 6Ps = pain, pallor, pulseless, paraesthesia, perishly cold, paralysis
Common causes = embolisation, thrombus in situ, trauma eg compartment syndrome
How would you manage acute limb ischaemia?
in >6 hours this can result in irreversible tissue damage!! a surgical emergency
- high flow o2 and IV access
- Emergency assessment by a vascular specialist!!!
- heparin bolus dose then heparin infusion asap
- paracetamol + opioid for analgesia
- Scoring system = Rutherford score for limb ischaemia
- 1st line = Surgery
- viable limb and a thrombotic cause = percutaneous catheter directed thrombolysis
- viable limb and an embolic cuase = embolectomy with balloon catheter
- Non viable limb = amputation
Long term management
- smoking cessation
- diet and exercise
- statin therapy
- manage dm and htn
- antiplatelet therapy = clopidogrel 75mg daily
What is chronic limb ischaemia?
Chronic limb ischaemia is a peripheral artery disease that results in symptomatic reduced blood supply to limbs.
What are the stages of chronic limb ischaemia?
what is critical limb ishaemia?
Fontaine classification of CLI
- asymptomatic
- intermittent claudication
- ischaemic rest pain (critical limb ischaemia)
- ulceration or gangrene
Critical limb ischaemia is advanced chronic limb ischaemia.
- ischaemic rest pain >2 weeks duration
- presence of ischaemic lesions or gangrene
- abpi<0.5
- limbs are pale, cold, weak or absent pulses
What is leriche syndrome?
PAD affects aortic bifurcation, resulting in buttock/thigh pain and Erectile Dysfunction
What is Buerger’s test?
Pt lies supine and raises legs until they go pale or lowers them until colour returns.
angle of paleness = buerger’s angle
<20 degrees is severe ischaemia
how would you manage critical limb ishchaemia?
- urgently refer to vascular MDT
- paracetamol or opioids for pain (+laxatives and anti-emetics)
- Surgical options
- Angioplasty (+/- endarterectomy procedure or bypass)
- surgical bypass eg femoropopliteal, femorodistal, etc
- amputation if angio/bypass have failed
Long term
- smoking cessation
- diet, weight management, exercise
- lipid modification, statin therapy
- manage dm and htn
- antiplatelets = clopidogrel 75mg
What are varicose veins? what are some risk factors?
Tortuous dilated veins that occur due to incompetent valves.
they allow bloodflow from deep venous system to superficial venous system.
Results in venous htn and dilation of superficial venous system.
Risks = prolonged standing, pregnancy, obesity, fhx
How do varicose veins present?
- cosmetics = discolouration, visible veins
- aching, itching, heaviness particularly after standing for prolonged periods in hot weather
- nocturnal cramps in elderly
- venous insufficiency = ulceration, varicose eczema, haemosiderin, deposition, thrombophlebitis, atrophe blanche, lipodermatosclerosis
- saphena varix = dilation of saphenous vein at saphenofemoral junction in the groin
- cough impulse so often mistaken for fem hernia
- if pt has other variscosities in the limb then raise suspicions of SV
- do a Duplex US
- Manage with high saphenous ligation
How would you investigate and manage varicose veins?
Investigations = DUPLEX US gold standard
- do abpi to check before compression stockings
- Classify with CEAP classification
- Trendelenburgs test or Tourniquet test to help define levels of superficial venous incompetence
Non invasive Management
- patient education to avoid prolonged standing, do exercise
- compression stockings if interventional treatment not appropriate (do abpi >0.8)
- venous ulceration = 4 layer bandaging
Surgical management
- = if symptomatic, lower limb skin changes, superficial vein thrombosis (hard painful veins), or venous leg ulcer
- vein ligation, stripping avulstion
- or foam sclerotherapy with US guidance
- or thermal ablation with US guidance
How is deep venous insufficiency classified?
Primary = due to congenital defects or connective tissue disorders
Secondary = post thrombotic disease, post phlebitic disease, etc
What are some risk factors and presentation for deep venous insufficiency?
Risks = increasing age, female, pregnancy, prev dvt, obesity, smoking, long periods of standing
Presentation:
- chronically swollen limbs that ache, get pruritic and painful
- venous claudication (bursting pain/tightness on walking that resolves with leg elevation)
- varying degree of pedal oedema and venous ulcers
- o/e = varicose eczma, thrombophlebitis, haemosiderin skin staining, lipodermatosclerosis (inverted champagne bottle appearance of legs), atrophie blanche
How would you investigate and manage deep venous insufficiency?
- doppler US
- bloods, fbc, u&es, lfts
- echo
- ABPI
- documentation of foot pulses
Management
- compression stockings and analgesia
- elevate feet above heart level
- Surgery = valvuloplasty
- severe post thrombotic syndrome = venous stenting
How would venous ulcers present?
An ulcer is an abnormal break in the skin or mucous membranes.
Venous ulcers:
- o/e = shallow with irregular borders, granulating base, over medial malleolus
- pain worse at the end of the day
- gaiter region (above ankle to below knee)
- symptoms of chronic venous disease eg. aching, itching, bursting
- visible symptoms of varicose eczema, thrombophlebitis, haemosiderin staining, lipodermatosclerosis, atrophie blanche
How would you investigate and manage a venous ulcer?
- document size, apperance and site
- venous Duplex US for superficial or deep venous incompetence
- arterial duplex if reduced ABPI
- assess peripheral arterial pulses and do ABPI (>0.9 is no significant arterial insufficiency)
- bloods for dm, etc
- swab for infections
- leg ulcer biopsy if any suspicious features of malignancy
Management
- leg elevation
- increased mobility, reduce obesity, improve nutrition
- antibiotics if infection
- multicomponent compression bandaging (3-4 layers) if abpi >0.6
- change 1-2 times a week
- treat varicose veins
How would an arterial ulcer present?
- small, deep lesions with well defined borders and necrotic base
- at sites of trauma or pressure areas
- hx of intermittent claudication or critical limb ischaemia
- cold limbs, thick nails, necrotic toes, hair loss
- absent pulses
- sensation maintained
Risk factors = risk factors of PAD like smoking, htn, dm, hyperlipidaemia, obesity, etc
How would you investigate and manage an arterial ulcer?
-
ABPI
- 0.9-0.8 is mild
- 0.8-0.5 is moderate
- <0.5 is severe
- Duplex US
- CT Angiography
- Magnetic Resonance Angiogram
Management
- urgent vascular review if critical limb ischaemia!!
- Conservative = smoking cessation, reduce obesity, supervised exercise programmes
- Medical = statins, antiplatelets, ooptimise bp and glucose
- Surgical = angioplasty or bypass grafting
- Analgesia!!!
How would a neuropathic ulcer present?
- painless ulcers on pressure points on the limb
- hx of peripheral neuropathy or PAD
- o/e it is “punched out” on sites of pressure like metatarsal heads or heels
- peripheral neuropathy in glove and stocking distribution
- warm feet and good pulses
Risk factors = peripheral neuropathy (dm and b12 def), foot deformity, PAD
How would you investigate and manage neuropathic ulcers?
- blood glucose (random and hba1c)
- B12 levels
- ABPI and Duplex US for concurrent arterial disease
- microbiology swab and culture for infection
- Xray too for osteomyelitis if deep infection! (visible bones etc)
- Assess extent of peripheral neuropathy using 10g monofilament or Ipswich touch test and test vibration sensation with a 128Hz tuning fork
Management
- refer to diabetic foot clinics
- optimise diabetic control
- improve diet and increase exercise
- regular chiropody to maintain good foot hygiene
- antibiotics eg fluclox for infection
- debride any ischaemic or necrotic tissue
How would an abdominal aortic aneurysm present?
an aneurysm is a dilation of a blood vessel by >50% of its normal diameter.
an Abdo aortic aneurysm is a dilation of the abdo aorta >3cm
Presentation
- asymptomatic or detected incidentally
- abdo pain
- back or loin pain
- distal embolsation producing limb ischaemia
- aortoenteric fistula
- o/e pulsatile mass in abdo (above umbilical level)
What is the screening for AAA?
Abdo US for men >65 years old
How would you investigate a AAA?
- Abdo US to diagnose
- follow up with CT Contrast if diameter is 5.5cm or more
- ECG and serum amylase to rule out the other differentials (mi or acute pancreatitis)
How would you manage a AAA?
Conservative
-
<5.5cm diameter = Dupex USS Monitor
- 3-4.4 = annual US
- 4.5-5.4 = 3 monthly US
- smoking cessation, improve bp, statins, aspirin, weight loss
- >6.5 notify dvla = no driving until repaired
Surgical
- consider if >5.5cm, AAA is expanding >1cm a year, or symptomatic and pt is fit for surgery
- if unfit, leave until AAA is >6cm otherwise the risk is not worth it
- endovascular or open repair
- endovascular is safer but will probably need repeating and life long surveillance
- endovascular complication = endovasuclar leak
How would a ruptured AAA present?
- back pain + hypotension/shock/collapse + pulsatile tender abdo mass
- haemodynamic compromise
- vomiting and nausea
How would you manage a ruptured AAA?
- high flow o2, iv access, urgent bloods and crossmatch 6U minimum
-
keep bp <100mmhg as this could dislodge clots and cause more bleeding
- permissive hypotension
- transfer pt to local vascular unit
- stable = ct angiogram to determine if it is suitable for endovascular repair
- unstable = theatre for open repair
What are some risk factors for an aortic dissection?
- men
- connective tissue disorders like marfans and ED
- 50-70 years old
- HTN
- atherosclerotic disease
- bicuspid aortic valve
how would you classify aortic dissections?
Stanford classification and debakey classification
stanford type a = involves ascending aorta and can propagate to aortic arch and descending aorta (debakey types 1 and 2)
stanford type b = does not involve ascending aorta (debakey type 3)
How does aortic dissection typically present?
- tearing severely painful chest pain radiating to back
- tachycardia, hypotension
- new aortic regurg murmur
- signs of end organ hypoperfusion eg lower limb ischaemia, reduced urine output, reduced consciousness
How would you investigate and manage an aortic dissection?
- bloods and crossmatch atleast 4U
- abg
- ecg to exclude cardiac
- amylase to exclude pancreatitis
- CT angiogram to diagnose and classify
- Transoesophageal ECHO
Management
- A-E
- keep bp below 110mmhg systolic
- Stanford Type A = surgery (remove dissected aorta and replace with synthetic graft)
- Stanford Type B = manage htn with labetalol IV
- surgery for complications
What would you think when you see a hot swollen painful leg?
DVT!!!
- also would be painful and firm
Investigate
-
Wells score
- 2 points or more is likely
- do a proximal leg vein US in 4 hours
- if +ve, then start anticoagulation
- if -ve , do D Dimer
- If you can’t do the proximal leg vein US in 4 hours then start a DOAC interim therapeutic anticoagulation (apixaban)
- 1 or less is unlikely
- do a D Dimer within 4 hours
- if you can’t do a D DImer in 4 hours, start Doac ITA
- if +ve, then do a proximal leg vein US in 4 hours (can continue doac ITA for now)
- 2 points or more is likely
- D Dimer
- VQ/CTPA for PE
- CXR and ECG
Manage
- 1st line = DOAC!!! (apixaban, rivaroxaban)
- continue it on from the DOAC Interim Therapeutic Anticoagulation
- 2nd line = LMWH followed by edoxaban or dabigatran
- continue for 3 months for provoked
- continue for 6 months for unprovoked
