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MBBS IV - CCT Preparation > Surgery - Vascular > Flashcards

Surgery - Vascular Flashcards

1
Q

Symptoms of PAD

A

Intermittent claudication (crampy, achy pain in the calf, thigh or buttock muscles)

Rest pain

Non-healing ulcers and gangrene

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2
Q

Risk factors for atherosclerosis

A
  • Non-modifiable risk factors:
    Older age
    Family history
    Male
- Modifiable risk factors:
Smoking
Alcohol consumption
Poor diet (high in sugar and trans-fat and low in fruit, vegetables and omega 3s)
Low exercise / sedentary lifestyle
Obesity
Poor sleep
Stress
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3
Q

Co-morbidities that increase risk of atherosclerosis

A 
Diabetes
Hypertension
Chronic kidney disease
Inflammatory conditions such as rheumatoid arthritis
Atypical antipsychotic medications
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4
Q

End-stage diseases of atherosclerosis

A 
Angina
Myocardial infarction
Transient ischaemic attack
Stroke
Peripheral arterial disease
Chronic mesenteric ischaemia
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5
Q

features of critical limb ischaemia (6P)

A 
Pain (burning pain, worse at night)
Pallor
Pulseless
Paralysis
Paraesthesia (abnormal sensation or “pins and needles”)
Perishing cold
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6
Q

Clinical triad of Leriche syndrome

A

Leriche syndrome occurs with occlusion in the distal aorta or proximal common iliac artery

Thigh/buttock claudication
Absent femoral pulses
Male impotence

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7
Q

Arterial ulcer appearance

A 
Are smaller than venous ulcers
Are deeper than venous ulcers
Have well defined borders
Have a “punched-out” appearance
Occur peripherally (e.g., on the toes)
Have reduced bleeding
Are painful
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8
Q

Venous ulcer appearance

A

Occur after a minor injury to the leg
Are larger than arterial ulcers
Are more superficial than arterial ulcers
Have irregular, gently sloping borders
Affect the gaiter area of the leg (from the mid-calf down to the ankle)
Are less painful than arterial ulcers
Occur with other signs of chronic venous insufficiency (e.g., haemosiderin staining and venous eczema)

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9
Q

Investigations for PVD

A

Ankle-brachial pressure index (ABPI)

Duplex ultrasound – ultrasound that shows the speed and volume of blood flow

Angiography (CT or MRI) – using contrast to highlight the arterial circulation

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10
Q

ABI

  • Define
  • Ranges of normal and abnormal results
A

Ratio of systolic blood pressure (SBP) in the ankle (around the lower calf) compared with the systolic blood pressure in the arm

0.9 – 1.3 is normal
0.6 – 0.9 indicates mild peripheral arterial disease
0.3 – 0.6 indicates moderate to severe peripheral arterial disease
Less than 0.3 indicates severe disease to critical ischaemic

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11
Q

Management of intermittent claudication due to PVD

A

Lifestyle: modifiable risk factors

Exercise training

Medical:
Clopidogrel
Atorvastatin

Surgery:
Endovascular angioplasty and stenting
Endarterectomy – cutting the vessel open and removing the atheromatous plaque
Bypass surgery – using a graft to bypass the blockage

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12
Q

Management of critical limb ischaemia

A

Endovascular angioplasty and stenting
Endarterectomy
Bypass surgery
Amputation of the limb if it is not possible to restore the blood supply

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13
Q

Management of acute limb ischaemia

A

Endovascular thrombolysis – inserting a catheter through the arterial system to apply thrombolysis directly into the clot

Endovascular thrombectomy – inserting a catheter through the arterial system and removing the thrombus by aspiration or mechanical devices

Surgical thrombectomy – cutting open the vessel and removing the thrombus

Endarterectomy

Bypass surgery

Amputation of the limb if it is not possible to restore the blood supply

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14
Q

Risk factors to DVT

A 
Immobility
Recent surgery
Long haul travel
Pregnancy
Hormone therapy with oestrogen (combined oral contraceptive pill and hormone replacement therapy)
Malignancy
Polycythaemia
Systemic lupus erythematosus
Thrombophilia
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15
Q

Prophylaxis for venous thromboembolism

Contraindications?

A

1) low molecular weight heparin, such as enoxaparin

Contraindications include active bleeding or existing anticoagulation with warfarin or a DOAC.

2) Anti-embolic compression stockings

main contraindication for compression stockings is significant peripheral arterial disease.

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16
Q

DVT

- Typical presentation

A 
Calf or leg swelling
Dilated superficial veins
Tenderness to the calf (particularly over the site of the deep veins)
Oedema
Colour changes to the leg
17
Q

Scoring for severity of DVT

A

Wells score predicts the risk of a patient presenting with symptoms having a DVT or PE

includes risk factors such as recent surgery and clinical findings such as unilateral calf swelling 3cm greater than the other leg.

18
Q

Diagnosis of venous thromboembolism

A

Doppler ultrasound of the leg

Positive D-dimer test

Pulmonary embolism can be diagnosed with a CT pulmonary angiogram (CTPA) or ventilation-perfusion (VQ) scan.

19
Q

Management of DVT

A

Immediate treatment dose apixaban or rivaroxaban.

catheter-directed thrombolysis in patients with a symptomatic iliofemoral DVT

Long-term:
DOAC, warfarin, or LMWH
Inferior vena cava filters are devices inserted into the inferior vena cava

20
Q

Differentiate dilated veins by size (3)

A

Varicose veins are distended superficial veins measuring more than 3mm in diameter, usually affecting the legs.

Reticular veins are dilated blood vessels in the skin measuring less than 1-3mm in diameter.

Telangiectasia refers to dilated blood vessels in the skin measuring less than 1mm in diameter. They are also known as spider veins or thread veins.

21
Q

Risk factors for varicose veins

A

Increasing age
Family history
Female
Pregnancy
Obesity
Prolonged standing (e.g., occupations involving standing for long periods)
Deep vein thrombosis (causing damage to the valves)

22
Q

Varicose vein presentation

A 
Heavy or dragging sensation in the legs
Aching
Itching
Burning
Oedema
Muscle cramps
Restless legs
23
Q

Special tests for varicose veins

A

Perthes test – apply a tourniquet to the thigh and ask the patient to pump their calf muscles by performing heel raises whilst standing. If the superficial veins disappear, the deep veins are functioning.

Trendelenburg’s test – with the patient lying down, lift the affected leg to drain the veins completely. Then apply a tourniquet to the thigh and stand the patient up. The tourniquet should prevent the varicose veins from reappearing if it is placed distally to the incompetent valve.

Tap test – apply pressure to the saphenofemoral junction (SFJ) and tap the distal varicose vein, feeling for a thrill at the SFJ

Cough test – apply pressure to the SFJ and ask the patient to cough, feeling for thrills at the SFJ. Thrill suggest Saphenous Varix

24
Q

Surgical options for varicose veins

A

Endothermal ablation – inserting a catheter into the vein to apply radiofrequency ablation
Sclerotherapy – injecting the vein with an irritant foam that causes closure of the vein
Stripping – the veins are ligated and pulled out of the leg

25
Q

Complications of varicose veins

A 
Prolonged and heavy bleeding after trauma
Superficial thrombophlebitis (thrombosis and inflammation in the superficial veins)
Deep vein thrombosis
All the issues of chronic venous insufficiency (e.g., skin changes and ulcers)
26
Q

Describe venous insufficiency skin changes

A

Haemosiderin staining is a red/brown discolouration caused by haemoglobin leaking into the skin.

Venous eczema (or varicose eczema) is dry, itchy, flaky, scaly, red, cracked skin. chronic inflammatory response in the skin.

Lipodermatosclerosis is hardening and tightening of the skin and tissue beneath the skin. Inflammation and fibrosis of the subcutaneous fat

Atrophie blanche refers to patches of smooth, porcelain-white scar tissue on the skin

Cellulitis
Non-healing ulcers

27
Q

Treatment of venous insufficiency skin changes

A

Monitoring skin health and avoiding skin damage

Regular use of emollients (e.g., diprobase, oilatum, cetraben and doublebase)

Topical steroids to treat flares of venous eczema

Very potent topical steroids to treat flares of lipodermatosclerosis

28
Q

Lifestyle changes for venous insifficiency

A

Weight loss if obese
Keeping active
Keeping the legs elevated when resting
Compression stockings (exclude arterial disease first with an ankle-brachial pressure index)

29
Q

Presentation of AAA

A

Non-specific abdominal pain
Pulsatile and expansile mass in the abdomen when palpated with both hands
As an incidental finding on an abdominal x-ray, ultrasound or CT scan

30
Q

Investigations for AAA

A

Ultrasound is the usual initial investigation for establishing the diagnosis.

CT angiogram gives a more detailed picture of the aneurysm and helps guide elective surgery to repair the aneurysm.

31
Q

Severity classification for AAA

Surgical repair options

A

Normal: less than 3cm
Small aneurysm: 3 – 4.4cm
Medium aneurysm: 4.5 – 5.4cm
Large aneurysm: above 5.5cm

Open repair via a laparotomy
Endovascular aneurysm repair (EVAR) using a stent inserted via the femoral arteries
Permissive hypotension treatment

32
Q

System to classify aortic dissection

A

The Stanford system:

Type A – affects the ascending aorta, before the brachiocephalic artery
Type B – affects the descending aorta, after the left subclavian artery

33
Q

Risk factors of aortic dissection

A

Bicuspid aortic valve
Coarctation of the aorta
Aortic valve replacement
Coronary artery bypass graft (CABG)

Connective tissue diseases:
Ehlers-Danlos Syndrome
Marfan’s Syndrome

34
Q

Investigation for aortic dissection

A

CT angiogram is usually the initial investigation to confirm the diagnosis and can generally be performed very quickly.

MRI angiogram provides greater detail and can help plan management but often takes longer to get.

35
Q

Carotid artery stenosis

  • Risk factors
  • Complications
  • Investigation
A

Risk factors:
age, male sex, smoking, hypertension, poor diet, reduced physical activity and raised cholesterol.

Complications

  • TIA
  • Stroke

Carotid ultrasound
CT or MRI angiogram (DSA)

36
Q

Surgical options for carotid artery stenosis

A

Carotid endarterectomy (Endarterectomy involves an incision in the neck, opening the carotid artery and scraping out the plaque)

Angioplasty and stenting

37
Q

Indication for carotid endarterectomy

A

Under 75 years old
>70% occlusion
<3% stroke risk

38
Q

Complications of carotid endarterectomy

A

Facial nerve injury causes facial weakness (often the marginal mandibular branch causing drooping of the lower lip)

Glossopharyngeal nerve injury causes swallowing difficulties

Recurrent laryngeal nerve (a branch of the vagus nerve) injury causes a hoarse voice

Hypoglossal nerve injury causes unilateral tongue paralysis

39
Q

Buerger disease

  • Age group
  • Risk factors
  • Presentation
  • Treatment
A

men aged 25 – 35

very strong association with smoking., risk factors for atherosclerosis

Raynaud’s phenomenon, pain worse at night, asso. with ulcers, gangrene, amputation

Stop smoking entirely
IV  iloprost (a prostacyclin analogue that dilates blood vessels)

MBBS IV - CCT Preparation (10 decks)

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