Surgery - Vascular Flashcards
Symptoms of PAD
Intermittent claudication (crampy, achy pain in the calf, thigh or buttock muscles)
Rest pain
Non-healing ulcers and gangrene
Risk factors for atherosclerosis
- 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
Co-morbidities that increase risk of atherosclerosis
Diabetes Hypertension Chronic kidney disease Inflammatory conditions such as rheumatoid arthritis Atypical antipsychotic medications
End-stage diseases of atherosclerosis
Angina Myocardial infarction Transient ischaemic attack Stroke Peripheral arterial disease Chronic mesenteric ischaemia
features of critical limb ischaemia (6P)
Pain (burning pain, worse at night) Pallor Pulseless Paralysis Paraesthesia (abnormal sensation or “pins and needles”) Perishing cold
Clinical triad of Leriche syndrome
Leriche syndrome occurs with occlusion in the distal aorta or proximal common iliac artery
Thigh/buttock claudication
Absent femoral pulses
Male impotence
Arterial ulcer appearance
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
Venous ulcer appearance
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)
Investigations for PVD
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
ABI
- Define
- Ranges of normal and abnormal results
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
Management of intermittent claudication due to PVD
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
Management of critical limb ischaemia
Endovascular angioplasty and stenting
Endarterectomy
Bypass surgery
Amputation of the limb if it is not possible to restore the blood supply
Management of acute limb ischaemia
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
Risk factors to DVT
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
Prophylaxis for venous thromboembolism
Contraindications?
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.
DVT
- Typical presentation
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
Scoring for severity of DVT
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.
Diagnosis of venous thromboembolism
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.
Management of DVT
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
Differentiate dilated veins by size (3)
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.
Risk factors for varicose veins
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)
Varicose vein presentation
Heavy or dragging sensation in the legs Aching Itching Burning Oedema Muscle cramps Restless legs
Special tests for varicose veins
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
Surgical options for varicose veins
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
