Surgery - Vascular Flashcards
What is an aortic dissection?
Tear in the tunica intima
What is the biggest RF for aortic dissection?
HTN
Recall 2 ways in which aortic dissection can be classified and what these entail
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
How should aortic dissection be managed?
Aortic root replacement surgery
Bed rest and beta blockers
What are the main symptoms of aortic dissection?
Tearing chest pain, radiates to back, 20mmHg BP difference between arms
Possible Horner’s
How should aortic dissection be imaged?
If stable –> CT CAP
If unstable –> TOE/TTE (transoesophageal echo/ transthoracic echo)
In which type of aortic dissection is surgery not indicated?
Descending
What are the 3 subtypes of peripheral artery disease?
- Intermittent claudication
- Critical limb ischaemia
- Acute limb-threatening ischaemia
How can you differentiate between critical and acute limb-threatening limb ischaemia clinically?
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
What are the 6 Ps of acute limb ischaemia?
Pain
Perishingly cold
Pallor
Pulseless
Paralysis
Paraesthesia
What is the expected ankle arterial pressure in critical limb ischaemia?
<40mmHg
What are the causes of limb ischaemia?
TRIED to walk:
Thromboangiitis obliterans
Raynaud’s
Injury
Embolism/thrombosis
Diabetes
How should ischaemic limb be investigated?
1st: ABPI
2nd: duplex USS
3rd: MRA/CTA
What ABPI result is indicative of critical limb ischaemia?
<0.5
At what ABPI would you refer to vascular surgeons?
<0.8 or >1.3
How should asymptomatic limb ischaemia/intemittent claudication be managed?
Conservative: (WL, quit smoking etc)
Medical: statin + anti-platelet (1st line is atorvastatin 80mg + clopidogrel 75mg)
Rarely used - naftidrofuryl oxalate (vasodilator)
How is critical limb ischaemia managed?
1st: Angioplasty, stenting, bypass, embolectomy
2nd: Amputation
What are the indications for amputation in critical limb ischaemia?
Dead (eg severe PAD/ thromboangiitis obliterans)
Dangerous (sepsis, NF)
Damaged (trauma, burns, frostbite)
Darned nuisance (pain, neurological damage)
What is thromboangiitis obliterans also known as?
Buerger’s disease
What is thromboangiitis obliterans?
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
Recall 2 classification systems used to classify limb ischaemia
Fontaine
Rutherford
What are the 3 stages of venous insufficiency?
- Phlegmasia alba dolens (white leg)
- Phlegmasia cerulea dolens (blue/red leg)
- Gangrene (secondary to acute ischaemia)
How can venous insufficiency be managed?
Conservative: compression bandages (ABPI >0.8 required)
Surgical: grafts
What % of varicose veins are primary?
95%
How should varicose veins be investigated?
Cough impulse (should be neg in varicose pathology)
Tap test - tap proximally and feel for an impulse distally
Tourniquet test
How is the tourniquet test for varicose veins performed?
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
How can varicose veins be managed?
Conservative: WL, avoid prologed standing, compression stockings, emollients
Medical: injection sclerotherapy, radiofrequency ablation
Surgical: various types of ligation
What investigations should be done in suspected DVT?
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
How should DVT be managed?
DOAC (if renal impairment –> LMWH + warfarin)