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ICSM Year 6 COPY Helen Lashwood > Surgery - Vascular > Flashcards

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

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21
Q

Recall 2 classification systems used to classify limb ischaemia

A

Fontaine
Rutherford

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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)
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23
Q

How can venous insufficiency be managed?

A

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

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24
Q

What % of varicose veins are primary?

A

95%

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25
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
26
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
27
How can varicose veins be managed?
Conservative: WL, avoid prologed standing, compression stockings, emollients Medical: injection sclerotherapy, radiofrequency ablation Surgical: various types of ligation
28
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
29
How should DVT be managed?
DOAC (if renal impairment --\> LMWH + warfarin)
30
Recall the components of the Wells score
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
What is the most common site of superficial thrombophlebitis?
Saphenous vein
32
What are the symptoms of superficial thrombophlebitis?
Palpable/nodular cord Inflammation Varicose veins
33
How should superficial thrombophlebitis be investigated?
Doppler USS
34
How should superficial thrombophlebitis be managed?
``` Compression stockings + 1st line = NSAIDs 2nd line (if SVT \>5cm long/\<5cm from SFJ) = DOAC 3rd line = varicose vein surgery ```
35
How should venous ulcers be investigated?
Doppler USS, ABPI (to exclude arterial)
36
How should venous ulcers be managed?
1st - graded compression stockings 2nd line - skin grafting (if not resolved in 12w or area \>10cm^2)
37
Where do arterial ulcers typically appear?
Toes and heel
38
How should arterial ulcers be managed?
Pain mx IV prostaglandins RF modification Chemical lumbar sympathectomy
39
Where do neuropathic ulcers typically appear?
Over plantar surface of metatarsal head and plantar surface of hallux
40
How can neuropathic ulcers be managed?
Cushioned shoes to reduce callous formation
41
How should popliteal aneurysms be managed?
If stable: femoral-distal bypass If acute: embolectomy +/- femoral-distal bypass
42
What is an abdominal aortic aneurysm?
DIlation of the abdominal aorta to \>50% of normal diameter/ 3cm, involving all layers of the endothelium
43
What are the 2 types of AAA?
Fusiform (equally round) Saccular (outpouching)
44
What is the process for AAA screening?
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
What is the elective operation used for AAA repair?
EVAR If particularly young you can do an open replacement - has longer recovery time but lower chance of further procedures
46
What are the complications of AAA?
Rupture Embolism (trash foot) Thrombus Fistulation
47
What is the 1st line treatment for SVCO?
Dexamethosone
48
How should stridor due to SVCO be managed?
Intubation --\> endovascular stenting
49
What is the gold standard test for peripheral vascular disease?
CT arteriogram
50
Briefly describe the Fontaine classification of chronic limb ischaemia
Stage 1: asymptomatic Stage 2: intermittent claudication Stage 3: Ischaemic rest pain Stage 4: Ulceration +/- gangrene
51
Recall the 3 ways in which critical limb ischaemia can be defined
1. ABPI \<0.5 2. Presecne of ischaemic lesions/ gangrene objectively attributable to the arterial disease 3. Ischaemic rest pain for \>2w duration
52
What is the key differential for symptoms of limb ischaemia?
Spinal stenosis ('neurogenic claudication')
53
How can cardiovascular risk factors be managed in patients with chronic limb ischaemia?
Lifestyle changes Statin Anti-platelet (ideally clopidogrel 75mg) Optomise diabetes control
54
What can cause varicose veins?
1. 98% are primary idiopathic Secondary causes include: 2. Pelvic masses (eg malignancy, fibroids) 3. AV malformations eg Klippel-Trenaunay Syndrome
55
What are the 4 major risk factors for developing varicose veins?
1. Prolonged standing 2. Obesity 3. Family history 4. Pregnancy
56
Recall 3 signs of venous insufficiency
Ulceration Varicose eczema Haemosiderin deposition
57
What is a saphena varix?
A dilatation of the saphenous vein at the saphenofemoral junction in the groin. As it displays a cough impulse, it is commonly mistaken for a femoral hernia.
58
Briefly describe the classification system for varicose veins
CEAR system - C0-6 is based on clinical features with C1 being telangiectasias and C6 being an active venous ulcer E = aEtiology (Ep = primary, Es = secondary, Ec = congenital) Anatomical (s = superficial, d = deep, p = perforating) R = reflux/obstruction?
59
What is the gold standard test for varicose veins?
Duplex ultrasound
60
How should venous ulcers be managed?
4-layer bandaging to produce graduated compression - aims to move blood distal --\> proximal
61
Recall 3 options for treating varicose veins
1. Venous ligation, stripping + avulsion: tying off responsible vein and stripping it away 2. Foam sclerotherapy: injection of a sclerosing agent causes inflammation which causes the vein to close off 3. Thermal ablation: heating from the inside to cause irreversible damage which closes it off
62
Recall 5 signs of deep venous insufficiency
Varicose eczema (dry and scaly skin) Thrombophlebitis Haemosiderin skin staining Lipodermatosclerosis Atrophie blanche
63
What is venous stenting and what is it used for?
Metal mesh stent expanded in occluded vein Patients with severe post thrombotic syndrome with an occluded **iliac vein** may be suitable for deep venous stenting
64
What are the 3 main groups of causes of acute limb ischaemia?
1. Embolisation 2. Thrombus in sit (eg due to local atheroma) 3. Trauma (less common) eg compartment syndrome
65
What are the 6 Ps of acute limb ischaemia?
* **P**ain * **P**allor * **P**ulselessness * **P**aresthesia * **P**erishingly cold * **P**aralysis
66
What classification system is used to classify acute limb ischaemia?
Rutherford
67
How should suspected acute limb ischaemia be investigated?
Duplex ultrasound followed by consideration of CT angiography
68
Within what time frame will complete arterial occlusion in the lower lib lead to irreversible tissue damage?
6 hours
69
How should acute limb ischaemia be managed?
Initially: oxygen, IV access, heparin infusion Ongoing: * If low Rutherford classification can have conservative mx via heparin * If higher Rutherford classification, needs surgical input
70
How should irreversible acute limb ischaemia be managed?
Urgent amputation
71
What is the mortality rate of acute limb ischaemia?
20%
72
What is reperfusion injury?
Important complication of acute limb ischaemia treatment Sudden increase in capillary permeability can result in: * **Compartment syndrome** * Release of substances from the **damaged muscle cells**, such as: * K+ ions causing **hyperkalaemia** * H+ ions causing **acidosis** * Myoglobin, resulting in **significant AKI**
73
What is Leriche's syndrome?
Triad of symptoms due to atherosclerosis of abdominal aorta/ iliac arteries: 1. Claudication of the buttocks and thighs 2. Atrophy of the musculature of the legs 3. Impotence (due to paralysis of the L1 nerve)
74
How do symptoms of peripheral vascular disease differ in femoral and iliac stenosis?
Iliac stenosis = buttock pain Femoral stenosis = calf pain

ICSM Year 6 COPY Helen Lashwood (20 decks)

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