Surgery - Vascular Flashcards
1
Q
What is an aortic dissection?
A
Tear in the tunica intima
2
Q
What is the biggest RF for aortic dissection?
A
HTN
3
Q
Recall 2 ways in which aortic dissection can be classified and what these entail
A
Stanford classification
Type A: ASCENDING aorta
Type B: DESCENDING aorta
De Bakey classification
Type 1 originates in ASCENDING aorta, EXTENDs to arch + possibly beyond
Type 2: confined to ASCENDING aorta
Type 3: originates in DESCENDING aorta
4
Q
How should aortic dissection be managed?
A
Aortic root replacement surgery
Bed rest
Beta blockers
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
6
Q
How should aortic dissection be imaged?
A
Stable: CT CAP
Unstable: TOE/ TTE (transoesophageal echo/ transthoracic echo)
7
Q
In which type of aortic dissection is surgery not indicated?
A
Descending
8
Q
What are the 3 subtypes of peripheral artery disease?
A
- Intermittent claudication
- Critical limb ischaemia
- Acute limb-threatening ischaemia
9
Q
Give 4 features of intermittent claudication
A
Aching/ burning in leg muscles following walking
Typically can walk for predictable distance before Sx start
Usually relieved within mins of stopping
No rest pain
10
Q
How should a patient with intermittent claudication be assessed?
A
Check femoral, popliteal, posterior tibialis + dorsalis pedis pulses
Check ABPI
1st line Ix: Duplex USS
Magnetic resonance angiography (MRA) should be performed prior to any intervention
11
Q
What is the usual clinical correlation of each score on ABPI?
A
1: Normal
0.6-0.9: Claudication
0.3-0.5: Rest pain
<0.3: Impending
12
Q
How can you differentiate between critical and acute limb-threatening limb ischaemia clinically?
A
Onset
CLI = >2w
ALI = <2w
Colour:
CLI = pink
ALI = marble white
Temp:
CLI: warm
ALI: cold
13
Q
What are the 6 Ps of acute limb ischaemia?
A
Pain
Perishingly cold
Pallor
Pulseless
Paralysis
Paraesthesia
14
Q
What is the expected ankle arterial pressure in critical limb ischaemia?
A
<40mmHg
15
Q
What are the causes of limb ischaemia?
A
TRIED to walk:
Thromboangiitis obliterans
Raynaud’s
Injury
Embolism/ thrombosis
Diabetes
16
Q
How should ischaemic limb be investigated?
A
1st: ABPI
2nd: duplex USS
3rd: MRA/CTA
17
Q
Describe interpretation of ABPI
A
> 1.2: calcified, stiff arteries. Seen in advanced age, DM or PAD
1.0-1.2: normal
0.9-1.0: acceptable
<0.9: likely PAD
<0.5: severe disease, refer urgently
18
Q
At what ABPI would you refer to vascular surgeons?
A
<0.8 or >1.3
19
Q
How should asymptomatic limb ischaemia/ intemittent claudication be managed?
A
Conservative: (WL, quit smoking)
Medical: statin + anti-platelet (Atorvastatin 80mg + Clopidogrel 75mg)
Rarely used: naftidrofuryl oxalate (vasodilator)
20
Q
What is peripheral arterial disease strongly linked to?
A
Smoking
All should be given help to quit
21
Q
List 3 co-morbidities that are important to treat in PAD
A
HTN
DM
Obesity
22
Q
What is the first line intervention recommended for PAD?
A
Exercise training (supervised)
23
Q
How is severe PAD or critical limb ischaemia managed?
A
Endovascular revascularisation
* percutaneous transluminal angioplasty +/- stent
* endovascular techniques
Surgical revascularisation
* surgical** bypass **with autologous vein or prosthetic material
* endarterectomy
* open surgery
24
Q
What is angioplasty?
A
Minimally invasive procedure to widen narrowed/ obstructed arteries
Improves blood flow + alleviates Sx of intermittent claudication
25
When are endovascular revascularisation techniques used in PAD?
Short segment stenosis <10cm
Aortic iliac disease
High risk patients
26
When are open surgical techniques used for revacularisation in PAD?
Long segment lesions >10cm
Multifocal lesions
Lesions of common femoral artery
Purely infrapopliteal disease
27
What treatment is reserved for patients with critical limb ischaemia who are unsuitable for angioplasty or bypass surgery?
Amputation
28
Which drugs are licensed for use in PAD?
Naftidrofuryl oxalate: vasodiltor, used if poor QoL
Cilostazol: phosphodiesterase III inhibitor with antiplatelet + vasodilator effects (not recommended by NICE)
29
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)
30
What is thromboangiitis obliterans also known as?
Buerger's disease
31
What is thromboangiitis obliterans?
Smoking-related condition that results in thrombosis in small + medium-sized arteries, + less commonly veins
Ends of digits look all necrotic + nasty
32
Recall 2 classification systems used to classify limb ischaemia
Fontaine
Rutherford
33
What are the 3 stages of venous insufficiency?
- Phlegmasia alba dolens (white leg)
- Phlegmasia cerulea dolens (blue/ red leg)
- Gangrene (secondary to acute ischaemia)
34
How can venous insufficiency be managed?
Conservative: compression bandages (ABPI \>0.8 required)
Surgical: grafts
35
What are varicose veins?
Dilated, tortuous, superficial veins
Most commonly in
legs.
Often visible + palpable,
Are an indication of superficial lower extremity venous insufficiency.
36
What causes varicose veins?
Valve incompetency in affected vein: results in reflux of blood + increased pressure in vein distally
+/- Weakness/ degeneration of vein wall
37
List 7 risk factors for varicose veins
Age
FH
Female
Obesity
Prolonged standing/ sitting
Hx DVT
Pregnancy
38
Why is pregnancy a risk factor for varicose veins?
Uterus causes compression of pelvic veins
39
How do deep veins differ to superficial veins subjected to increased pressure?
Deep: thick walls, confined by fascia
Superficial: unable to withstand pressure- become dilated + tortuous
40
What % of varicose veins are primary?
95%
41
List 5 signs/ symptoms of varicose veins
Pain/ ache
Itch
Swelling
Discomfort after prolonged standing + relief with elevation
Restless legs + nocturnal leg cramps
42
List 4 skin changes that may arise as a complication of varicose veins
Varicose eczema (aka venous stasis)
Haemosiderin deposition → hyperpigmentation
Lipodermatosclerosis → hard/ tight skin
Atrophie blanche → hypopigmentation
43
List 5 complications of varicose veins
Skin changes
Bleeding
Superficial thrombophlebitis
Venous ulceration
DVT
44
How should varicose veins be investigated clinically?
Cough impulse (should be -ve in varicose pathology)
Tap test: tap proximally + feel for an impulse distally
Tourniquet test
45
What is the investigations for varicose veins?
Venous duplex US: demonstrates retrograde venous flow
46
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
47
How can varicose veins be managed?
Conservative: WL, avoid prologed standing, compression stockings, emollients
Medical: foam sclerotherapy, endothermal ablation
Surgical: ligation + stripping
48
What is the MOA of endothermal ablation in VV?
Energy from high frequency radiowaves or endovenous lasers to seal off affected veins
49
What is the MOA of foam sclerotherapy in VV?
Injection of irritant foam into vein
Results in an inflammatory response that causes closure of the vein.
50
Give 5 indications to refer to secondary care for varicose veins
Significant/ troublesome LL Sx: pain, discomfort, swelling
Previous bleeding from VV
Skin changes secondary to chronic venous insufficiency: pigmentation + eczema
Superficial thrombophlebitis
Active or healed venous leg ulcer
51
What investigations should be done in suspected DVT?
First do a Well's score
If >,2 --\> USS leg
If 0 or 1 --\> D-dimer within 4h --\> USS if +ve, other dx if -ve
If DVT is confirmed + unprovoked do a CT AP to identify possible malignancy
52
How should DVT be managed?
DOAC (if renal impairment --\> LMWH + warfarin)
53
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 symptomatic leg) [+1]
Recently bedridden for 3 days [+1]
Entire leg swollen [+1]
Something else equally likely [-2]
54
What is superficial thrombophlebitis?
Thrombus formation in superficial vein + inflammation in surrounding tissue
55
What is the association to DVT in superficial thrombophlebitis?
~20% have underlying DVT at presentation
3-4% progress to DVT if untreated
Risk linked to length of vein affected (>5cm, more likely a/w DVT)
56
What sites of thrombophelbitis have increased risk of DVT?
Where affected superficial vein joins deep veonus system e.g. long saphenous vein (superficial) with the femoral veins (deep)
57
What is the most common site of superficial thrombophlebitis?
Saphenous vein
58
What are the symptoms of superficial thrombophlebitis?
Palpable/ nodular cord
Inflammation
Varicose veins
59
How should superficial thrombophlebitis be investigated?
Doppler USS
60
How should superficial thrombophlebitis be managed?
Compression stockings + NSAIDs PO
If SVT \>5cm long/\<5cm from SFJ): + Fondaparinux (LMWH)
If anticoagulation CI: saphenofemoral ligation
If recurrent with extensive VV: VV surgery + prophylactic LMWH
61
What is the cause of venous leg ulcers?
Venous HTN, secondary to chronic venous insufficiency (most commonly)
Calf pump dysfunction
Neuromuscular disorders
62
Why do venous ulcers form?
Due to capillary fibrin cuff or leucocyte sequestration
63
Give 4 features of venous insufficiency
Oedema
Brown pigmentation: haemosiderin deposition
Lipodermatosclerosis: champagne bottle legs
Eczema
64
Give 2 characteristics of venous ulcers
Above ankle (medial malleolus)
Painless
65
How does deep venous insufficiency differ from superficial venous insufficiency?
Deep: related to previous DVT
Superficial: a/w varicose veins
66
How should venous ulcers be investigated?
Doppler USS: presence of reflux
Duplex USS: anatomy + flow
ABPI (to exclude arterial)
67
How should venous ulcers be managed?
1st: graded compression stockings
2nd: skin grafting (if not resolved in 12w or area \>10cm^2)
68
What are Marjolin's ulcers? Where do they occur?
Squamous cell carcinoma
Occur at sites of chronic inflammation e.g. burns, osteomyelitis after 10-20y
Mainly on LL
69
Describe the appearance of pyoderma gangrenosum
Erythematous nodules or pustules which ulcerate
"Margerita pizza": red base + yellow topping
70
What is pyoderma gangrenosum associated with? Where can it occur?
a/w IBD + RhA
Can occur at stoma sites
71
Where do arterial ulcers typically appear?
Toes and heel
72
List 5 characteristics of arterial ulcers
Deep, punched out appearance
Painful
Areas of gangrene
Cold + no palpable pulses
Low ABPI
73
How should arterial ulcers be managed?
Pain Mx
IV prostaglandins
RF modification
Chemical lumbar sympathectomy
74
Where do neuropathic ulcers typically appear?
Over plantar surface of metatarsal head + plantar surface of hallux
= sites of pressure
75
Which type of ulcer most commonly leads to amputation in diabetic patients?
Plantar neuropathic ulcer
76
How can neuropathic ulcers be managed?
Cushioned shoes to reduce callous formation
77
How should popliteal aneurysms be managed?
If stable: femoral-distal bypass
If acute: embolectomy +/- femoral-distal bypass
78
In over 50s, what is the normal diameter of the infrarenal aorta?
F: 1.5cm
M: 1.7cm
79
List 6 risk factors for AAA
Smoking
HTN
COPD
Coronary, cerebrovascular or PAD
Hyperlipidaemia
FH
80
List 3 genetic condition associated with development of AAA
Ehlers Danlos
Marfans
Turners
81
What is an abdominal aortic aneurysm?
DIlation of the abdominal aorta to \>50% of normal diameter/ 3cm, involving all layers of the endothelium
82
What are the 2 types of AAA?
Fusiform (equally round)
Saccular (outpouching)
83
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
84
Give 2 features suggestive of low rupture risk in AAA. What should ongoing management be?
Asymptomatic
Diameter <5.5 cm
USS surveillance + optimise cardiovascular RFs
85
Give 2 features suggestive of high rupture risk in AAA. What should ongoing management be?
Symptomatic
Diameter >5.5cm or rapidly enlarging >1cm/ year
2ww referral to vascular surgery
Treat with EVAR or open surgery
86
What operations are used for AAA repair?
EVAR
Stent placed in abdominal aorta via femoral artery to prevent blood collecting in the aneurysm
Open replacement
If young (longer recovery time but lower chance of further procedures)
87
Give 1 complication of EVAR
Endo-leak: stent fails to exclude blood from the aneurysm
Usually presents w/o Sx on routine f/u
88
What can ruptured AAA present similarly to?
Renal colic
Loin to groin pain
89
What are the complications of AAA?
Rupture
Embolism (trash foot)
Thrombus
Fistulation
90
How can ruptured AAA present?
Catastrophic: sudden collapse
Sub-acute: persistent severe central abdo pain with developing shock
91
What is the mortality rate for ruptured AAA?
~80%
92
Give 3 features of ruptured AAA
Severe, central abdominal pain radiating to the back
Pulsatile, expansile mass in abdomen
Shock: hypotension + tachycardia, collapse
93
Describe management of ruptured AAA
Urgent vascular review
Crossmatch 6 units blood
HD UNstable: clinical dx, send to theatre. If frail consider palliation
HD stable: CT angiogram if dx is in doubt + assess ability of endovascular repair
| HD = Haemodynamically
94
What is the 1st line treatment for SVCO?
Dexamethosone
95
How should stridor due to SVCO be managed?
Intubation --\> endovascular stenting
96
What is the gold standard test for peripheral vascular disease?
CT arteriogram
97
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
98
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
99
What is the key differential for symptoms of limb ischaemia?
Spinal stenosis ('neurogenic claudication')
100
How can cardiovascular risk factors be managed in patients with chronic limb ischaemia?
Lifestyle changes
Statin
Anti-platelet (ideally clopidogrel 75mg)
Optomise diabetes control
101
What can cause varicose veins?
98% are primary idiopathic
Secondary causes include:
Pelvic masses (eg malignancy, fibroids)
AV malformations eg Klippel-Trenaunay Syndrome
102
What are the 4 major risk factors for developing varicose veins?
Prolonged standing
Obesity
FH
Pregnancy
103
Recall 3 signs of venous insufficiency
Ulceration
Varicose eczema
Haemosiderin deposition
104
What is a saphena varix?
Dilatation of saphenous vein at the saphenofemoral junction in the groin.
Displays a cough impulse- commonly mistaken for a femoral hernia.
105
Briefly describe the classification system for varicose veins
CEAR system -
C0-6 is based on clinical features with C1 being telangiectasias + C6 being an active venous ulcer
E = aEtiology (Ep = primary, Es = secondary, Ec = congenital)
Anatomical (s = superficial, d = deep, p = perforating)
R = reflux/obstruction?
106
What is the gold standard test for varicose veins?
Duplex ultrasound
107
How should venous ulcers be managed?
4-layer bandaging to produce graduated compression - aims to move blood distal --\> proximal
108
Recall 3 options for treating varicose veins
1. Venous ligation, stripping + avulsion: tying off responsible vein + 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
109
Recall 5 signs of deep venous insufficiency
Varicose eczema (dry + scaly skin)
Thrombophlebitis
Haemosiderin skin staining
Lipodermatosclerosis
Atrophie blanche
110
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
111
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
112
What are the 6 Ps of acute limb ischaemia?
* **P**ain
* **P**allor
* **P**ulselessness
* **P**aresthesia
* **P**erishingly cold
* **P**aralysis
113
What classification system is used to classify acute limb ischaemia?
Rutherford
114
How should suspected acute limb ischaemia be investigated?
Handheld Doppler USS (at bedside, 1st line)
ABPI (doesn't guide acute Mx)
115
Give 4 features of acute limb ischaemia suggestive of thrombus
Pre-existing claudication with sudden deterioration
No obvious source of emboli
Reduced/ absent pulses in contralateral limb
Evidence widespread vascular disease e.g. MI, stroke, TIA
116
Give 5 features of acute limb ischaemia suggestive of embolus
Sudden onset painful leg <24h
No hx claudication
Clinically obvious source of embolus e.g.** AF**, recent MI
No evidence PVD (normal pulses in contralateral limb)
vidence of proximal aneurysm e.g. abdominal or popliteal
117
Within what time frame will complete arterial occlusion in the lower limb lead to irreversible tissue damage?
6 hours
118
How should acute limb ischaemia be managed?
Initial: O2, IV access, heparin infusion, analgesia + vascular review
Ongoing:
* Low Rutherford: conservative Mx via heparin
* High Rutherford: surgical input
119
Give 2 endovascular interventions for acute limb ischaemia
Percutaneous catheter-directed thrombolytic therapy
Percutaneous mechanical thrombus extraction
120
List 3 surgical interventions for acute limb ischaemia
Surgical thromboembolectomy
Endarterectomy
Bypass surgery
121
How should irreversible acute limb ischaemia be managed?
Urgent amputation
122
What is the mortality rate of acute limb ischaemia?
20%
123
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**
124
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)
125
How do symptoms of peripheral vascular disease differ in femoral and iliac stenosis?
Iliac stenosis = buttock pain
Femoral stenosis = calf pain
126
How does the anatomy of the collateral circulation of arterial inflow impact vacular disorders of the upper limb?
In region of subclavian + axillary arteries, collateral vessels passing around the shoulder joint may provide pathways for flow if main vessels are stenotic or occluded
If increased metabolic demand, collateral flow is not sufficient + vertebral arteries may have diminished flow- diminished flow to brain + neuro sequalae e.g. syncope
127
Where do most upper limb emboli lodge?
50% Brachial artery
30% Axillary artery
128
What are the symptoms caused by axillary/ brachial emboli?
Sudden onset:
Pain
Pallow
Paresis
Pulselessness
Paraesthesia
129
What are the sources of axillary/ brachial emboli?
Left atrium with cardiac arrhythmia (mainly AF)
Mural thrombus
130
Other than embolus, what may cardiac arrhythmias result in?
Impaired consciousness
131
What is the most common cause of arterial occlusion?
Atheroma
132
What is a rare cause of arterial occlusion?
Trauma resulting in vascular changes + long term occlusion
133
Give 4 features of arterial occlusion
Claudication
Ulceration
Gangrene
Proximally sited lesions: subclavian steal syndrome
134
What causes subclavian steal syndrome?
Proximal stenotic lesiono of subclavian artery
Results in retrograde flow through vertebral/ internal thoracic arteries
Decreases cerebral blood flow leading to syncope
135
5 RFs for subclavian steal syndrome
Age
HTN
Hyperlipidaemia
Smoking
DM
| Offending lesions tend to be atherosclerotic
136
What are the investigations for subclavian steal syndrome?
Duplex USS: retrograde flow in affected vertebral artery
CT angiography: definitive- identifies occlusive lesion
137
7 S/S caused by subclavian steal syndrome
Vertigo
Diplopia
Dysphagia
Dysarthria
Visual loss
Syncope
Arm claudication
138
What does the progressive nature of arterial occlusion allow?
Development of collaterals
Acute ischaemia may occur as a result of acute thrombosis
139
What is a cervical rib?
Supernumery fibrous band arising frfom 7th cervical vertebra
Incidence: 1 in 500
140
What can the presence of a cervical rib cause?
Thoracic outlet obstruction
141
What is Takayasu's arteritis? What does it typically cause?
Large vessel granulomatous vasculitis
Results in intimal thickening: occlusion of aorta
142
Epidemiology of Takayasu's arteritis
Young: 10-40y
Females
Asian
143
Give 6 S/S of Takayasu's arteritis
Systemic features e.g. malaise
Unequal BP in upper limbs
Carotid bruit + tenderness
Absent/ weak peripheral pulses
Upper + lower limb claudication
Aortic regurg (~20%)
144
Ix for Takayasu's arteritis
MR or CT angiography
145
Mx for Takayasu's arteritis
Prednisolone PO
146
What is Coarctation of the aorta?
Congenital narrowing of descending aorta at site of ductus arteriosus insertion
M > F despite a/w Turners
147
List 4 associations to coarctation of the aorta
Turner's syndrome
Bicuspid aortic valve
Berry aneurysms
Neurofibromatosis
148
How does coarctation of the aorta present in infants and adults?
Infants: heart failure
Adults: HTN
149
Give 4 clinical signs of coarctation of the aorta
Radio-femoral delay
Mid systolic murmur, max. over back
Apical click from aortic valve
Notching of inferior border of ribs (due to collateral vessels)
150
How may patients with coarctation of the aorta present?
Sx of arterial insufficiency e.g. syncope + claudication
151
Mx of coarctation of the aorta
Angioplasty or surgical resection
