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ICSM Year 6 > 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
Q

How should varicose veins be investigated?

A

Cough impulse (should be neg in varicose pathology)
Tap test - tap proximally and feel for an impulse distally
Tourniquet test

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26
Q

How is the tourniquet test for varicose veins performed?

A

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

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27
Q

How can varicose veins be managed?

A

Conservative: WL, avoid prologed standing, compression stockings, emollients

Medical: injection sclerotherapy, radiofrequency ablation

Surgical: various types of ligation

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28
Q

What investigations should be done in suspected DVT?

A

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 CAP to help identify possible malignancy

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29
Q

How should DVT be managed?

A

DOAC (if renal impairment –> LMWH + warfarin)

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30
Q

Recall the components of the Wells score

A

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]

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31
Q

What is the most common site of superficial thrombophlebitis?

A

Saphenous vein (calf)

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32
Q

What are the symptoms of superficial thrombophlebitis?

A

Palpable/nodular cord
Inflammation
Varicose veins

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33
Q

How should superficial thrombophlebitis be investigated?

A

Doppler USS

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34
Q

How should superficial thrombophlebitis be managed?

A 
Compression stockings + 
1st line = NSAIDs 
2nd line (if SVT \>5cm long/\<5cm from SFJ) = DOAC 
3rd line = varicose vein surgery
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35
Q

How should venous ulcers be investigated?

A

Doppler USS, ABPI (to exclude arterial)

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36
Q

How should venous ulcers be managed?

A

1st - graded compression stockings
2nd line - skin grafting (if not resolved in 12w or area >10cm^2)

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37
Q

Where do arterial ulcers typically appear?

A

Toes and heel

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38
Q

How should arterial ulcers be managed?

A

Pain mx
IV prostaglandins
RF modification
Chemical lumbar sympathectomy

39
Q

Where do neuropathic ulcers typically appear?

A

Over plantar surface of metatarsal head and plantar surface of hallux

40
Q

How can neuropathic ulcers be managed?

A

Cushioned shoes to reduce callous formation

41
Q

How should popliteal aneurysms be managed?

A

If stable: femoral-distal bypass
If acute: embolectomy +/- femoral-distal bypass

42
Q

What is an abdominal aortic aneurysm?

A

DIlation of the abdominal aorta to >50% of normal diameter/ 3cm, involving all layers of the endothelium

43
Q

What are the 2 types of AAA?

A

Fusiform (equally round)
Saccular (outpouching)

44
Q

What is the process for AAA screening?

A

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
Q

What is the elective operation used for AAA repair?

A

EVAR
If particularly young you can do an open replacement - has longer recovery time but lower chance of further procedures

46
Q

What are the complications of AAA?

A

Rupture
Embolism (trash foot)
Thrombus
Fistulation

47
Q

What is the 1st line treatment for SVCO?

A

Dexamethosone

48
Q

How should stridor due to SVCO be managed?

A

Intubation –> endovascular stenting

49
Q

What is the gold standard test for peripheral vascular disease?

A

CT arteriogram

50
Q

Briefly describe the Fontaine classification of chronic limb ischaemia

A

Stage 1: asymptomatic
Stage 2: intermittent claudication
Stage 3: Ischaemic rest pain
Stage 4: Ulceration +/- gangrene

51
Q

Recall the 3 ways in which critical limb ischaemia can be defined

A
  1. ABPI <0.5
  2. Presecne of ischaemic lesions/ gangrene objectively attributable to the arterial disease
  3. Ischaemic rest pain for >2w duration
52
Q

What is the key differential for symptoms of limb ischaemia?

A

Spinal stenosis (‘neurogenic claudication’)

53
Q

How can cardiovascular risk factors be managed in patients with chronic limb ischaemia?

A

Lifestyle changes - weight loss, smoking cessation
Statin
Anti-platelet (ideally clopidogrel 75mg)
Optomise diabetes control
Exercise - “walk through the pain” as this will help to develop collateral vessels and reduce need for surgery

54
Q

What can cause varicose veins?

A
  1. 98% are primary idiopathic
    Secondary causes include:
  2. Pelvic masses (eg malignancy, fibroids)
  3. AV malformations eg Klippel-Trenaunay Syndrome
55
Q

What are the 4 major risk factors for developing varicose veins?

A
  1. Prolonged standing
  2. Obesity
  3. Family history
  4. Pregnancy
56
Q

Recall 3 signs of venous insufficiency

A

Ulceration
Varicose eczema
Haemosiderin deposition

57
Q

What is a saphena varix?

A

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
Q

Briefly describe the classification system for varicose veins

A

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
Q

What is the gold standard test for varicose veins?

A

Duplex ultrasound

60
Q

How should venous ulcers be managed?

A

4-layer bandaging to produce graduated compression - aims to move blood distal –> proximal

61
Q

Recall 3 options for treating varicose veins

A
  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
Q

Recall 5 signs of deep venous insufficiency

A

Varicose eczema (dry and scaly skin)
Thrombophlebitis
Haemosiderin skin staining
Lipodermatosclerosis
Atrophie blanche

63
Q

What is venous stenting and what is it used for?

A

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
Q

What are the 3 main groups of causes of acute limb ischaemia?

A
  1. Embolisation
  2. Thrombus in sit (eg due to local atheroma)
  3. Trauma (less common) eg compartment syndrome
65
Q

What are the 6 Ps of acute limb ischaemia?

A
  • Pain
  • Pallor
  • Pulselessness
  • Paresthesia
  • Perishingly cold
  • Paralysis
66
Q

What classification system is used to classify acute limb ischaemia?

A

Rutherford

67
Q

How should suspected acute limb ischaemia be investigated?

A

Duplex ultrasound followed by consideration of CT angiography

68
Q

Within what time frame will complete arterial occlusion in the lower lib lead to irreversible tissue damage?

A

6 hours

69
Q

How should acute limb ischaemia be managed?

A

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
Q

How should irreversible acute limb ischaemia be managed?

A

Urgent amputation

71
Q

What is the mortality rate of acute limb ischaemia?

A

20%

72
Q

What is reperfusion injury?

A

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
Q

What is Leriche’s syndrome?

A

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
Q

How do symptoms of peripheral vascular disease differ in femoral and iliac stenosis?

A

Iliac stenosis = buttock pain

Femoral stenosis = calf pain

75
Q

How can neurogenic claudication be differentiated from other causes?

A

Pain is relieved by flexion e.g. leaning forwards on something

76
Q

When is arterial and venous claudication better and worse respectively?

A

Arterial - better with rest, worse on exercise or when lying down/night

Venous - worse with rest or standing for long periods of time

77
Q

What is a normal ABPI?

A

1 - 1.2

78
Q

What ABPI result correlates with mild, moderate and severe arterial disease?

A

0.8-0.9 = mild
0.5-0.79 = moderate
<0.5 = severe (critical limb ischaemia)

79
Q

What is a normal doppler wave pattern?

A

Tri-phasic but can become biphasic with age (wouldn’t be too worrying)

80
Q

What is a quick way to characterise strength of pulses (often used by GPs)?

A

3+ = aneurysm
2+ = normal
1+ = weak
0 = absent

81
Q

What is a diabetic ulcer?

A

Combination of neuropathic and ischaemic (arterial) ulcer

82
Q

What is the difference between dry and wet gangrene?

A

Wet gangrene is tissue necrosis + overlying infection

(dry gangrene typically has a much clearer demarcation)

83
Q

What is a tell-tale sign of necrotising fascitis?

A

Crepitus (caused by gas gangrene)

84
Q

What are the 6 CEAR stages of venous disease?

A

1) spider veins
2) varicose veins
3) oedema (pitting)
4) skin changes
5) healing venous ulcer
6) active venous ulcer

85
Q

When would an open AAA repair be preferred over an EVAR?

A

If patient is young/expected to live more than 5-10 years, an open repair is preferred as there is no chance of recurrence or complications despite the longer recovery period

86
Q

Which method of resvascularisation is preferred in patients with multifocal lesions or long segments of ischaemia?

A

Open

87
Q

What is the characteristic pain caused by a cervical rib?

A

Typically causes symptoms to be the worst when the hands are used about the head e.g. tightening a lightbulb

88
Q

What type of ulcer is associated with IBD?

A

Pyoderma gangrenosum

89
Q

What is a Marjolin’s ulcer?

A

Marjolin’s ulcer is a squamous cell carcinoma occurring at sites of chronic inflammation or previous injury.

90
Q

What does an ABPI > 1 indicate?

A

An ABPI value of >1 can indicate vessel calcificaiton common in diabetes

91
Q

What length of stenosis is endovascular stenting suggested for?

A

<10cm (short segments)

92
Q

What rate of growth for an AAA would be concerning and warrant referral to vascular surgery?

A

> 1cm/year

93
Q

How does the dose of atorvastatin differ in primary and secondary prevention of PAD?

A

Primary - 20mg
Secondary (following an event) - 80mg

(+75mg clopidogrel)

ICSM Year 6 (21 decks)

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