Surgery - Vascular Flashcards
What is an aortic dissection?
Tear in the tunica intima
What is the biggest RF for aortic dissection?
HTN - smoking second
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 (iv - easier control)
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? PVD?
Conservative: (WL, quit smoking etc + supervised exercise programme)
Medical: statin + anti-platelet (1st line is atorvastatin 80mg + clopidogrel 75mg) - ALL PATIENTS
Rarely used - naftidrofuryl oxalate (vasodilator) - can increase kidney stones - increase blood flow
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)
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]
What is the most common site of superficial thrombophlebitis?
Saphenous vein
What are the symptoms of superficial thrombophlebitis?
Palpable/nodular cord
Inflammation
Varicose veins
How should superficial thrombophlebitis be investigated?
Doppler USS
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
How should venous ulcers be investigated?
Doppler USS, ABPI (to exclude arterial)
How should venous ulcers be managed?
1st - graded compression stockings
2nd line - skin grafting (if not resolved in 12w or area >10cm^2)
all - elevation, exercise, debridement, clean with saline, dressing
Where do arterial ulcers typically appear?
Toes and heel
How should arterial ulcers be managed?
Pain mx
IV prostaglandins
RF modification
Chemical lumbar sympathectomy
Where do neuropathic ulcers typically appear?
Over plantar surface of metatarsal head and plantar surface of hallux
How can neuropathic ulcers be managed?
Cushioned shoes to reduce callous formation
How should popliteal aneurysms be managed?
If stable: femoral-distal bypass
If acute: embolectomy +/- femoral-distal bypass
What is an abdominal aortic aneurysm?
DIlation of the abdominal aorta to >50% of normal diameter/ 3cm, involving all layers of the endothelium
What are the 2 types of AAA?
Fusiform (equally round)
Saccular (outpouching)
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
What is the elective operation used for AAA repair?
endovascular repair of abdominal aneurysm (evar)
If particularly young you can do an open replacement - has longer recovery time but lower chance of further procedures
avoid if obesity, age, allergies, cvs conditions, smoking, diabetes
What are the complications of AAA?
Rupture
Embolism (trash foot)
Thrombus
Fistulation
What is the 1st line treatment for SVCO?
Dexamethosone
How should stridor due to SVCO be managed?
Intubation –> endovascular stenting
What is the gold standard test for peripheral vascular disease?
CT arteriogram
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
Recall the 3 ways in which critical limb ischaemia can be defined
- ABPI <0.5
- Presecne of ischaemic lesions/ gangrene objectively attributable to the arterial disease
- Ischaemic rest pain for >2w duration
What is the key differential for symptoms of limb ischaemia?
Spinal stenosis (‘neurogenic claudication’)
How can cardiovascular risk factors be managed in patients with chronic limb ischaemia?
Lifestyle changes
Statin
Anti-platelet (ideally clopidogrel 75mg)
Optomise diabetes control
What can cause varicose veins?
- 98% are primary idiopathic
Secondary causes include: - Pelvic masses (eg malignancy, fibroids)
- AV malformations eg Klippel-Trenaunay Syndrome
What are the 4 major risk factors for developing varicose veins?
- Prolonged standing
- Obesity
- Family history
- Pregnancy
Recall 3 signs of venous insufficiency
Ulceration
Varicose eczema
Haemosiderin deposition
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.
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?
What is the gold standard test for varicose veins?
Duplex ultrasound
How should venous ulcers be managed?
4-layer bandaging to produce graduated compression - aims to move blood distal –> proximal
Recall 3 options for treating varicose veins
- Venous ligation, stripping + avulsion: tying off responsible vein and stripping it away
- Foam sclerotherapy: injection of a sclerosing agent causes inflammation which causes the vein to close off
- Thermal ablation: heating from the inside to cause irreversible damage which closes it off
Recall 5 signs of deep venous insufficiency
Varicose eczema (dry and scaly skin)
Thrombophlebitis
Haemosiderin skin staining
Lipodermatosclerosis
Atrophie blanche
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
What are the 3 main groups of causes of acute limb ischaemia?
- Embolisation
- Thrombus in sit (eg due to local atheroma)
- Trauma (less common) eg compartment syndrome
What are the 6 Ps of acute limb ischaemia?
- Pain
- Pallor
- Pulselessness
- Paresthesia
- Perishingly cold
- Paralysis
What classification system is used to classify acute limb ischaemia?
Rutherford
How should suspected acute limb ischaemia be investigated?
Duplex ultrasound followed by consideration of CT angiography
Within what time frame will complete arterial occlusion in the lower lib lead to irreversible tissue damage?
6 hours
How should acute limb ischaemia be managed?
Initially: oxygen, IV access, unfractionated heparin infusion (modify and slowly alter and reverse it)
clopidogrel - anti-platelet
Ongoing:
- If low Rutherford classification can have conservative mx via heparin
- If higher Rutherford classification, needs surgical input
- endovascular thrombolysis - directly into clot via artery
- thrombo embolectomy - cathter - fogerty catheter
- open thrombectomy
- bypass
- amputation
How should irreversible acute limb ischaemia be managed?
Urgent amputation
What is the mortality rate of acute limb ischaemia?
20%
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
What is Leriche’s syndrome?
Triad of symptoms due to atherosclerosis of abdominal aorta/ iliac arteries at the bifurcation, ask about erectile dysfunction;
- Claudication of the buttocks and thighs
- Atrophy of the musculature of the legs
- Impotence (due to paralysis of the L1 nerve)
treat with aorto-bi femoral bypass
How do symptoms of peripheral vascular disease differ in femoral and iliac stenosis?
Iliac stenosis = buttock pain
Femoral stenosis = calf pain
Long saphenous vein superficial thrombophlebitis require what
USS to exclude underlying DVT
If AAA grows by more than 1cm in a year what is required
Rapidly enlarging
2ww for surgical repair
Strongest risk factor for PVD
smoking
Main risk factor for embolic acute limb ischaemia
AF - formation of thrombi in atrium that migrate
Factors suggestive of thrombus vs embolus in ALI
T
- pre existing claudication
- no obvious source of emboli
- absent pulses in contralateral limb
- widespread disease e.g. MI
E
- sudden onset
- no claudication
- source of embolus e.g. AF
- no evidence pvd - normal pulse in contralateral limb
- proximal aneurysm
Presentation of chronic obliterative arterial disease
painful lower calf ulcer, mild pitting oedema and low abpi
How is severe PVD treated?
Endovascular revascularisation
- percutaneous transluminal angioplasty +/- stent placement
-short segment stenosis <10cm, aortic iliac disease and high risk
Surgical revascularisation
- surgical bypass with autologous vein / prosthetic material
- endarterectomy - manual removal
- open surgical techniques - long segment lesions >10cm, multifocal lesions, common femoral artery and purely infrapopliteal disease
Indications for endovascular revascularisation in CLI
short segment stenosis <10cm, aortic iliac disease and high risk patients
Indications for surgical revascularisation in CLI
long segment lesions >10cm, multifocal lesions, common femoral artery and purely infrapopliteal disease
Treatment for superficial thrombophlebitis
Compression stockings
+ LMWH for 30 days
or
+ Fondaparinux for 45 days
to stop DVT formation
if lmwh is contraindicated 8-12 days of NSAIDs
if extends towards sapheno-femoral junction = therapeutic anticoagulation 6-12 weeks
Contraindications for LMWH
trauma, epidural half-life, hemorrhagic disorders, peptic ulcer disease, recent cerebral hemorrhage, severe hypertension, and recent surgery to the eye or nervous system
What should be arranged in patients with suspected ruptured abdominal aorta aneurysm
6 units of blood crossmatch
What is ABPI
a calculation of the ratio of the patient’s systolic blood pressure at their ankle to the systolic pressure in their arm.
What can increase ABPI
diabetes due to high vessel calcification
what is marjolin’s ulcer
squamous cell carcinoma occuring at sites of chronic inflammation / previous injury
what is pyoderma gangrenosum
ibd association
lower limbs and painful
red and yellow
treat with steroids
what is venous duplex uss and what is it used first line for
doppler with vein structures shown
varicose veins and chronic venous disease
What is the classical presentation of takayasu arteritis
young asian
pulseless peripheries
Classical presentation of subclavian steal syndrome
increased metabolic need of arm, retrograde flow and cns vascular insufficiency
main signs of aortic coarctation
weak arm pulses
radiofemoral delay
noticing of ribs if disease long standing
why is aaa cause pain at the back
retroperitoneal pain
main scan for aaa
USS, ct angiogram
what is the main complication of evar
endoleak with aneurysm expansion and rupture
Key feature of CLI
hang foot over the bed for blood flow improvement
Main management for IC
rf modification
supervised exercise programme
CAN - treatment
other material for bypass than veins
Plastics - dacron and ptfe
What is the rutherford classification
Acute limb ischaemia
call vascular
acute limb ischaemia investigations
bedside - ecg, abpi, dopplar
- af
bloods
- gas, fbc, u&e, ck, clotting, group & save (all surgical patients)
imaging
- digital subtraction angiography
most common complication of venous disease
leg ulcer
Main difference between arterial and neuropathic ulcer
arterial is painful
neuropathic is on pressure based areas
Most common ulcer
venous 60-80%
Signs of venous disease
leg pain, oedema, worse at night, relieved by rest, aching
What should you check for before putting on stockings
arterial disease
