Surgery - Vascular Flashcards
Describe screening for AAA
All males >65yrs invited
Get one-off abdominal USS
At risk individuals are kept under observation
How is a ruptured AAA managed?
- high flow O2
- Iv access
- FBC, coag, clotting
- cross match >6 units
transfer to vascular surgeons: - stable = CT angiogram and possible endovascular repair
- unstable = open repair
How is an unruptured AAA managed?
Medical:
- <5.5cm = observation, reduce CV risk factors
Surgery: - for: AAA >5.5cm symptomatic AAA's AAA's expanding at >1cm/yr
- either open repair or EVAR (introduce graft through femoral artery and fixing a stent across the aneurysm)
- EVAR has higher re-aneurysm and re-intervention rate, but better post-op hospital stay and lower 30-day mortality
What are the 2 presentations of chronic limb ischaemia?
Intermittent claudication
Chronic limb threatening ischaemia (CLTI)
What are the risk factors for limb ischaemia?
Modifible: smoking, cholesterol, HTN, DM
Non-modifiable: Age, sex, race
How does intermittent claudication present?
arterial insufficiency, cramping pain when walking a fixed distance, relieved by rest and symptoms reproducible, distal muscle groups affected first
calf pain = SFA disease
buttock pain = iliac disease
How does chronic limb threatening ischaemia (CLTI) present?
> 2 weeks of recurrent pain requiring regular opiate use and associated with ankle systolic pressure >50mmHg
- pain at rest and especially at night, helps to hang foot out of bed
- associated with tissue loss and gangrene
How is chronic limb ischaemia investigated?
pulses
CRT
Buerger’s angle (normal 90 degrees, <20 = severe ischaemia)
walking test
bloods
imaging (USS doppler, CT, catheter angiogram)
ABPI (normal >1)
ECG
CXR (may have lung cancer due to shared RFx)
How is IC classified
Rutherford classification
How is chronic limb ischaemia managed?
Conservative: prevention, exercise to increase collaterals, smoking cessation, weight loss
Medical: BP control (B blockers may worsen claudication symptoms!), statins, antiplatelets
Surgery: endovascular revascularisation (angioplasty +/- stenting), peripheral bypass (use great saphenous vein or superficial femoral vein)
Describe acute limb ischaemia and its causes
vascular emergency due to sudden deterioration in blood supply to a previously stable limb (dangerous as no collaterals have formed)
Causes:
1) thrombus in vessel with existing atherosclerosis
2) embolus
3) rare causes e.g. iatrogenic, trauma, IVDU
What are the S/Sx of acute limb ischaemia
6Ps
paralysis paraesthesia -> means the disease is limb-threatening! pale pulseless perishingly cold painful
Describe the differentiating features between an embolus and a thrombus
Thrombus vs embolus
Onset: hrs/days vs sudden Severity: less severe vs profound ischaemia Source: at site vs AF? History of claudication: yes vs no Contralateral pulses: no vs yes
How is acute limb ischaemia investigated?
Bloods
ECG (?AF)
Imaging (CTA/Doppler USS)
Angiography (used pre-op to guide bypass)
How is acute limb ischaemia managed?
A-E Oxygen and IV access IV heparin Analgesia (call vascular surgery)
Complete occlusion -> surgical embolectomy/bypass/thrombolysis
Incomplete occlusion -> CTA, angioplasty, thrombolysis or amputation
Describe carotid artery disease and its causes:
Atheroembolism in the carotid arteries which can lead to CVA (stroke or TIA)
Turbulent blood-flow at the carotid bifurcation can lead to atherosclerosis and plaque formation
How is carotid artery disease investigated?
Duplex carotid doppler
CT (rule out stroke)
MRA/CTA
call vascular surgeons
How is carotid artery disease managed?
Medical: - anti-platelet - control RFx Surgery: - cerebral endarterectomy (prophylactic, removal or plaque and repair artery with a patch) - stenting
Define a varicose vein
Tortuous dilated segment of vein usually associated with vascular incompetence of the superficial venous system (great/lesser saphenous veins)
Describe the causes of varicose veins:
1) valvular insufficiency
2) DVT/obstruction
Describe the S/Sx of varicose veins:
often asymptomatic but cause cosmetic issues
- haemosiderin deposition, venous eczema, ulcers, oedema, thrombophlebitis, cramps, heaviness, tingling, restless legs
How are varicose veins investigated and managed?
Examination, Duplex USS, Bloods, ECG, CXR
Management - reassure pt it is only cosmetic issue and no medical emergency
- Conservative (weight loss, avoid prolonged standing, compression stockings)
- Surgery (sclerotherapy, ligation and stripping, endovenous ablation)
Describe and compare venous and arterial ulcers
Venous (75%)
- painless
- shallow with a rolled edge
- associated with haemosiderin deposition
Arterial (2%)
- painful
- deep and punched out
- occur at pressure points
Describe the meaning of ABPI measurements
1.2 - 1 = normal
0.9-0.8 = mild claudication
0.5 - 0.79 = severe claudication
<0.5 = severe arterial disease
Describe acute mesenteric ischaemia and how it may present:
sudden reduction in blood supply to the gut resulting in bowel ischaemia and gangrene/death if not treated properly
caused by atherosclerosis/embolisms/thrombuses
Presents with triad of:
- acute abdo pain +/- PR bleeding
- pain out of proportion
- hypovolaemia
