Surgery - Vascular

Question 1

Describe screening for AAA

Answer 1

All males >65yrs invited
Get one-off abdominal USS
At risk individuals are kept under observation

Question 2

How is a ruptured AAA managed?

Answer 2

• 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

Question 3

How is an unruptured AAA managed?

Answer 3

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

Question 4

What are the 2 presentations of chronic limb ischaemia?

Answer 4

Intermittent claudication

Chronic limb threatening ischaemia (CLTI)

Question 5

What are the risk factors for limb ischaemia?

Answer 5

Modifible: smoking, cholesterol, HTN, DM

Non-modifiable: Age, sex, race

Question 6

How does intermittent claudication present?

Answer 6

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

Question 7

How does chronic limb threatening ischaemia (CLTI) present?

Answer 7

> 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

Question 8

How is chronic limb ischaemia investigated?

Answer 8

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)

Question 9

How is IC classified

Answer 9

Rutherford classification

Question 10

How is chronic limb ischaemia managed?

Answer 10

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)

Question 11

Describe acute limb ischaemia and its causes

Answer 11

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

Question 12

What are the S/Sx of acute limb ischaemia

Answer 12

6Ps

paralysis
paraesthesia
-> means the disease is limb-threatening!
pale
pulseless
perishingly cold
painful

Question 13

Describe the differentiating features between an embolus and a thrombus

Answer 13

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

Question 14

How is acute limb ischaemia investigated?

Answer 14

Bloods
ECG (?AF)
Imaging (CTA/Doppler USS)
Angiography (used pre-op to guide bypass)

Question 15

How is acute limb ischaemia managed?

Answer 15

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

Question 16

Describe carotid artery disease and its causes:

Answer 16

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

Question 17

How is carotid artery disease investigated?

Answer 17

Duplex carotid doppler
CT (rule out stroke)
MRA/CTA
call vascular surgeons

Question 18

How is carotid artery disease managed?

Answer 18

Medical:
- anti-platelet
- control RFx
Surgery:
- cerebral endarterectomy (prophylactic, removal or plaque and repair artery with a patch)
- stenting

Question 19

Define a varicose vein

Answer 19

Tortuous dilated segment of vein usually associated with vascular incompetence of the superficial venous system (great/lesser saphenous veins)

Question 20

Describe the causes of varicose veins:

Answer 20

1) valvular insufficiency

2) DVT/obstruction

Question 21

Describe the S/Sx of varicose veins:

Answer 21

often asymptomatic but cause cosmetic issues

- haemosiderin deposition, venous eczema, ulcers, oedema, thrombophlebitis, cramps, heaviness, tingling, restless legs

Question 22

How are varicose veins investigated and managed?

Answer 22

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)

Question 23

Describe and compare venous and arterial ulcers

Answer 23

Venous (75%)

• painless
• shallow with a rolled edge
• associated with haemosiderin deposition

Arterial (2%)

• painful
• deep and punched out
• occur at pressure points

Question 24

Describe the meaning of ABPI measurements

Answer 24

1.2 - 1 = normal
0.9-0.8 = mild claudication
0.5 - 0.79 = severe claudication
<0.5 = severe arterial disease

Question 25

Describe acute mesenteric ischaemia and how it may present:

Answer 25

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