surgery - vascular peripheral arterial disease + other Flashcards
1
Q
what is acute limb ischaemia?
A
sudden decrease in limb perfusion that threatens the viability of the limb
2
Q
aetiology of acute limb ischaemia?
A
Embolisation
thrombosis in situ
trauma including compartment syndrome
3
Q
features of acute limb ischaemia
A
4
Q
categories of acute limb ischameia?
A
5
Q
ix of acute limb ischameia
A
routine bloods, lactate, thormbophilia screen
ECG
Doppler USS
CT angiography
6
Q
initial mx of acute limb ischameia
A
therapeutic dose heparin or intravenous heparin infusion
7
Q
conservative mx of acute limb ischameia
A
prolonged course of heparin
regular assessment though APTT:PT ratios
8
Q
surgical mx of acute limb ischaemia
embolic vs thrombotic
A
9
Q
how does irreversible limb iscahmeia present?
mx?
A
mottled non-blanching appearance with hard woody muscles
requires urgent amputation or taking a palliative approach.
10
Q
long term mx of acute limb ischaemia?
A
weight loss, regular exercise, smoking cessation
anti-platelet agent, such as low-dose aspirin or clopidogrel,
11
Q
complications of acute limb ischaemia?
A
reperfusion injury leading to compartment syndrome + damaged msuycle cells
12
Q
what is compartment syndrome
A
13
Q
how do damaged muscle cells present
A
Release of substances from the damaged muscle cells, such as K+ ions causing hyperkalaemia, H+ ions causing acidosis, Myoglobin resulting in significant AKI
14
Q
what os acute mesenteric ischameia?
A
sudden decrease in the blood supply to the bowel, resulting in bowel ischaemia and necrosis
15
Q
causes of acute mesenteric ischameia
A
thrombosis in situ
embolism
non-occlusic cause
venous occlusion + congestion
16
Q
underlying cause of each AMI case?
A
thrombosis = atherosclerosis
embolism = cardiac
non-occlusive = Hypovolaemic shock, cardiogenic shock
venous = Coagulopathy, malignancy, autoimmune disorders
17
Q
RF of acute mesenteric ischameia?
A
moking, hyperlipidaemia, and hypertension,
18
Q
features of acute mesenteric ischameia
A
generalised abdominal pain that is out of proportion
diffuse + constant pain
N+V
non-specific tenderness
19
Q
ix of acute mesenteric ischaemia
A
ABG - acidosis
FBC, U&Es, clotting, lactate, amylase, and LFTs
20
Q
imaging for acute mesenteric ischameia
A
CT with IV contrast
shows oedematous bowel, loss of bowell wall enhancement + penumatosis
21
Q
what’s this
A
showing bowel ischaemia
22
Q
initial mx of acute mesenteric ischameia?
A
urgent resuscitation
IV fluids, urinary catheter
brand spec abx
23
Q
definitive mx for acute mesenteric ischameia?
A
Excision of necrotic or non-viable bowel
revascularisation of bowel
24
Q
complications of acute mesenteric ischameia?
A
bowel necrosis and perforation
short gut syndrome if resected
25
what is chronic limb iscahemia?
form of peripheral arterial disease that results in a symptomatic reduced blood supply to the limbs.
26
RF for chronic limb ischaemia?
smoking, diabetes mellitus, hypertension, hyperlipidaemia, increasing age, a strong family history, and obesity or physical inactivity
27
features of chronic limb ischameia
intermittent claudication, a cramping-type pain in the calf, thigh, or buttock after walking a fixed distance relieved by rest
colder limb
asent peripheral pulses
buerger's test - goes pale
28
what is leriche syndrome?
Leriche syndrome is a form of peripheral arterial disease affecting the aortic bifurcation. It specifically presents with buttock or thigh pain and is associated erectile dysfunction.
29
what is critical limb threatening ischaemia?
advanced form of chronic limb ischaemia.
30
ix for chronic limb ischameia?
ABPI
doppler USS
CT angioprahy
31
medical mx of chronic limb ischaemia
32
surgical mx of chronic limb ischameia?
angioplasty with or without stenting
Bypass grafting, typically used for diffuse disease or in younger patients
Amputations are considered for any patients who are unsuitable for revascularisation, with ischaemia causing incurable symptoms or gangrene leading to sepsis.
33
complications of acute limb ishcaemia
sepsis (secondary to infected gangrene), acute-on-chronic ischaemia, amputation, and reduced mobility and quality of life.
34
what is chronic mesenteric ischameia
35
pathophysiology of chronic mesenteric ischaemia?
radual build-up of atherosclerotic plaque
impairs blood flow, inadequate blood supply to bowel
any increased demand on the blood supply, i.e. after eating, or a reduction in overall blood volume, such as severe haemorrhage, will exacerbate symptoms.
36
37
RF for chronic mesenteric ischaemia
smoking, hypertension, diabetes mellitus, and hypercholesterolemia.
females
38
features of chronic mesenteric ischaemia
Postprandial pain – classically occurring around 10mins-4hrs after eating*
Weight loss – a combination of decreased calorie intake and malabsorption
Concurrent vascular co-morbidities, e.g. previous MI, stroke, or PVD
39
ix for chronic mesenteric ischaemia
FBC, U&Es, and LFTs
CT angiography
40
mx of chronic mesenteric ischameia
endovascular treatment is often preferred
41
what is mesenteric angioplasty?
42
complications of chronic mesenteric ischaemia?
bowel infarction or malabsorption
43
presentation of popliteal aneurysm?
as either acute limb ischaemia (from aneurysm thrombosis or distal emboli) or less commonly with intermittent claudication
44
ix of popliteal aneurysm?
duplex USS
CT angio
45
mx of popliteal aneurysm?
Endovascular repair involves stent insertion across the aneurysm
Surgical repair involves ligation of the aneurysm or resection of the aneurysm with a bypass graft
46
presentation of femoral artery aneurysm?
thrombosis, rupture, or embolisation of the aneurysm
infection
varying degrees of claudication or acute limb ischaemia
47
causes of femoral artery aneurysm?
Percutaneous vascular interventions
Patient self-injecting
48
ix and mx of femoral artery aneurysm?
ultrasound duplex scan
CT Angiography or MR Angiography
open surgical repair
49
RF of splenic artery aneurysm?
emale sex, multiple pregnancies, portal hypertension, and pancreatitis or pancreatic pseudocyst formation.
50
presentation of splenic artery aneurysm?
vague epigastric or left upper quadrant abdominal pain
rupture will present with severe abdominal pain and haemodynamic compromise
51
ix and mx of splenic artery aneurysm?
CT Angiography or MR Angiography.
endovascular repair
52
hepatic aneurysm presentation
vague RUQ or epigastric pain; jaundice
53
ix and mx of hepatic artery aneurysm
CT Angiography or MR Angiography.
endovascular repair
54
renal artery aneurysm features
haematuria, resistant hypertension, or loin pain
55
ix and mx of renal artery aneurysm?
CT Angiography or MR Angiography.
endovascular repair
56
what is deep venous insufficiency?
failure of the venous system, characterised by valvular reflux, venous hypertension and obstruction
DVT
valvular insufficiency
varicose veins
57
causes of DVI?
58
RF of DVI?
increasing age, female gender, pregnancy, previous DVT or phlebitis, obesity, and smoking.
ong periods of standing or with a strong family history
59
features of DVI?
chronically swollen lower limbs
aching, pruritic, and painful
venous claudication, characterised by a bursting pain and tightness on walking which resolves on leg elevation
varicose eczema
thrombophlebitis, haemosiderin skin staining, lipodermatosclerosis*, or atrophie blanche**
60
what is post thrombotic syndrome?
heaviness, cramps, pain, pruritis, and paraesthesia
pretibial oedema, skin induration, hyperpigmentation, venous ectasia, redness, and ulceration.
61
ix of DVI?
doppler USS
FBC, U&Es, and LFTs, BNP (+/- an ECHO if indicated).
ABPI
foot pulses
62
mx of DVI?
compression treatment:
4-layer bandage, short stretch bandage, stockings, or compression wrap
63
what can you do in DVI if symptoms remain with compression
elevating the feet above the level of the precordium can reduce symptoms and disease progression.
64
surgical mx of DVI?
deep venous stenting; this procedure is reserved for patients with the most severe symptoms
65
complications of DVI?
swelling, recurrent cellulitis, chronic pain and ulceration
deep vein thrombosis, secondary lymphoedema, and varicose veins.
66
what is marjolin ulcer?
rare type of cutaneous squamous cell carcinoma (SCC) developing at the site of severe or recurrent inflammation (such as in venous insufficiency)
non-healing ulcers, steadily increasing in size and have excessive granulation tissue, often bleeding easily on contact, and be painful.
67
what is hyperhidrosis?
sweating in excess of that required for regulation of body temperature.
68
what causes sweating?
Sweating is controlled by the autonomic nervous system. Increased sympathetic stimulation from thoracolumbar autonomic fibres stimulate the eccrine (water) sweat glands (rather than the oily apocrine glands) to increase sweat production.
69
causes of hyperhidrosis?
70
features of primary hyperhidrosis?
focal sweating, typically bilateral and symmetrical
once a week min
<25 yo
>6m long
71
features of secondary hyperhidrosis?
generalised sweating
night time
pyrexia, palpitations, or unexplained weight loss
72
ix of hyperhidrosis?
FBC, CRP, U&Es, TFTs, and glucose, and a CXR
73
mx of hyperhidrosis?
Loose fitting clothes of natural fibre and leather shoes
Anti-perspirants
Propantheline
74
what is propantheline?
anticholinergics
75
surgical mx of hyperhidrosis
Iontophoresis involves use of a weak electrical current through the area through water soaked sponges
Botulinum toxin can be injected into the skin in very small doses to block the nerve supply to the sweat glands.
Endoscopic thoracic sympathectomy (ETS) involves causing damage to the thoracic sympathetic ganglion (Fig. 2) supplying the affected region (most useful for palm and face involvement)
76
what is subclavian steal syndrome?
condition causing syncope or neurological deficits when the blood supply to the affected arm is increased through exercise
econdary to a proximal stenosing lesion or occlusion in the subclavian artery, typically on the left
77
pathophysiology of subclavian steal
In order to compensate for the increased oxygen demand in the arm, blood is drawn from the collateral circulation, which results in reversed blood flow in the ipsilateral vertebral artery (or less commonly the internal thoracic artery).
78
what is Coronary-Subclavian Steal Syndrome
occurs in patients who have undergone an Internal Mammary Artery (IMA) Graft. An increase in oxygen demand in the left arm then steals blood from the IMA leading to cardiac ischaemia.
79
RF of subclavian steaL
atherosclerotic
increasing age, hyperlipidaemia, hypertension, smoking, and diabetes mellitus.
80
features of subclavian steal
vertigo, diplopia, dysphagia, dysarthria, visual loss, or syncope.
arm claudication = arm pain or paraesthesia, made worse with arm movement.
81
ix of subclavian steal
duplex USS
CXR
CT angio
82
mx of subclavian steal
anti-platelet and statin therapy
smoking cessation, weight loss, and optimising diabetic control
percutaneous angioplasty ± stenting
bypass
83
what is thoracic outlet syndrome?
clinical features that arise from compression of the neurovascular bundle within the thoracic outlet.
neurologica, venous and arterial symtoms
84
what causes thoracic outlet syndrome?
hyperextension injuries, repetitive stress injuries
secondary to anatomical abnormalities eg 1st rib, an anomalous cervical rib, or bands within the thoracic outlet.
85
pathophysiology of thoracic outlet syndrome
hypertrophy of the scalene muscles, abnormality in the first rib, or the presence of a cervical rib can all lead to compression on the brachial plexus or subclavian artery
86
what is cervical rib?
A cervical rib is an extra rib that arises from the seventh cervical vertebra
87
RF of thoracic outlet syndrome
Recent trauma, repetitive motion occupations, athletes*, or anatomical variations
88
features of thoracic outlet syndrome
worsen with certain movements, e.g. shoulder abduction or extension.
paraesthesia and/or motor weakness.
ulnar distribution
deep vein thrombosis and extremity swelling
claudication symptoms or acute limb ischaemia
89
special tests for thoracic outlet syndrome?
adson
roo's
elvey's
90
what is adson's
Palpate the radial pulse on the affected side, with the arm initially abducted to 30 degrees, then ask the patient to turn their head and look at the affected side’s shoulder; fully abduct, extend, and laterally rotate the shoulder
Any decrease or loss of pulse is suggestive of TOS
91
what is roo's
Abduct and externally rotate the shoulder on the affected side to 90 degrees, bend the elbow to 90 degrees, then ask the patient to open and close the hands slowly over a 3-minute period
Any worsening of symptoms will develop if TOS is present
92
what is elvey's
Extend the arm to 90 degrees, with the elbow extended and wrist dorsiflexed, then tilt the patients ear to each shoulder
Any loss of the radial pulse or worsening symptoms is suggestive of TOS
93
ix of thoracic outlet syndrome
FBC and clotting screen
CXR
venous and arterial duplex ultrasound
CT?MRI?
venogram
nerve conduction studies
CT angio
94
mx of thoracic outlet syndrome
physiotherapy
Botulinum toxin injections
thrombolysis and anti-coagulation
surgical = decompression via supraclavicular or transaxillary
95
complications of thoracic outlet syndrome>
permanent nerve damage, aneurysmal dilation of the subclavian artery leading to embolisation, or loss of limb function.
96
what are varicose veins?
tortuous dilated segments of vein associated with valvular incompetence
97
pathophysiology of varicose veins?
arise from incompetent valves, which permit blood flow from the deep venous system to the superficial venous system
results in venous hypertension and subsequent dilatation of the superficial venous system
98
causes of varicose veins
idiopathic
DVT
pelvic mass
arterivenous malformations
99
RF for varicose veins
Prolonged standing
Obesity
Pregnancy
Family history
100
features of varicose veins?
unsightly visible veins or discolouration of the skin
aching or itching
thrombophlebitis, ulceration or bleeding
ulceration, varicose eczema, or haemosiderin deposition.
101
what is saphena varix?
102
classification of varicose veins?
CEAP Classification
103
C in CEAP?
104
E in CEAP?
105
A in CEAP?
106
P in CEAP?
107
ix for varicose veins?
duplex ultrasound, assessing for valve incompetence
108
non-invasive tx for varicose veins?
avoiding prolonged standing, weight loss, and increase exercise
Compression stockings
109
surgical tx of varicose veins?
Thermal ablation
Foam sclerotherapy
Vein ligation, stripping, and avulsion
110
who is eligible for surgery with varicose veins?
111
what is thermal ablation?
involves heating the vein from inside (via radiofrequency or laser catheters), causing irreversible damage to the vein, resulting in fibrosis and closure of the vein lumen; this is done under ultrasound guidance and can be performed under local (or general) anaesthetic, and is the most common treatment method currently
112
what is foam sclerotherapy?
involves injecting a sclerosing (irritating) agent directly into the varicosed veins, causing an inflammatory response that closes off the vein (Fig. 3); this is done under ultrasound guidance to ensure the foam does not enter the deep venous system, however this method often only requires local anaesthetic
113
what is Vein ligation, stripping, and avulsion
involves making an incision in the groin (or popliteal fossa) and identifying the responsible refluxing vein, before tying it off and stripping it away; whilst less commonly done as the primary procedure, avulsions may be performed under local anaesthetic alongside thermal ablation techniques
