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Surgery > Vascular > Flashcards

Vascular Flashcards

1
Q

What is peripheral arterial disease?

A

Narrowing or arteries to limbs and peripheries-> reduces blood supply

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2
Q

What is intermittent claudication?

A
  • Ischaemia in limb
  • During exertion + relieved by rest
  • Crampy/achy pain in leg
  • Associated with muscle fatigue when walk intensely
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3
Q

What is critical limb ischaemia?

A
  • End stage PAD
  • Inadequate blood supply
  • Pain at rest
  • Non-healing ulcers + gangrene
  • Risk of losing leg
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4
Q

What is acute limb ischaemia?

A

Rapid ischaemia due to clot blocking arterial supply

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5
Q

What is gangrene?

A

Death of tissue due to inadequate blood supply

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6
Q

What is ischaemia?

A

Inadequate oxygen causing tissue necrosis + death

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7
Q

What is artherosclerosis?

A
  • Chronic inflammation + activation of immune system-> lipid deposits + plaques
  • Happens to medium and large arteries
  • Can lead to stiff walls (HTN), heart strain, stenosis, plaque rupture + thrombus
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8
Q

What are the signs of critical limb ischaemia?

A
  • Pain
  • Pallor
  • Pulseless
  • Paralysis
  • Paraesthesia
  • Perishing cold
  • Often worse at night when raised
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9
Q

What can cause critical limb ischaemia?

A
  • Thrombosis
  • Emboli-> more sudden presentation
  • Graft/angioplasty occlusion
  • Trauma
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10
Q

How should critical limb ischaemia be investigated?

A
  • Neuro exam
  • Obs
  • Arterial + venous dopplers
  • CT angiogram
  • Rutherford scoring
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11
Q

What is the Rutherford scoring system?

A
  • For critical limb ischaemia-> risk of limb
  • Stage I-> viable
  • Stage IIa
  • Stage IIb-> immediate threat to limb
  • Stage III-> irreversible damage
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12
Q

How is critical limb ischaemia treated?

A
  • Heparin infusion

- Revascularisation-> within 4-6 hours

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13
Q

Wha tis the main post-op complication of revascularisation?

A

Reperfusion injury-> functional loss of nerves + muscles, can cause compartment syndrome

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14
Q

What is Lerich syndrome?

A

Occlusion of distal aorta or proximal common iliac artery

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15
Q

What is the clinical triad or Lerich syndrome?

A

Thigh/buttock claudication + absent femoral pulse + male impotence

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16
Q

What are some signs of peripheral arterial disease?

A
  • RFs-> tar staining on fingers, xanthomata
  • CVD-> amputations, midline sternotomy, focal weakness (previous stroke)
  • Weak peripheral pulses
  • Reduced skin temperature, reduced sensation, prolonged CRT
  • Arterial-> pallor, cyanosis, dependent rubour, muscle wasting, hair loss, ulcers, poor wound healing, gangrene
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17
Q

What is Buerger’s test?

A
  • Lie on back + lift leg to 45 degrees for 1-2 minutes
  • Pallor-> arterial supply unable to overcome gravity
  • Assess Buerger’s angle-> where legs go pale
  • Sit up with legs off bed-> should go pink
  • PAD-> go blue (ischaemic tissue- deoxygenated blood) then dark red (vasodilation due to waste products of anaerobic)
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18
Q

What causes an ulcer?

A

Skin/tissue struggling to heal due to impaired blood flow

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19
Q

What are the signs of an arterial ulcer?

A
  • Small
  • Deep
  • Well definited border
  • ‘Punched out’
  • Peripheral (eg toes)
  • Reduced bleeding
  • Painful-> worse at night + improved when lower leg (gravity helps)
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20
Q

What are the signs of a venous ulcer?

A
  • Larger
  • More superficial
  • Irregular or sloping borders
  • Affect gaiter area (mid calf to ankle)
  • Less painful
  • Worse when lower leg
  • Other chronic venous insufficiency signs
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21
Q

How should peripheral arterial disease be investigated?

A
  • ABPI
  • DUplex US-> speed + volume of flow
  • Angiography
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22
Q

What is ABPI?

A
  • Ankle-brachia pressure index
  • Ratio of systolic in ankle to arm using doppler probe
  • Ankle systolic 80 and arm 100-> ABPI of 0.8
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23
Q

What ABPI result is normal?

A

0.9-1.3

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24
Q

What ABPI result shows mild PAS?

A

0.6-0.9

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25
Q

What ABPI result shows moderate-severe PAD?

A

0.3-0.6

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26
Q

What ABPI result shows severe to critical ischaemia?

A

<0.3

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27
Q

What ABPI result indicates calcification?

A

> 1.3

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28
Q

How is intermittent claudication managed?

A
  • Risk factor and lifestyle management
  • Exercise training
  • Medical-> high dose statin, aspirin/clopidogrel, Naftidrofuryl
  • Surgical-> endovascular angiogram + stent, endartectomy, bypass
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29
Q

How is acute limb ischaemia managed?

A
  • Urgent referral
  • Endovascular thrombolysis or thrombectomy
  • Surgical thrombectomy
  • Endartectomy
  • Bypass
  • Amputation
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30
Q

What are varicose veins?

A

Distended superficial leg vein-> >3mm diameter + usually legs

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31
Q

What are reticular veins?

A

Dilated vessels in the skin-> 1-3mm

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32
Q

What is telangiectasia?

A

-Spider/thread veins-> <1mm

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33
Q

How do varicose veins develop?

A
  • Valves allow flow in 1 direction towards heart
  • Legs contract + squeeze blood up against gravity
  • Incompetent-> blood back down + pools in veins + feet
  • Perforating veins connect deep + superficial-> incompetent valves mean flow back to superficial-> dilation + engorged
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34
Q

What happens in chronic venous insufficiency?

A
  • Blood pools + pressure causes leakage to tissues
  • Brown deposits/discolouration to shins-> Hb in blood breaks down to haemosiderin
  • Venous eczema-> inflammation + dry
  • Lipodermatosclerosis-> tight + hard skin + tissues (fibrosis)
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35
Q

What are the risk factors for varicose veins?

A
  • Older age
  • FH
  • Female
  • Pregnancy
  • Obesity
  • Prolonged standing
  • DVT
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36
Q

How do varicose veins present?

A
  • Engorged + dilated superficial leg veins
  • Heavy/dragging feeling
  • Aching
  • Itching
  • Burning
  • Oedema
  • Muscle cramps
  • Restless legs
  • Chronic insufficiency
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37
Q

What special tests should be done in varicose veins?

A
  • Tap test
  • Cough test
  • Trendelenburg’s
  • Perthe’s test
  • Duplex US
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38
Q

How is the tap test performed?

A
  • Pressure to SFJ + tap distal varicose vein
  • Feel for thrill
  • Suggests incompetent venous valve between 2
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39
Q

How is the cough test performed?

A
  • Pressure to SJF + cough

- Thrills-> dilated vein at SJF

40
Q

How is Trendelenburg’s test (for varicose veins) performed?

A
  • Lie down + lift leg to drain veins
  • Apply tourniquet to thigh
  • Stand up
  • Assess where incompetent valve is
  • When vein appears-> valve below level of tourniquet
  • Not reappear-> distal to valve
41
Q

How is Perthe’s test performed?

A
  • Tourniquet to thigh
  • Heel raises when standing to pump calf muscles
  • Superficial veins disappear-> deep vein is functioning
  • If superficial dilatation increases-> deep vein problem
42
Q

How are varicose veins?

A
  • If pregnant-> improve after delivery
  • Simple-> weight loss, activity, keep leg elevated, compression stockings
  • Surgical-> endothermal ablation, sclerotherapy, stripping
43
Q

What are the complications of varicose veins?

A
  • Prolonged bleeding
  • Superficial thrombophlebitis
  • DVT
  • Chronic venous insufficiency
44
Q

What causes arterial ulcers?

A

Insufficient blood supply-> eg PAD

45
Q

What causes venous ulcers?

A

Pooling of blood and waste products in skin-> secondary to venous insufficiency

46
Q

What causes diabetic foot ulcers?

A
  • Neuropathy-> less likely to realise injured/poor fitting shoes
  • Damage to small + large blood vessels-> impair supply + healing
  • Raised BMs, immune system change, autonomic neuropathy etc to contribute
47
Q

What is a major complication of diabetic foot ulcers?

A

Osteomyelitis

48
Q

What causes pressure ulcers?

A
  • Reduced mobility + prolonged pressure on area
  • Reduced supply
  • Local ischaemia
  • Reduced lymphatic drainage
  • Abnormal change in shape (deformation) or tissues under pressure
49
Q

How can pressure ulcers be prevented?

A
  • Risk assessment-> Waterlow score
  • Regular repositioning
  • Inflating mattress
  • Skin checks
  • Dressings/creams
50
Q

What is the Waterlow score?

A

Risk assessment tool for pressure ulcers

51
Q

How are ulcers investigated?

A
  • ABPI
  • Bloods-> infection, co-morbidities
  • Charcoal swabs-> infection + organism
  • Skin biopsy-> may be SCC (need 2WW)
52
Q

How are arterial ulcers managed?

A
  • Same as PAD
  • Urgent referral
  • Consider revascularisation
  • Treat underlying disease
53
Q

How are venous ulcers managed?

A
  • Tissue viability/specialist leg ulcers clinic
  • Derm-> when alternative diagnosis possible
  • District/tissue viability nurse-> clean, debride, dress wound
  • Compression therapy-> venous after arterial excluded
  • Antibiotics
  • Analgesia
  • Pentoxifylline
54
Q

What is lymphoedema?

A

Impaired lymph drainage causing excess protein-rich fluid to accumulate in the tissues

55
Q

What is lipoedema?

A
  • Abnormal build up of fat in the legs
  • Feet are spared
  • Differential for lymphoedema (involves feet)
56
Q

What is primary lymphoedema?

A
  • Genetic
  • Rare
  • Faulty development of lymphatic system
  • Presents before age 30
57
Q

What is secondary lymphoedema?

A

Due to a condition-> commonly removal of axillary LNs in breast cancer surgery`

58
Q

How is lymphoedema assessed?

A
  • Stemmer’s sign
  • Limb volume-> circumference measurement or perometry
  • Bioelectric impendance spectrometry
  • Lymphoscintigraphy
59
Q

How is lymphoedema managed?

A
  • Manual-> massage, compression bandages, exercise, weight loss, skin care
  • Lymphaticovenular anastamosis surgery
  • CBT
  • Antidepressants
  • Avoid bloods + cannulas in limb
60
Q

What is lymphatic filariasis?

A
  • Parasitic worms spread by mosquitoes
  • Live in system + cause damage
  • Thicken + fibrose-> elephantitis
61
Q

What is an aneurysm?

A

Dilation of all layers of a vessel

62
Q

What is a pseudoaneurysm?

A

Dilation of only the adventitia layer of a blood vessel

63
Q

What are common sites of an aneurysm?

A

Aorta, iliac artery, femoral, popliteal

64
Q

What are the types of aneurysm?

A
  • Saccular-> ‘berry’

- Fusiform-> whole vessel

65
Q

What is an abdominal aortic aneurysm?

A

Dilation of more than 3cm of abdominal aorta-> often rupture + bleed (death)

66
Q

What are the risk factors for abdominal aortic aneurysm?

A
  • Men (at younger age than women)
  • Smoking
  • HTN
  • FH
  • CVD
  • Trauma
  • Infection
  • Connective tissue disorder
67
Q

Who is offered screening for abdominal aortic aneurysm?

A
  • All men age 65+

- Consider in women age 70+ with risk factors

68
Q

Who is referred after screening for abdominal aortic aneurysm?

A
  • For abdominal US when diameter >3cm

- Urgently if >5.5cm

69
Q

How does abdominal aortic aneurysm present?

A
  • Asymptomatic
  • Non-specific abdo pain
  • Pulsatile + expansive mass in abdomen
70
Q

How is abdominal aortic aneurysm diagnosed?

A

US or CT angiogram

71
Q

How is abdominal aortic aneurysm classified?

A
  • Small-> 3 to 4.4cm
  • Medium-> 4.5 to 5.4cm
  • Large-> 5.5cm+
72
Q

How is abdominal aortic aneurysm managed?

A
  • Stop progression with RF management
  • Screening + follow up scans-> yearly (small) or 3 monthly (medium)
  • Elective repair-> if 5.5cm+ or grows 1cm/year+ with open repair or stenting (endovascular aneurysm repair)
  • Inform DVLA-> if 6cm+ and stop driving if 6.5cm+
73
Q

How does ruptured abdominal aortic aneurysm present?

A
  • Severe abdo pain-> radiates to back or groin
  • Haemodynamic instability
  • Pulsatile + expansive abdo mass
  • Collapse
74
Q

How is ruptured abdominal aortic aneurysm managed?

A
  • Immediate surgical repair
  • Permissive hypotension-> aim for low BP to reduce loss
  • Prophylactic antibiotics-> cefuroxime + metronidazole
  • CT angiogram-> diagnose or exclude
75
Q

What is aortic dissection?

A
  • Break or tear in inner layer of aorta
  • Blood accumulates between wall layers-> false lumen
  • Usually between intima + media
76
Q

What are the layers of an artery?

A
  • Intima
  • Media
  • Adventitia
77
Q

Where is aortic dissection most common?

A
  • Ascending aorta-> often right lateral as most stress from blood exiting heart
  • Aortic arch
78
Q

How is aortic dissection classified?

A
  • Stanford-> A (ascending) or B (descending)

- DeBakey-> types I, II, IIIa, IIIb (ascend to descend)

79
Q

What are the risk factors for aortic dissection?

A
  • HTN
  • CVD factors
  • Biscuspid aortic valve
  • Coarctation of aorta
  • AV replacement
  • CABG
  • Ehler-Danlos
  • Marfans
80
Q

How does aortic dissection present?

A
  • Sudden severe ripping/tearing chest pain
  • Different location-> where + time
  • HTN then hypotension
  • Difference of 20mmHg+ between arms
  • Radial pulse deficit
  • Diastolic murmur
  • Focal neurology
  • Collapse
81
Q

How is aortic dissection diagnosed?

A
  • CT angiogram
  • MRI angiogram
  • ECG + CXR-> exclude other causes
82
Q

How is aortic dissection managed?

A
  • Emergency surgery-> graft or thoracic EVAR (stent)
  • Morphine
  • BP + HR control with beta-blockers
83
Q

What are some complications of aortic dissection?

A
  • MI
  • Stroke
  • Paraplegia
  • Tamponade
  • AV regurgitation
  • Death
84
Q

What is carotid artery stenosis?

A

Narrowing of carotid arteries in neck secondary to atherosclerosis

85
Q

What are the risk factors of carotid artery stenosis?

A

Same as CVD

86
Q

What are the risks of carotid artery stenosis?

A

Increased risk of CAD, MI, stroke + TIA

87
Q

How does carotid artery stenosis present?

A
  • Asymptomatic
  • Post-TIA/stroke
  • Carotid bruit-> whooshing during systole
88
Q

How is carotid artery stenosis classified?

A
  • Mild-> <50% reduction in diameter
  • Moderate-> 50-69%
  • Severe-> 70%
89
Q

How does carotid artery stenosis get diagnosed?

A
  • Post- TIA/stroke
  • Carotid US
  • CT/MRI angiography
90
Q

How is carotid artery stenosis managed?

A
  • Lifestyle and risk factor management
  • Antiplatelets-> aspirin, clopidogrel, ticagrelor
  • Surgery-> endartectomy (1st line), angioplasty, stenting
91
Q

What are some complications of endartectomy?

A
  • Stroke
  • Damage to CNs VII, IX or XII
  • Recurrent laryngeal palsy
92
Q

What is Buerger disease?

A

Thromboangiitis obliterans-> inflammatory + causes thrombi in small + medium vessels of hands + feet

93
Q

Who is most at risk of developing Buerger disease?

A

Men age 25-35 who smoke

94
Q

What is the diagnostic criteria for Buerger disease?

A

Age <50, smoker, no other RFs

95
Q

How does Buerger disease present?

A
  • Painful + blue discolouration to fingertips + toes
  • Pain worse at night
  • Can progress to ulcers + gangrene
96
Q

What is the typical angiogram finding in Buerger disease?

A

Corkscrew collaterals-> new vessels formed to bypass arteries

97
Q

How is Buerger disease managed?

A
  • Stop smoking

- IV iloprost-> prostacylin analogue that dilates BVs

Surgery (8 decks)

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