Vascular Flashcards
What is Paget-Schroetter Syndrome?
A type of thoracic outlet syndrome caused by venous compression between first rib, clavicle and medial border of anterior scalene muscle resulting in upper limb DVTs.
Can be associated with body building (subclavius hypertrophy, axillary vein microtrauma)
What are the symptoms of thoracic outlet syndrome most commonly due to?
Neurogenic - 80-90% of cases with ulnar nerve root distribution symptoms. There is often no anatomical abnormality identified
What is Adson’s sign?
Loss of radial pulse in abducted arm by rotating head to ipsilateral side with extended neck after deep inspiration - a sign of TOS, although not specific
What are the borders and contents of the thoracic outlet?
Borders
1. Superior - Clavicle
2. Inferior - 1st rib
3. Lateral - middle scalene/cervical rib (if present)
Contents
1. Subclavian vein (medial)
2. Anterior scalene
3. Subclavian artery + brachial plexus (lateral)
What is Charcot’s Foot?
Neuropathic arthropathy with degeneration of weight bearing joint (often tarsometatarsal or metatarsophalangeal joints).
Presents as a hot swollen foot (joint) with palpable pulses in patient with peripheral neuropathy
Which 5 nerves can be injured during carotid endarterectomy, and how do these manifest?
- VII (Facial), marginal mandibular branch - ipsilateral drooping
- IX (glossopharyngeal) difficulty swallowing
- XII (hypoglossal) ispilateral tongue deviation (taste normal)
- Superior laryngeal - voice quality and high pitch phonation
- X (Vagus) - hoarseness or impaired cough
What are the characteristic arterial findings in Buerger’s disease?
Corkscrew arteries in both involved and unaffected limbs
Occurs in mostly Men between 20-40, smokers and usually distal extremities. Needs exclusion of proximal embolic and hypercoagulable states for diagnosis
What is the most common cause of prosthetic graft infection?
Staphylococcus species - (epidermidis or MRSA) - about 50%
Remainder pseudomonas, proteus, e.coli.
MRSA has a poor prognosis
What is the Samson classification of Prosthetic Graft infection (1-5)
- Confined to Dermis
- Involves SC tissue not contacting graft
- Involves body of graft but not anastomosis
- Involves exposed anastomosis without bacteraemia/haemorrhage
- Involves exposed anastomosis with bacteraemia/haemorrhage
What classification system can be used to grade arterial ischaemia?
Rutherfords
From which cells do Carotid body tumours arise?
Paraganglion cells.
Carotid body tumours arise at bifurcation splaying internal/external carotid arteries. They are more common in women and diagnosed in 40-50%
10% familial. Usually benign and mobile side-side
What is the inheritance of carotid body tumours?
Usually autosomal dominant.
May be associated with MENIIa or IIb or Von Hippel-Lindau syndrome
What is the genetic abnormality in Von Hippel Lindau syndrome?
Mutation of VHL tumour suppressor on Chromosome 3 (3p25-26)
What tumours are seen in Von Hippel Lindau syndrome?
Haemangioblastomas (cerebral in 60-80%, most common presentation), Phaeochromocytomas, RCC, Pancreatic serous cystadenoma
Retinal angiomatosis –> visual loss
How do Carotid body tumours present?
Slow growing spherical neck mass which may cause cranial nerve palsies (IX, X, XII).
Fixed in carotid sheath so can go side to side but not up and down
Endoscopic Thoracoscopic sympathectomy targets which nerve ganglions?
T2,T3 +/- T4 of paraspinal sympathetic chain
Hyperhidrosis when refractory to medical management with antiperspirants, anticholinergics and botox
80% satisfaction rates, 85-95% symptom improvement.
86% compensatory sweating (contralateral side)
<25% gustatory sweating
<5% cardiac sympathetic denervation
1-2% Horner’s Syndrome
Describe the 5 types of endoleak
In patients with an AAA, how many will also have popliteal aneurysms?
2-10%
Popliteal aneurysms are bilateral in 50% of cases
In patients with a popliteal aneurysm, how many will have a coexisting AAA?
40%
When should popliteal aneurysms be repaired?
In general if they are symptomatic (although they most often present with occlusion/embolisation i.e. acutely, rather than with claudication), or over 2cm. Definitely over 3cm
Usually bypass and exclude
When should carotid endarterectomy be performed?
70-99% symptomatic stenosis of ipsilateral carotid
Small benefit for 50-69% stenosis (NASCET)
What is Subclavian steal syndrome?
Retrograde flow of blood down vertebral artery to distal subclavian artery if proximal subclavian is stenosed/occluded.
Blood flows through common carotid to circle of Willis and back to vertebral
Most patients are asymptomatic, and can be treated with secondary prevention techniques.
Angioplasty is usually first line interventional, but can do transposition or bypass. Endarterectomy is not performed
Which coagulation factors are degraded by Protein C and Protein S
Factor V
Why does Factor V Leiden cause hypercoagulability
The mutated Factor V is not inactivated by protein C
How does Antiphospholipid syndrome cause hyper coagulability?
APL inhibits protein C which normally degrades factor V
Absolute contraindications to thrombolysis (6)
- Active bleeding (not menorrhagia)
- Aortic Dissection
- Cerebral aneurysm or AVM
- Intracranial neoplasia
- Previous cerebral/intracranial haemorrhage (ever)
- Recent thromboembolic stroke
Relative contraindications to thrombolysis (7)
- Active PUD
- Bleeding diathesis (tendancy to bleed) or anti coagulated
- Pregnancy
- Recent head trauma (2-4 weeks)
- Recent GI Bleeding (within 6 months)
- Recent major surgery (2-3 weeks)
- Severe hypertension (>180/110)
What is the most common type of visceral artery aneurysm?
Splenic 60-80%
Hepatic 20%
SMA, GDA, pancreatic 6%
IMA <1%
What is the most common site of compartment syndrome in the leg?
Anterior compartment of both upper and lower legs
What are the compartments of the the thigh?
Anterior, posterior and medial
What are the compartments of the lower leg?
Anterior, lateral, superficial posterior and deep posterior
Describe the Crawford system for Aortic Aneurysms
For thoracoabdominal aneurysms.
1 - L SCA to suprarenal aorta
2 - L SCA to aortic bifurcation
3 - 6th rib/IC space to aortic bifurcation
4 - Diaphragm to aortic bifurcation
5 - 6th rib/IC space to suprarenal aorta
Describe the De-bakey and Stanford classifications
Stanford A/Debakey I-II originate in ascending aorta proximal to left subclavian
Debakey I is ascending/descending (60%)
Debakey II ascending only (10%)
Debakey III descending only (30%)
What is the most common type of aortic dissection
Ascending and descending (60%)
10% confined to ascending
30% descending only
Which of the following is protective against vascular restenosis?
von Willebrand Factor
Vascular endothelial growth factor
Platelet derived growth factor
ICAM-1
E-selectin
VEGF - angiogenic factor, creates new blood vessels, promotes endothelial recovery.
vWF = platelet adhesion
ICAM1 = adhesion migration of leucocytes
E-selectin - endothelial dysfunction, lymphocyte migration
PDGF - smooth muscle migration and intimal thickening
What is Nutcracker syndrome?
Compression of left renal vein between aorta and SMA
Amputations
1. Symes
2. Lisfranc
3. Burgess
4. Chopart
5. Ray
6. Gritti-Stokes
- Ankle amputation, provides durable end and reliant on good PTa
- Through tarsometatarsal joint
- Proximal tibial/fibular amputation with long posterior flap
- Disarticulation at midtarsal joint
- Through distal metatarsal head
- Below knee resection of supracondylar femur and stick patella onto end
What classification system is used for venous incompetence
The CEAP classification.
Main distinction is primary (Ep) or secondary (Es) or congenital (Ec)
With increasing severity going C1 (superficial) to C6 (active ulcer)
What is the most common side effect of statins?
Myopathy (1.5-3%)
What is the most problematic side effect of Gadolinium?
Nephrogenic systemic fibrosis - contraindicated where eGFR <60
Which syndrome is associated with congenital lymphedema?
Milroy’s disease
Also pitting, skin changes
Autosomal dominant
What is the difference between Parkes-Weber and Klippel Trenaunay syndrome?
In KTS there are capillary venous and lymphatic malformations associated with limb overgrowth
In PWS there is the same along with AVFs.
Where should AV fistulae be sited?
In the non-dominant arm and as distal as possible apparently
1) Snuffbox
2)Radiocephalic (Brescia-Cimino) fistula
3) Braciochephalic
4) transposed brachiobasilic (needs transposition)
Which arteries cause Type 2 Endoleaks?
Usually IMA or lumbar or median sacral arteries
What is May-Thurner syndrome?
Compression of LCIV by RCIA
Leads to DVT - consider where no provoking factors, more common in women
What is popliteal entrapment syndrome?
Compression of popliteal artery due to anatomical variant at knee - with abnormal attachment of gastrocnemius lateral medial to popliteal artery
What are important trials in AAA?
UK SAT Chichester/MASS trials and US Veterans studies.
Caucasian smokers 50-79 had higher prevalence - 4.9% of people
MASS trial defined aneurysmal as >3cm
What is the UK screening program for AAA?
Single USS of males at 65.
If <3cm - discharge
3-4.4cm - annual USS
4.5-5.4cm - 3/12 USS
5.5 or greater –> urgent referral for CTA
What is the aneurysm rupture risk at 1 year for:
1) 3-3.9cm
2) 4-4.9cm
3) 5-5.9cm
4) 6-6.9cm
5)>7cm
1) 0%
2) 1%
3) 11%
4) 11-22%
5) 33%
How can you classify types of vasculitis?
1) Aortic - Takayasu’s, Bergers, Giant cell arteritis
2) Large and medium - Buerger’s, Giant cell arteritis, Polyarteritis
3) Medium muscular - Polyarteritis, Wegener’s granulomatosis
4) Small muscular - Wegener’s, Rheumatoid vasculitis
What is Takayasu’s arteritis?
• Inflammatory, obliterative arteritis affecting aorta and branches
• Females> Males
• Symptoms may include upper limb claudication
• Clinical findings include diminished or absent pulses
• ESR often affected during the acute phase
What is Buergers Disease?
• Segmental thrombotic occlusions of the small and medium sized lower limb vessels
• Commonest in young male smokers
• Proximal pulses usually present, but pedal pulses are lost
• An acuter hypercellular occlusive thrombus is often present
• Tortuous corkscrew shaped collateral vessels may be seen on angiography
What is giant cell arteritis?
• Systemic granulomatous arteritis that usually affects large and medium sized vessels
• Females > Males
• Temporal arteritis is commonest type
• Granulomatous lesions may be seen on biopsy (although up to 50% are normal)
What is polyarteritis nodosa
• Systemic necrotising vasculitis affecting small and medium sized muscular arteries
• Most common in populations with high prevalence of hepatitis B
• Renal disease is seen in 70% cases
• Angiography may show saccular or fusiform aneurysms and arterial stenoses
What is Wegener’s granulomatosis?
• Predominantly affects small and medium sized arteries
• Systemic necrotising granulomatous vasculitis
• Cutaneous vascular lesions may be seen (ulceration, nodules and purpura)
• Sinus imaging may show mucosal thickening and air fluid levels
What is the commonest cause of acute mesenteric ischaemia?
Embolic (50%) - 50% survival, 30% if delayed
Thrombotic - usually prodromal, asymptomatic until >80% stenosis
Mesenteric vein thrombosis - 60% thrombophilia
What is the cause of a cervical rib?
Elongation of transverse process of 7th cervical vertebra - usually a fibrous band attaching to mid 1st rib
0.2-0.4% incidence
70% bilateral
Treat trans axillary approach
How can you grade femoropopliteal stenosis/occlusion
TransAtlantic Inter-Society Consensus (TASC)
A - single stenosis <5cm
B - Multiple stenosis <5cm, total <10cm, occlusion <3cm
C - multiple stenosis/occlusion >10cm
D - multiple occlusions >10cm
Key is that C or D lesions should be stented if plastid
When should fasciotomies be performed
Consider if >6hr since symptom onset
What is dysphagia lusoria?
Dysphagia due to aberrant right subclavian
What is superior mesenteric artery syndrome?
Angle between SMA and Aorta is 6-25deg (as opposed to 38-56)
3rd part of duodenum is constricted
4th part of duodenum may be high inserted.
What is Homan’s procedure
Indications for surgery
Marked disability or deformity from limb swelling
Lymphoedema caused by proximal lymphatic obstruction with patent distal lymphatics suitable for a lymphatic drainage procedure
Lymphocutaneous fistulae and megalymphatics
Procedures
Homans operation: Reduction procedure with preservation of overlying skin (which must be in good condition). Skin flaps are raised and the underlying tissue excised. Limb circumference typically reduced by a third.
Charles operation: All skin an subcutaneous tissue around the calf is excised down to the deep fascia. Split skin grafts are placed over the site. May be performed if overlying skin is not in good condition. Larger reduction in size than with Homans procedure.
Lymphovenous anastamosis: Identifiable lymphatics are anastomosed to sub dermal venules. Usually indicated in 2% of patients with proximal lymphatic obstruction and normal distal lymphatics.
What are the grades of compression stockings?
1) 14-17
2) 18-24
3) 25-35
Usually use Class 2 for venous ulcers
What is the 5 year patency rate of a PTFE above knee bypass?
47% (66% vein)
What is a potential reason for failure of thorascopic sympathectomy?
Failure to divide nerve of Kuntz between T1 and T2 (connection from 2nd IC nerve to first IC ventral rams)
How is LMWH derived?
Derived from UFH by depolymerisation to yield fragments about 1/3 the size of UFH.
How does LMWH differ from UFH? (4)
1) Reduced ability to catalyse inactivation of thrombin because the reduced size fragments cannot bind thrombin, but can still inactivate Xa
2)reduced non specific binding of plasma proteins, which results in increased predictability of dose-response relationship
3) reduced binding of endothelial cells and macrophages –> increased half life
4) reduced platelet binding (?reduced rate of HIT)
Why is Warfarin prothrombotic when started?
It inhibits Protein C > Protein S in addition to II, VII, IX and X, which take effect later
What is the evidence for the use of NOACs?
Einstein PE
Einstein DVT
both rivaroxaban - non-inferior to warfarin/enoxaparin
What is the evidence for thrombolysis in DVT?
CAVENT Study (2012) - reduced incidence of PTS for iliofemoral DVT
ATTRACT (2018) no overall advantage, subgroup of iliofemoral DVT shows reduced PTS
Within 14 days. Consider temporary filter (remove <6 weeks)
Describe the arterial anatomy of the leg
1) Femoral artery arises from external iliac beneath inguinal ligament
2) Divides into SFA (medially) and Profunda (thigh)
3) SFA enters posterior compartment of thigh through Hunters canal (sub sartorial canal) through opening in Adductor Magnus
4) The popliteal artery passes behind the knee, medial to the vein and tibial nerve and trifurcates at the lower border of popliteus
5) Anterior Tibial and tibioperoneal trunk (divides into posterior tibial and peroneal artery)
What is the appropriate technique for arteriotomy?
Usually should be transverse - will need patch closure if longitudinal
Close interrupted double ended prolene from inside to out
What size of Fogarty Catheter is used for embolectomy?
4/5 Proximal and 3/4Fr distal (3 times each way)
Where are Fasciotomy incisions made?
Full length skin incisions
1) Anterior - two fingers lateral to anterior border of tibia (beware common fibular nerve) –> anterior and lateral compartments
2) Posterior - two fingers posterior to the medial malleolus (superficial and deep posterior)
When would you consider thrombolysis for an acutely ischaemic limb?
Mostly where the limb is not immediately threatened and no contraindications. May be of particular use for thrombosed grafts
What is the stroke/TIA risk with a 75-99% Carotid stenosis at 1 year
19.5%
30-74% = 5.7
0-29% = 2.1
What is the stroke or TIA risk at 5 years for a carotid stenosis of >75%
60%
Which trials investigated asymptomatic carotid atherosclerosis?
Compared CEA + BMT to BMT –>
1) Veterans Administration Cooperative Trial (VA) - lower risk of stroke but NS
2) Asymptomatic carotid atherosclerosis trial (ACAS) - lower risk of stroke or death (5 vs 11%)
3) Asymptomatic carotid surgery trial (ACST) - lower risk of stroke (6.4 vs 11.8%)
Metanalysis of ACAS And ACST looking at 5 year stroke rates found no benefit for women (OR 0.96), but good for men (OR 0.49)
How do patients with chronic mesenteric ischaemia tend to present?
Colicky or dull abdomina pain in epigastrium radiating to back. Usually 15-30mins after eating and lasting for 1-3 hours.
Often cachectic with food fear
What conditions can cause secondary hyperhidrosis?
Diabetes mellitus
Hypothyroidism
Hyperpitruitarism
Phaeochromocytoma
Malignancy
Neurological conditions
Drugs
Menopause
What medical treatments are available for primary hyperhidrosis?
Topical agents (aluminium chloride)
Systemic anticholinergics
Iontophoresis
Botox
What is the evidence for treatment of infrainguinal occlusive disease (5) ?
Veterans - Bypass vs Angioplasty - no difference
STILE - Surgery vs Thrombolysis - favours surgery
Lundgren - surgery vs exercise - favours surgery when exercise fails
Holm study - surgery vs angioplasty - no difference
BASIL trial - surgery vs angioplasty - Bypass vein > angioplasty >bypass PTFE
What is the threshold for AAA repair in Women
5cm - higher risk of rupture in women. Also consider if >1cm in a year
Also consider reducing threshold by 0.5cm in Asians
What is the evidence for EVAR in infrarenal AAA?
EVAR-1 - reduced 30 day mortality (1.7 vs 4.7%), same 4 year/10year mortality, increased reintervention (20 vs 6%)
EVAR-2 showed no benefit to EVAR over no treatment for patients unfit for open surgery
DREAM and OVER also show similar
IMPROVE looked at rupture EVARs - again similar outcomes, may be improved outcomes after 6 years with EVAR. May be more likely to return home
What are the major risks of AAA repair (open)?
Mortality at 30 day (5%)
MI/Heart failure (5-7%)
Renal failure
Intestinal ischaemia
Limb ischaemia
Pneumonia
MOF
What are the principles of BMT for Vascular disease?
1) Stop smoking
2) Manage blood pressure (ACE inhibitors)
3) Manage cholesterol (Statin)
4) Antiplatelet therapy (aspirin and clopidogrel)
5) Supervised exercise program
What drugs can be helpful for PVD?
Naftidrofuryl oxalate (5-HT2 R i) — recommended by NICE
Cilostazole (PDE3i)
Pentoxifylline
Inositol nicotinate
What are the management options for aortic dissection
Stanford A or Debakey I-II –> Surgery
Standford B or Debakel III –> medical management (IV esmolol SBP<120 - alleviates hemodynamic stress on wall + aspirin) unless evidence of end organ malperfusion –> TEVAR
In INSTEAD trial - 20% of patients managed conservatively had aneurysmal dilatation requiring endovascular or open repair
What investigations are required for Paget Shroetter syndrome?
Thrombophillia screen (can occur in up to 67%)
Duplex USS
CT (anatomical abnormalities)
What is the definition of Varicose Veins?
Abnormal dilated tortuous superficial veins affecting lower limb ≥3mm in diameter
What are the indications for surgery with varicose veins?
Varicose bleeding
Varicose eczema, lipodermatosclerosis, ulceration
Superficial thrombophlebitis
Night pain
Calcification
Psychological
Comsetic
Which nerves might be damaged by endovenous thermal ablation?
1) Sural (SSV)
2)Saphenous (GSV)
What are the named venous branches that must be tied off for a high tie and strip?
1) Superficial inferior epigastric
2) Superficial external pudendal
3) Deep external pudendal
4) Superficial circumflex iliac
5) Anterolateral thigh
6) Posteriomedial thigh
What is the recommended management of symptomatic varicose veins?
NICE:
1) Endovenous thermal ablation
2) UGFS
3) High tie and strip
What is the French (Fr) size?
Circumference in mm
When should carotid surgery be performed for symptomatic patients? (5)
1) rapid neurological recovery/plateau
2) no carotid occlusion
3) Rankin 0-2 (if able to look after own affairs without help)
4) Area of infarction <1/3 MCA territory
5) No haemorrhage
Risk of restroke is up to 8% in first week
What are the components of a thrombophilia screen
Protein C/S/Antithrombin 3
FVLeiden
Prothrombin Gene mutation
(Jak2 PNH)
In what setting is a thromboelastogram unreliable?
In patients who are warfarinised the R time is normal in 50%
Who benefits from carotid endarterectomy for symptomatic disease?
Combined Carotid Trial study (CCT) - 50-69% or 70-99% stenosis
Ideally within 2/52, but benefit persists to 6/52 (particularly <75 years men)
How frequent are cranial nerve injuries after carotid endarterectomy?
10% temporary 1% permanent
What is the GALA study?
GA vs LA for carotid surgery - 2008. No difference in stroke risk, possible increase in MI risk for LA (non sig)
What is the evidence for endovascular treatment of Type B aortic dissection
The MOTHER registry
What size repair for Iliac Aneurysms?
4-4.5cm
What guidelines exist for mesenteric ischaemia?
European Society of Vascular Surgery (ESVS) guidelines
D-dimer > Lactate (sensitive)
CTA > Duplex
How can the SMA be accessed for embolectomy etc?
Lift transverse colon cephalad and small bowel caudad and palpate root of transfers colon mesentery
Incise peritoneum at base of transverse colon mesentery
Also could Kockerise duodenum and access that way
Why is there biphasic or triphasic waveforms on doppler?
Pump causes vessel stretch (systolic peak), muscular layer recoils (biphasic signal), aortic valve snaps shut (triphasic)
Monophasic reduction in pressure or flow or volume - vessel wall not stretched or cannot stretched to calcification
How does reduced ABPI manifest?
<0.8 Claudication
<0.6 Short distance claudication
<0.4 Critical limb ischaemia
What is a target HbA1c for elective surgery?
<70 - improved outcomes
How would you approach the femoral artery
Longitudinal incision starting at midpoint of inguinal ligament
How would you approach the popliteal artery?
P1 - above Knee P2 at knee P3 below knee
Mostly accessing P2/P3
Usually best to approach medially below knee with longitudinal incision on posterior border of tibia 7cm
Beware GSV and will see gastrocnemius
How would you approach the brachial artery?
Lazy S incision in ACF medial to medial biceps tendon (longitudinal sup to ACF, cross then down to radial)
How would you approach the Carotid artery?
Head hyperextended and turned to contralateral side. Longitudinal Skin incision along anterior border of the SCM from angle of mandible to medial border of clavicle
Divide through platysma and stay anterior to SCM
Divide facial vein as branch of IJV to get to carotid bifurcation
What types of vascular shunts are available?
Pruitt shunt - balloons
Burbank 15cm - 15Fr-10Fr or 12-9, 18-12
JAvid - long straight tube 27.5cm = 17Fr-10Fr
How do you know a fistula is good to use?
6weeks to mature
6mm diameter
no deeper than 6mm
6cm length
Flow 600ml/min
How should post PCI pseudo aneurysms be managed
USS guided thrombin injection > USS guided compression
What timing for Symptomatic Carotid after disease?
within 2 weeks
What is phlegmasia cerulea dolens?
Occlusion of superficial and deep venous systems of leg –> venous ischaemia
Left leg > right
How much more likely are children of patients with AAA to develop a AAA?
Female children –> 2-3 times average population
Female patient –> increased risk of inheritance
What distance is measured for USS for AAA?
Inner to inner Maximum AP diameter
For patients >80 with acute limb ischaemia requiring embolectomy, what is their perioperative mortality?
20-30%
How can you approach the Internal Iliac artery
Extraperitoneal - 2cm above and parallel to inguinal ligament from lateral rectus sheath to 2cm above ASIS. Divide through EOA and sup gastric vessels, open IO, transverses and transversalis fascia laterally. Then distract peritoneum with sponge stick superomedially
Midline - Low midline, eviscerate small bowel cephalad and to the patients RUQ.
Left - Divide white line of Toldt and bring sigmoid medially. Find iliopsoas artery and dissect medially to artery. Ureter crosses iliac bifurcation
Right - Similar with caecum
How would you approach the aorta?
Midline laparotomy
Pack the small bowel out of the way to right of patient
Mobilise ligament of trietz and mobilise small bowel
incise retroperitoneum up to left renal vein
What pathological findings are found in AAA?
Loss of intima and elastic fibres from media
Which prothrombotic states can be tested for whilst anticoagulated?
FVL
APL
AT3
Need to test for Protein C/S def off anticoagulation
Above which size are visceral artery aneurysms repaired?
25mm, unless pregnant
What is cystic adventitial disease?
Cyst forming in an artery that blocks blood flow, usually the popliteal artery (85%)
Males middle age most common
Usually requires excision and interposition of autologous vein graft
What is fibromuscular dysplasia?
Most commonly found in renal and carotid/vertebral arteries
String of beads appearance
Intimal, medial (most common), perimedial
What is popliteal entrapment syndrome?
Compression of popliteal artery, usually by MEDIAL head of gastrocnemius
how is lymphodema classified?
Primary (congenital, praecox, tarda)
Secondary
Stage -
0 - reversible <10%
1 - mild 10-20%
2 moderate 20-30% (total occlusion)
3 severe (30-40%)
4 very severe (>40% –> Charles procedure)
Where does the thoracic duct drain?
Left subclavian/IJV confluence
What is the origin of the internal jugular vein?
Both begin in the jugular foramen, as a continuation of the sigmoid sinus
They unite with the subclavian veins at the medial clavicles
What is the orientation of structures in the carotid sheath?
Carotid artery - antero-medial
IJV - antero lateral
Vagus - posterior
Also contains IX, XI and XII in upper portion
Where does the CCA become the ICA?
upper border of thyroid cartilage
At what level does the IVC enter the abdomen?
T8
At what level does the Oesophagus enter the abdomen?
T10
At what level does the Aorta enter the abdomen?
T12
At what level does the aorta bifurcate?
L4
At which levels do the visceral arteries come off the aorta?
Coeliac T12
SMA L1
IMA L3
At what vertebral level are the renal arteries?
L1/L2
What are the borders of the femoral triangle?
Roof - fascia lata and superficial fascia (GSV)
Floor - pectineus, iliopsoas, adductor longus
Medially - adductor longs
Laterally - sartorius
Superiorly - inguinal ligament
What are the borders of the popliteal fossa?
Floor - Femur, posterior ligament of knee and popliteus
Roof - superficial and deep fascia
Superomedial - semimembranosus and semitendinosus
Inferolateral - lat head of gastroc
Superolateral - biceps femoris
Inferomedial - med head of gastroc
In the superior aspect of the popliteal fossa, what is the orientation of major structures?
Medial -Popliteal artery
Middle - Popliteal vein
Lateral - Sciatic nerve
In the middle aspect of the popliteal fossa, what is the orientation of major structures?
Medial - popliteal artery
Popliteal vein
Tibial nerve
Lateral - common fibular nerve
In the inferior aspect of the popliteal fossa, what is the orientation of major structures?
Medial Tibial nerve
Popliteal vein
Popliteal artery
Lateral
At what level does the IVC originate?
L5
Paired segmental lumbar veins
Right gonadal vein (L2)
Renal (L1)
hepatic veins (T8)
What are the borders of the Hunters canal (Adductor Canal)?
Posteriorly - vastus medialis
Lateral - adductor longus, adductor Magnus
Roof - sartorius
Terminates by piercing adductor Magnus
What are the contents of the Hunters canal (Adductor Canal)?
Saphenous nerve
SFA
SFV
Under which structure does the left recurrent laryngeal nerve course?
Ligamentum venosum
Under which structure does the right recurrent laryngeal nerve course?
brachiocephalic trunk
Under which structure does the right recurrent laryngeal nerve course?
right subclavian
At which vertebral levels are sympathetic ganglia present?
T1-L2
What vertebral level is a lumbar sympathectomy conducted?
L2
(L1 –> ejaculation)
If present, where does the thyroid ima artery originate from?
Brachiocephalic artery
What medication has been shown to produced the greatest decrease in stroke risk after TIA?
Atorvastatin 80mg
Which symptomatic patients should undergo carotid endarterectomy?
Males 50-99%
Females 50-99%
What is the threshold for intervention in iliac aneurysm?
3.5-4cm
What is the recommended treatment for SFJ incompetence?
Endovenous ablation > Foam sclerotherapy > High tie
When should visceral artery aneurysms be treated?
In women who are pregnant or possibly if of childbearing age
Splenic > 20mm
Others >25mm, except gastro/pancreaticoduodenal arcades - higher risk of rupture
Symptomatic
How should infected aortic grafts be sorted?
Insitu repair with deep femoral vein
Could consider silver or rifampicin bonded synthetic grafts, but less favoured
Extra-anatomical repair
What is the default treatment for minimally symptomatic dissection?
Conservative, aspirin, follow up
What is the arc of Riolan?
Connects middle colic to left colic close to root of mesentery (mesenteric meandering artery of Moskowitz)
how frequent are popliteal aneurysms bilateral?
50%
What increase in size is concerning for AAA rupture and should prompt intervention?
> 5mm in 6 months or >1cm in 1 year
What is the expected patency of PD catheters at 1 year?
80%
When is treatment indicated for renal artery stenosis?
Only if flash pulmonary oedema with significant disease, fibromuscular dysplasia, part of other procedures or in transplanted kidney
What are the zone of the carotid in trauma?
Zone 1 - clavicle to cricoid (CT/MR)
Zone 2 - cricoid to mandible (Duplex?)
Zone 3 - above mandible (CT/MR)
what is the perioperative mortality after embolectomy in acute limb ischaemia?
up to 20-30% at 1 year
What is the most common cause of UGI bleeding in patients who have undergone an AAA repair?
Peptic ulceration!
What are the buttonhole and rope ladder techniques for fistula access?
Button hole - same hole every time (don’t use for synthetic grafts)
Rope ladder - rotating (most frequent technique)
What are the key features of vasculitides?
1) Takayasu’s
2) Fibromuscular Dysplasia
3) Giant cell arteritis
4) Polyarteritis nodosa
5) Wegener’s Granulomatosis
6) Churg-Struass
7) Bechcets
Large vessel
1) Predominantly aortic and large vessel, young female
2) String of beads sign of Renal artery (also ICA), hypertension, young female
3) Older, most common large, headaches and jaw claudication
Medium vessel
4) Hepatitis B infection, systemic symptoms, myalgia, neuropathies
5) ANCA, granulomatous necrotising inflammation resp/renal
Small vessel
6) Eosinophil rich respiratory tract and small vessels, asthma
7) Multiple systems - mucous membranes, eyes, arthropathy
How are AAAs measured?
AP from inner wall to inner wall
What threshold of sac enlargement would prompt intervention for type 2 endoleak?
> 5mm
What are the components of a supervised exercise programme?
- 2 hours of exercise to the maximum point of pain
- every week
- 3 months
When should the DVLA be told about AAA?
Normal - tell at 6cm, no driving beyond 6.5cm
Bus/coach/lorry - tell at any size, no driving beyond 5.5cm
What aneurysms are often seen in patients with renal artery aneurysm?
Carotid, intracranial
What are the complications of IVC filter insertion?
Fracture
Migration
Damage to veins
Difficulty in retrieval (if more than 6-8 weeks)
What is the anatomy of the femoral artery?
- CFA arises at mid-inguinal point (1/2 between ASIS and PS)
- SFA given off medially and profunda femoris (thigh)
- SFA passes through adductor hiatus, enters the posterior compartment of the thigh and becomes the popliteal artery proximal to the knee
- At lower border of popliteal divides into anterior tibial and tibioperoneal trunk
– TP Trunk divides into posterior tibial and peroneal arteries
—PT along surface of deep muscles and emerges at medial malleolus
—Peroneal lateral compartment of leg
—AT assess between tibia and fibula between IO membrane and emerges as DP
How should patients with a suspected vascular injury and fracture be managed?
NICE and BOA trauma standards
Initial realignment
?CT Angio
If hard signs of arterial injury –> explore and shunt
Revascularise within 4 hours
Low threshold for fasciiotomies
What are the borders of the femoral triangle?
Superior - inguinal ligament
Lateral - medial border of sartorius
Medial - medial border of adductor longus
What are the risks of a high tie and strip?
General complications including infection, haematoma
Lymphocele/drainage
Vascular injuries
Nerve injuries leading to paraesthesia/numbness
DVTs
What is post-thrombotic syndrome?
Pain, heaviness, swelling, itching, varicose veins, skin discolouration or ulcer after DVT.
Vavlular incompetence and obstruction of deep venous system leads to superficial venous hypertension.
Leads to rupture of small superficial veins, subcutaneous haemorrhage and increase in tissue permeability
Treat with elevation, compression therapy, sometimes pentoxifylline. Risk of 20-60% with severe in 10% after DVT
What is spinal claudication?
Compression of cauda equina by narrowed spinal canal
Variable symptoms brought on by exercise and immediately ceasing when stopping activity
May need surgical decompression
What is the optimum treatment of VTE in cancer patients?
CLOT and CATCH trials showed warfarin was worse then LMWH
Einstein PE/VTE subgroup analysis showed Rivaroxaban similar to LMWH
Differential diagnosis of bilateral swollen legs?
-Proximal extensive Iliofemoral DVT
-Primary lymphoedema: congenital (Milroys AD/Lymphoedema-Distichiasis syndrome), praecox (<35), Tarda. Klippel Trenauney syndrome of leg overgrowth.
-Secondary: surgery, radiotherapy, infection, malignancy
-Systemic problems – heart failure, liver failure, nephrotic syndrome
Start with venous duplex, basic blood tests and thrombophilia screen, ECG
Consider Echo/Technetium scintigraphy if unclear
What are the different types of foot ulcer?
Venous
Arterial
Neuropathic
Pressure
Why do diabetics get foot problems?
Neuropathy - don’t notice problems
Arteriopathy - doesn’t heal
Susceptible to infection - arteriopathy and hyperglycaemia)
How is a thigh fasciotomy performed?
Mid lateral thigh incision and opening of tensor fascia lata (anterior compartment) to expose vastus lateralis. This is retracted medially to expose intermuscular septum.
Separate medial incision for adductor compartment
What are the characteristics of a venous ulcer?
Large irregular border with sloping edges
Shallow depth
Usually in medial ankle
Mildly painful
How would you examine varicose veins?
–Examine exposed and standing
CEAP - visible thread/truncal veins, swollen ankles, skin changes (venous eczema, lipodermatosclerosis, hyperpigmentation), healed or active ulcers
Saphena Varix (2-4cm inferolateral to pubic tubercle)
–Examine lying
Arterial disease – pulses, pitting oedema
–Trendelenburg test – lying flat, lift leg up to empty superficial veins occlude saphenofemoral function digitally (or with tourniquet). Ask patient stand and observe for filling of veins
–Perthes test to distinguish between deep, superficial and perforator incompetence by walking with tourniquet around mid-thigh. If varicose veins empty then no deep venous insufficiency, if do not then also deep problem.
How would you examine the median nerve?
The median nerve supplies the forearm flexors and thenar muscles and sensory to the lateral 2/3 of the palm and the 1-3.5 fingers dorsally. I would therefore assess
- Motor –Wrist/finger flexion & Thumb abduction/opposition
- Sensory – Sensation tip of 2nd and 3rd fingers
- Can also perform ok test, tinnels tapping sign and the Phalen maneouvre
How would you examine the radial nerve?
The radial nerve supplies elbow and wrist extension, and is sensory to the dorsal thumb/thenar eminence. I would therefore assess
- Motor – elbow/wrist/finger extension, thumb extension
- Sensation – dorsum of thumb
How would you examine the ulnar nerve?
The ulnar nerve supplies elbow and wrist extension, and is sensory to the medial 1.5 fingers. I would therefore assess:
- Motor finger abduction, grip strength
- Sensation fifth finger
