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Surgery > Vascular > Flashcards

Vascular Flashcards

1
Q

What are the 6 Ps of acute limb ischaemia

A

Pain

Pallor

Pulselessness

Paraesthesia

Perishing cold

Paralysis

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2
Q

Give an overview of acutely painful, cold and pale limbs

A

Treat as acute limb ischaemia until proven otherwise

Ask about: AF, HTN, smoking, diabetes, recent MI

CT angiogram, urgent vascular review

Get irreversible tissue damage in 6 hours

Start on IV heparin whilst decisions being made

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3
Q

Give an overview of acutely painful, hot and swollen limbs

A

Assess for potential DVT

Ask about: pro-thrombotic disease, recent immobility, recent surgery

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4
Q

What investigations are needed for acutely painful limb

A

Document neurovascular status at initial clerking

CT angiography

Routine bloods (+ group and save)

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5
Q

Give an overview of lower limb ulcers

A

Abnormal breaks in skin or mucous membrane

Most are venous

Often related to diabetic neuropathy

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6
Q

What are the 3 types of lower limb ulcers

A

Venous: shallow, granulating base, clinical features of venous insufficiency

Neuropathic: painless, over areas of abnormal pressure, often due to joint deformity in diabetes

Arterial: at distal sites, well-defined borders, evidence of arterial insufficiency

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7
Q

What are venous ulcers

A

Caused by venous insufficiency

Shallow

Irregular border

Granulating base

Characteristically over medial malleolus

Prone to infection (often present with cellulitis)

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8
Q

What are the risk factors for venous ulcers

A

Increasing age

Pre-existing venous incompetence

Pregnancy

Obesity

Physical inactivity

Severe trauma

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9
Q

How might venous ulcers present

A

Painful (worse at end of day)

In gaiter region of leg

Aching, itching, bursting sensation

May have varicose veins

Leg oedema

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10
Q

What investigations are needed for venous ulcers

A

Duplex ultrasound

Ankle brachial pressure index

Swab culture

Thrombophilia/vasculitis screen (young patients)

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11
Q

What is the management for venous ulcers

A

Leg elevation

Increase exercise

Weight loss

Antibiotics (if infected)

Multicomponent compression bandaging

Can operate on varicose veins

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12
Q

Give an overview of arterial ulcers

A

Due to reduced arterial blood flow

Small, deep lesions

Well-defined border

Necrotising base

At sites of trauma/pressure areas

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13
Q

What are the risk factors for arterial ulcers

A

Smoking

Diabetes

Hypertension

Hyperlipidaemia

Increasing age

Family history

Obesity

Physical inactivity

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14
Q

How might arterial ulcers present

A

History of intermittent claudication/critical limb ischaemia

Pain

Develop over a long period of time

Cold limb

Thickened nails

Necrotic toes

Hair loss

Reduced/absent pulses

Sensation maintained

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15
Q

What investigations are needed for arterial ulcers

A

Ankle brachial pressure index (> 0.9 = normal, 0.9 - 0.8 = mild, 0.8 - 0.5 = moderate, < 0.5 = severe)

Duplex ultrasound

CT angiography

MRA

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16
Q

What is the management for arterial ulcers

A

Urgent vascular review

Smoking cessation

Weight loss, exercise

Statins

Antiplatelets

Manage HTN and diabetes

Angioplasty (+/- stenting)

Bypass grafting (extensive disease)

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17
Q

What are neuropathic ulcers

A

Due to peripheral neuropathy

Painless ulcers on pressure points

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18
Q

What are the risk factors for neuropathic ulcers

A

Diabetes

B12 deficiency

Foot deformity

Peripheral vascular disease

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19
Q

How might neuropathic ulcers present

A

History of peripheral neuropathy

Burning

Tingling

Single nerve involvement

Punched out appearance

Glove and stocking distribution neuropathy

Good pulses

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20
Q

What is carotid artery disease

A

Buildup of atherosclerotic plaque in common or internal carotid artery

Causes stenosis and occlusion

Can cause ischaemic stroke (plaque rupture, atheroembolism)

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21
Q

What are the risk factors for carotid artery disease

A

> 65

Smoking

Hypertension

Hypercholesterolaemia

Obesity

Diabetes

History of cardiovascular disease

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22
Q

How might carotid artery disease present

A

Usually asymptomatic

TIA/stroke

Carotid bruit

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23
Q

What investigations are needed for carotid artery disease

A

Urgent non-contrast CT head

Routine bloods

Glucose

ECG

Duplex ultrasound (estimate degree of stenosis)

CT angiography

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24
Q

What is the acute management for carotid artery disease

A

Oxygen

Blood glucose optimisation

Ischaemic stroke: alteplase, aspirin

Haemorrhagic stroke: correct coagulopathy, refer to neurosurgery

Thrombectomy

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25
Q

What is the long term management for carotid artery disease

A

Antiplatelet therapy (aspirin, clopidogrel)

Statin

Aggressive management of hypertension and diabetes

Smoking cessation

Lifestyle advice

Carotid endarthrectomy

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26
Q

What is abdominal aortic aneurysm

A

Dilation of abdominal aorta to > 3 cm

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27
Q

What are the risk factors for abdominal aortic aneurysm

A

Smoking

Hypertension

Hyperlipidaemia

Family history

M>F

Age

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28
Q

How might abdominal aortic aneurysm present

A

Usually asymptomatic

Abdominal/back/loin pain

Distal embolisation (limb ischaemia)

Shock

Syncope

Pulsatile mass in abdomen

Signs of retroperitoneal haemorrhage

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29
Q

Describe the screening programme for abdominal aortic aneurysm

A

Abdominal ultrasound

Men > 65

If found: surveillance or elective repair

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30
Q

What investigations are needed for abdominal aortic aneurysm

A

Ultrasound

CT with contrast (once diagnosis confirmed)

31
Q

What is the management for abdominal aortic aneurysms < 5.5 cm

A

Monitor with duplex ultrasound ( 3 - 4.4 = yearly, 4.5 - 5.4 = 3 monthly)

Smoking cessation

Better BP control

Statins

Antiplatelet therapy

Weight loss

Exercise

32
Q

What are the indications for surgery in abdominal aortic aneurysm

A

> 5.5 cm

Expanding > 1 cm per year

Symptomatic AAA in otherwise fit patient

(In unfit patients, can leave until 6 cm)

33
Q

What are the 2 methods of surgery for abdominal aortic aneurysm

A

Open repair

Endovascular repair (introduce graft through femoral artery)

34
Q

Give an overview of ruptured abdominal aortic aneurysm

A

Abdominal/back pain, syncope, vomiting, haemodynamic instability, pulsatile abdominal mass, abdominal tenderness

Oxygen, IV fluids

Unstable patients: open repair

Stable patients: CT angiogram (see if suitable for endovascular repair)

35
Q

What is aortic dissection

A

Tear in tunica intima of aortic wall

Causes blood to flow between tunica intima and media, which split

Acute (< 14 days) or chronic (>14 days)

M>F

Associated with connective tissue disorders

50 - 70

36
Q

In which directions may aortic dissection progress

A

Anterograde: towards iliac arteries

Retrograde: towards aortic valves

37
Q

What are the classification systems for aortic dissection

A

Stanford classification: type A (involves ascending aorta), type B (doesn’t involve ascending aorta)

DeBakey classification: type 1 (originates in ascending aorta), type 2 (confined to ascending aorta), type 3 (originates distal to subclavian artery in ascending aorta)

38
Q

How might aortic dissection present

A

Tearing chest pain

Radiates to back

Tachycardia, hypotension

New aortic regurgitation murmur

39
Q

What investigations are needed for aortic dissection

A

Routine bloods (+ troponin + crossmatch)

ABG

ECG

CT angiogram (first line)

Transoesophageal ECHO

40
Q

What is the management for aortic dissection

A

Oxygen, IV fluids

Lifelong antihypertensives

Surveillance imaging

Surgical repair

41
Q

Why does thoracic aortic aneurysm develop

A

Degeneration of tunica media (artery loses structural integrity)

42
Q

What are the risk factors for thoracic aortic aneurysm

A

Family history

Hypertension

Atherosclerosis

Smoking

Obesity

M>F

Advancing age

43
Q

How might thoracic aortic aneurysm present

A

Usually incidental finding

Pain: anterior chest (ascending aorta), neck (aortic arch), between scapulae (descending aorta)

Back pain

Hoarse voice (damage to left recurrent laryngeal nerve)

Distended neck veins

Symptoms of heart failure

Dyspnoea/cough

44
Q

What investigations are needed for thoracic aortic aneurysm

A

Routine bloods

ECG

CXR (widened mediastinal silhouette, enlarged aortic knob, possible tracheal deviation)

CT chest with contrast

Transoesophageal ECHO

45
Q

What is the management for thoracic aortic aneurysm

A

Statins

Antiplatelet therapy

Smoking cessation

Surgery for: ascending aorta > 5.5 cm, aortic arch > 5.5 cm, descending aorta > 6 cm

46
Q

What is acute limb ischaemia

A

Sudden decrease in limb ischaemia that threatens viability of limb

Complete or partial occlusion of artery can lead to rapid ischaemia and poor functional outcome

Irreversible tissue damage in 6 hours

47
Q

What investigations are needed for acute limb ischaemia

A

Routine bloods (+ serum lactate + thrombophilia screen)

ECG

Doppler ultrasound

CT angiography

48
Q

What is the management for acute limb ischaemia

A

Oxygen, IV fluids

Start heparin

Surgery

HDU admission post-op

Lifestyle advice

Antiplatelet therapy

Consider anticoagulants

49
Q

What is chronic limb ischaemia

A

Peripheral artery disease that causes symptomatic reduction in blood supply to limb

Usually due to atherosclerosis

50
Q

What are the risk factors for chronic limb ischaemia

A

Smoking

Diabetes

Hypertension

Hyperlipidaemia

Increasing age

Family history

Obesity

Physical activity

51
Q

What are the stages of chronic limb ischaemia

A

Stage 1: asymptomatic

Stage 2: intermittent claudication

Stage 3: ischaemia at rest

Stage 4: ulceration or gangrene

52
Q

What is critical limb ischaemia

A

Advanced form of chronic limb ischaemia

Pain at rest for > 2 weeks

Presence of ischaemic lesion or gangrene

ABPI < 0.5

53
Q

How might chronic limb ischaemia present

A

Limb pale and cold

Weak/absent pulses

Hair loss

Skin changes

Thickened nails

54
Q

What investigations are needed for chronic limb ischaemia

A

Clinical diagnosis

Ankle brachial pressure index

Doppler ultrasound

CT angiography or MR angiography

55
Q

What is the management for chronic limb ischaemia

A

Lifestyle advice

Statins

Antiplatelet therapy

Optimise diabetic control

Surgery (angioplasty, bypass graft)

Amputation

56
Q

What is acute mesenteric ischaemia

A

Sudden decrease in blood supply to bowel

57
Q

How might acute mesenteric ischaemia present

A

Generalised abdominal pain

Out of proportion to clinical signs

Nausea and vomiting

At late stage, global peritonism

58
Q

What investigations are needed for acute mesenteric ischaemia

A

ABG

Routine bloods

CT with contrast (oedematous bowel, loss of bowel wall enhancement, pneumatosis)

59
Q

What is the management for acute mesenteric ischaemia

A

Urgent resus

Broad spectrum antibiotics

Early ITU input

Excision of necrotic/non-viable bowel

Revascularisation of bowel

60
Q

What is chronic mesenteric ischaemia

A

Reduced blood supply to bowel

Due to atherosclerosis in: coeliac trunk, superior mesenteric artery, inferior mesenteric artery

> 60s

F>M

61
Q

How might chronic mesenteric ischaemia present

A

Postprandial pain (10 mins - 4 hrs after eating)

Weight loss (malabsorption)

Change in bowel habits

Other vascular event

Nausea and vomiting

Generalised abdominal tenderness

Abdominal bruit

62
Q

What investigations are needed for chronic mesenteric ischaemia

A

Routine bloods

CT angiography

63
Q

What is the management for chronic mesenteric ischaemia

A

Smoking cessation

Antiplatelet therapy

Statins

Endovascular or open procedure (stenting, bypass)

64
Q

What is a pseudoaneurysm

A

Breach to artery wall, causing accumulation of blood between tunica media and adventitia

Direct communication between vessel lumen and aneurysm lumen

Usually following damage to vessel wall

Most common in femoral artery

65
Q

How might pseudoaneurysm present

A

Pulsatile, tender, painful lump

Possible limb ischaemia

If infected: erythematous, tender, purulent discharge, systemic features of sepsis

66
Q

What investigations are needed for pseudoaneurysm

A

Distal pulse status

Duplex ultrasound (gold standard)

CT

Routine bloods

Blood cultures

Pus swab and culture

67
Q

What is the management for pseudoaneurysm

A

Ultrasound-guided compression

Ultrasound-guided thrombin injection

Endovascular stenting

Surgery (repair artery directly)

68
Q

What are varicose veins

A

Tortuous dilated segments of vein, associated with valvular incompetence

Mostly idiopathic

69
Q

What are the risk factors for varicose veins

A

Prolonged standing

Obesity

Pregnancy

Family history

70
Q

How might varicose veins present

A

Cosmetic concerns

Aching

Itching

If left untreated: skin changes, ulceration, thrombophlebitis, bleeding

Can have clinical features of venous insufficiency: ulceration, varicose eczema, haemosiderin deposition

71
Q

What investigations are needed for varicose veins

A

Duplex ultrasound

72
Q

What is the management for varicose veins

A

Education

Compression stockings

4-layer bandaging

Surgery

73
Q

What is thoracic outlet syndrome

A

Compression of neurovascular bundle as it passes through thoracic outlet

Compression of: brachial plexus, subclavian artery, subclavian vein

74
Q

Give an overview of subclavian steal syndrome

A

Syncope or neurological deficit when blood supply to the affected arm is increased through exercise

Due to proximal stenosing lesion or occlusion of subclavian artery

Blood drawn away from collateral circulation

Surgery (7 decks)

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