Vascular Flashcards
Pain in the buttock when walking
common / Internal iliac stenosis
Pain in the thigh when walking
common / external iliac artery stenosis
Pain in the calve when walking
Superficial femoral artery stenosis
Typical narrowing of superficial femoral artery
Narrowed at adductor canal
BMT for vascular disease
Smoking cessation *****
Control of HTN
Statin
Single anti-platelet
Graduated exercise program
Weight-loss
IC due to aortoiliac disease
Balloon angioplasty + kissing iliac stents
-good 5 year patency
Three requirments for by-pass:
There must be high-flow, high-pressure blood entering
the graft (inflow)
The conduit must be suitable
The blood must have somewhere to go when it leaves
the graft (outflow or run-off).
Indications for carotid end-arterectomy
• There is a high degree of internal carotid artery stenosis (usually taken as a greater than 60–70% diameter reduction)
• The patient is expected to survive at least 2 years
• The intervention can be undertaken with a stroke and/ or death rate of less than 3–5%
• The intervention can be performed soon after the index event
Primary stenting for atherosclerotic renal
artery disease may be considered
Refractory hypertension not responsive to medical therapy
To preserve renal function
Subcritical ischaemia
Rest / night pain
Critical ischaemia
Tissue loss
Non-critical ischaemia
Intermittent claudication
aortic bifurcation (saddle) embolus
Paraplegia due to cauda equina ischaemia
White marble mottling to waist
Absent femoral pulses
Infectious causes of aneurysms
Arteries are generally resistant to infection, but
two organisms:
-Treponema pallidum (syphilis)
-Salmonella
Have a particular ability to produce primary mycotic aneurysms
How are varicose veins managed?
MUST undergo a duplex scan before treatment
What are the symptoms of an axillary / brachial embolus?
50% of upper limb emboli will lodge in the brachial artery
30% of upper limb emboli will lodge in the axillary artery
Sudden onset of symptoms; pain, pallor, paresis, pulselessness, paraesthesia
Sources are left atrium with cardiac arrhythmia (mainly AF), mural thrombus
Cardiac arrhythmias may result in impaired consciousness in addition to the embolus
How is Raynaud’s disease treated?
Calcium antagonists
What are the signs and symptoms of an upper limb venous thrombosis?
Gradual onset of upper limb swelling and discomfort.
Sensation and motor function are normal
Condition may complicate pre-existing malignancy (especially breast cancer) or arise as a result of repetitive use of the limb in a task such as painting a ceiling
The condition is diagnosed with duplex ultrasound and treatment is with anticoagulation
What are the signs and symptoms of a cervical rib?
Congenital cases may present around the third decade, some cases are reported to occur following trauma
Bilateral in up to 70%
Compression of the subclavian artery may produce absent radial pulse on clinical examination and in particular may result in a positive Adsons test (lateral flexion of the neck away from symptomatic side and traction of the symptomatic arm- leads to obliteration of radial pulse)
Treatment is most commonly undertaken when there is evidence of neurovascular compromise. A transaxillary approach is the traditional operative method for excision
What are the symptoms of subclavian steal syndrome?
Due to proximal stenotic lesion of the subclavian artery
Results in retrograte flow through vertebral or internal thoracic arteries
The result is that decrease in cerebral blood flow may occur and produce syncopal symptoms
A duplex scan and/ or angiogram will delineate the lesion and allow treatment to be planned
How is Takayasu’s arteritis treated?
Systemic steroids
What are the indications for surgical revascularisation of the lower limb?
Intermittent claudication
Critical ischaemia
Ulceration
Gangrene
Describe the procedure of an arterial bypass surgery e.g. between superficial femoral artery and above knee popliteal
Artery dissected out, IV heparin 3,000 units given and then the vessels are cross clamped
Longitudinal arteriotomy
Graft cut to size and tunneled to arteriotomy sites
Anastomosis to femoral artery usually with 5/0 ‘double ended’ Prolene suture
Distal anastomosis usually using 6/0 ‘double ended’ Prolene
Describe some facts about distal arterial disease treatment
Femoro-distal bypass surgery takes longer to perform, is more technically challenging and has higher failure rates.
In elderly diabetic patients with poor runoff a primary amputation may well be a safer and more effective option. There is no point in embarking on this type of surgery in patients who are wheelchair bound.
In femorodistal bypasses vein gives superior outcomes to PTFE
What are some rules for bypass surgery
Vein mapping 1st to see whether there is suitable vein (the preferred conduit). Sub intimal hyperplasia occurs early when PTFE is used for the distal anastomosis and will lead to early graft occlusion and failure.
Essential operative procedure as for above knee fem-pop.
If there is insufficient vein for the entire conduit then vein can be attached to the end of the PTFE graft and then used for the distal anastomosis. This type of ‘vein boot’ is technically referred to as a Miller Cuff and is associated with better patency rates than PTFE alone.
Remember the more distal the arterial anastomosis the lower the success rate.
When are amputations indicated?
Dead, deadly, dead useless
non viable tissue
Threat to life e.g. infection
viable, but prosthesis is preferable
What are the main types of amputations?
Pelvic disarticulation (hindquarter)
Above knee amputation
Gritti Stokes (through knee amputation)
Below knee amputation (using either Skew or Burgess flaps)
Syme’s amputation (through ankle)
Amputations of mid foot and digits
Pros and Cons of above knee amputations
Quick to perform
Heal reliably
Patients regain their general health quickly
For this benefit, a functional price has to be paid and many patients over the age of 70 will never walk on an above knee prosthesis.
Above knee amputations use equal anterior-posterior flaps
Pros and Cons of below knee amputations
Technically more challenging to perform
Heal less reliably than their above knee counterparts.
However, many more patients are able to walk using a below knee prosthesis.
In below knee amputations the two main flaps are Skew flaps or the Burgess long posterior flap. Skew flaps result in a less bulky limb that is easier to attach a prosthesis to
Indications for surgery in AAA
Symptomatic aneurysms (80% annual mortality if untreated)
Increasing size above 5.5cm if asymptomatic
Rupture (100% mortality without surgery)
What type of aneurysm is suitable for EVAR?
Long neck
Straight iliac vessels
Healthy groin vessels
What do each ABPI measurements indicate?
> 1.2 - abnormal calcification, often in diabetes
1 - Normal (be wary in DM)
0.9 - 0.6 = Claudication
0.6 - 0.3 = Rest pain
< 0.3 = impending
What are some types of anatomical bypass surgery?
aorto-bifemoral
femoral-popliteal
femoral-distal
What are some types of extra anatomical bypass surgery?
Axillo-femoral
fem-fem crossover
What classification system is used for peripheral arterial disease?
Fontaine
What are some signs and symptoms of peripheral venous disease?
Lipodermatosclerosis
Venous eczema
Haemosiderin deposits
Venous ulcer
How is peripheral venous disease managed?
Conservative: Compression bandages but ABPI must be > 0.8
Natural:
Trahere (axillary vein and valve into deep venous system)
Kistner (venous valvuloplasty)
Palma (venous operation with contralateral great saphenous vein)
Artificial:
Above IL - Dacron
Below IL - PTFE
How can varicose veins be treated?
Medical: sclerotherapy / radiofrequency ablation
Surgical: Trendelenburg ligation, Cockett ligation, Short saphenous vein ligation and SEPS
How often are AAA monitored?
3-4.5 cm f/u scan in 1 year
4.5-5.5 f/u scan in 3 months
> 5.5cm - 2ww referral
