VASCULAR Flashcards
saccular dilation of veins (
Varicose veins
Histological change in Varicose Veins
the typical changes include fibrous scar tissue dividing smooth muscle within media in the vessel wall
Tissue damage in chronic venous insufficiency occurs because
perivascular cytokine leakage resulting in localised tissue damage coupled with impaired lymphatic flow.
Features of Venous Stasis Ulcer
Located above the medial malleolus
Indolent appearance with basal granulation tissue
Variable degree of scarring
Non ischaemic edges
Haemosiderin deposition in the gaiter area (and also lipodermatosclerosis
clinical features of venous insufficiency
ulceration
varicose eczema
haemosiderin deposition.
I’d concurrent DVT and Varicose
Don’t treat superficial incompetence as the blood will not have any way back.
Tests for varicose veins
Brodie-Trendelenburg test: to assess level of incompetence
Perthes’ walking test: assess if deep venous system competent
Doppler vs Duplex for Varicose Veins investigation
Doppler exam: if incompetent a biphasic signal due to retrograde flow is detected
Duplex scanning: to ensure patent deep venous system (do if DVT or trauma)
What is usedin injection sclerotherapy
5% Ethanolamine oleate
Jf varicose vein with ulcer or skin changes then
Compression stocking
Rx of symptomatic Varicose Veins with no skin changes or ulcer
1st line is Endothermal Ablation
2nd line is Injection Sclerotherapy
3rd line is surgery which is saphenofemoral / popliteal disconnection, stripping and avulsions.
Saphenous vein should be stripped till
Saphenous vein stripped to level of knee/upper calf. NB increased risk of saphenous neuralgia if stripped more distally
Gold standard investigation for Varicose veins
Gold standard investigation is duplex ultrasound
rocker-bottom” sole
Any deformity causing the loss of the transverse arch is termed a “rocker-bottom” sole
In charcot foot
Indications for surgery to revascularise the lower limb
Intermittent claudication
Critical ischaemia
Ulceration
Gangrene
Leriche’s syndrome
Buttock claudication in association with sexual impotence resulting from arterial insufficiency is eponymously called Leriche’s syndrome
Charcot foot
Bounding pulsesin early phase
Always associated with trauma even minor
Erythema in early phase
Peripheral and autonomic neuropathy both
Bilateral swollen leg since birth vs after
Milroy disease before
Meige after
Lympuedema causes
accumulation of protein rich fluid, subdermal fibrosis and dermal thickening.
Fluid is confined to which region in lymphedema
Epifascial space (skin and subcutaneous tissue
muscle compartments are free of oedema
Foot findings in lymphedema
Buffalo hump’ on the dorsum of the foot and the skin cannot be pinched due to subcutaneous fibrosis.
Indications for surgery of lymphedema
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 for lymphedema
Homan
Charles
Arteriovenous anastomosis
Compression bandaging contra indicated at which ABPI
0.3 to 0.5
Type 2 diabetics ABPI
> 1.2 as they have calcification
Normal ABPI
1 to 1.2
Congenital lymphedema
Milroy’s disease is congenital
most common cause of cyanotic congenital heart disease
TOF
Shunting in TOF
Right to left
Features of TOF
causes a right-to-left shunt
ejection systolic murmur due to pulmonary stenosis (the VSD doesn’t usually cause a murmur)
a right-sided aortic arch is seen in 25% of patients
cyanotic episodes of TOF may be helped by
beta-blockers to reduce infundibular spasm
Degree of cyanosis in TOF depends upon
The severity of the right ventricular outflow tract obstruction determines the degree of cyanosis and clinical severity
Gritti Stokes amputation
through knee amputation ()
commonest cause of acute limb ischaemia
- Thrombosis of a pre-existing site of atherosclerosis is the commonest cause of acute limb ischaemia
Clinical Appearance of acute ischemic limb
Less than 6 hours = White leg
At 6 -12 hours = Mottled limb with blanching on pressure
More than 12-24 hours = Fixed mottling
Rx in these situation
1. White leg with sensorimotor deficit.
2. Dusky leg, mild anaesthesia
- Surgery and embolectomy
- Angiography
outof 6 P’s of C/F of acute limb which are ealry
Pain
Pallor
Pulselessness
Paralysis is last
irreversible tissue damage in acute ischemic after how many hours
within 6 hours.
Initial Rx of Acute limb ischemia
Start the patient on high-flow oxygen and ensure adequate IV access. A therapeutic dose heparin or preferably a bolus dose then heparin infusion should be initiated as soon as is practical.
Ischemic Reperfusion Injury
An important complication of acute limb ischaemia is reperfusion injury; sudden increase in capillary permeability can result in:
Compartment syndrome
Release of substances from the damaged muscle cells, such as:
K+ ions causing hyperkalaemia
H+ ions causing acidosis
Myoglobin, resulting in significant AKI
When to consider Fasciotomy in Acute limb ischaemia patient to prevent compartm3nt syndrome
Fasciotomy should be considered if the time between onset and surgery exceeds 6 hours
Klippel-Trenaunay-Weber syndrome vs Sturge - Weber syndrome
Sturge - Weber syndrome is a an arteriovenous malformation affecting the face and CNS, the peripheral vessels are not affected
KTW : mostly affect limbs
Varicose veins plus port wine lesions
Klippel-Trenaunay-Weber syndrome
Klippel-Trenaunay-Weber syndrome features
One or more distinctive port-wine stains with sharp borders
Varicose veins
Hypertrophy of bony and soft tissues, that may lead to local gigantism or shrinking.
An improperly developed lymphatic system
atypical Klippel-Trenaunay syndrome’.
When no port wine lesion
Arterial vs venous ulcers
A are well demarcated
V are with irregular borders
Marjolin’s ulcer
Squamous cell carcinoma
Occurring at sites of chronic inflammation e.g; burns, osteomyelitis after 10-20 years
Mainly occur on the lower limb
features associated with venous insufficiency,
varicose eczema or thrombophlebitis,
haemosiderin skin staining,
lipodermatosclerosis,
or atrophie blanche.
Compression application only when ABPI is
> 0.6
skin grafting may be needed for venous ulcers when
If fail to heal after 12 weeks or >10cm2
Arterial vs neuropathic ulcers
A has sensation but N doesn’t.
Common site of Neuropathic ulcer
plantar surface of metatarsal head and plantar surface of hallux
Lymphangiosarcoma
Lymphangiosarcoma is a rare condition arising as a result of chronic oedema. It is an aggressive malignancy.
Femoro-femoral bypass indication
Unilateral iliac artery obstruction with normal other side.
When the overlying skin is healthy (and limb deformity a problem) in lymphedema patient
Which procedure to perform
Homans operation
1st line Rx of Stanford type B
Beta blockers
2nd line Ca channel blockers
Debakey and Stanford classification
For aortic dissection
DeBakey classification
Type Site affected
I Ascending aorta, aortic arch, descending aorta
II Ascending aorta only
III Descending aorta distal to left subclavian artery
Stanford Classification
Type Location Treatment
A Ascending aorta/ aortic root Surgery- aortic root replacement
B Descending aorta Medical therapy with antihypertensives
Most common site of dissection of aorta
90% occurring within 10 centimetres of the aortic valve
Venous ulcers have granulation tissue but doesn’t have
Exophytic granulation tissue
Initial Rx of Stanford type A and B
Stanford Type A dissections should be managed surgically in the first instance and carry a worse prognosis than Type B dissections.
Any uncomplicated Type B dissections can usually be managed medically.
Lifelong Rx of all kind of aortic dissection
antihypertensive therapy and surveillance imaging*, due to the high risk of developing further dissection or other complications.
*Imaging would usually be at 1, 3, and 12 months post-discharge, with further scans at 6-12 month intervals thereafter depending on the size of the aorta.
Imaging criteria post Rx of aortic dissection
*Imaging would usually be at 1, 3, and 12 months post-discharge, with further scans at 6-12 month intervals thereafter depending on the size of the aorta.
Klippel-Trenaunay-Weber syndrome usually spares which vein
Long saphenous
As it’s a lateral
}Klippel-Trenaunay vein
The Klippel-Trenaunay vein is a large, lateral, superficial vein sometimes seen at birth. This vein begins in the foot or the lower leg and travels proximally until it enters the thigh or the gluteal area.
Klippel-Trenaunay syndrome vs Parker Weber syndrome
low flow rates in klippel in contrast to Parkes Weber syndrome where high flow rates are seen.
Patient with cardiac Hx and B/L iliac vessel occlusion
Which graft to be done
Axillo bifemoral
technique is particularly useful in providing a distal arterial roadmap prior to bypass
Angiogram
Before any vascular surgery
Always perform a test
If known juntional problem even then perform Venous duplex scan
Monophonic vs triphasic signals
Monophasic signals are associated with a proximal stenosis and reduction in flow.
Triphasic signals provide reassurance of a healthy vessel.
Ejection systolic murmur
Aortic stenosis
Pulmonary stenosis, HOCM
ASD, Fallot’s
Austin-Flint murmur
(severe aortic regurgitation)
Late systolic murmur in
Mitral valve prolapse
Coarctation of aorta
Graham-Steel murmur is also called
pulmonary regurgitation
Filariasis is caused by
Filariasis is caused by the nematode Wuchereria bancroft
Treatment of filariasis
diethylcarbamazine
Always have what before saphenofemoral junction ligation
Du0lex scan
Proceed to surgery post this procedure.
diastolic murmur at the apex
Mitral stenosis
Cyanotic disease at birth
TGA
Paget–Schrötter disease
Thrombosis of the axillary vein
Thoracic outlet syndrome is caused by which kind of movement
hyperextension injuries, repetitive stress injuries
Investigation of choice of Thoracic outlet syndrome/ Axillary vein thrombosis
Duplex
which cord is affected in Thoracic outlet syndrome
Lower cord thus ulnar nerve
Treatment of axillary vein thrombosis
Treatment
Local catheter directed TPA
Heparin
Warfarin
Features of marfan syndrome
Erotic dissection causing mediastinal Widening
bilateral inguinal hernia
tall
which antihypertensives may exacerbate claudication
antihypertensives (particularly β-blockers) may exacerbate claudication
The arteries that form the three-vessel runoff include
the peroneal artery
posterior tibial artery (PTA) and
anterior tibial artery (ATA).
Superficial femoral artery disease can be treated
by femoropopliteal bypass
Rx of Raynaud’s disease
Treatment is with calcium antagonists
Which surgical method is used for treatment of cervical rib
A transaxillary approach is the traditional operative method for excision
Favourable situation for endoscopic vascular aneurysmal repair
Long neck
Straight iliac vessels
Healthy groin vessels
supra renal AAAare treated by
Fenestrated grafts
connective tissue disease associated with AAA
Marfan’s disease, Ehler’s Danlos, Loey Dietz
Takayasu’s aortitis) is associated with which vascular disaese
AAA
Which disease is a negative risk factor for abdominal aortic aneurysm
Diabetes mellitus is a negative risk factor for AAA
Abdominal aortic aneurysms screening at what age and by which method
abdominal US scan for all men in their 65th year.
If AAA <5.5 cm then how to asses
3.0 – 4.4cm: yearly ultrasound
4.5 – 5.4cm: 3-monthly ultrasound
classic triad’ of ruptured AAA
flank or back pain, hypotension, and a pulsatile abdominal mass).
At which stage during aortic abdominal aneurysmal surgery does cardiac issue is very high
When clamps or off End tidal CO2 Rises
Cervical rib
Tests 1st line vs GS
Arterial Duplex 1st line
CT Angio GS
Cervical rib Rx
Angioplasty
Bypass
