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Y3 surgery > Vascular > Flashcards

Vascular Flashcards

1
Q

What is an ulcer? What are the three different types?

A

Abnormal breaks in the skin or mucous membranes
1) Venous ulcers
2) Arterial ulcers
3) Neuropathic ulcers

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2
Q

Describe the differences between the types of ulcers

A

Venous ulcer – shallow ulcers with a granulated base, often with other clinical features of venous insufficiency present
Neuropathic ulcers – painless ulcers over areas of abnormal pressure, often secondary to joint deformity in diabetics
Arterial ulcers – found at distal sites, often with well-defined borders & other evidence of arterial insufficiency

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3
Q

Describe the pathophysiology of venous ulcers

A

Valvular incompetence/venous outflow obstruction leads to impaired venous return
Resultant venous hypertension causes trapping of WBCs in capillaries & formation of fibrin cuff hinders oxygen transportation into the tissue
WBCs become activated, with release of inflammatory mediators -> tissue injury, poor healing & necrosis

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4
Q

List risk factors for venous ulcers

A

Increasing age
Pre-existing venous incompetence/history of VTE
Pregnancy
Obesity/physical inactivity
Severe leg injury/trauma

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5
Q

List clinical features of venous ulcers

A

Painful (particularly worse at the end of the day) & often found in the gaiter region of the legs
Associated symptoms of chronic venous disease: aching, itching, bursting sensation
Examination: varicose veins, ankle/leg oedema, features of venous insufficiency (varicose eczema/thrombophlebitis, haemosiderin skin staining)

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6
Q

List investigations for venous ulcers

A

Clinical diagnosis
Underlying venous insufficiency confirmed by Duplex ultrasound
Ankle brachial pressure index: assess for any arterial component to the ulcers
Swab cultures if suspecting an associated infection

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7
Q

Outline the management for venous ulcers

A

Conservative management – leg elevation & increased exercise
Lifestyle changes
Abx only with clinical evidence of wound infection
Mainstay – multicomponent compression bandaging changed once/twice every week (ABPI must be > 0.6 before bandaging)
Concurrent varicose veins – treated with endovenous techniques/open surgery

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8
Q

Describe an arterial ulcer

A

Ulcer caused by a reduction in arterial blood flow, leading to decreased perfusion of the tissues & subsequent poor healing
Form as small deep lesions with well-defined borders & necrotic base (commonly occur distally at sites of trauma and in pressure areas)

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9
Q

List risk factors for an arterial ulcer

A

Smoking
Diabetes mellitus
Hypertension
Hyperlipidaemia
Increasing age
Positive family history
Obesity
Physical inactivity

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10
Q

List clinical features of arterial ulcers

A

Preceding history of intermittent claudication/critical limb ischaemia
Ulcer may be painful & often develops over a long period of time, with little to no healing
Other signs: cold limbs, thickened nails, necrotic toes & hair loss
Examination – limbs will be cold & have reduced/absent pulses
(NOTE: in pure arterial ulcers, sensation is maintained)

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11
Q

List investigations for arterial ulcers

A

Ankle brachial pressure index measurement: quantify the extent of any peripheral arterial disease
Imaging: duplex ultrasound, CT angiography/magnetic resonance angiogram

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12
Q

Describe the management for arterial ulcers

A

Urgently referred for a vascular review:
1) Conservative: lifestyle changes
2) Medical: CVS risk factor modification (statin therapy, antiplatelet agent), optimisation of BP and glucose
3) Surgical: angioplasty/ bypass grafting

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13
Q

Describe a neuropathic ulcer

A

Occurs as a result of peripheral neuropathy
Loss of protective sensation -> repetitive stress & unnoticed injuries forming -> painless ulcers forming on the pressure points on the limb

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14
Q

List risk factors of neuropathic ulcers

A

Develop with any condition with peripheral neuropathy:
1) Diabetes mellitus
2) B12 deficiency
Foot deformity
Concurrent peripheral vascular disease

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15
Q

List clinical features of neuropathic ulcers

A

History of peripheral neuropathy/symptoms of peripheral vascular disease
Examination: neuropathic ulcers are variable in size and depth (punched out appearance)

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16
Q

List investigations for neuropathic ulcers

A

Blood glucose levels & serum B12 should be checked
Signs of infection: microbiology swab & any evidence of deep infection may warrant an x-ray
Important to assess the extent of peripheral neuropathy

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17
Q

Describe the management of neuropathic ulcers

A

Specialised diabetic foot clinics – managed by MDT
Diabetic control should be optimised
Improved diet & increased exercise should be encouraged
Regular chiropody to maintain good foot hygiene

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18
Q

What is Charcot’s foot?

A

Neuroarthropathy whereby a loss of joint sensation results in continual unnoticed trauma & deformity occurring -> predisposes people to neuropathic ulcer formation
Patients present with swelling, distortion, pain & loss of function
Requires a specialist review for consideration of off-loading abnormal weight & sometimes immobilisation of the affected joint in plaster

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19
Q

What is an abdominal aortic aneurysm?

A

Dilation of the abdominal aorta greater than 3cm

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20
Q

List risk factors of AAA

A

Atherosclerosis
Trauma
Infection
Connective tissue disease
Inflammatory disease (Takayasu’s aortitis)
Smoking, hypertension, hyperlipidaemia, family history, male gender & increasing age

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21
Q

List clinical features of an AAA

A

Many are asymptomatic/ simply detected on incidental finding or screening
Can present with: abdominal pain, back/loin pain, distal embolisation
Examination – pulsatile mass can be felt in the abdomen (above the umbilical level)

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22
Q

Describe the screening programme for AAA

A

Abdominal US for all men in their 65th year
Most men with a detected AAA will spend 3 to 5 years in surveillance prior to reaching the threshold for elective AAA repair

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23
Q

Describe the medical management of an AAA

A

AAA < 5.5 cm, can be monitored via duplex USS
- 3 to 4.4cm = yearly USS
- 4.5 to 5.4cm = 3 monthly USS
CVS risk factors should be reduced as appropriate: smoking cessation, improve BP control, commence statin and aspirin therapy & weight loss/increased exercise

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24
Q

Describe the surgical management of an AAA

A

Should be considered for:
- AAA > 5.5cm
- AAA expanding at >1cm/year
- Symptomatic AAA
Main treatment options are open repair/endovascular repair:
1) Open repair: midline laparotomy/long transverse incision, exposing the aorta & clamping the aortic proximally & iliac arteries distally, before segment is removed & replaced with a prosthetic graft
2) Endovascular repair: introducing a graft via femoral arteries & fixing the stent across the aneurysm

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25
Q

List complications of an AAA

A

AAA rupture
Retroperitoneal leak
Embolisation
Aortoduodenal fistula

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26
Q

Describe the clinical features of a ruptured AAA

A

Abdominal pain
Back pain
Syncope
Vomiting
Examination: haemodynamically compromised with a pulsatile abdominal mass & tenderness
Classic triad (50% of patients) – flank/back pain, hypotension & a pulsatile abdominal mass

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27
Q

Describe the management of a ruptured AAA

A

Immediate high flow O2, IV access & urgent bloods taken with crossmatch
Any shock should be treated very carefully (aim to keep the BP < 100mmHg)
Patient should be transferred to local vascular unit:
- Unstable – require immediate transfer to theatre for open surgical repair
- Stable – require a CT angiogram to determine whether the aneurysm is suitable for endovascular repair

28
Q

What are varicose veins?

A

Tortuous dilated segments of vein associated with valvular incompetence
Arise from incompetent valves -> results in venous hypertension & dilatation of the superficial venous system

29
Q

List causes of varicose veins

A

Primary – idiopathic
Secondary – DVT, pelvic masses or arteriovenous malformations

30
Q

List risk factors of varicose veins

A

Prolonged standing
Obesity
Pregnancy
Family history

31
Q

Describe the clinical features of varicose veins

A

Typically present initially with cosmetic issues – unsightly visible veins/discolouration of the skin
Aching/itching
Skin changes, ulceration, thrombophlebitis or bleeding
Examination – varicosities will be present in the course of the great and/or short saphenous veins, clinical features of venous insufficiency (ulceration, varicose eczema, haemosiderin deposition)

32
Q

List investigations for varicose veins

A

Gold standard – duplex ultrasound
- Assess valve incompetence at the great/short saphenous veins & any perforators

33
Q

Describe the non-invasive treatments for varicose veins

A

Patient education – avoid risk factors
Compression stockings if interventional treatment is not appropriate (need to be worn for the rest of the patients life)
Any venous ulceration – four-layer bandaging

34
Q

Describe surgical treatment for varicose veins

A

Should be referred if they meet the following NICE criteria:
- Symptomatic primary or recurrent varicose veins
- Lower-limb skin changes
- Superficial vein thrombosis
- Venous leg ulcer
Treatment options include: vein ligation, stripping & avulsion, foam sclerotherapy & thermal ablation

35
Q

List complications of untreated varicose veins

A

Worsen over time
Typical complications seen post-operatively include haemorrhage, thrombophlebitis, DVT, disease recurrence & nerve damage

36
Q

What is aortic dissection?

A

Tear in the intimal layer of the aortic wall, causing blood to flow between & splitting apart the tunica intima and media
Aortic dissections from the initial intimal tear can progress distally, proximally/in both directions from the point of origin

37
Q

List the two classification systems for aortic dissection

A

Stanford
DeBakey

38
Q

List risk factors for aortic dissection

A

Hypertension
Atherosclerotic disease
Male gender
Connective tissue disorders
Bicuspid aortic valve

39
Q

Describe the clinical features of aortic dissection

A

Tearing chest pain, classically radiating through to the back
Tachycardia, hypotension, new aortic regurgitation murmur or signs of end-organ hypoperfusion

40
Q

List differential diagnoses of aortic dissection

A

Myocardial infarction
Pulmonary embolism
Pericarditis
MSK back pain

41
Q

List investigations for aortic dissection

A

Baseline blood tests, ECG
Imaging: CT angiogram, transoesophageal ECHO

42
Q

Describe the management of aortic dissections

A

Urgent initial assessment – start high flow oxygen & gain IV access, fluid resus should be done cautiously
Type A dissections – managed surgically in the first instance
Any uncomplicated type B dissections – usually be managed medically
All patients need lifelong antihypertensive therapy & surveillance imaging

43
Q

List complications of aortic dissections

A

Aortic rupture
Aortic regurgitation
Myocardial ischaemia
Cardiac tamponade
Stroke or paraplegia

44
Q

Define acute limb ischaemia

A

Sudden decrease in limb perfusion that threatens the viability of the limb
Complete/even partial occlusion of the arterial supply to a limb

45
Q

Describe the aetiology of acute limb ischaemia

A

1) Embolisation – thrombus from a proximal source travels distally to occlude the artery
2) Thrombosis in situ
3) Trauma, including compartment syndrome

46
Q

List the signs and symptoms of acute limb ischaemia

A

Pain
Pallor
Pulselessness
Paraesthesia
Perishingly cold
Paralysis

47
Q

List investigations for acute limb ischaemia

A

Routine bloods – serum lactate, a thrombophilia screen & a group and save along with an ECG
Bedside Doppler ultrasound scan, followed by potential CT angiography
If limb is considered salvageable, a CT arteriogram can provide more information regarding the anatomical location of the occlusion & can help decide the operative approach

48
Q

Describe the initial and conservative management for acute limb ischaemia

A

Initial management – surgical emergency: start patient on high-flow oxygen & ensure adequate IV access
Conservative management – prolonged course of heparin

49
Q

Describe the surgical management of acute limb ischaemia

A

If cause is embolic:
- Embolectomy via a Forgarty catheter
- Local intra-arterial thrombolysis
- Bypass surgery
If cause is thrombotic:
- Local intra-arterial thrombolysis
- Angioplasty
- Bypass surgery
Irreversible limb ischaemia – urgent amputation/taking a palliative approach

50
Q

Describe the long term management of acute limb ischaemia

A

Reduction of the CVS mortality risk – promoting regular exercise, smoking cessation & weight loss
Most cases should be started on an anti-platelet agent
Cases resulting in amputation will require OT, PT with long term rehab plan

51
Q

List complications of acute limb ischaemia

A

Reperfusion injury
Compartment syndrome
Release of substances from damaged muscle cells – hyperkalaemia, acidosis & significant AKI

52
Q

Describe chronic limb ischaemia

A

Form of peripheral arterial disease that results in a symptomatic reduced blood supply to the limbs
Typically caused by atherosclerosis, rarely vasculitis & commonly affect the lower limbs

53
Q

List risk factors for chronic limb ischaemia

A

Smoking
Diabetes mellitus
Hypertension
Hyperlipidaemia
Increasing age
A strong family history
Obesity
Physical inactivity

54
Q

Describe the clinical features of chronic limb ischaemia

A

Fontaine classification:
- Stage I: asymptomatic
- Stage II: intermittent claudication
- Stage III: ischaemic rest pain
- Stage IV: ulceration or gangrene, or both
Examination: affected limbs will be colder, may be evidence of arterial ulcers, patients will typically have reduced/absent peripheral pulses

55
Q

What is critical limb threatening ischaemia?

A

Advanced form of chronic limb ischaemia
Defined in three ways:
1) Ischaemic rest pain > 2 weeks duration
2) Presence of ischaemic lesions/gangrene
3) ABPI less than 0.5
Examination: limbs may be pale and cold with week or absent pulses, limb hair loss, skin changes & thickened nails

56
Q

List investigations of chronic limb ischaemia

A

Ankle-brachial pressure index
Doppler ultrasound
CT angiography/MR angiography
CVS risk assessment

57
Q

Describe the medical management for chronic limb ischaemia

A

CVS risk factor modification: lifestyle advice, statin therapy, anti-platelet therapy, optimise diabetes control
Local supervised exercise programme

58
Q

Describe the surgical management of chronic limb ischaemia

A

Surgical intervention can be offered in suitable patients
- Risk factor modification has been discussed
- Supervised exercise has failed to improve symptoms
Any patients with critical limb ischaemia should be urgently referred for surgical intervention
Two main surgical options:
-angioplasty with/without stenting
-bypass grafting, typically used for diffuse disease/in younger patients

59
Q

List complications of chronic limb ischaemia

A

Sepsis
Acute-on-chronic ischaemia
Amputation
Reduced mobility & quality of life

60
Q

What is deep venous insufficiency?

A

Chronic disease that can result in significant morbidity
Commonly caused by either DVT or valvular insufficiency, and together with varicose veins
Occurs as a result of the failure of the venous system – valvular reflux, venous hypertension and obstruction

61
Q

List causes of deep venous insufficiency

A

Primary – underlying defect to the vein wall/valvular component (includes congenital defects & connective tissue disorders)
Secondary – defects occur secondary to damage (post-thrombotic disease, post-phlebitic disease, venous outflow obstruction & trauma)

62
Q

List risk factors of DVI

A

Increasing age
Female gender
Pregnancy
Previous DVT or phlebitis
Obesity
Smoking

63
Q

Describe the clinical features of deep venous insufficiency

A

Chronically swollen lower limbs – aching, pruritic & painful
May report venous claudication
Examination: varicose eczema, thrombophlebitis, haemosiderin skin staining, lipodermatosclerosis or atrophie blanche
Varying degree of dependent pedal oedema & may also have venous ulcers

64
Q

List investigations for DVI

A

Doppler ultrasound scan, allowing the assessment for the extent of venous reflux
Routine blood tests
Documentation of foot pulses & ABPI

65
Q

Describe the management of DVI

A

Early treatment may reduce long-term complications
Conservative management – compression stockings & suitable analgesic control
Surgical management is less successful (some evidence that patients who had deteriorating symptoms had a mild clinical improvement)

66
Q

Describe the complications of DVI

A

Swelling, recurrent cellulitis, chronic pain and ulceration
More serious but less common complications – DVT, secondary lymphoedema & varicose veins
Marjolin ulcer – rare type of cutaneous SCC developing at the site of severe/recurrent inflammation

Y3 surgery (21 decks)

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