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Surgery > Vascular > Flashcards

Vascular Flashcards

1
Q

Risk Factors for DVT?

A

immobility
recent sx
long haul travel
pregnancy
hormone therapy with oestrogen (COCP or HRT)
malignancy
polycythaemia
SLE
thrombophilia

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2
Q

Examples of thrombophilias?

A

antiphospholipid syndrome
Factor V Leiden
antithrombin deficiency
Protein C or S deficiency
hyperhomocysteinaemia
prothrombin gene variant
activated protein C resistance

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3
Q

Contraindication for compression stockings?

A

Peripheral Arterial Disease

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4
Q

Presentation of DVT?

A

unilateral calf swelling
dilated superficial veins
calf tenderness
oedema
red, hot calf

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5
Q

How to examine for calf swelling in suspected DVT?

A

measure the circumference of the calf 10cm below the tibial tuberosity

> 3cm difference between calves is significant

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6
Q

Components of Wells Score?

A

clinical signs of DVT
tachycardia
recent sx or immobilisation
prev PE or DVT
haemoptysis
malignancy
alt diagnosis less likely than PE

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7
Q

Diagnosis of DVT?

A

d-dimer is non-specific but good rule out test if negative
Doppler US
CTPA if susp of PE

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8
Q

When to repeat negative Doppler US if suspected DVT?

A

repeat after 6-8 days if positive D-dimer and Wells score suggests DVT likely

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9
Q

Initial management of DVT?

A

anticoagulation with apixaban or rivaroxaban
consider catheter-directed thrombolysis in patients with iliofemoral DVT

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10
Q

Long-term management of DVT?

A

DOACs first-line
warfarin (antiphospholipid syndrome)
LMWH (pregnancy)

3 months if ‘provoked’ reversible cause
6 months if ‘unprovoked’ or irreversible cause
3-6 months in active cancer

IVC filter can be used

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11
Q

Virchow’s Triad contributing to thrombosis?

A

stasis of blood flow
endothelial injury
hypercoagulability

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12
Q

Complications of DVT?

A

PE
stroke (if septal defect)
chronic venous insufficiency
venous gangrene

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13
Q

Indications for IVC filter?

A

recurrent PEs despite treatment
contraindication to anticoagulation
if anticoagulation can not be used in major sx

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14
Q

Risks of placing IVC filter?

A

air embolism
arrhythmia
pneumothorax
haemothorax
IVC obstruction
bleeding

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15
Q

What is intermittent claudication?

A

muscular crampy pain brought on by exercise and relieved by rest
caused by increased demand for oxygen during exercise in the context of a reduced blood supply

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16
Q

What is critical limb ischaemia?

A

end-stage of PAD, where there is not enough blood supply for the limb to function normally at rest
typically worse at night
some relief by hanging over the edge of the bed

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17
Q

What is acute limb ischaemia?

A

rapid onset of ischaemia in a limb
due to a thrombus blocking artery

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18
Q

RFs for PAD?

A

Non-modifiable:
age
FHx
male
Modifiable:
smoking
alcohol
diet
obesity
sedentary lifestyle
poor sleep
stress
HTN
cholesterol
DM
prev stroke/MI

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19
Q

6 P’s of acute limb ischaemia?

A

pain
pallor
pulseless
perishing cold
paraesthesia
paralysis

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20
Q

What is Leriche Syndrome?

A

occurs with occlusion in the distal aorta or proximal common iliac artery

triad of:
thigh/buttock claudication
absent femoral pulses
erectile dysfunction

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21
Q

Signs of PAD on examination?

A

skin pallor
cyanosis
dependent rubor
muscle wasting
hair loss
ulcers
gangrene
poor wound healing
reduced temp
reduced sensation
positive Buerger’s test
prolonged cap refill time

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22
Q

What is Buerger’s test?

A

legs up 1 or 2 mins
pallor
hang over side of bed
blue then dark red in PAD
pink in normal

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23
Q

Features of arterial ulcers?

A

caused by ischaemia secondary to a reduced blood supply
smaller
deeper
well-defined borders
‘punched-out’ appearance
occur peripherally (toes, heels)
have reduced bleeding
painful

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24
Q

Investigations in PAD?

A

Hx and exam
ABPI
Duplex US
angiography (CT/MRI)

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25
Q

DDx for PAD?

A

spinal stenosis
osteoarthritis
nerve root entrapment e.g., sciatica
trauma

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26
Q

Interpretation of ABPI results?

A

0.9-1.2 - normal
0.6-0.9 - mild PAD
0.3-0.6 - moderate PAD
<0.3 - critical ischaemia
>1.2 - calcified arteries (DM, CKD)

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27
Q

Management of intermittent claudication?

A

conservative (lifestyle changes, smoking cessation)
medical (atorvastatin 80mg, clopidogrel 75mg, optimise medical treatment of co-morbidities)
surgical (endovascular angioplasty and stenting, endartectomy, bypass sx)

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28
Q

Management of critical limb ischaemia?

A

endovascular angioplasty and stenting
endartectomy
bypass sx
amputation if limb is unsalvageable

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29
Q

Management of acute limb ischaemia?

A

UFH infusion ASAP
endovascular thrombolysis
endovascular thrombectomy
surgical thrombectomy
endartectomy
bypass sx
amputation if limb is unsalvageable

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30
Q

Complications of reperfusion in PAD?

A

reperfusion injury
rhabdomyolysis
compartment syndrome

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31
Q

Causes of acute limb ischaemia?

A

thrombosis (acute-on-chronic)
embolic (AFib, AAA, post-MI)
trauma (compartment syndrome)

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32
Q

When does irreversible tissue damage occur in acute limb ischaemia?

A

> 6hrs of onset

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33
Q

What are varicose veins?

A

tortuous dilated segments of veins associated with valvular incompetence between the deep and superficial veins

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34
Q

Risk Factors for varicose veins?

A

prolonged standing
obesity
FHx
pregnancy
female
incr. age
DVT

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35
Q

Clinical presentation of varicose veins?

A

heavy or dragging sensation
aching
itching
burning
oedema
muscle cramps
restless leg
signs and symptoms of chronic venous insufficiency

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36
Q

Special Tests for varicose veins?

A

Tap test
Cough test
Trendelenburg’s test
Perthe’s test

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37
Q

Management of varicose veins?

A

conservative (weight loss, elevation)
medical (compression stockings, moisturiser)
surgical (endothermal ablation, sclerotherapy, stripping)

38
Q

Complications of varicose veins?

A

prolonged and heavy bleeding post-trauma
superficial thrombophlebitis
DVT
skin changes and ulcers (chronic venous insufficiency)

39
Q

Indications for sx intervention in varicose veins?

A

symptomatic
lower limb skin changes
venous ulcers
superficial thrombophlebitis

40
Q

Gold standard investigation for varicose veins?

A

Duplex US

41
Q

What is Buerger Disease?

A

aka thromboangiitis obliterans
inflammatory condition that causes thrombus formation in small and medium arteries
affects the peripheries

42
Q

Presentation of Buerger Disease?

A

painful, blue discolouration to fingers and toes
pain worse at night
may progress to gangrene
corkscrew collaterals are typical finding on angiograms

43
Q

RFs for Buerger’s Disease?

A

smoking!!!
male gender
25-35yrs

44
Q

Management of Buerger’s Disease?

A

complete cessation of smoking (cutting down or nicotine replacement not enough)
IV iloprost

45
Q

Features of chronic venous insufficiency?

A

haemosiderin deposition
venous eczema
lipodermatosclerosis
atrophie blanche
venous ulcers

46
Q

Management of chronic venous insufficiency?

A

moisturisers, topical steroids
weight loss, elevation, compression stockings
antibiotics for infections
analgesia for pain
wound care for ulcers

47
Q

Complications of chronic venous insufficiency?

A

recurrent cellulitis
chronic pain
ulceration
DVT
secondary lymphoedema
varocise veins
Marjolin’s ulcer

48
Q

Types of skin ulcers?

A

Arterial ulcers
Venous ulcers
Pressure ulcers
Diabetic foot ulcers

49
Q

Features of venous ulcers?

A

occur in the gaiter area
associated with chronic venous insufficiency changes
occur after a minor injury
larger
more superficial
irregular, gently sloping borders
more likely to bleed
less painful
pain relieved by elevation and worsened by lowering

50
Q

Where is the gaiter area?

A

mid calf to just below medial malleolus

51
Q

Investigations of ulcers?

A

ABPI
Bloods for infection
Charcoal swab (cellulitis)
Skin biopsy (SCC)

52
Q

Management of arterial ulcers?

A

treatment of underlying arterial disease
no place for debridement or compression

53
Q

Management of venous ulcers?

A

cleaning, debriding and dressing of wound
compression therapy (ABPI first)
pentoxifylline orally
antibiotics for infection
analgesia (avoid NSAIDs)

54
Q

Definition of ulcer?

A

abnormal breaks in the skin surface or mucous membranes

55
Q

Causes of lymphoedema?

A

primary (rare, <30)
secondary (e.g., post axillary clearance in breast ca)

56
Q

What is Stemmer’s sign?

A

ability to pinch the skin at base of fingers or toes
if positive -> lymphoedema?

57
Q

Lymphoedema vs Lipoedema?

A

Lipoedema spares the feet

58
Q

Management of lymphoedema?

A

manual lymphatic drainage
compression bandages
exercises to improve drainage
weight loss if overweight
lymphaticovenular anastomosis if other treatments fail

***avoid taking blood, inserting cannula or giving injections in lymphoedema limb

59
Q

What is an AAA?

A

dilatation of the aorta with a diameter >3cm
often asymptomatic

60
Q

RFs for AAA?

A

male
incr. age
smoking
HTN
hyperlipidaemia
FHx
CVD
CT disease

61
Q

Definition of an aneurysm?

A

abnormal dilatation of a blood vessel by >50% of its normal diameter

62
Q

Presentation of AAA?

A

usually asymptomatic, picked up incidentally or during screening
non-specific abdo or back pain
pulsatile, expansile mass

63
Q

Diagnosis of AAA?

A

US
CT

64
Q

Management of AAA?

A

treat reversible RFs
surveillance (3-4.4cm yearly, 4.5-5.2cm 3 monthly)
elective repair (symptomatic, >5.5cm, growing >1cm per year)

65
Q

Options for Sx repair of AAA?

A

open repair via laparotomy
EVAR (femoral)

66
Q

Presentation of ruptured AAA?

A

severe abdo pain (may radiate to back)
hypotension, tachycardia
pulsatile, expansile mass
collapse
LOC

67
Q

Management of ruptured AAA?

A

permissive hypotension
surgical emergency

68
Q

What is an aortic dissection?

A

tearing of the intima of the aorta so that blood flows between the intima and the media, creating a false lumen

69
Q

Types of aortic dissection?

A

Type A - ascending aorta, before brachiocephalic artery
Type B - descending aorta, after left subclavian artery

70
Q

RFs for aortic dissection?

A

hypertension
bicuspid aortic valve
coarctation of the aorta
aortic valve replacement
CABG
Marfans
Ehlers-Danlos
PAD RFs

71
Q

Presentation of aortic dissection?

A

severe, sudden onset ‘ripping’ or ‘tearing’ chest pain
HTN
difference in blood pressure between
arms
radio-radial delay
diastolic murmur
chest and abdo pain
collapse
hypotension late sign

72
Q

Diagnosis of aortic dissection?

A

ECG
CXR
CT angiogram
MR angiogram

73
Q

Mx of aortic dissection?

A

surgical emergency
analgesia
beta blockers (BP)

Type A - open surgery
Type B - conservative or TEVAR

74
Q

Complications of aortic dissection?

A

MI
stroke
paraplegia
cardiac tamponade
aortic regurgitation
death

75
Q

Classification of carotid artery stenosis?

A

mild (<50%)
moderate (50-69%)
severe (>70%)

76
Q

Presentation of carotid artery stenosis?

A

usually asymptomatic
diagnosed after TIA or stroke
carotid bruit

77
Q

Diagnosis of carotid artery stenosis?

A

US
CT/MR angiogram

78
Q

Mx of carotid artery stenosis?

A

modify risk factors
antiplatelets + statins

surgery:
carotid endartectomy
angioplasty and stenting

79
Q

Complications of carotid endartectomy?

A

stroke
facial nerve damage
hypoglossal nerve damage
glossopharyngeal nerve damage
recurrent laryngeal nerve damage

80
Q

Symptoms of unruptured AAA?

A

back pain
acute limb ischaemia secondary to embolus from aneurysm sac
buttock claudication/Leriche syndrome
GI bleed secondary to aorto-enteric fistula

81
Q

Complications of AAA repair?

A

Early:
death
haemorrhage
MI
arrhythmias
heart failure
bowel ischaemia
abdominal compartment syndrome
atelectasis, ARDs
endoleak
renal dysfunction
limb ischaemia

Late:
graft infection
graft limb occlusion
aortoenteric fistula
endoleak

82
Q

Rutherford-Fontaine Classification of Limb Ischaemia?

A

I - asymptomatic
IIa - intermittent claudication >200m
IIb - intermittent claudication <200m
III - rest pain
IV - tissue loss (gangrene, ulcers, necrosis)

83
Q

DDx for PAD?

A

spinal stenosis
osteoarthritis
nerve root entrapment (sciatica)
trauma

84
Q

Differentiating spinal stenosis from PAD?

A

PAD improves on rest, independent of posture
spinal stenosis improves with sitting down

PAD worse going up a hill, spinal stenosis worse going down

85
Q

Compartments of the lower limb?

A

anterior
lateral
deep posterior
superficial posterior

86
Q

What is Trendelenburg’s test for varicose veins?

A

used to find what level the valve defect is
raise affected leg so that blood drains out
apply tourniquet around the thigh and get patient to stand
if the varicose veins do not refill, the level of the defect is above the tourniquet, if they do, it’s below
repeat until they don’t refill

87
Q

Anatomical landmark for dorsalis pedis pulse?

A

lateral to the extensor hallucis tendon
within 1cm of the navicular bone

88
Q

Anatomical landmark for posterior tibial pulse?

A

immediately posterior to the medial malleolus

89
Q

Anatomical landmark for the popliteal pulse?

A

in the popliteal fossa, between the heads of gastrocnemius muscles

90
Q

Anatomical location for the femoral pulse?

A

below the inguinal ligament
midway between the ASIS and the pubic tubercle

Surgery (10 decks)

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