Vascular Flashcards
Cervical rib symptoms
Altered sensation in arm
Worse when using
AT C7
70% bilateral
Compression of the subclavian artery may produce absent radial pulse
Test for cervical rib
Adsons test (lateral flexion of the neck towards the symptomatic side and traction of the symptomatic arm- leads to obliteration of radial pulse
Management of Takayasu arteritis
Steroids
Subclavian steal syndrome sx
Posterior circulation symptoms- dizziness and vertigo during exertion of arm
Due to subclavian occlusion proximal to origin of vertebral artery causing reversal in flow
Tx of subclavian steal sydnrome
Percutaenous angioplasty or stent
Rest pain with bilateral occlusion of both common iliac arteries, unsuitable for stunting, what tx
Axilla bifemoral bypass- if older with more comorbidities
Aorta- better patency rates
Indication for CABg
Left main stem disease
Triple vessel
Diffuse disease unsuitable for PCI
ABPI values
> 1.2- calcified
0.5-0.8-moderate disease- claudication when walking, resolves at rest
<0.5- severe- arterial ulcers
0.3- critical ischaemia-
gangrene
Tx options for occlusion
Angioplasty- short, reasonable vessel runoff
Bypass- long lesion
Heparin regime for bypass
3000U of UF heparin 3 mins prior to clamping
Kipperl trenaunary weber syndrome
Port wine stain
Varicose veins- Varicosities may be extensive, though they often spare the saphenous distribution.
Bone/soft tissue hypertrophy- gigantism of limb
An improperly developed lymphatic system
Management of AAA
3-4.5- 12m USS
4.5-5.5- 3m
>5.5 surgery
If increased by more than 0.5 cm in 6m
Indication of AAA surgery
Symptomatic aneurysms (80% annual mortality if untreated)
Increasing size above 5.5cm if asymptomatic
Rupture
Risk of infrarenal AAA rupture over 5 years
5-5.9- 25%
6-6.9- 35%
7 and over- 75%
AAA over 5cm on USS, next ix
CT
Nerve at risk for short saphenous vein surgery
Sural
Swelling after varicose vein surgery tx
Multilayer compression banding
From lymphedema
Surgical Tx of lymphedema
Surgery- if severe deformity
Homan- if overlying skin is healthy, limb deformity
Charles- if overlying skin not normal
Lymphovenous anastomosis- if proximal lymphatic not patent
Cause of lymphedema
Primary
Milroy - 1-35
Meige- >35
Secondary
Filariasisi
Malignancy
Radio to LN or resection
Adductor canal compression syndrome
Young males
Acute limb ischaemia with exertion
Compression of femoral artery from adductor Magnus
Popliteal fossa entrapment sx
Pulse disappears when fully extended
Aortic dissection features
Usually affects 50% of aortic circumference
50% mortality in first 2 days
Systolic below <110
Varicose veins ix
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)
Ulcer at stoma site with crohns
Pyoderma gangrenosum
Margarita pizza
Charcot foot features
Neuropathy - peripheral and autonomic
Bounding foot pulses early
Erythema
Marjolins ucler
SCC occurring at sites of chronic inflammation e.g ulcers
Lower limb
Changes occurring in marfans with aortic dissection
Cystic medial necrosis ( or cystic medial degeneration) occurs when basophils and mucoid material lie in between the intimal elastic fibres of the aorta.
Cell types of carotid boded tumour
Paraganglionoma
Ix of carotid body tumour
Imaging
They are readily imaged using duplex ultrasonography. CT angiography is sometimes helpful.
Treatment
Typically this comprises surgical resection. This is preceded by embolization in selected case
Osteomyelitis with fixed flexion deformity
Above knee amputation as would not be able to walk otherwise
Malignancy of arm post mastectomy
Lymphangiosarcoma
What vessel conditions are good for angioplasty
Short occlusion and good vessel run off
Which amputation uses Skew flaps
Below knee
Unilateral iliac occlusion tc not suitable for stunting
Fem Fem crossover
Types of carotid body tumour
Sporadic - Accounts for 85% of cases
Familial - Seen in around 10% of cases and usually in younger patients
Hyperplastic - Seen in those at high altitude or in those with COPD
Mx of delayed presentation of ischaemic limb
Embolectomy and fasciotomy
Axillary embolism tx
Catheter directed TPA
Tx of venous ulcers
If Deep- debride and 4 layer compression banding after exclusion of arterial disease or surgery
If fail to heal after 12 weeks or >10cm2 skin grafting may be needed
pentoxifylline may speed up healing
If superficial- sclerotherapy
Congenital heart disorders differentiating
Cyanotic- TGA at birth
Fallot
Acyanotic- VSD most common
Highly co morbid patent with non healing ulcer that shows small patency of limb arteries tx
Amputation
Fixed mottling limb mx
Unsalvageable- amputation
Mx of ascending aortic dissection
Aortic root replacement
Gritti Stokes
Through knee
Femoral condyles removed
Patella maintained
DeBakey classification of aortic dissection
1- ascending, arch, descending
2- ascending only
3- descending- distal to left subclavian
Ix of arterial disease
ABPI
Arterial duplex
Angiography
Superficial femoral artery occlusion to the above knee
Angioplasty may be attempted but otherwise these patients will require a femoro-popliteal bypass graft.
- Patency rates for Polytetrafluoroethylene (PTFE) and vein are similar, so PTFE preferred unless co-existing
infection makes use of prosthetic material undesirable.
Vein attached to end of PTFE - miller cuff
Tetrology of Fallot
ventricular septal defect (VSD)
right ventricular hypertrophy
right ventricular outflow tract obstruction, pulmonary stenosis- this in combo with VSD causes right to left Shunt
overriding aorta
Medication for SAH
Nimodipine
Presentation of extra dural haemorrhage
Trauma to side of head
May have LOC or lucid interval before rapid deterioration
The car collides with a brick wall at around 140km/h. When he arrives in the emergency department he is comatose. Dx?
Diffuse axonal injury
What signs for trochlear nerve damage
Double vision on walking down stairs and reading.
May have head tilt
On testing ocular convergence, one eye faces downwards but the other does not
Function- down and out
Only nerve to dessucate
Painful, with eye down and out
Posterior communicating artery aneurysm
Runs over CN3
Acute neurological deterioration in premature neonates
Intraventricular haemorrhage
Wernickes triad
Altered mental state
Ataxia
Opthalmoplegia
Babinski sign
Extensor
Normally flexor- pyramidal tract lesions
Unilateral dilated pupil post trauma to head
Epidural bleed causing trans tentori herniation
The medial aspect of the temporal lobe (uncus) herniates across the tentorium and causes pressure on the ipsilateral oculomotor nerve, interrupting parasympathetic input to the eye and resulting in a dilated pupil.
Ipsilateral craniotomy
Which part of the scalp is susceptible to spread of infection into the CNS
Loose areolar tissue as contain emissary veins in to CNS
Injury and presentation risk of head haematoma requiring removal
Concussion no fracture, orientated- 1/6000
Concussion no fracture, not orientated- 1/120
Skull fracture, orientated- 1/32
Skull fracture, not orientated- 1/4
Changes seen in marfans in a dissecting aortic aneurysm
Cystic medial necrosis ( or cystic medial degeneration) occurs when basophils and mucoid material lie in between the intimal elastic fibres of the aorta.
Venous stasis ulcer features
Located above the medial malleolus
Indolent appearance with basal granulation tissue
Painless
Sloping edges
Variable degree of scarring
Non ischaemic edges
Haemosiderin deposition in the gaiter area (and also lipodermatosclerosis).
Tender mass in groin, red streaks
Lymphadenitis
Primary vs secondary raynauds
Primary- idiopathic
Both hands
Secondary - SLE
Colour changes with raynauds
White
Blue
Crimson
Common complication of ascending dissecction
MI
Aortic valve incompetence and regurgitation
Inflammatory AAA- wall affected, complications
Posterior wall is spared
Can lead to retroperitoneal fibrosis causing entrapment and renal failure
Best graft latency rates
Above knee saphenous vein
Vein should be used- if unable to PTFE
Syphillitic aneurysm features and mx
Don’t result in rupture
Cause aortic incompetence and are surgical ally repaired
False aneurysm vs dissecting
False- between muscular and adventitia
Trauma
Dissecting- intima tear
Pathological cause of dissection
Reduced elastin
Increased collagen:elastin ratio
Most common place for mycotic aneurysm
Femoral
Indication for popliteal aneurysm operation
Symptomatic- acute limb ischaemia, severe claudication
Asymp- with thrombus
Usually if >2cm can be considered
% of people with 1 aneurysm have another elsewhere
25
CI to surgical treatment of varicose veins
Occluded deep veins
Causes of raynauds
Thoracic outlet
Lupus
CREST
Vinyl chloride
Was is important to do before SPJ surgery
Mark where it is with duplex imaging as portion highly variable
Complications of aortic surgery
Trash foot - acute lower limb ischaemia following surgery
Ischaemic colitis
Paraplegia - damage of artery of adamkeiwicz
What is thrombophlebitis migrant associated with
Pancreatic carcinoma
Recurrent superficial thrombophlebitis usually in lower extremities
Angle and sign in Buergers test indicating severe ischamia
<20
If feet blue then hyperaemia
Pathology of acute on chronic limb ischamia
Thrombosis
Rupture of plaque
Superimposed thrombus
Most common complication of venous insufficiency
Leg ulceration
Euvolaemic AKI following EVAR
Contrast nephrotoxicity
Uses iodinated contrast
Screening for AAA
One off US all men 65 and older
Complications of sclerotherapy
Brown dislocation of skin
Superficial thrombophlebitis
DVT
Nerve injury
Phlegmasia alba dolens and mx
Painful white oedema/inflammation
Complication of deep vein thrombosis
Superficial not able to manage
Painful white leg
Thrombolysis or thrombectomy
Phelgmasia cerula dolens
Painful blue oedema
Progression of PAD
Shuts off superficial venous system
Massive congestion
Tx thrombolysis or thrombecotmy
Most common presention of thoracic outlet syndrome
Neurological 95%
Can cause swelling
Venous thrombosis in 1-2%
Trendelenburg operation
SF valve incompetence
Under spinal
Flush ligated to femoral vein - upper 10cm excised
High reoccurrence
What affects the gaiter area
Venous ulcers
Lump after angioplasty dx and tx
Pseudo aneurysm
Conservative- if fail - surgical repair or thrombin injection
Anatomical location of SF junction
1-4cm lateral and inferior to pubic tubercle
Trench foot sx and cause
Itching, pain, numbness, tingling
Red then pale then grey
Cold, wet prolonged period
Types of EVAR leaks
Endoleak 1- graft does not seal to vesse leading to flow in aneurysm
2- branch vessels into aneurysm with retrograde flow
EVAR access
Minimally invasive
Femoral artery
Suitability for EVAR
Aneurysm neck angle
DIameter
Distance of common iliac and diatmeter
What stent to use in EVAR with juxta/supra renal aneurysms
Fenestrated graft stent
Burgers disease sx and RF and tx
Rest pain
Raynauds
Painful ulceration
Gangrene
SMoking
Male
<45
Stop smoking - otherwise amputation
Access for ascending vs descending dissections
Median sternotomy - ascending
Left thoracotomy- descending
Mortality of AAA rupture in hospital
50%
What ABPI warrants urgent specialist referral
<0.5
Most common cause of AAA
Atherosclersis
Pt presenting with 9cm AAA on FAST scan what next
If stable CT
After emergency repair
Mx of PAD
Statin 80mg and clopi 75mg
Surgical if- intermittent claudication, critical ischaemia, ulceration, gangrene
Angioplasty for short with good run off
If this fails or not suitable- bypasss
Axilla- if comorbid
Aorta- if not as best patency rates
Critical ischameia definition
Rest pain for > 2w
Presence of ischaemic lesions or gangrene
ABPI <0.5
When are varicose treated
Symptomatic or recurrent varicose veins
Lower‑limb skin changes, such as pigmentation or eczema, thought to be caused by chronic venous insufficiency
Superficial vein thrombosis (characterised by the appearance of hard, painful veins) with suspected venous incompetence
A venous leg ulcer (a break in the skin below the knee that has not healed within 2 weeks)
Mx of varicose veins
Thermal ablation most common -volves heating the vein from inside (via radiofrequency or laser catheters), causing irreversible damage to the vein, resulting in fibrosis and closure of the vein lumen
Sclerotherapy
Surgical
Patient at 15 presents with unilateral lymphedema
Lymphedema Proaecox
