vascular Flashcards
how do you define a AAA?
dilatation of the aorta to > 3 cm
what are risk factors for AAA?
atherosclerosis, marfans, ehlos danlos syndrome. inflammatory like takyatsus.
at what size is surgery considered for AAA
> 5 cm
what is the medical management of AAA?
reduction in cardiovascular risk factors? stop smoking, start aspirin and statins. blood pressure control. esercise and weight loss.
what surgical management options are there for repair of AAA?
open with replacement of a prosthetic graft. and endoscopically with endovascular stent graft.
what is the most improtant complication to be aware of post EVAR?
endo leak grade 1 - 5
what are the principle of management of AAA rupture.
management for severe bleeding resusitation but with permissing hypotension < 100
how will someone present having a ruptured AAA? what examination findings do you expect?
abdominal and back pain, nausea and syncope? haemodynamically compromised with a pulsatile abdominal mass.
what layer in an artery can you find arterial dissection?
between the intima and media
What are the consequences of retrograde aortic dissection?
cardiac tamponade and prolapse of the aortic valve.
what are the risk factors for young and old people respectively for aortic dissection?
young connective tissue disorders
old hypertension and atherosclerosis
What are some clinical features of an aortic dissection?
tearing chest pain with tachycardia and hypotension, and a new aortic regurg murmur,
what are signs of end organ hypoperfusion which might be seen in an aortic dissection?
kidneys: reduced UO
intesines: abdominal pain from ischaemia
spinal cord: lower limp paralysis.
Iliacs: lower limb ishchaemia
What initial management would you provide a patient with an aortic dissection?
IV managment and 02 supplmenetation, permissive hypertension < 110
What is the definitive management of aortic dissection
Type A: cardiothoracic surgery
type B: can be managed medicllay , discharge with antihypertensive and serial imaging. Surgical intervention in Type B dissections is only warranted in the presence of certain complications, such as rupture, renal, visceral or limb ischaemia, refectory pain, or uncontrollable hypertension.
What would be the first sign or symtpom of corotid artery disease?
TIA or CVA. may or may not be a bruit.
What is the initial investigations for a patient presenting with a CVA?
bloods including clotting, lipids and glucose.
ECG
CT head and then CT A if this is showing an infarction.
What follow up investigations are necessary post CVA or TIA?
carotid artery USS which can be followed up by CT angiography
what is the acute diagnosis of a patient with a stroke
F: face
A: arms
S: Speech
T: time (call for help)
what is the initial managenent of a patient with a stroke?
high flow oxygen
glucose optimised
NBM until swallow assesssment.
ischaemic stroke: consider thrombllysis with alteplase or 300mg PR aspirin. or thrombectomy
haemaohhgic stroke: refferal to neurosurgery for consideration of clot retrieval
When should someone be considered for a carotid end arterectomy?
if they have had a TIA and their occlusion is > 50%
what are the risks of carotid end arterectomy?
CVA, damage to the hypoglossal, vagus or glossopharyngeal nerves.
what is the most common aetiology for thoracic aortic aneurysm?
connective tissue disease and bicuspid aortic valves.
What category of acute limb ischaemia is salvagable if immeidately revascularised and what are the clinical findings?
Rutherfrd 2B. sensory deficit to toes only, the rest is pain only , mild to moderate motor deficit and pulses are inaudible.
When taking the history of a person with critical limb ischaemia which essential questions should you ask?
claudication when and how far? pain at rest and relieving features like handing foot over bed, embolis phenomena like AF or IE recent MI, any aneurysms?
whatimaging modalaties canbe helpful in identifying an acute ischaemia limb?
USS doppler but CT angiography is better because it will help to know the location of the obstruction to know where to operate, femoral vs popliteal incision.
complete arterial occlusion will lead to irreversible tissue damage in how many hours?
6
Once a diagnosis is made of an acutely ischaemic limb what initial managment do you provide?
02, IVH and PIVC, bloods need to be taken, give heparin infusion.
which rutherford grades are suitable for initial conservative management? and what treatment is recommended?
rutherford 1 and 2a and give a heparin infusion.
What surgical intervention options are available for a rutherford 2F?
emboliectomy, bypass, angioplasty,
What is the treatment for irreversible limb ischaemia?
amputation or palliation?
what complications can occur post re-perfusion?
re-perfusion injury can cause acidosis from H+ ions, hyperkalaemia from K, myoglobinuria and AKI and compartment syndrome
what are 4 common causes for mesenteric ischemia?
thrombsis in situ: atherosclerosis of the mesenteric artery
emoblism in situ: embolic source from elsewhere.
non-occlusive cause: hypovolaemic or cardiogrenic shock
venous occlusion: mesenteric venous thrombus coagulopathy, malignancy autoimmuni disorders.
what is the initial management of mesenteric ischaemaia?
IVH and monitoring with IDC
broad spectrum antibiotics because of transudate
refer to ICU
what is the definitive management for bowel ischaemia ?
laparotomy and excision of dead bowel with covering loop or end stoma.
thrombectomy or thyrobolysis of the affected blood vessel
What are complications of treatment for ischaemic bowel?
perforation, short gut,
What Ankle Brachial pressure woudl indicate severe arterial disease?
< 0.5
What is a complication of chronic limb ischaemia
Sepsis (Secondary to infected gangrene)
acute on chronic ischaemia
risk of amputation
reduced mobility and reduced QoL
What are some clinical features of chronic mesenteric ischaemia?
other signs of PVD
post prandial pain
weight loss from malnutrition
What is the gold standard imaging modality to diagnose a pseudoaneurysm and what would you find?
Duplex ultrasound and a yin-yang doppler profile
What minimally invasive treatment option is available for treatment of pseudoaneurysm?
injection of thrombin into the psuedoaneurysm, this works best for ones with long thin necks.
What is a marjolins ulcer?
a type of SCC which grows at the edge of a chronic venous ulcer (from severe recurrent inflammation) easy bleeding on contact, non healing, may be painful .
What is the clinical manifestation of subclavian steel syndrome and what is it caused from?
patient presents with syncope and neurological defecits from a proximal stensosi in the subclavian artery, usually on the left. the increased blood demand in the limb leads to reverse blood flow from the vertebrial artery
Common causes of subclavian steel syndrome?
commonly atherosclerosis but can also be vasculitis or thoracic outflow obstruction from a cervical rib.
What is thoracic outlet syndrome?
thoracic outlet syndrome is a term given to compression of the neurovascular bundle as it comes through the thoracic outlet. These can be venous, arterial or nervous tissues.
What causes thoracic outlet syndrome?
most common cause is bony obstruction from a cervical rib coming out of C7. can also be from repeditive stress injuries over head movements or hyperextension.
What is the pathophysiology of thoracic outlet syndrome?
brachial plexus and the subclavian artery pass through the scalene triangle posterior to the anterior scalene and the subclavian vein passes anteriorly. Compression of the brachial plexus on the medial scalene or bony promemence typically irritates the lower cord in an ulnar nerve distribution.
Which endoscopic AAA repair options have a higher risk of bowel and kidney ischaemia
branched or fenestrated EVAR
What are key things to consent for in EVAR
catastrophic damage to the AAA requiring open conversion
damage to groin nerves
late complications
Endo leak - possibly from migration
limb occlusion - ischaemic limb
erecrile dysfunction
may require re-intervention
OPen AAA repair consent
All the normal open surgery things but
haemohhrage risk high, will use cell saver, high likelyhood will need blood.
damage to surrounding structures.
bowel ischaemia: the IMA is excluded from this operation and collaterals need to exist.
late
the graft may become occluded, may require re-intervention,
impotence
consent for a femoral endarterectomy
haemohhrage, damage to surrounding structures like the femoral nerve or vein, compartment syndrome. groin incision problems. may re-accumulate and require a re-do in the future
post embolectomy one key thing to look out for in recovery
compartment syndrome
What specifi things do you discuss with AAV fistula formation?
failure to mature, steal syndrome,
how can you reduce the risk of compartment syndrome?
elevation of the limb, not too much pressure on it in a cast, act quickly is thinking compartment syndrome. .
