Vascular Flashcards
What is the definition of an arterial aneurysm?
Abnormal dilation >150% original diameter of blood vessel due to weakness in the vessel wall
What is the difference between a true aneurysm and a false aneurysm?
True: abnormal dilation of blood vessel
False: collection of blood around the vessel wall communicating with the lumen
What is the meaning of a ‘number needed to screen’ in screening programs
Number of patients who will need to be screened by the programme to prevent one excess death
Why may the number needed to screen be quite high in AAA
Relatively rare disease
AAA 6cm
Next step in management?
> 5.5cm - refer urgently to vascular
Name 2 causes of AAA
Atheromatous degeneration
Connective tissue disorders (e.g. Marfan’s)
List 4 CVD risk factors
Smoking
FH
DM
HTN
Hyperlipidaemia
Increasing age
Male
Name 4 possible complications of AAA surgery
Bleeding
Infection
DVT/PE
MI
a) What factor would make a pt with AAA a candidate for endovascular aneurysm repair as opposed to laparotomy?
b) What are the possible disadvantages of using EVAR?
a) Multiple co-morbidities
b) Long-term follow up, high re-intervention rate
Sudden-onset severe abdominal and back pain, low BP, tachycardic, tender expansile mass
Most important diagnosis to consider? Name 2 other diagnoses
Ruptured AAA
Acute pancreatitis, acute MI
Diagnostic imaging in stable AAA
CT angiogram
Name 2 investigations important in AAA
FBC
Cross-match at least 6 units
Amylase
U&E
ECG
A pt loses 4L of blood intraoperatively
Name 2 blood products that Barry requires
RBC
Fresh frozen plasma
Platelets
2 days post-op, mottled skin and darkened segments in toes - what is this phenomenons name and what is it due to?
Cholesterol embolism - atheromatous debris shed during surgery travels and lodges in distal vessels
Innermost layer to outermost layer, name the 4 layers of an arterial vessel wall
Endothelium (intima)
Tunica media
Tunica externa
Adventitia
Name a cell type that may be present in an aneurysmal wall
Fibroblasts
Macrophages
Lymphocytes
Sudden-onset severe lower leg pain, absent limb pulses
Serious diagnosis to consider?
Acute limb ischaemia
Other than pain, name 4 other symptoms associated with peripheral vascular disease
Pallor
Perishingly cold
Paraesthesia
Paralysis
What are the 2 commonest causes of PVD
Acute thrombosis
Emboli
What 2 treatments can you institute in the interim before surgical treatment in acute limb ischaemia?
High flow oxygen
Analgesia
Heparin infusion
IV fluids
Name 2 possible definitive treatments for acute limb ischaemia
Why must definitive treatment be performed urgently?
Endovascular thrombolysis
Endovascular thrombectomy
Surgical thrombectomy
Endarterectomy
Arterial bypass surgery
Explain how heparin prevents blood clots
activation of anti-thrombin III (inactivates thrombin and factor Xa)
Name 2 potential disadvantages using a heparin infusion
frequent monitoring of APTT and dose adjustment
increased risk of haemorrhage
heparin-induced thrombocytopenia
Burning pain in calf and thigh that develops when walking 50 yards and pt needs to stop and rest until it goes away - name of symptom?
Intermittent claudication
What disease is intermittent claudication a symptom of? What other diseases is he at risk of?
Peripheral vascular disease
Atherosclerotic diseases:
- Stroke
- MI
- Mesenteric ischaemia
- Acute limb ischaemia
Conservative treatment for PVD
Smoking cessation
Weight loss
Diet and exercise
Pain in leg at rest and pt has to hang leg out of bed at night to relieve his pain - symptom of PVD?
Critical ischaemia
Explain 2 possible locations of an arterial stenosis causing impotence and buttock pain
Internal iliac artery
Common iliac
Diagnostic investigations for PVD
ABPI
Doppler duplex
Angiogram
CT/MRI angiogram
1 blood test a pt may undergo before angioplasty and stenting
U&E (IV contrast and renal disease)
clotting (as using arterial puncture)
group and save
glucose, lipids (RFs)
FBC
Guide wire fed from arterial puncture in the common femoral into the aorta - list the arteries it would have to travel through
common femoral
external iliac
common iliac
aorta
What does incidence rate mean?
number of new cases in a given population in a given time frame
Why might the incidence of TIAs be decreasing?
Better AF control with anticoagulation
Better control of CVD RFs
What may an ECG reveal about a TIA
AF
Old infarcts
- both can cause emboli
Name 2 radiological investigations indicated in TIA
MRI head
Carotid doppler
Echo
What criteria make up the ABCD2 score?
Age
Blood pressure
Clinical features (weakness, speech w/o weakness)
Duration (> 60 min)
Diabetes
Pt feels like a curtain fell over left-eye vision which lasted about 10 minutes - name of symptom and what causes it
Amaurosis fugax
Blocking of central retinal artery
Name 2 specific risks of carotid endarterectomy
Death
Major disabling stroke
MI
Wound haematoma
For a carotid endarterectomy, an incision is made anterior to the sternomastoid and the carotids are dissected and clamped - what structures are at risk of damage in this area?
Hypoglossal nerve
Vagus nerve
internal jugular
Why does doing a carotid endartectomy under regional anaesthetic have advantages
Patient can stay awake and respond to command sto look for neurological deficits
Avoids risks of GA
What is the definition of an ulcer?
Abnormal break in an epithelial surface
List 4 possible vascular complications of long-term diabetes
Nephropathy
Retinopathy
Neuropathy
MI
Stroke
PVD
List 4 causes of skin ulceration
Venous disease
Arterial disease
Vasculitis
Infection
Trauma
Neuropathy
Ulcers may be neuropathic or ischaemic - how would you distinguish
Neuropathic: sensory loss
Ischaemia: cold foot and absent pulses
What 2 things can help a pt prevent ulcers
Improve diabetic glycaemic control
Chiropody for callus removal and pressure area care
Education (don’t walk bearfoot, right shoes)
Why must metformin be stopped for 48h before angiogram
It can interact with IV contrast precipitating lactic acidosis
Left-toe ulcer becoming increasingly painful and leaking offensive pus
Principles of management?
Broad-spectrum antibiotics for underlying osteomyelitis
Debridement of dead tissue
Drainage of pus
What should be used for prevention of DVT in surgical patients at high risk of DVT?
LMWH
Compression stockings
Early mobilisation
What are the clinical features of a unilateral DVT?
Swelling and warmth
Redness
Pain
Mild fever
Tachycardia
Pitting oedema
Name 4 risk factors for DVT
Long haul flight
COCP
Immobility
Cancer
Recent surgery
What are the 3 aspects of virchows triad?
Stasis
Vessel damage
Hypercoagulability
Why should a D-dimer be used with caution in DVT?
sensitive but not specific
Investigation warranted if pelvic or lower-limb DVT is suspected
Duplex USS of leg
Treatments for DVT
a) short term
b) long term
a) DOAC (apixaban or rivaroxaban)
b) DOAC, warfarin, LMWH
What are 2 possible complications of complete DVT?
PE, chronic venous insufficiency
Apart from oral anticoagulant therapy, what further mechanical treatment may be possible for DVT
IVCF
List 3 indications for an amputation
gangrene
major trauma
necrotising fasciitis
Name 2 examples of each of the following that are transected in a below-knee amputation: bones, arteries and muscles
Bones: tibia, fibula
Arteries: common peroneal, posterior tibial
Muscles: soleus, gastrocnemius, tibialis anterior
What is important to ensure with regard to the operative site?
Ensure correct limb is marked
Ensure no cellulitis at operative site
Burning pain where the limb used to be after amputation - what is it and what is the bases
phantom limb - hypersensitivity of divided nerves
What sort of medical treatments are available for neuropathic pain?
ADs e.g. amitriptyline
Antiepileptics e.g. gapapentin, carbamazepine
Broadly, what are the main stages of the model of wound healing?
Haemostasis (fibrin plug)
Inflammation (cytokines recruit macrophages - ECM)
Proliferation (angiogenesis and collagen production)
Remodelling (scar tissue)
How do varicose veins arise?
Incompetent valves, dilation of veins - this leads to venous HTN causing worsening valve incompetence and further dilation
List 2 risk factors for varicose veins
Family history
Prolonged standing
Obesity
Pregnancy
Name 2 conditions that may cause varicose veins
Gravid uterus
Ovarian mass
Pelvic tumour
DVT
What skin changes would you look for in varicose veins?
Eczema
Venous ulceration
Oedema
Lipodermatosclerosis
Where is the saphenovenous junction located?
5cm below and medial to femoral pulse
What non-medical interventions could you advise a pt of for varicose veins
Support stockings
Avoid prolonged standing
Weight loss
Regular walking
What complications may arise in long-term varicose veins?
Bleeding
Pain
Ulceration
Psychological
Saphenofemoral ligation and long saphenous tripping
a) what nerve could get damaged?
b) what symptoms would this produce below the knee?
a) Saphenous nerve
b) Loss of sensation and paraesthesia in medial and anterior aspect of calf
Major bleeding - first 3 things to assess
Airway (w/ cervical spine protection)
Breathing
Circulation (haemorrhage control)
What can be done immediately for a life-threatening wound?
Direct pressure to wound
Elevation of wound
a) What are the boundaries of the femoral triangle?
b) What structures are at risk from an injury to this region?
Inguinal ligament, adductor longus, sartorius
Femoral artery, femoral vein, femoral nerve, lymphatics
What signs on examination suggest vascular injury?
Absent or reduced pulses
Expanding or pulsatile mass
Audible thrill over mass
What complications can arise from a vascular injury?
Gangrene
Amputation
12 hours post-op, excruciating pain in leg
Surgical emergency?
Compartment syndrome
Fasciotomy
Medical management of PVD
Antihypertensives
Statin therapy
Antidiabetic therapy if required
Antiplatelets
