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CP3 Surgery > Vascular > Flashcards

Vascular Flashcards

1
Q

List the differential causes of arterial aneurysms (7)

A

V: artherosclerotic
Infective: mycotic endocarditis, tertiary syphilis
Trauma
C/D: berry, ehlers-danlos, marfans

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2
Q

What are the indications for surgery on AAA (3)

What rupture RFs may allow this earlier (4)

A

> 6cm
Expanding >1cm/yr
Symptomatic

Female
HTN
Smoker
FH rupture

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3
Q

What is the main procedure done for AAAs?
What special considerations must be made?
Commonest complication

A

EVAR (endovascular arterial repair)

Need thorough pre-op (cardiac/resp/RENAL problems)
EVAR: Contrast nephrotoxic
Open: prolonged renal ischaemia

Common comp: endoleak

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4
Q

What are some complications of popliteal aneurysms (3)

A

Acute limb ischaemia (rupture/thrombosis/emboli)
Chronic ischaemia (gradual occlusion)
DVT (if inc/ pop vv’s)

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5
Q

What Ix and management are done for popliteal aneurysms

A

USS + Angiogram (pre-op assess distal aa tree)

Distal popliteal aa bypass graft
Intravascular thrombolysis/embolectomy

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6
Q

Outline the Fontaine classification of peripheral arterial disease

A
  1. Asymp
  2. IC
  3. Ischaemic rest pain (critical)
  4. Ulceration/gangrene
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7
Q

What is normal ABPI

What are the diff ABPI thresholds for arterial disease (3)

A

Normal: 0.8–1.2

<0.8 = arterial disease
<0.4 = critical
>1.2 = DM arterial calcification/stiff
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8
Q

What are the causes of peripheral arterial disease (3)

A

Artherosclerosis
Fibromuscular dysplasia (non-inflamm thickening)
Buerger’s

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9
Q

What is Buerger’s disease

What are the RFs (4)

A

Thromboangiitis obliterans = acute inflamm / thrombosis

Male
Young (20-40)
SMOKING***
Middle/Far East

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10
Q

What ABPI are conservative measures taken for IC/Rest pain

Describe these measures (6)

A

ABPI >0.6 = conservative

Lifestyle: Lose wt/ STOP SMOKING
Shoe heel
Foot care (avoid minor trauma)
Control HTN
Control DM
Clopidogrel/atorvastatin
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11
Q

What are the indications for surgical intervention of IC/Rest pain (3)

A

ABPI <0.6
Highly symptomatic (loss of func)
Conservative ineffective

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12
Q

List some life/limb threatening causes in an acutely painful limb (7)

A 
Acute ischaemia
Compartment syndrome
Spinal cord compression
Septic arthritis
Gangrene
Nec Fasc
Sickle cell crisis
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13
Q

What are the diff surgical options for arterial limb disease (4)

A

Percutaneous transluminal angioplasty (balloon/stent)
Bypass reconstruction
Sympathectomy
Amputation

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14
Q

What features appear in diabetic neuropathy of the foot (7)

A 
Dry skin
Corns
Bunions
Callus
Ulcers
Bad toenails
Deformity
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15
Q

How does peripheral neuropathy of lower limb present
With
Without presence of arterial disease

A

With arterial:
Severe ischaemia yet painless
Ulceration / rapid gangrene

W/o arterial:
Stabbing pain
Red/warm
Strong pulses
Not relieved lifting over bed/off floor
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16
Q

Whats the diff b/wn dry + wet gangrene?

A 
Dry = bact not prolif
Wet = bact prolif (emergency)
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17
Q

What Ix are done for ?Ao Dissection

A

ECG – mimicks MI
CXR – widened mediastinum (not sensitive)
CT – Dx

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18
Q

How is aortic dissection managed

A 
A–E
Analgesia
Urgent cardiothoracic advice
ITU control SBP to 100 (IV esmolol)
Type A: surgery if fit
Type B: medically unless comps
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19
Q

List possible complications of aortic dissection (1+6)

A 
Cardiac tamponade (retrograde spread)
Distal arterial blockage:
Coronary – MI
Brachiocephalic – unequal arm pulses / stroke sx
L carotid / L subclav – same
Renal – haematuria/anuria/AKI
SMA/IMA – acute mesenteric ischaemia
Iliac – acute lower limb ischaemia
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20
Q

Outline the management of venous leg ulcers

A

Assess for:
Arterial (ABPI/Doppler)
Infection

Uncomplicated:
Washing + Compression bandaging (2 or 4-layer)
Leg elevation

Infected:
Swab + Dress
Abx (fluclox)

Long-term: compression stockings
Lifestyle / avoid prolonged standing
DM control

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21
Q

List 5 diff types of lower leg ulcers

A 
Arterial
Venous
Neuropathic
Marjolin's (SCC)
Pyoderma gangrenosum
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22
Q

Differentiate arterial / venous ulcers in regards to:

  1. History
  2. Progression
  3. Ulcer features (site/appearance/pain)
  4. Oedema
  5. Skin appearance
A

Arterial:

  1. PMH IHD/IC / HTN / DM
  2. Small but rapid
  3. Lat mall / toes / heels – punched out – v painful
  4. No oedema
  5. Shiny/hairless / cool/pale / atrophic nails

Venous

  1. PMH DVT/VVV / Obese
  2. Slow but large
  3. Med mall / gaiter – shallow / sloughy – painless
  4. Oedema common
  5. Venous insufficiency / red+warm
23
Q

List 5 diff types of lower leg ulcers

A 
Arterial
Venous
Neuropathic
Marjolin's (SCC)
Pyoderma gangrenosum
24
Q

List the features of small bowel ischaemia (4)

A

Post-prandial pain (gut claudication)
PR bleed
Malabsorption
Wt loss (eating painful)

25
Q

List the features of large bowel ischaemia (3)

A

L sided abdo pain
Bloody diarrhoea
Peritonitis / sepsis (tachycardia / WCC / pyrexial) ± shock

26
Q

In acute arterial occlusion of limb (thrombi/emboli)
What are the features of a threatened limb (4)
Features of a non-viable limb (2)

A

Paralysis
Paraesthesia
Pain passively moving limb
Pain squeezing calf

Non-blanching stain (purple/mottled)

27
Q

In acute arterial occlusion of limb (thrombi/emboli)
What are the features of a threatened limb (4)
Features of a non-viable limb (2)

A

Paralysis
Paraesthesia
Pain passively moving limb
Pain squeezing calf

Non-blanching stain (purple/mottled)
Rigid muscles

28
Q

Differentiate b/wn thrombosis / embolus presentations of acute arterial occlusion of limb

  1. Onset
  2. Hx
  3. Source
  4. Pulses
A

Thrombosis

  1. Gradual onset, less severe (collaterals)
  2. H/o arterial disease
  3. No obvious source
  4. Long-standing weak bilateral pulses

Embolus

  1. Sudden onset severe (lack collaterals)
  2. No H/o arterial disease (IC/MI/CVA)
  3. Obvious source (AAA/AF)
  4. Unilateral absent pulse, contralat normal, prev normal
29
Q

Outline the management of acute limb ischaemia (6)

A

A–E resus
IV heparin
Assess limb
Urgent CT angio
Surgery (embolectomy/thrombolysis/bypass/amputation)
Post-op monitoring (reperfusion/compartment)

30
Q

List the causes of an AV fistula (3)

A

Penetrating trauma (commonest)
Neighbouring aneurysm erosion
Iatrogenic (haemodialysis)

31
Q

What are the features of a (non-iatrogenic) AV fistula (5)

A 
Pain / heaviness
Oedema
Prominent vv's
Audible murmur / palpable thrill
S/o CCF (severe)
32
Q

What Ix may be done if suspecting a non-iatro AV fistula (4)

How are they treated?

A

VBG (distal – O2 sats)
Coag
Duplex USS
Contrast CT

33
Q

What Ix/management for:
Chronic small bowel ischaemia
Chronic large bowel ischaemia

A

Small bowel: angiography / angioplasty

Large: 
Contrast enema / AXR (thumb printing)
MR angiography**
Conservative – fluid/abx
Stenting (for severe)
34
Q

Causes of secondary VVVs (4)

A

Prev DVT
Compression (pelvic tumour / preg)
Av fistula
Severe tricuspid incompetence

35
Q

Symptoms of VVV/Deep VV insuffs

A 
Leg tiredness/aching
Nocturnal cramps
Itching
Oedema
Haemosiderin (gaiter)
Atrophie blanche
Lipodermatosclerosis
Ulceration
36
Q

What Ix can be done into VVV/insufficiency (3)

A

Doppler (SFJ/SPJ reflux)
Duplex
Venography

37
Q

What are the indications for managing VVVs? (4)

A

Symptomatic
Grossly dilated
Deep vv insufficiency (e.g. skin changes)
Incompetent perforator valves

38
Q

What are the management options for VVVs (5)

A

Lifestyle (avoid prolonged standing / exercise / lose wt)

Compression stockings (for minor/unfit/preg)

Endothermal ablation (USS laser + thrombose)

Sclerotherapy (foam injected + compression = fibrose)

Surgery (vv stripping / ligate incompetent perforators)

39
Q

What are the complications of VVVs?

A

Haemorrhage (from minor trauma)

Phlebitis (spontaneously/post-sclero)

40
Q

List some other causes for a raised D-dimer in DVT? (4)

A

Pregnancy
Post-op
Malignancy
Infection

41
Q

What are the components of a DVT Well’s score (9)

A 
Malignancy (active/<6m)
Calf swelling >3cm than other
Prominent superficial vvs (non-varicose)
Pitting oedema (> in affected leg)
Swelling of entire leg
Localised pain along deep vv distrib
Immob (paralysis/cast)
Bed rest >3d / Major Surgery (<12wks)
PMH DVT/PE

Alternative Dx just as probable (subtract 2 points)

42
Q

How is a proven DVT managed? + how long these Tx for?

A 
Start together:
LMWH: stop when INR = 2–3
Warfarin:
• Lifelong if recurrent/thrombophilia
• 6m if no obv cause
• 3m if post-op
43
Q

What are the indications for an IVC filter in a DVT?

A

If PE despite anticoag

If bleeding from anticoag

44
Q

List the DDx causes for Reynaud’s sydrome

Cold Temp Makes Cold Digits

A

CTDs (sys sclerosis / SLE/ sjorgen’s / polayarteritis)
Trauma (occupational) (vibration / chem)
Macrovascular (arthero / buerger’s / thoracic outlet)
Cancer / cancer drugs
Drugs (B-blockers / OCP)

45
Q

What features in Reynaud’s may suggest a 2º cause? (4)

A

Dilated nail fold capillaries
Young child / >30
Asymm distrib
Male

46
Q

What Ix may be done into Reynauds?

A

Only do if suspect 2º

FBC (polycythaemia / malig)
ESR
UEs (renal / dehyd)
Urine dip (GN)
ANA (if suspect CTD)
47
Q

What are the causes of 1º/2º lymphoedema?

A

1º – Milroy’s (lymphatic defc)

2º – Filaria infection/Recurrent cellulitis // Malig/Post-op

48
Q

What is the main DDx feature of lymphoedema vs normal oedema

A

Lymphoedema = non-pitting

49
Q

How is lymphoedema managed (4)

A

Elevation
Compression stockings
Physical massage
Long-term Abx (for recurrent cellulitis)

50
Q

What Ix can be done into a non-iatro AV fistula?

How would it be managed?

A

VBG (distal to AVF)
Coag (coagulopathies due to turbulent flow)
Duplex USS
Contrast CT

Surgical Rx / Interventional radiology

51
Q

List the life/limb threatening DDx of leg pain

A 
4 physiological:
• acute ischaemia
• compartment syndrome
• spinal cord compression
• sickle

3 infective:
• gangrene
• nec fasc
• septic arthritis

52
Q

Causes of thoracic outlet obstruction (3)

A

Cervical rib
Healed clavicular #
Excess mm development

53
Q

DDx to thoracic outlet obstrn

A

Cervical Myelopathy

CP3 Surgery (10 decks)

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