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Y3 Surgery > Vascular > Flashcards

Vascular Flashcards

1
Q

Give 5 risk factors for peripheral artery disease

A
  • smoking
  • diabetes
  • hypertension
  • hyperlipidaemia
  • increased age
  • FHx
  • obesity
  • inactivity
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2
Q

Describe the clinical features of peripheral artery disease

A
  • cramping like pain in calf, thigh or buttocks after walking a fixed distance, releived after standing still/ resting for a minute
  • hairloss
  • skin changes
  • thickened nails
  • weak pulses, pale, cold feet
  • pain at night, relieved by dangling foot out of the bed
  • beurgers angle <20 degrees= severe ischaemia
  • ulceration and gangrene (stage 4)
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3
Q

What is the definition of critical limb ischaemia?

A
  • rest pain going on for 2 weeks despite analgesia or presence of ischaemia lesions or gangrene
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4
Q

give 3 differentials for peripheral vascular disease

A
  • spinal stenosis: pain going down legs on walking variable distances or prolonged standing, relieved by sitting down for 3-10 mins
  • acute limb ischaemia
  • neuropathy
  • sciatica
  • lower limb arthritis
  • MSK strain
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5
Q

How should suspected peripheral artery disease be investigated?

A
  • Bloods: fbc (anaemia will precipitate symptoms), lipids, hba1c, u&e (many need contrast so need renal function check)
  • Ankle brachial pulse pressure index (normal is 1-1.3)
  • duplex USS of lower limb arteries
  • CT w/ contrast (angio) if arterial tree not well visualised on USS or disease is very proximal
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6
Q

How is intermittent claudication managed?

A
  • CVS risk factor modification
  • supervised exercise programme
  • antiplatelet therapy with aspirin or clopidogrel
  • angioplasty if supervised exercise programme as not helped
  • prescribe naftidrofuryl oxalate if they dont want referal for surgery
  • bypass if claudication distance is short and angioplasty fails
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7
Q

Give a complication of peripheral artery disease

A
  • sepsis secondary to infected (wet) gangrene
  • acute on chronic ischaemia
  • amputation
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8
Q

Describe the clinical features of chronic mesenteric ischaemia (usually due to atherosclerosis)

A
  • abdo pain 10 mins - 4hrs after eating
  • weightloss
  • vascular comorbidities
  • loose stool, N+V, generalised tenderness and bruits may also be present
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9
Q

How is chronic mesenteric ischaemia managed?

A
  • antiplatelet
  • CVS risk factor reduction
  • mesenteric angioplasty and stending
  • end arterectomy or bypass less often used
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10
Q

What is the difference between deep venous insufficiency and varciose veins?

A

deep venous insufficiency is when the veins of the deep venous system become incompetent, usually due to DVT or valvular insufficiency

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11
Q

How may deep venous insufficiency present?

A
  • chronically swollen lower limbs
  • aching, pruritis in lower limbs
  • burting pain and tightness on walking which is relieved by elevation
  • venous ulcers (usually medial malleolus)
  • varicose eczema, thrombophelbitis, haemosiderin staining, lipodermatosclerosis
  • post thrombotic syndrome
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12
Q

How is deep venous insufficiency investigated?

A
  • duplex USS and assesment of venous reflux, stenosis and DVT
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13
Q

How is deep venous insufficiency managed?

A
  • compression stockings and analgesia
  • treat ulcers
  • elevate feet where possible to reduce symptoms and disease progression
  • little evidence for valvulopasty of venous stents
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14
Q

What are the 3 types of varicose veins?

A
  • trunk: dilated, tortuous from long or short saphenous vein or their branches
  • reticular: permanently dilated bluish intradermal veins, usually 1-3mm in diameter
  • telangiectasia: a confluence of permanently dilated intradermal veins of less than 1mm in diameter
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15
Q

What are the 3 causes of varicose veins?

A
  • primary/ simple: valvular failure resulting in dilated superficial veins in lower limb
  • secondary: when superficial veins carry reverse flow (which dilates them) as a collateral mechanism compensating for obstructed neighbouring veins
  • AV fistula
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16
Q

What are the most common presenting complaints of varicose veins?

A
  • cosmetic deformity
  • discomfort: localised to vein site, aching, tension, heaviness and itching, particularly if hot or standing long time
  • nocturnal cramps
17
Q

Describe the 4 common skin changes with varicose veins

A
  • varicose eczema: eczema along vein site
  • haemosiderin staining: extravascularised RBCs make the skin browny/ red around the vein
  • lipodermatosclerosis: inflammation leads to skin induration and fibrosis of SC fat
  • Atrophe blanche: white scarring in lower leg due to venous hypertension
  • thrombophlebitis: bruising and pain along vein length due to inflammation
  • also: venous ulcers
18
Q

When should varicose veins be referred to vascular surgeons?

A
  • symptomatic
  • lower limb skin changes
  • superficial vein thrombosis (hard,painful veins)
  • venous leg ulcer (break in skin below knee, not healed in 2 weeks)
19
Q

What are the 2 surgical options fo varicose veins in leicester

A

Open surgery: long saphenous stripping, saphenfemoral disconnection, multiple avulsions
Endovascular laser ablation: of long or short saphenous veins, under local, combined with foam scleropathy to improve cosmetic appearance

20
Q

How may AAA present?

A
  • with rupture: hypotension, shock, LOC, severe central abdo/ back pain
  • asymptomatic, picked up on screening (all men over 65 get an USS)
  • pulsatile masses in abdomen
21
Q

How are non ruptured AAA managed?

A
  • USS/ CT angio
  • if 3-4.5cm, do yearly duplex USS to monitor
  • if 4-5.4 cm 3 monthly USS monitoring
  • when >5.5cm, expanding >1cm a year or symptomatic surgery is considered
  • CVS risk reduction
22
Q

What are the two surgical options for unruptured AAA repair?

A
  • open repair: prosthetic graft is inserteed via midline laparotomy (used in younger pts)
  • endovascular repair: needs 1.5cm normal aorta below renal vessels, lifelong monitoring and more thorough pre op assessment but fewer complications, better survival rate and recovery times.
23
Q

What may cause leg ulcers

A
  • venous disease
  • arterial disease (AV malformations, atheroslcerosis)
  • vasculitis (SLE, RA, scleroderma, wengers)
  • lymphatic insufficiency
  • neuropathic (usually diabetes)
  • haematological (sickle cell)
  • trauma (burns, pressure sore, cold injury)
  • neoplasm (BCC, SCC, melanoma)
  • others: sarcoid, pyoderma
24
Q

Describe the pathophysiology of venous ulcers

A
  • chronic venous hypertension (due to varicose veins, DVT, CVI)
  • get odema in lower limb
  • results in impaired tissue perfusion as oxygen and metabolites have to diffuse greater distances to get to tissue cells
  • become ischaemic when walking
  • then reperfusion injury when rest
  • more inflammation- more odema- more tissue fibrosis
  • ulceration is last after the other skin changes
25
Q

How should venous ulcers be managed?

A
  • 4 layer compression bandaging if arterial circulation is ok
  • leg elevation
  • improve mobility
  • reduce obesity and improve nutrition
  • varicose vein surgery if thats the cause
  • skin grafting in selected pts
  • monitor for infection
26
Q

What are the 6 signs of acute limb ischaemia

A 
pale, pulseless, paraesthesia, perishingly clold, paralysis
acute onset (mins- hrs) if embolic, insidious (hrs- days) if thrombotic
27
Q

What causes acute limb ischaemia

A
  • 60% are thrombosis of atheromatous plaque
  • 30% are emboli from AF, post MI, AAA, prosthetic heat valves
  • 10% untreated compartment syndrome
28
Q

How is an acute limb ischaemia managed?

A
  • arrange, bloods (inc lactate, G&S), ECG, duplex USS, CT angio, urgent vascular review
  • theraputic dose heparin
  • if the limb is viable, there are may interventions they may have: percutaneous catheter directed thrombolysis, surgical embolectomy or endovascular revascularisation
  • if irreversible they need urgent amputation
  • long term they need clopidogrel or aspirin, treat cause and modify RFs
29
Q

How should a DVT be managed?

A
  • wells score- USS or/ and D dimer
  • apixaban for at least 3 months (warfarin w/ LMWH to bridge if DOAC contraindicated)
  • CVS RF modification
  • if cant get USS within 4 hrs, give anticoag for 24 hrs in interim
  • if unprovoked do CXR, FBC, serum calcium, LFTs, urinalysis, examine for cancer +/- CT CAP and mammogram
30
Q

How may carotid artery disease present?

A
  • asymptomatic but bruit picked up
  • TIA (transient cerebral or monocular visual loss)
  • CVA (usually hemisensory/ motor deficit affecting face arm and leg or loss of higher cortical function (dysphagia, neglect))
31
Q

How is carotid artery disease investigated?

A
  • carotid artery duplex USS
  • CT or MRI angio where the artery isnt easy to asses on USS (calcification or thick neck) or if distal/ proximal disease suspected
32
Q

How is carotid disease managed?

A
  • CVS risk factor modification
  • antiplatelets (aspirin or clopidogrel)
  • carotid endarterectomy (if symptomatic severe stenosis as reduces stroke risk, used if pt fit for surgery)

Y3 Surgery (7 decks)

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