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Yr3 - General Surgery > Vascular > Flashcards

Vascular Flashcards

1
Q

What should an acutely painful limb that is cold and pale be treated as?

A

Acute limb ischaemia

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2
Q

What is acute limb ischaemia associated with?

A

6 Ps

  • pain
  • pallor
  • pulselessness
  • paresthesia
  • perishingly cold
  • paralysis
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3
Q

Risk factors of acute limb ischaemia

A 
Atrial fibrillation
Hypertension
Smoking
Diabetes mellitus
Recent myocardial infarction
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4
Q

Investigation for acute limb ischaemia

A

CT angiogram

Urgent vascular review

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5
Q

Treatment for acute limb ischaemia

A

Surgical emergency - irreversible tissue damage occurs in 6 hours
Sufficient resuscitation
IV heparin

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6
Q

What should be considered in a sudden onset hot and swollen limb?

A

Deep vein thrombosis

Cellulitis

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7
Q

Presentation of DVT

A

Sudden onset hot swollen limb
Pain localised to calf
Calf tenderness and firmness
History or family history or pro-thrombotic disease

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8
Q

Treatment for DVT

A

Therapeutic doses of Low-Molecular Weight Heparin

Long-term anticoagulation

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9
Q

Neurological causes of acute painful limb

A

Radiculopathies - back pain that radiates to affected area and worse on movement
Central - MS
Spinal - disc herniation
Peripheral - infective or traumatic

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10
Q

Define an ulcer

A

Break in skin or mucous membranes

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11
Q

Common causes of lower limb ulcers

A

Venous insufficiency
Arterial insufficiency
Diabetic-related neuropathy
Pressure ulcers

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12
Q

Features of a venous ulcer

A 
Shallow with irregular borders
Granulating base
Associated
- varicose veins
- oedema
- thrombophlebitis
- lipodermatosclerosis
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13
Q

Risk factors for a venous ulcer

A 
Increasing age
Pre-existing venous incompetence or history of thromboembolism
- varicose veins
Pregnancy
Obesity or physical inactivity
Severe leg injury or trauma
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14
Q

Investigations for venous ulcers

A

Dulpex ultrasound - diagnose venous insufficiency
Ankle-brachial pressure - determine whether pressure therapy suitable
Swab cultures

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15
Q

Management of venous ulcers

A 
Leg elevation
Increased exercise
Lifestyle changes
- weight reduction
- improved nutrition
Antibiotics - evidence of infection
Mulitcomponent compression bandaging
Surgical treatment of varicose veins
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16
Q

Features of arterial leg ulcers

A 
Small deep lesion
Well-defined borders
Necrotic base
Associated
- intermittent claudication or critical limb ischaemia
- cold limbs with absent pulses
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17
Q

Risk factors for arterial ulcers

A 
Peripheral arterial disease
- smoking
- diabetes
- hypertension
- hyperlipidaemia
Increasing age
Obesity
Physical inactivity
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18
Q

Management of arterial ulcers

A 
Lifestyle changes
- smoking cessation
- weight loss
- increased exercise
Medical
- statin therapy
- antiplatelet - aspirin or clopidogrel
- optimisation of blood pressure and glucose
Surgical
- angioplasty
- bypass grafting
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19
Q

Risk factors for neuropathic ulcers

A

Diabetes mellitus

B12 deficiency

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20
Q

Clinical features of neuropathic ulcers

A

History of peripheral neuropathy
Punched out appearance
Glove and stocking distribution
Warm feed and good pulses

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21
Q

Investigations for neuropathic ulcers

A

Blood glucose levels - random glucose or HbA1c
Microbiology swab - deep infection
X-ray - osteomyelitis

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22
Q

Management of neuropathic ulcers

A

Diabetic control optimised
Improved diet and increased exercise
Regular chiropody to maintain good foot hygiene

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23
Q

Define carotid artery disease

A

Build-up of atherosclerotic plaque in one or both common and internal carotid arteries -> stenosis or occlusion

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24
Q

Stages of carotid artery disease

A

Fatty streak
Lipid core
Fibrous cap

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25
Q

Risk factors of carotid artery disease

A 
Age - > 65 years
Smoking
Hypertension
Hypercholesterolaemia
Obesity
Diabetes mellitus
History/family history of cardiovascular disease
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26
Q

Clinical features of carotid artery disease

A

Asymptomatic
TIA
Stroke
Carotid bruit auscultated in neck

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27
Q

Investigations of carotid artery disease

A

Urgent non-contrast CT head - evidence of infarction
Bloods - FCS, U&Es, clotting, lipid profile and glucose
ECG - AF
Duplex ultrasound scans
CT angiography

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28
Q

Management of carotid artery disease

A

Acute
- high flow O2
- blood gluose optimisation
- ischaemic stroke - IV alteplase + aspirin
- haemorrhagic stroke - coagulopathy
- thrombectomy
Long Term
- anti-platelet - aspirin then clopidogrel
- statin - high-dose atorvastatin
- management of hypertension and/or diabetes mellitus
- smoking cessation
- regular cardiovascular exercise + active lifestyle + weight loss
- cardiac endarterectomy

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29
Q

Define an aneurysm

A

Abnormal dilation of a blood vessel by more than 50% of its normal diameter

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30
Q

Define an AAA

A

Abdominal Aortic Aneurysm

Dilation of the abdominal aorta greater than 3cm

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31
Q

Risk factors for AAA

A 
Smoking
Hypertension
Hyperlipidaemia
Family history 
Male gender
Increasing age
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32
Q

Clinical features of AAA

A 
Many asymptomatic - incidental finding or screening
Abdominal pain
Back or loin pain
Distal embolisation -> limb ischaemia
Pulsatile mass
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33
Q

Who is eligible for AAA screening in the UK?

A

Men over 65 years

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34
Q

How is AAA screening performed?

A

Abdominal US scan

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35
Q

Investigations for AAA

A

USS

CT scan with contrast

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36
Q

Medical management of AAA

A 
Less than 5.5cm monitored via Duplex USS
- 3-4.4cm - yearly
- 4.5-5.4cm - 3 monthly
Smoking cessation
Improve blood pressure control
Commence statin and aspirin therapy
Weight loss and increased exercise
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37
Q

Criteria for surgical management of AAA

A

AAA > 5.5cm
AAA expanding at > 1cm/year
Symptomatic AAA

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38
Q

Surgical management of AAA

A

Open repair - laparotomy and prosthetic graft

Endovasuclar repair - introduce graft via femoral arteries

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39
Q

Complications of AAA

A

Rupture
Retroperitoneal leak
Embolisation
Aortoduodenal fistula

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40
Q

Presentation of ruptured AAA

A 
Abdominal pain
Back pain
Syncope
Vomitting
Haemodynamically compromised on examination with puslatile abdominal mass
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41
Q

Management of ruptured AAA

A 
High flow O2
IV access
Urgent bloods + crossmatch
Keep BP <100mmHg - reduce risk of further bleeding
Open surgical repair
CT angiograom - endovascular repair
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42
Q

Define aortic dissection

A

Tear in intimal layer of the aortic wall - blood flows between and splits apart the tunica intima and media

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43
Q

Describe the DeBakey classification of aortic dissection

A

Type 1 - originated in the ascending aorta and propagates to the aortic arch
- under 65s
- highest mortality
Type 2 - confined to ascending aorta
- elderly pts with atherosclerotic disease and hypertension
Type 3 - orginates distal to the subclavian artery in the descending aorta

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44
Q

Describe the Stanford classification of aortic dissection

A

Group A - involved ascending aorta and can propagate to aortic arch and descending aorta
Group B - Do not involve ascending aorta

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45
Q

Risk factors for aortic dissection

A 
Hypertension
Atherosclerotic disease
Male gender
Connective tissue disorders
- Marfan's syndrome
- Ehler's Danlos syndrome
Bicuspid aortic valve
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46
Q

Clinical features of aortic dissection

A

Tearing chest pain - radiates through back
Tachycardia
Hypotension
New aortic regurgitation murmur

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47
Q

Investigations for aortic dissection

A 
Baseline bloods - crossmatch at least 4 units
ABG
ECG - exclude cardiac pathology
CT angiograpm
Transoeophogeal ECHO
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48
Q

Management of aortic dissection

A

High flow O2
IV access - fluid resuscitation cautiously
Stanford Type A = surgical managment
Uncomplicated Stanford Type B = medical management
Antihypertensive therapy
Surveillance imaging

49
Q

Management of Standord Type A aortic dissection

A

Transfer to cardiothoracic centre
Removal of ascending aorta
Replacement with synthetic graft

50
Q

Management of uncomplicated Stanford Type B aortic dissections

A

Management of hypertension
- IV beta blockers - labetalol
Only surgical if presence of complications

51
Q

Complications of aortic dissection

A

Aortic rupture
Aortic regurgitation
Myocardial ischaemia - secondary to coronary artery dissection
Cardiac tamponade
Storke or paraplegia - secondary to cerebral or spinal artery involvement

52
Q

How to thoracic aneurysms form?

A

Degradation of tunic media
Loss of structural integrity
Dilation

53
Q

Causes of thoracic aneurysms

A 
Connective tissue diseases
- Marfan's syndrome
- Ehlers-Danlos syndrome
Bicuspid aortic valve
Trauma
Aortic dissection
Aortic arteritis
Tertiary syphilis
54
Q

Risk factors for thoracic aneurysms

A 
Family history
Hypertension
Atherosclerosis
Smoking
High BMI
Male gender
Advancing age
55
Q

Clinical features of thoracic aneurysms

A

Typically asymptomatic - incidental findings
Pain
- anterior chest - ascending aorta
- neck - aortic arch
- between scapulae - descending arch
Back pain - spinal compression
Hoarse voice - damage to left recurrent laryngeal nerve
Distended neck veins
Symptoms of heart failure
Dyspnoea or cough - tracheal or bronchial compression

56
Q

Investigations for thoracic aneurysms

A

Diagnosed through imaging
- seen on CXR but not sensitive enough to diagnose
- CT chest with contrast
Transoesophageal echocardiography

57
Q

Management for thoracic aneurysms

A 
Medical
- statin and antiplatelet therapy
- blood pressure controlled
- smoking cessation
Surgical
- dependent on location
58
Q

Define acute limb ischaemia

A

Sudden decrease in limb perfusion that threatens the viability of the limb

59
Q

Classificaiton of acute limb ischaemia

A

Embolisation - thrombus from proximal source travels distally to occlude the artery
Thrombosis in situ - atheroma plaque in the artery ruptures and thrombus forms on plaque’s cap
Trauma - compartment syndrome

60
Q

Clinical features of acute limb ischaemia

A

Sudeen onset of

  • Pain
  • Pallor
  • Pulselessness
  • Paresthesia
  • Perishingly cold
  • Paralysis
61
Q

Causes of potential embolisation

A 
Chronic limb ischaemia
AF
Recent MI
Symptomatic AAA
Peripheral aneurysms
62
Q

Investigations for acute limb ischaemia

A

Routine bloods - serum lactate
ECG
Doppler ultrasound scan
CT angiography

63
Q

Initial management of acute limb ischaemia

A

Surgical emergency - irreversible tissue damage withing 6 hours
High flow oxygen
Therapeutic dose heparin or bolus dose then heparin infusion

64
Q

Conservative management of acute limb ischaemia

A

Prolonged course of heparin

Regular assessment

65
Q

Surgical management of acute limb ischaemia

A 
Embolectomy
Local intra-arterial thrombolysis
Bypass surgery
Angioplasty
Irreversible limb ischaemia requires urgent amputation
66
Q

Long term managment of acute limb ischaemia

A 
Reduction of cardiovascular mortality risk
Change lifestyle
- regular exercise
- smoking cessation
- weight loss
Anti-platelet
- apsirin
- clopiderogrel 
Resulting amputation
- occupation therapy
- physiotherapy
- long term rehabilitation plan
67
Q

Complications of acute limb ischaemia

A

Reperfusion injury - sudden increase in capillary permeability

  • compartment syndrome
  • release of substances from damaged muscle cells - hyperkalaemia, acidosis and myoglobin (AKI)
68
Q

Define chronic limb ischaemia

A

Peripheral arterial disease that results in symptomatic reduced blood supply to the limbs]
Typically caused by atherosclerosis

69
Q

Risk factors for chronic limb ischaemia

A 
Smoking
Diatbetes mellitus
Hypertension
Hyperlipidaemia
Increasing age
Family history
Obesity and physical inactivity
70
Q

Clinical features of chronic limb ischaemia

A

Stage I = asymptomatic
Stage II = intermittent claudication
Stage III = ischaemic rest pain
Stage IV = ulceration or gangrene

71
Q

Describe Buerger’s test

A

Lie pt supine and raise legs until they go pale and lowering them until colour returns
Buerger’s angle = angle at which limb goes pale
- less than 20 degrees = severe ischaemia

72
Q

Define critical limb ischaemia

A 
Advanced from of chronic limb ischaemia
Clinically defined by
- ischaemic rest pain for greater than 2 weeks duration
- presence of ischaemic lesions
- ABPI less than 0.5
73
Q

Investigations for chronic limb ischaemia

A

Ankle-Brachial Pressure Index
Doppler ultrasound
CT angiography

74
Q

Medical management of chronic limb ischaemia

A 
Lifestyle advice
- smoking cessation
- regular exercise
- weight reduction
Statin therapy
Anti-platelet therapy
Optimise diabetes control
75
Q

Surgical management of chronic limb ischaemia

A

Angioplasty
Bypass grafting - diffuse disease or younger pts
Amputation - ischaemia causing incurable symptoms or gangrene leading to sepsis

76
Q

Complications of chronic limb ischaemia

A

Sepsis
Acute-on-chronic ischaemia
Amputation
Reduced mobility and quality of life

77
Q

Define acute mesenteric ischaemia

A

Sudden decrease in blood supply to the bowel

Resulting in bowel ischaemia, rapid gangrene and death

78
Q

Common causes of acute mesenteric ischaemia

A

Thrombus-in-situ - Acute Mesenteric Arterial Thrombosis - AMAT
- atherosclerosis
Embolism - Acute Mesenteric Arterial Embolism - AMAE
- cardiac causes
- abdominal/thoracic aneurysm
Non-occlusive cause - Non-Occlusive Meseneteric Ischaemia - NOMI
- hypovolaemic shock
- cardiogenic shock
Venous occlusion and congestion - Mesenteric Venous Thrombosism - MVT
- coagulopathy
- malignancy
- inflammatory disorders

79
Q

Clinical features of acute mesenteric ischaemia

A

Generalised abdominal pain
N+V
Examination unremarkable

80
Q

Investigations for acute mesenteric ischaemia

A 
ABG - serum lactate and acidosis
Routine bloods
CT scan with IV contrast
- oedematous bowel
- loss of bowel wall enhancement
- pneumatosis
81
Q

Management of acute mesenteric ischaemia

A

Surgical emergency - urgent resuscitaiton
- IV fluids
- catheter
- fluid balance chart
Broad-spectrum antibiotics - risk of faecal contamination
Excision of necrotic or non-viable bowel
Revascularisation of bowel

82
Q

Complications of acute mesenteric ischaemia

A

Bowel necrosis
Bowel perforation
Short gut sydrome - post-op

83
Q

Define chronic mesenteric ischaemia

A

Reduced blood supply to the bowel which gradually decreases over time
Result of atherosclerosis in coeliac trunk, SMA or IMA

84
Q

Risk factors for chronic mesenteric ischaemia

A

Smoking
Hypertension
Diabetes mellitus
Hypercholesterolaemia

85
Q

Clinical features of chronic mesenteric ischaemia

A

Postprandial pain
Weight loss - decreased calorie intake and malabsorption
Concurrent vasuclar co-morbidities
Examination findings non-specific

86
Q

Investigations for chronic mesenteric ischaemia

A

Blood tests
Anaemia may be confounding symptoms
CT angiography

87
Q

Management of chronic mesenteric ischaemia

A 
Modify risk factors
- smoking cessation
- anti-platelet and statin therapy
Mesenteric angioplasty with stenting - endovascular
Endartectomy or bypass - open
88
Q

Complications of chronic mesenteric ischaemia

A

Bowel infarction

Malabsorption

89
Q

Investigations for peripheral and visceral aneurysms

A

CT angiography
MR angiography
US duplex scans

90
Q

Management for peripheral and visceral aneurysms

A 
Watchful waiting whilst optimising medical therpay
- antiplatelet + statin
- smoking cessation
Surgical intervention
- endovasuclar
- open
91
Q

Presentation of popliteal aneurysm

A 
Symptomatically
- acute limb ischaemia
- intermittent claudication
Incidentally
Compression symptoms on popliteal vein or nerve
92
Q

Causes of femoral artery aneurysms

A

Percutaneous vascular interventions

Patient self-injecting

93
Q

Risk factors for splenic artery aneurysm

A

Female sex
Multiple pregnancies
Portal hypertension
Pancreatitis

94
Q

Presentation of splenic artery aneurysm

A

Vague epigastric or LUQ pain

95
Q

Causes of hepatic artery aneurysm

A

Percutanous instrumentation
Trauma
Degenerative disease
Post-liver transplant

96
Q

Presentation of hepatic artery aneurysm

A

Asymptomatic
Vague RUQ or epigastric pain
Jaundice - if biliary obstruction

97
Q

Presentation of renal artery aneurysm

A

Asymptomatic - incidental finding
Haematuria
Resistant hypertension
Loin pain

98
Q

Define varicose veins

A

Tortuous dilated segments of vein associated with vascular incompetence

99
Q

How do varicose veins form?

A

Incompetent valves - blood flow from deep to superficial venous system
Venous hypertension and dilation of superficial venous system

100
Q

Causes of varicose veins

A 
Idopathic - 98%
Deep vein thrombosis
Pelvic masses
- pregnancy
- uterine fibroids
- ovarain masses
Arteriovenous malformations
101
Q

Risk factors for varicose veins

A

Prolonged standing
Obesity
Pregnancy
Family history

102
Q

Clinical features of varicose veins

A

Usually present with cosmetic issues - unsightly visible veins or discolouration of skin
Pain, aching, swelling and itching - often worse at end of day
Varicosites present in course of great/short saphenous veins
Features of venous insufficiency
Saphena varix

103
Q

Investigations for varicose veins

A

Duplex ultrasound - assess valve incompetence

104
Q

Management of varicose veins

A

Patient eduction
- weight loss
- avoid prolonged standing
- increase exercise
Compression stockings - if interventional treatment not appropriate
Four-layer bandaging for venous ulceration

105
Q

Indications for surgical treatment of varicose veins

A

Symptomatic primary or recurrent
Lower-limb skin changes
Superficial vein thrombosis - hard painful veins
Venous leg ulcer

106
Q

Surgical management of varicose veins

A

Vein ligation, stripping and avulsion
Foam sclerotherapy - inflammatory response closes of vein
Thermal ablation

107
Q

Complications of varicose veins

A 
Worsen over time
Re-intervention
Post-op
- haemorrhage
- thrombophlebitis
- DVT
- disease recurrence
- nerve damage
108
Q

Causes of deep venous insufficiency

A 
Primary - underlying defect to vein wall or valvular compenent
- congenital defects
- connective tissue disorders
Secondary 
- post-thrombotic
- post-phlebitic
- venous outflow obstruction
- trauma
109
Q

Risk factors for DVI

A 
Increasing age
Female gender
Pregnancy
Previous DVT
Obesity
Smoking
Long periods of standing
Family history of venous disease
110
Q

Clinical features of DVI

A 
Chronically swollen lower limbs
Aching, painful and pruritic
Venous claudication - bursting pain and tightness on walking
Varicose eczema
Thrombophlebitis
Haemosiderin
Skin staining 
Lipodermatosclerosis
Atrophie blanche
111
Q

Investigations for DVI

A

Doppler ultrasound scan - assess for the extent of venous reflux
Documentation of foot pulses
ABPI

112
Q

Management of DVI

A

Conservative
- compression stockings
- suitable analgesic control
Surgical management less successful

113
Q

Define thoracic outlet syndrome

A

Clinical features that arise from compression of the neurovascular bundle within the thoracic outlet

114
Q

Pathophysiology of thoracic outlet syndrome

A

Rib anomalies - cervical ribs and costoclavicular ligament
Muscular anomalies - repetitive stress and hyperextension can cause acute spasm of scalene muscles, haemorrhage or swelling of scalene muscles -> narrowing of thoracic outlet
Result of injury - clavicular fractures can cause extra bone formation

115
Q

Risk factors of thoracic outlet syndrome

A

Recent trauma
Repetitive motion occupations
Athletes
Anatomical variations

116
Q

Clinical features of thoracic outlet syndrome

A 
Symptoms worsen on certain movements
Paraesthesia and/or motor weakness
Deep vein thrombosis 
Extremitiy swelling
Claudication 
Acute limb ischaemia 
Weakness and numbness
117
Q

Investigation for thoracic outlet syndrome

A 
CXR - bony abnormalities
Venous and arterial duplex ultrasound
CT imaging
Venogram
Nerve conduction studies
118
Q

Management for thoracic outlet syndrome

A 
Treatment only indicated in symptomatic patients
- physio
- weight loss
- botulinum toxin A injection
Thrombolysis 
Anti-coagulation
Surgical decompression
119
Q

Complications of thoracic outlet syndrome

A

Permanent nerve damage
Aneurysm dilation of subclavian artery leading to embolisation
Loss of limb function

Yr3 - General Surgery (17 decks)

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