Vascular Flashcards
What are the usual indications, in an otherwise fit person, for considering them for repair of an abdominal aortic aneurysm?
Indications include: AAA diameter >5.5cm in males, >5 cm in females AAA growth of >0.5cm/year Leaking/rupture of aneurysm Saccular aneurysm
What are the features of a patient who presents with a rupturing Abdominal Aortic Aneurysm?
Triad of AAA includes: haemodynamic instability, acute severe abdominal pain radiating to the back, pulsatile abdominal mass.
Risk factors include age >65, HTN, hyperlipidaemia, smoking, FHx, vascular disease
Anterior aneurysm is considered more dangerous
A 68 year-old man presents to ED with a one hour history of pain in the left side of his abdomen and mid back. It started suddenly, has not moved, and is getting worse. It is the worst pain he has experienced. He has a history of stable angina, managed with beta blockers and nitrates. On examination, he is pale, sweaty, has a pulse of 110 bpm, blood pressure of 100/65 mmHg, normal chest and cardiac exam. Abdominal exam reveals a tender mass in the epigastrium, which is pulsatile and expansile, peripheral pulses and neuro exam are normal. What is the diagnosis?
What investigations and treatments are needed?
Diagnosis is ruptured AAA.
Do not delay time to theatre
USS, Bloods (FBC, UEC, LFT, coags)
CT
Treatment is an urgent laparotomy with closure of the AAA. Aorta is clamped both distally and proximally to the aneurysm
What are the treatment options for an otherwise fit 75 year-old man who has been found to have a 6cm AAA (abdominal aortic aneurysm) on routine screening?
AAA is >5.5 cm, therefore it is indicated for repair.
Treatment options include: no treatment. Lifestyle modification
Surgical repair with endovascular stent placement or with resection of the aneurysm.
EVAR is unable to be performed of located within 15mm of the renal arteries
What are the common complications of endovascular (stent) repairs of abdominal aortic aneurysms?
Intra-operative -> perforation of vessels, anaesthetic reaction, haemorrhage, AKI, MI
Post-operative -> stent displacement, failure of stent, infection, SSI, sepsis, atelectasis, pain, seroma, embolism formation
What are the main indications for carotid endarterectomy (CEA, carotid surgery)?
Indications for carotid endarterectomy include:
>70% stenosis, symptomatic with >50% stenosis, >5 year survival. No contraindications (bilateral occlusions, previous neck radiation)
A 71 year-old man presented to the ED with weakness and numbness in his left arm. These symptoms started suddenly two hours ago. His vision was not affected, and the numbness and weakness is getting better. He has no other symptoms, he is a lifelong smoker. Physical exam is normal, other than the numbness. What is the likely diagnosis?
What investigations are needed?
TIA
Bloods -> FBC, UEC, LFT, coags, lipids
USS (doppler), CT angiography
ECG
Examination neurology and CN
Initial treatment of:
aspirin, monitoring, USS, treatment if required.
A 71 year old man presents to the ED with weakness and numbness in his left arm. These symptoms started suddenly two hours ago. His vision was not affected, and the numbness and weakness is getting better. He has no other symptoms, he is a lifelong smoker. Physical exam is normal, other than the numbness. What is the likely diagnosis?
What are the risk factors for this disease?
TIA
Risk factors include:
Smoking, alcohol, sedentary lifestyle, diet, DM, male, FHx, AF, valvular heart disease, PFO
A 65 year-old man presents to the ED with an eight hour history of severe, generalised abdominal pain. Earlier in the day he passed fresh blood in his stool, there is no previous episodes of blood PR. His medical history included AF, diabetes mellitus and hypertension. He is a long term smoker. He is restless with pain. His pulse is 110 irregularly irregular. His BP is 90/50 mmHg. His temperature is 37.5°C. Abdominal examination shows acute pain but a soft, non-rigid abdomen. Rectal exam shows fresh blood mixed into normal stools. His venous blood tests show a normal Hb, slightly raised white cell count (neutrophilia), a moderately raised CRP at 40, a near normal amylase and the rest are normal. His arterial blood gases show a pH of 7.29, lactate of 9.4 and base deficit of - 6.5, and a PaCO2 of 3.5. What does the arterial blood gas show?
What is the most likely diagnosis?
What are reasonable differential diagnoses?
ABG shows metabolic acidosis with a high lactate.
The most likely diagnosis for this man is ischaemic gut, caused by a thrombus resulting from his AF becoming lodged in the SMA of the bowel. This ischaemia is resulting in metabolic acidosis and pain. Bleeding is from breakdown of the mucosa and submucosa due to ischaemia. Perforation has not yet occured .
Reasonable DDx include colitis, Crohn’s, torsion of mesentery, AAA
A 65 year-old man presents to the ED with an eight hour history of abdominal severe, generalised abdominal pain. Earlier in the day he passed fresh blood in his stool, there is no previous episodes of blood PR. His medical history included AF, diabetes mellitus and hypertension. He is a long term smoker. He is restless with pain. His pulse is 110 irregularly irregular. His BP is 90/50 mmHg. His temperature is 37.5°C. Abdominal examination shows acute pain but a soft, non-rigid abdomen. Rectal exam shows fresh blood mixed into normal stools. His venous blood tests show a normal Hb, slightly raised white cell count (neutrophilia), a moderatley raised CRP at 40, a near normal amylase and the rest are normal. His aterial blood gases show a pH of 7.29, lactate of 9.4 and base deficit of - 6.5, and a PaCO2 of 3.5. What does the arterial blood gas show?
What is the most likely diagnosis?
How should he be managed?
Metabolic acidosis
Ischaemic gut
Manage with analgesic, fluid resuscitation, ABCDE, NG decompression
Urgent laparotomy to resect necrotic bowel.
Inform the family of high morbidity with this procedure
Bowel takes 4-6 hours to necrose.
You are the ED intern on duty. You are asked to see and treat a 75 year-old man who has presented with sudden onset of pain in his left leg. On examination he has a left cold leg from mid thigh downwards with no palpable pulses below the femoral pulse. His right leg is normal. What are you going to do?
DDx of ischaemic limb.
Appropriate analgesia, ABCDE
Pain, pallor, poilikothermia, pulselessness, paraesthesia, paralysis
USS doppler, CT angiography, Bloods, ABPI
Referral to surgery for endovascular clot retrieval or open removal
Heparin management, thrombolysis, or amputation are other options
You are the ED intern on duty. You have seen a 75 year-old man with a painful left leg of sudden onset. He has a cardiac history (AF and hypertension) and he smoked for 60 years. On examination he has a left cold leg from mid thigh downwards with no palpable pulses below the femoral pulse. His right leg is normal. What is the likely diagnosis, what may have caused it and what are you going to do?
DDx of thrombus resulting in ischaemic limb. AF resulting in clot formation has occluded an artery in his leg.
Referral to vascular surgeon. Options include thrombolysis, anticoagulation, surgical revascularisation or amputation.
You are the ED intern on duty. You have seen a 75 year-old man with a painful left leg of sudden onset. He has a cardiac history (AF and hypertension) and he smoked for 60 years. On examination he has a left cold leg from mid thigh downwards with no palpable pulses below the femoral pulse. His right leg is normal. What are the clinical signs that you will assess to determine whether the leg is salvageable, or that it is beyond help and needs amputation?
Clinical signs incoude the 6 Ps: pain, pallor, paraesthesia, paralysis, poilikothermia, pulselessness
Non-viable limb includes sensation loss, motor loss, no clear option for surgical revascularisation, tissue loss, contraindications to treatment
Viable tissue has no significant tissue loss, no sensory loss or nerve damage
Rutherford sign is tissue loss, nerve loss and arterial or venous insufficiency
A 54 year-old insulin diabetic presents to the ED complaining of increasing pain in her right foot that has been developing over one week. It is worse at night, partially relieved by hanging her foot over the side of the bed. Her right great toe has become swollen, red in parts and discoloured in others. She is febrile (37.7°C), pulse 86 regular, BP 130/80 mmHg, blood glucose 13.2 mmol/L. Femoral pulses are present bilaterally, but no distal pulses can be felt below this, the right great toe is erythematous with a large fluctuant swelling at the base. What does this clinical appearance suggest?
What investigations are needed?
What treatment is needed?
Clinical picture suggests an abscess.
Ix include doppler USS, MCS, ABPI, HbA1C, FBC, UEC,
Does not need to be initiated on sepsis pathway. Surgical drainage/debridement. Treat with empirical Abx of ceftriaxone until sensitivities come through. Manage DM better
What factors will a vascular surgeon consider when planning treatment for peripheral vascular disease in a patient’s foot?
Consider extent of disease (6Ps)
Patient co-morbidities (DM, smoker, alcohol etc)
State of the patients vasculature (CT angiography/ABPI)
Indications for urgent surgery are tissue necrosis/gangrene
