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Surgery Block > Vascular > Flashcards

Vascular Flashcards

1
Q

Chronic limb ischaemia (CLI)

A

PAD, resulting in symptomatic reduction in blood supply to the lower limb. Generally caused by atherosclerosis.

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2
Q

CLI risk factors

A 
Smoking 
Hyperlipidaemia
Hypertension 
Male
DM
Increasing age
FHx
Obesity
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3
Q

CLI Fontaine classification

A

Stage 1- Asymptomatic
Stage 2- intermittent claudication (cramping after walked fixed distance- claudication distance)
Stage 3- ischaemic rest pain
Stage 4- ulceration/gangrene/both

Buergers test- Pt supine, raise leg until pale, lower down to reperfuse. If buergers angle less than 20 degrees then severe ischaemia.

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4
Q

CLI investigations

A

ABPI- <0.5 is severe
>0.9 is normal. If >1.2 then consider incorrect reading due to calcification or hardening.

Also conduct CVS assessment as usually have the risk factors.

If <50yrs without RF consider thrombophilia screen.

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5
Q

CLI management

A

Lifestyle
Statin (80mg Atorvastatin)
Anti-platelet therapy
Optimise diabetes control

Enrol in supervised exercise programme.

Consider surgery when supervised exercise and lifestyle failed and RF modification failed.

Surgery options; angioplasty, bypass graft or combination. Also amputation.

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6
Q

CLI complications

A

Sepsis (infected gangrene)
Acute on chronic ischaemia
Amputation
Reduced mobility and QoL

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7
Q

Critical limb ischaemia

A

Complication of CLI;
>2wk of ischaemic rest pain
Gangrene/ischaemic lesions
ABPI<0.5

Differentials; spinal stenosis, acute limb ischaemia

Investigate with a Doppler USS (severity and location). Follow with CT/MRI.

Needs immediate surgical intervention.

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8
Q

Acute Limb Ischaemia (ALI)

A

Sudden full/partial occlusion of the artery, leading to poor functional outcomes/rapid ischaemia.

Caused by embolism (normal contralateral pulse), thrombus from plaque or trauma.

Differentials- critical CLI, acute DVT, SC compression.

Pallor, pulselessness, perishingly cold, paralysis, pain and paraesthesia.

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9
Q

ALI Investigations

A

Bloods (lactate-look at ischaemia, thrombophilia screen if <50yrs without RF, group and save), ECG.
Doppler USS with CT angiography follow up (CT arteriogram if limb salvageable)

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10
Q

ALI Management

A

Surgical emergency-within 6hrs. Embelctomy (if embolic), bypass, intra-arterial thrombolysis, angioplasty.

High flow O2, IV fluids and therapeutic heparin dose.

Conservative- Prolonged heparin, regular assessment.

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11
Q

Irreversible Limb Ischaemia

A

(Mottled, non-blanching, hard woody muscles)- Urgent amputation.

Long term- Reduce CVS RF, start on antiplatelet.

Amputation- Regular physio and occupational health.

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12
Q

ALI complications

A

High mortality
Reperfusion Injury
Compartment syndrome
Damaged muscles releasing K+, H+ and myoglobin (AKI)

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13
Q

AAA

A

Greater than 3mm dilation

RF and aetiology discussed in cardiology.

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14
Q

AAA symptoms

A

Usually asymp.
Ab, loin, back pain.
Pulsatile mass at abdomen

Ruptured may present with shock, syncope, pain, vomiting.

Differential- renal colic

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15
Q

AAA Investigations

A

USS

CT with contrast if >5.5cm

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16
Q

AAA Management

A

Medical- Monitor if <5.5cm.
Reduce CVS risk- BP control, statin, stop smoking, weight loss.

Surgical- Open repair- midline laprotomy.
Endovascular repair- graft via the femoral artery and fixing a stent across the aneurysm.

Endovascular- short hospital stay but increased reintervention.

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17
Q

AAA Complications

A

Rupture (Most common)
Retroperitoneal leak
Embolisation
Aortoduodenal fistula.

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18
Q

Ruptured AAA

A

Increased risk with increased size.
Haemodynamically compromised.
Triad- Flank/back pain, hypotension, pulsatile ab mass.

Manage- Immediate referral and bloods, O2, crossmatch. Stable need CT angiogram to see if endovascular repair appropriate. Unstable need open surgical repair.

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19
Q

Deep Venous Insufficiency

A

DVT+Valvular insufficiency+varicose vein= chronic venous insufficiency.

Causes: Primary- defect to wall/valve (inc congenital).
Secondary- post damage

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20
Q

DVI- RF

A 
Increase Age
Female
Pregnancy
previous DVT
Obesity
Smoking
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21
Q

DVI
Differentials
Investigations

A

Renal, hepatic and cardiac disease.
Doppler USS
Foot pulses and ABPI- compression stocking.

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22
Q

DVI- Management

A

Early identification and management.
Compression stocking, analgaesia.
Surgical less succesfful.

23
Q

DVI- Clinical Features

A 
Swollen legs
Tightness when walking resolved by elevation (v.claudication)
Varicose eczema 
Haemosiderin staining
Thrombophlebitis
Lipodermatosclerosis
Atrophie blanche
Venous ulcers.
24
Q

Varicose veins

A

Incompetent valves, so blood moves from deep to superficial. Therfero get turtuous dilated superficial veins with venous HTN.

RF: Long standing, obesity, pregnancy, FHx.

25
Q

Varicose veins- Clinical Features

A

Usually present for cosmetics. Can beocme itchy/achy.

May get skin changes, ulceration, thrombophelbitis etc if left untreated.

26
Q

Varicose veins- Investigations

A

Duplex USS is gold standard.

27
Q

Varicose veins- Management

A

Modify RF- reduced standing, lose weight etc.
Only give compression stockings if treatment inappropriate since life long commitment.
Venous ulcers need 4 layer bandaging.

Surgical only if skin changes, recurrent/symptomatic, superficial vein thrombosis, venous leg ulcer.

28
Q

Varicose veins- Surgery types

A

Thermal ablation
Venous ligation and stripping
Foam slcerotherapy- Foam leads to inflammation and closing of vein.

NB if have DVT at the same time then surgery is contraindicated.

29
Q

Varicose veins- Complications

A

Untreated will worsen.

Post op complications- haemorrhage, thrombophlebitis, DVT, disease recurrence and nerve damage.

30
Q

Ulcers

A

Breaks in the skin/mucous membranes. Lower likmb mainly venous, but also arterial and neuropathy related.

31
Q

Venous ulcers-
Appearance
RF

A

Shallow, irregular border, granulated base, located at medial malleolus, featuresof venous insufficiency.

Prone to infection, cellulitis related.

RF: 
Increasing age
Pre-existingvenous incompetence
Hx of venous thromboembolism
Varicose veins
Pregnancy
Obesityorphysical inactivity
Severeleg injuryor trauma
32
Q

Venous ulcers-
Features
Investigations

A

Aching, itching, DVI features i.e. haemosiderin staining.

Investigations: Duplex USS. ABPI- is compression suitable.
Swab cultures if infection suspected.

33
Q

Venous ulcers- Management

A

Conservative- Leg elevation, increased exercise, lifestyle changes.
Abx if infection.

Importantly- Multicomponnet compression bandaging- change 1/2 times per week (Need ABPI>0.6)
Ensure area is moist, not dried out by soap, to allow healing.
Treat varicose veins to imporve condition.

34
Q

Arterial ulcers-
Appearance
RF

A

Reduced BF induced, poor healing.
Deep, well defined border, necrotic base. Occur distal to trauma site and at pressure areas.

RF:
PAD
DM
Smoking
HTN
Obestiy
Increased age
35
Q

Arterial ulcers-
Features
Investigations

A

Intermittent claudication or critical LI preceding. Painful and develops over time. Cold limb, absent/reduced pulses, necrotic toes etc.

Investigations: ABPI. Locate with duplex USS/CT angiogrpahy/MRI.

36
Q

Arterial ulcers- Management

A

Need vascular review.
Lifestyle changes, CVS modification (statin, anti-P, BP control etc)
Angioplasty (+/- stenting) or bypass.
If non healing despite good BS- skin graft.

37
Q

Neuropathic ulcers
Appearance
RF

A

Due to peripheral neuropathy, therefore repeated stress and injuries. Get painless ulcer at pressure points (secondary to joint deformities in diabetics). Punched out appearnace.

RF:
DM
B12 deficiency
Any peripheral neuropathy

38
Q

Neuropathic ulcers
Features
Investigations

A

Hx of peripheral neuropathy.

Investigations: BG, B12, ABPI. Swab for infection, X-Ray if shows osteomyelitis.

39
Q

Neuropathic ulcers- Management

A 
DM foot clinics
Good diabetes control
Reduced CVS RF
Good foot hygiene and appropriate footwear. 
Necrotic digits may need amputating.
40
Q

Charcot’s Foot

A

May get alongside neuropathic ulcers.
Loss of joint sensation, therefore increased unnoticed trauma and deformity.
Swelling, distortion, pain and loss of function. Loss of transverse arch.
Need to reduce weight load on foot.

41
Q

Acutely painful leg

A

Cold and Pale- Acute limb ischaemia
Hot and swollen- DVT (can also be MSK, cellulitis)
Trauma- low weight bearing, bony tenderness
Neurological- Worse on movement, radiates from back.

Need detailed history and examination.

42
Q

Carotid Artery stenosis

A

Mainly asymptomatic-since dual supply. Can cause TIA or stroke. Ischaemic stroke treat with 300mg aspirin + IV alteplase if within 4.5hrs, haemorrhagic stroke correct anti-coagulation.
Investigate stroke wit CT, carotids with duplex USS.
Manage stroke/TIA. If stable then remove atheroma.
Long term aspirin, statins, HTN control, DM control, lifestyle changes, exercise, smoking cessation.

43
Q

Carotid artery occlusion classification

A

<50%- Mild
50-69%- Moderate
70-99%- Severe
100%- Total/complete

44
Q

Thoracic Aortic Aneurysm

A

Usually asymptomatic but can present with pain (ascending-anterior chest, descending-@scapulae, arch-neck).
Common in connective tissue disorders or bicuspid valve. RF same as IHD.
Investigate with bloods and ECG. Image with CT contrast.
Manage medically by reducing CVS RF. Surgical repair is possibility depending on location, likely to recur.

45
Q 
Acute Mesenteric Ischaemia-
Features 
Causes
RF
Differentials
A

Ab pain, N+V, disproportionate to the clinical findings.

Main cause is embolus, but also thrombus, non occlusive and occlusive causes.

RF- Depends on cause. Embolism RF include smoking, HTN, hyperlipidaemia etc.

DDx- Symptomatic AAA, bowel perforation, peptic ulcer.

46
Q

Acute Mesenteric Ischaemia-

Investigations

A

ABG- Raised lactate.
Catheter- Monitor output
Bloods- FBC, U+E, LFTs, amylase, clotting, G+S.
CT with IV contrast- see oedematous bowel, loss of bowel wall enhancement.

47
Q

Acute Mesenteric Ischaemia-

Management

A

Initially; Fluid resuss, catheter, broad spectrum Abx, analgesics, anti-emetics, needs ITU. Surgical emergency!!

Removal of necrosed bowel- will need a stoma following this.
More commonly-Revascularisation by thrombo/embolectomy- using radiological intervention.

48
Q

Acute Mesenteric Ischaemia-

Complications

A

Perforated bowel

Bowel necrosis

49
Q 
Chronic Mesenteric Ischaemia-
Causes
Features
RF
Differentials
A

Atherosclerotic plaque of effecting the CT, SMA or IMA. At least two need to be affected to cause symptoms.

Presenting with postprandial pain (since increased demand of blood to colon), weight loss (reduced intake and malabsorption), other existing comorbidities.

RF: Smoking, HTN, DM, hypercholesteralaemia. More common in female and >60yrs.

DDX: Chronic pancreatitis, GB pathology, peptic ulcer.

50
Q

Chronic Mesenteric Ischaemia-
Investigations
Management

A

Blood will be normal, check Ca2+ and Mg2+- ?nutrition.
CT angiography investigation of choice.
Manage initially with reducing RF i.e. smoking cessation, statins, anti-platelets. Then with either endovascular stent insertion (via femoral/brachial) or open surgery bypass graft.

51
Q

Pseudoaneurysm

A

Between tunica media and adventitia, due to vessel trauma (IVDU), commonly at femoral artery.
Present tender, painful, swollen, erythematous (if infected).
Investigate with doppler.
Manage small by leaving alone, larger ones can either apply direct compression or US guided thrombin injected into pseudoaneurysm lumen.
Can rupture or become infected- sepsis.

52
Q

AAA- Stanford Classification

A

Type A- Includes DaBakey class I and II as well as the ascending aorta and can include descending aorta and aortic arch. Tear can be anywhere along here.

Type B- Includes DaBakey class III and not the ascending aorta.

53
Q

AAA- DaBakey Classification

A

Class I- Starts at A.aorta and radiates to the arch. (<65)
Class II- Confined to ascending aorta. (elderly, HTN)
Class III- Starts in D.aorta, distal to subclavian artery. IIIa extends to diaphragm, IIIb to abdominal aorta.

54
Q

Acute Limb Ischaemia- Rutherford Classification

A

I- Viable, normal.
IIa- Marginally threatened, can be salvages, loss of sensory.
IIb- Immediately threatened, needs immediate revascularisation. Increased loss of sensory, rest pain and motor loss.
III- Irreversible, profound sensory and motor loss.

Surgery Block (7 decks)

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