Vascular and cardiothoracic surgery Flashcards
What is the difference between varicose veins and reticular veins?
Varicose are when they are above 3mm diameter, reticular is below that.
Telangiectasia is when they are less than 1mm
What is the cause of varicose veins?
Valve dysfunction in the perforating veins cause blood flow from the deep veins back into the superficial veins and overload them.
What is chronic venous insufficiency?
Blood pools in distal veins, causing leakage
Haemoglobin in the leaked blood breaks down and causes a brown discolouration to the lower legs
What are the changes that happen in chronic venous insufficiency?
Venous eczema
Lipodermatosclerosis (fibrous and tight skin in the legs)
Heavy legs
Aching
Itching
Burning
Oedema
Muscle cramps
Restless legs
What are the risk factors for varicose veins?
Increasing age
Family history
Female
Pregnancy
Obesity
Prolonged standing
DVT
What is the tap test for varicose veins?
Tap test - apply pressure to the saphenofemoral junction and tap the distal varicose vein (feel for a thrill)
What is the cough test for varicose veins?
Cough test - apply pressure to the SFJ and cough, feeling for thrills
What is the Trendelenburg’s test for varicose veins?
Trendelenburg’s test - patient lying down, affected leg lifted, tourniquet applied to thigh. Stand patient up: if varicose veins reappear, the incompetent valve is below the level of the tourniquet
What is the Perthes test for varicose veins?
Apply tourniquet to thigh and ask the patient to pump calf muscles by doing heel raises. If increased dilation of superficial veins = problem with deep veins, such as DVT
What is the management for varicose veins?
Weight loss, staying active, elevation and compression
Endothermic ablation
Scleropathy
Stripping veins out of leg
What are the complications of varicose veins?
Prolonged and heavy bleeding after trauma
Superficial thrombophlebitis
DVT
Skin changes and ulcers
What causes venous ulcers?
Pooling of blood and waste products
Where do arterial vs venous ulcers happen?
Arterial: distally - toes or dorsum of feet
Venous: Gaiter area (between top of the foot and bottom of calf muscle)
Which are bigger, arterial or venous ulcers?
Venous
Which are deeper, arterial or venous ulcers?
Arterial
What are the borders like in arterial vs venous ulcers?
Arterial: well defined punched-out appearance
Venous: irregular, gently sloping border
Which is more likely to bleed, arterial or venous ulcers?
Venous
Which are more painful, arterial or venous ulcers?
Arterial
When is pain worst in arterial ulcers?
At night, or on elevation
Which pain improves on elevation, arterial or venous ulcers?
Venous - opposite to each other
Arterial is worse on elevation and improved by lowering the leg
What is used to assess for arterial disease?
Ankle-brachial pressure index (ABPI)
What is the management for arterial ulcers?
Urgent surgical revascularisation
What is Bueger disease?
Thromboangiitis obliterans - inflammatory condition that causes thrombus formation in small and medium blood vessels in the distal arterial system
Who is affected by Buerger disease?
Men aged 25-35 with a strong association with smoking
How does Buerger disease present?
Painful blue discolouration to the fingertips or tips of toes.
Worse at night
How is Buerger disease managed?
Stopping smoking
Intravenous iloprost is considered
What is Leriche Syndrome?
Occlusion in the distal aorta or proximal common iliac artery:
Triad of :
Thigh/buttock claudication
Absent femoral pulses
Male impotence
What is Buerger’s test?
Part 1:
Lie patient on back with legs at 45 degrees for 1-2 mins
Pallor indicates inadequate arterial supply: angle refers to the angle at which the legs go pale
Part 2: Sit patient up with legs hanging over the side. Blood will flow back and in PAD the legs will go blue and then dark red.
What ankle-brachial pressure index is normal?
0.9-1.3
0.6-0.9 is mild PAD
0.3-0.6 is moderate to severe
What causes pericardial effusion?
Increased venous pressure can reduce drainage from the cavity, resulting in a transudative effusion, e.g. in congestive heart failure, pulmonary hypertension
Causes of exudative effusions are inflammation such as: infection, autoimmune, injury, uraemia, cancer, medications (e.g. methotrexate)
Rupture and bleeding can also cause it
What are symptoms of chronic pericardial effusion?
Chest pain
Shortness of breath
Feeling of fullness in chest
Orthopnoea
Hiccups due to phrenic nerve compression
Dysphagia due to oesophageal compression
Hoarse voice due to recurrent laryngeal nerve compression
What signs on examination of pericardial effusion?
Quiet heart sounds
Pulsus paradoxus (abnormally large fall in BP during inspiration)
Hypotension
Raised JVP
Fever
Pericardial rub
What is the investigation of choice for pericardial effusion?
Echo
Fluid analysis too
What is the most common are for thoracic aortic aneurysm?
Ascending aorta (should be less than 4.5cm)
What are the three layers to the aorta?
Intima
Media
Adventitia
What is a false aneurysm?
When the inner two layers rupture and their is dilation of the vessel
Often after trauma e.g. RTA
What is a true aneurysm?
When the three layers of the aorta are intact but dilated
What are symptoms of a ruptured thoracic aortic aneurysm?
Severe chest or back pain
Haemodynamic instability
Collapse
Haematemesis
Haemoptysis
Cardiac tamponade
How do you decide whether to treat a pneumothorax?
No SOB and less than a 2cm rim of air on CXR: no treatment and follow up in 2-4 weeks
Where are chest drains inserted?
Triangle of safety is formed by:
5th intercostal space (inferior nipple line)
Midaxillary line
Anterior axillary line
Inserted just above the rib to avoid the neuromuscular bundle
External end of the drain is placed underwater to prevent air from flowing back through the drain. Air should bubble through it and should see swinging of the water with normal respiration
What causes a tension pneumothorax?
Trauma creating a one way valve that lets air in but not out
What is the management of a tension pneumothorax?
Insert a large bore cannula into the second intercostal space in the midclavicular line
