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MRCS- physiology + surgery > Vascular COPY > Flashcards

Vascular COPY Flashcards

1
Q

What is the most common cause of acute limb ischaemia?

A

Thrombosis of pre-existing site of atherosclerosis
Acute thrombosis of popliteal aneurysms poses the greatest threat to the limb

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2
Q

Describe the timeline of acute limb iscahemia

A

< 6 hours - white leg
6-12 hours - mottled, blanching onpressure
12-24 - fixed mottling

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3
Q

How does treatment correlate to appearance of limb?

A

White leg with sensorimotor - surgery and embolectomy

Dusky leg, mild anaesthesia - Angiography

Fixed mottling - primary amputation

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4
Q

Describe the role of thrombolysis in acute limb ischaemia

A

Intra arterial thrombolysis is better than peripheral thrombolysis
Mainly indicated in acute on chronic thrombosis
Avoid if within 2 months of CVA or 2 weeks of surgery
Aspiration of clot may improve success rate if the thrombosis is large

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5
Q

Describe surgery in acute limb ischaemia

A

Both groins should be prepared
Transverse arteriotomy is easier to close
Poor inflow should be managed with iliac trawl- if this fails to improve then consider a femoro-femoral cross over or axillo-femoral cross over.
A check angiogram should be performed on table and prior to closure
Systemic heparinisation should follow surgery
Fasciotomy should be considered if the time between onset and surgery exceeds 6 hours

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6
Q

Indications for amputations

A

Dead non viable
Deadly where it is posing a major threat to life
Dead useless where it is viable but a prosthesis would be preferable

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7
Q

When is an amputation preferable in Orthopaedic surgery?

A

Chronic fracture non union or significant limb shortening following trauma
Occasionally following major trauma a primary amputation is preferable.
open fracture with major distal neurovascular compromise and other more life threatening injuries are present

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8
Q

Describe the main types of amputations

A

Pelvic disarticulation (hindquarter)
Above knee amputation
Gritti Stokes (through knee amputation, patella preserving)
Below knee amputation (using either Skew or Burgess flaps)
Syme’s amputation (through ankle)
Amputations of mid foot and digits

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9
Q

Above knee amputations pros and cons

A

Quick to perform
Heal reliably
Patients regain their general health quickly
For this benefit, a functional price has to be paid and many patients over the age of 70 will never walk on an above knee prosthesis.
Above knee amputations use equal anterior-posterior flaps

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10
Q

Below knee amputations pros and cons

A

Technically more challenging to perform
Heal less reliably than their above knee counterparts.
However, many more patients are able to walk using a below knee prosthesis.
In below knee amputations the two main flaps are Skew flaps or the Burgess long posterior flap. Skew flaps result in a less bulky limb that is easier to attach a prosthesis to.

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11
Q

What is a specific contraindication of below knee amputations?

A

Fixed flexion deformities

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12
Q

Describe the ABPI values and correlations

A

1.2 or greater - Usually due to vessel calcification
1.0- 1.2 Normal

0.8-1.0 Minor stenotic lesion
Initiate risk factor management

0.50-0.8 Moderate stenotic lesion
Consider duplex
Risk factor management
If mixed ulcers present then avoid tight compression bandages

0.3 - 0.5 Likely significant stenosis
Duplex scanning to delineate lesions needed
Compression bandaging contra indicated

Less than 0.3 Indicative of critical ischaemia
Urgent detailed imaging required

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13
Q

Describe the features of aortic dissection

A

tear in the intimal layer, followed by formation and propagation of a subintimal hematoma. Cystic medial necrosis (Marfan’s)

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14
Q

Where is the most common site for aortic dissection

A

90% occurring within 10 centimetres of the aortic valve

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15
Q

How does the location of the dissection correlate to treatment?

A

A - ascending aorta / root: surgery, aortic root replacement

B - descending aorta: Medical therapy and antihypertensive

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16
Q

Describe the DeBakey classification of aortic dissection

A

I Ascending aorta, aortic arch, descending aorta
II Ascending aorta only
III Descending aorta distal to left subclavian artery

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17
Q

Clinical features of aortic dissection

A

Tearing, sudden onset chest pain (painless 10%)
Hypertension or Hypotension
A blood pressure difference (in each arm) greater than 20 mm Hg
Neurologic deficits (20%)

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18
Q

Investigations for aortic dissection

A

CXR: widened mediastinum, abnormal aortic knob, ring sign, deviation of the trachea/oesophagus
CT angiography of the thoracic aorta
MRI angiography
Conventional angiography (now rarely used diagnostically)

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19
Q

Management of aortic dissection

A

Beta-blockers: aim HR 60-80 bpm and systolic BP 100-120 mm Hg
For type A dissections the standard of care is aortic root replacement

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20
Q

Causes of axillary vein thrombosis

A

Primary cause is associated with trauma, thoracic outlet obstruction or repeated effort in a dominant arm (young active individuals)
Secondary causes include central line insertion, malignancy, pacemakers

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21
Q

Clinical features of axillary vein thrombosis

A

Pain and swelling (non pitting)
Numbness
Discolouration: mottling, dusky
Pulses present
Congested veins

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22
Q

Investigations for axillary vein thrombosis

A

FBC: viscosity, platelet function
Clotting
Liver function tests
D-dimer
Duplex scan: investigation of choice
CT scan: thoracic outlet obstruction

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23
Q

Treatment of axillary vein thrombosis

A

Local catheter directed TPA
Heparin
Warfarin

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24
Q

What is the most common head and neck paraganglionoma?

A

Carotid body tumour

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25
Q

Presentation of carotid body tumours

A

They typically present as an asymptomatic neck mass in the anterior triangle of the neck. They are typically slow growing lesions

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26
Q

Describe the types of carotid body tumour

A

Sporadic - Accounts for 85% of cases
Familial - Seen in around 10% of cases and usually in younger patients
Hyperplastic - Seen in those at high altitude or in those with COPD

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27
Q

Imaging for carotid body tumours

A

They are readily imaged using duplex ultrasonography. CT angiography is sometimes helpful.

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28
Q

Treatment of carotid body tumour

A

Typically this comprises surgical resection. This is preceded by embolization in selected cases.

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29
Q

Where is the most common site of cervical rib?

A

Consist of an anomalous fibrous band that often originates from C7 and may arc towards, but rarely reaches the sternum

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30
Q

Clinical features of cervical ribs

A

Compression of the subclavian artery may produce absent radial pulse on clinical examination and in particular may result in a positive Adsons test (lateral flexion of the neck towards the symptomatic side and traction of the symptomatic arm- leads to obliteration of radial pulse)

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31
Q

Treatment of cervical ribs

A

Treatment is most commonly undertaken when there is evidence of neurovascular compromise. A transaxillary approach is the traditional operative method for excision.

32
Q

What causes varices

A

Varices occur because of localised weakness in the vein wall resulting in dilatation and reflux of blood due to non union of valve cusps.

33
Q

Describe the histology of chronic venous insufficiency

A

Histologically, the typical changes include fibrous scar tissue dividing smooth muscle within media in the vessel wall.

34
Q

What causes tissue damage in chronic venous insufficiency

A

Tissue damage in chronic venous insufficiency occurs because of perivascular cytokine leakage resulting in localised tissue damage coupled with impaired lymphatic flow

35
Q

Describe symptoms of chronic venous insufficiency

A

Dependant leg pain
Prominent leg swelling
Oedema extending beyond the ankle
Venous stasis ulcers

36
Q

Describe the two tests used in chronic venous insufficiency

A

Brodie-Trendelenburg test: to assess level of incompetence
Perthes’ walking test: assess if deep venous system competent

37
Q

Describe the investigations used in chronic venous insufficiency

A

Doppler exam: if incompetent a biphasic signal due to retrograde flow is detected
Duplex scanning: to ensure patent deep venous system (do if DVT or trauma)

38
Q

What must be done for ALL patients prior to treatment in chronic venous insufficiency?

A

Doppler assessment to assess for venous reflux and should be classified as having uncomplicated varicose veins or varicose veins with associated chronic venous insufficiency.

Duplex scan on day of surgery for patients with saphenopopliteal incompetence

39
Q

Indications for Treatment of chronic venous insufficiency

A

Cosmetic: majority
Lipodermatosclerosis causing venous ulceration
Recurrent superficial thrombophlebitis
Bleeding from ruptured varix

40
Q

Treatment of Symptomatic uncomplicated varicose veins

A

endothermal ablation,
foam sclerotherapy,
saphenofemoral / popliteal disconnection,
stripping and avulsions,
compression stockings

41
Q

Treatment of varicose veins with skin changes

A

endothermal ablation,
foam sclerotherapy,
saphenofemoral / popliteal disconnection,
stripping and avulsions,
compression stockings

42
Q

Treatment of Chronic venous insufficiency or ulcers

A

Class 2-3 compression stockings (ensure no arterial disease).

43
Q

Describe the trendelenburg procedure

A

Head tilt 15 degrees and legs abducted
Oblique incision 1cm medial from artery
Tributaries ligated (Superficial circumflex iliac vein, Superficial inferior epigastric vein, Superficial and deep external pudendal vein)
SF junction double ligated
Saphenous vein stripped to level of knee/upper calf. NB increased risk of saphenous neuralgia if stripped more distally

44
Q

Most common causes of acyanotic congenital heart disease

A

Ventricular septal defects (VSD) - most common, accounts for 30%
Atrial septal defect (ASD)
Patent ductus arteriosus (PDA)
Coarctation of the aorta
Aortic valve stenosis

45
Q

Causes of cyanotic congenital heart disease

A

Tetralogy of Fallot
Transposition of the great arteries (TGA)
Tricuspid atresia
Pulmonary valve stenosis

46
Q

Describe KT syndrome

A

Klippel-Trenaunay-Weber syndrome generally affects a single extremity, although cases of multiple affected limbs have been reported. The leg is the most common site followed by the arms, the trunk, and rarely the head and the neck

47
Q

Describe the signs and symptoms of KT syndrome

A

One or more distinctive port-wine stains with sharp borders
Varicose veins
Hypertrophy of bony and soft tissues, that may lead to local gigantism or shrinking.
An improperly developed lymphatic system

48
Q

What can KT syndrome affect?

A

KTS can either affect blood vessels, lymph vessels, or both. The condition most commonly presents with a mixture of the two. Those with venous involvement experience increased pain and complications

49
Q

What causes ulcers to form in venous leg ulcers?

A

capillary fibrin cuff or leucocyte sequestration

50
Q

Investigations of venous ulcers

A

Doppler ultrasounds to look for presence of reflux and duplex ultrasound

51
Q

Management of venous ulcers

A

4 layer compression banding after exclusion of arterial disease or surgery

52
Q

What is a Marjolin’s ulcer?

A

Squamous cell carcinoma
Occurring at sites of chronic inflammation e.g; burns, osteomyelitis after 10-20 years
Mainly occur on the lower limb

53
Q

Describe arterial ulcers

A

Occur on the toes and heel
Painful
There may be areas of gangrene
Cold with no palpable pulses
Low ABPI measurements

54
Q

Describe neuropathic ulcers

A

Commonly over plantar surface of metatarsal head and plantar surface of hallux
The plantar neuropathic ulcer is the condition that most commonly leads to amputation in diabetic patients
Due to pressure
Management includes cushioned shoes to reduce callus formation

55
Q

Describe pyoderma gangrenosum

A

Associated with inflammatory bowel disease/RA
Can occur at stoma sites
Erythematous nodules or pustules which ulcerate

56
Q

Causes of primary lymphoedema

A

Congenital < 1 year: sporadic, Milroy’s disease
Onset 1-35 years: sporadic, Meige’s disease
> 35 years: Tarda

57
Q

Causes of secondary lymphoma

A

Bacterial/fungal/parasitic infection (filariasis)
Lymphatic malignancy
Radiotherapy to lymph nodes
Surgical resection of lymph nodes
DVT
Thrombophlebitis

58
Q

Indications for surgery in lymphoedema

A

Marked disability or deformity from limb swelling
Lymphoedema caused by proximal lymphatic obstruction with patent distal lymphatics suitable for a lymphatic drainage procedure
Lymphocutaneous fistulae and megalymphatics

59
Q

Describe the Homans operation for lymphoedema

A

Reduction procedure with preservation of overlying skin (which must be in good condition). Skin flaps are raised and the underlying tissue excised. Limb circumference typically reduced by a third

60
Q

Describe the Charles operation for lymphoedema

A

All skin and subcutaneous tissue around the calf are excised down to the deep fascia. Split skin grafts are placed over the site. May be performed if overlying skin is not in good condition. Larger reduction in size than with Homans procedur

61
Q

Describe lymphovenous anastomosis for lymphoedema

A

Identifiable lymphatics are anastomosed to sub dermal venules. Usually indicated in 2% of patients with proximal lymphatic obstruction and normal distal lymphatics.

62
Q

What are the indications fo surgery to revascularise the lower limb?

A

Intermittent claudication
Critical ischaemia
Ulceration
Gangrene

63
Q

Describe an angioplasty

A

In order for angioplasty to be undertaken successfully the artery has to be accessible. The lesion relatively short and reasonable distal vessel runoff. Longer lesions may be amenable to sub-intimal angioplasty.

64
Q

Describe the procedure of bypass surgery

A

Artery dissected out, IV heparin 3,000 units given and then the vessels are cross clamped
Longitudinal arteriotomy
Graft cut to size and tunneled to arteriotomy sites
Anastomosis to femoral artery usually with 5/0 ‘double ended’ Prolene suture
Distal anastomosis usually using 6/0 ‘double ended’ Prolene

65
Q

Describe bypass in distal disease

A

Femoro-distal bypass surgery takes longer to perform, is more technically challenging and has higher failure rates.
In elderly diabetic patients with poor runoff a primary amputation may well be a safer and more effective option. There is no point in embarking on this type of surgery in patients who are wheelchair bound.
In femorodistal bypasses vein gives superior outcomes to PTFE.

66
Q

What are the ‘rules’ of bypass surgery

A

Vein mapping 1st to see whether there is suitable vein (the preferred conduit). Sub intimal hyperplasia occurs early when PTFE is used for the distal anastomosis and will lead to early graft occlusion and failure.
Essential operative procedure as for above knee fem-pop.
If there is insufficient vein for the entire conduit then vein can be attached to the end of the PTFE graft and then used for the distal anastomosis. This type of ‘vein boot’ is technically referred to as a Miller Cuff and is associated with better patency rates than PTFE alone.

67
Q

What are the 4 characteristic features of Tetralogy of Fallot?

A

ventricular septal defect (VSD)
right ventricular hypertrophy
right ventricular outflow tract obstruction, pulmonary stenosis
overriding aorta

68
Q

Describe the management in ToF

A

surgical repair is often undertaken in two parts
cyanotic episodes may be helped by beta-blockers to reduce infundibular spasm

69
Q

What are some other features of ToF

A

cyanosis
causes a right-to-left shunt
ejection systolic murmur due to pulmonary stenosis (the VSD doesn’t usually cause a murmur)
a right-sided aortic arch is seen in 25% of patients
chest x-ray shows a ‘boot-shaped’ heart, ECG shows right ventricular hypertrophy

70
Q

Describe axillary / brachial emboli

A

50% of upper limb emboli will lodge in the brachial artery
30% of upper limb emboli will lodge in the axillary artery
Sudden onset of symptoms; pain, pallor, paresis, pulselessness, paraesthesia
Sources are left atrium with cardiac arrhythmia (mainly AF), mural thrombus
Cardiac arrhythmias may result in impaired consciousness in addition to the embolus

71
Q

Describe arterial occlusions

A

Those resulting from atheroma are the most common, trauma may result in vascular changes and long term occlusion but this is rare
Features may include claudication, ulceration and gangrene. Proximally sited lesions may result in subclavian steal syndrome
The progressive nature of the disease allows development of collaterals, acute ischaemia may occur as a result of acute thrombosis

72
Q

Treatment of Raynaud’s disease

A

Calcium antagonists

73
Q

What is a venous doppler?

A

The simplest investigation for assessment of venous junctional incompetence is a Doppler assessment. This involves the patient standing and manual compression of the limb distal to the junction of interest. Flow should normally occur in one direction only. Where junctional incompetence is present reverse flow will occur and is relatively easy to identify.

74
Q

What are venograms and duplex scans

A

Structural venous information is historically obtained using a venogram. This is an invasive test and rarely required in modern clinical practice. The most helpful test is a venous duplex scan which will provide information relating to flow and vessel characteristics. Duplex is also useful in providing vein maps for bypass surgery.

75
Q

What is an arterial duplex

A

As with the vein the duplex scan can provide a substantial amount of information about arterial patency and flow patterns. In skilled hands they can provide insight as to the state of proximal vessels that are anatomically inaccessible to duplex (e.g. Iliacs). Through assessment of distal flow patterns. It is an operator dependent test.

76
Q

What is a conventional angiogram?

A

Vessel puncture and catheter angiography is the gold standard method of assessing arteries
This technique is particularly useful in providing a distal arterial roadmap prior to femoro-distal bypass.

77
Q

Describe CT angiography

A

These tests provide a considerable amount of structural and flow information. They require contrast

They are particularly useful in the setting of GI bleeding

MRCS- physiology + surgery (32 decks)

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