Vascular (Imperial Jan Revision Course)

Question 1

scars

Answer 1

midline laparotomy: AA, Thoracolaporotomy=AA, roof top=AA, left flank=iliac artery (kidney/renal Tx), bilateral vertical joint incisions=CFA, Straight down in front of SCM=carotid

Question 2

Dx and Ix and Ddx

and Mx

Ex:

• Pulse pattern and symptoms will tell you where the stenosis ise.g.
• femoral pulse, no popliteal/pedal pulse, blockage most likely in CFA or popliteal segment
• no femoral, popliteal, foot pilse, stenosis most likely in aortoiliac segment)
• Bruits often help
• There will be no ulcers
• Buerger’s test usually negative
• ABPIs will be >0.6

Hx:

• Site
• Calf claudication=SFA
• thigh + calf=common femoral and profunda or iliac or aorta
• Buttock+ thigh + calf claudication = above the internal iliac= common iliac or aortic

“I have no pain at rest, as soon as I walk further than 100 yards, I develop cramping pain and have to stop soon after (if I continue walking my leg pain is agonising). I stop and rest on my walking stick and look often into a shop window (it is quite embarrassing sometimes). The pain subsides after 5 minutes entirely and I can walk the same distance again. It is worse uphill and up stairs”

Answer 2

Claudication

Ddx; spinal stenosis, nerve route entrapment from disc prolapse (positional e.g. upstairs worse than downstairs, need to rest c.30mins! + backpain, motor and sensory loss), venous claudication (bursting pain in the leg, relieved by lifting the leg), musculoskeletal pain

Ix:

• exercise treadmill ABPIs (drop>0.2=likely arterial disease)
• Duplex; B mode US and multidirectional doppler
• Angiography

Management: (issue=MI, CVA, Renal Failure)

• stop smoking
• Control cholesterol; statin
• BP control
• DM control

Question 3

Critical ischaemia difinition

Answer 3

• Rest pain or tissue loss
• > 2weeks
• Ankle pressure <40 (or Diabetic, toe pressure<30)

Question 5

Acute Ischaemia Ps

and causes/Mx

Answer 5

• Painful
• Pulseless
• Perishingly cold
• Pale

If there is the following then immediate revascuarisation is usually necessary:

• Paralysis
• Paraesthesia

Embolism; rapid onset, RF e.g. AF, ventricular aneurysms (post MI), or valvular disease, or aortic disease (e.g AA)

Rx: embolectomy and post op embolise (?fasciotomy + ?reperfusion injury)

Thrombotic (acute on chronic, Acute ischaemia that occurs on a background of claudication: Usually thrombotic occlusion of atherosclerotic vessels.A less severe ischaemia, so the leg may look pale, be cold and pulseless, but paraesthesia and paralysis not present. As collaterals have developed the degree of ischaemia is not so severe

Rx- thrombolysis, baloon angioplasty/stenting/bypass grafting

Question 7

Aneurysm Presentation

Answer 7

Asymptomatic (screening program, 65 YO men 1 off US, >3->refer)

look for popliteal aneurysms

Symptomatic

pain in back and tender aneurysm

Due to complications:

Rupture – uncommon in short cases

Embolisation – trash foot in AAA, missing pulses in popliteal aneurysm

Thrombosis – acutely ischaemic leg

Pressure - DVT

Fistulation – Acutely unstable usually

Question 8

'’Present’’

What? cause? complications?

and pathophysiology

Answer 8

Abnormal, Tortuous, dilated veins of the superficial venous system. clearly in the distribution of the LSV in the medial side of the thigh and calve. These can be primary: which 99% are, which replies a failure of the valves and reflux down the superficial venous system. They can be secondary; as a result of blockage in the deep viens and increased pressure on the venous system higher up.

Complications:

• Swelling and oedema
• Thrombophlebitis
• Bleeding
• Varicose ecsema
• Haemosidering deposition-> lipodermatosclerosis-> venous ulceration

Pathophysiology

• One-way flow from sup → deep maintained by valves
• Valve failure → ↑ pressure in sup veins → varicosity
• Fibrous tissue invades tunica intima and media, breaking up the SM
• Prevents maintenance of vascular tone → dilatation
• 3 main sites where valve incompetence occurs
  
  • SFJ: 3cm below and 3cm lateral to pubic tubercle
  • SPJ: popliteal fossa
  • Perforators: draining GSV
• Chronic venous insufficiency is distinct and results from incompetency in the deep system itself.
  
  • May co-exist c¯ varicose veins

Question 9

Answer 9

Venous Ulcer: compression bandage district nurse

Question 10

Answer 10

Haemosidering deposition

Question 11

Answer 11

lipodermatosclerotosis: HArd woody sclerotic

Champagne bottle leg