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Vascular Surgery > Vascular Surgery > Flashcards

Vascular Surgery Flashcards

1
Q

How is ABPI calculated

A

Foot artery occlusion pressure / brachial systolic pressure

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2
Q

ABPI >1.1 indicates

A

Calcified or incompressible vessels e.g. diabetes and renal failure

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3
Q

ABPI 0.7-0.9 indicates

A

Mild ischaemia

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4
Q

ABPI 0.4-0.7 indicates

A

Moderate ischaemia

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5
Q

ABPI <0.4 indicates

A

Critical ischaemia

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6
Q

What is the most accurate investigation for imaging the arterial system

A

Intra-arterial digital subtraction angiography (IADSA)

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7
Q

What is the investigation of choice for imaging the lymphatic system

A

Lymphoscintigraphy

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8
Q

How is lymphoscintigraphy performed

A

Radiolabelled colloid is injected into the webspace between the 2nd and 3rd toes and images obtained with a gamma camera

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9
Q

What are the 3 histological layers of an artery

A
  1. Tunica intima
  2. Tunica media
  3. Tunica adventitia
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10
Q

What are the 2 types of artery

A
  1. Elastic conducting arteries

2. Muscular distributing arteries

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11
Q

Describe the tunica intima

A
  • Innermost layer

- Single layer of endothelial cells orientated in the direction of flow

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12
Q

Describe the tunica media

A
  • Middle layer

- Composed of elastin and collagen fibres with vascular smooth muscle cells

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13
Q

Describe the tunica adventitia

A
  • Outermost layer

- Connective tissue

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14
Q

What are the histological differences between the thoracic and abdominal aorta

A

Thoracic aorta has >30% elastin compared to <20% in the abdominal section

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15
Q

What crosses the abdominal aorta anteriorly

A
  • Splenic vein
  • Body of pancreas
  • 3rd part of duodenum
  • Left renal vein
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16
Q

What lies immediately to the right of the abdominal aorta

A
  • IVC
  • Right ureter
  • Azygous vein
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17
Q

What lies immediately to the left of the abdominal aorta

A
  • Left sympathetic trunk

- Left ureter

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18
Q

Define an aneurysm

A

Pathological dilatation of an artery to >1.5x its normal diameter

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19
Q

What is the diameter of the aorta

A

2cm

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20
Q

Define a true aneurysm

A

Dilatation of an artery involving all layers of the arterial wall

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21
Q

Define a false aneurysm

A

Pulsatile, expansile swelling due to a defect in an arterial wall, with blood outside of the lumen, surrounded by a capsule of fibrous tissue or compressed surrounding tissue

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22
Q

List the causes of aneurysms

A
  1. Degenerative (atherosclerotic) - MOST common
  2. Inflammatory
  3. Congenital (Berry aneurysm)
  4. Mycotic (bacterial, IE)
  5. Infective
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23
Q

Where is the most common site of atherosclerotic AAA

A

Infrarenal

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24
Q

Mortality rate for elective AAA repair

A

5%

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25
Q

In whom is elective AAA repair offered

A

Those with a AAA >5.5cm

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26
Q

What percentage of AAAs involve the iliac arteries

A

30%

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27
Q

What percentage of AAAs are asymptomatic

A

75%

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28
Q

Where does a AAA typically rupture and what does this cause

A
  • Posterior wall

- Retroperitoneal haematoma (bruising of the flanks/scrotum

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29
Q

Who is screened for AAA in the UK

A

65 year-old men

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30
Q

What histological changes are seen in AAAs of those with Marfan’s

A

Cystic medial necrosis

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31
Q

How much blood should be cross-matched for ruptured AAA repair

A

10 units

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32
Q

What type of AAA repair is preferred if there is iliac involvement

A
  • Open

- Trouser Y-graft

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33
Q

List the immediate complications of AAA repair

A
  • Primary Haemorrhage

- Distal embolisation (ischaemic leg, trash foot)

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34
Q

List the early complications of AAA repair

A
  • Haemorrhage (reactionary, secondary)
  • MI
  • Renal failure (esp if proximal clamp above renal vessels)
  • Multi-organ failure/DIC/ARDS
  • Colonic ischaemia
  • Pneumonia
  • Stroke
  • DVT/PE
  • Paraparesis due to spinal ischaemia
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35
Q

How much heparin is to be used prior to cross-clamping of the aorta

A

3000 units

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36
Q

What bacteria cause myoctic aneurysms

A
  • Staph aureus
  • Salmonella
  • Streptococcus
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37
Q

List the late complications of AAA repair

A
  • Late graft infection
  • Aortoenteric fistula
  • Anastomotic aneurysm
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38
Q

What are the requirements of conventional EVAR

A

Aneurysm needs to have a proximal neck of at least 5mm above the aneurysm and below the renal arteries

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39
Q

What type of endovascular graft can be used in those aneurysms not suited for conventional EVAR

A

Fenestrated EVAR (very expensive)

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40
Q

What are the follow-up implications for EVAR

A

Long-term due to high risk of late complications e.g. endoleak

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41
Q

Describe type 1 endoleaks

A

Leak from stent-graft attachment site

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42
Q

Describe type 2 endoleaks

A

Leak due to retrograde flow through visceral or lumbar arteries into aneurysm sac (most common type)

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43
Q

Describe type 3 endoleaks

A

Due to structural failure of the stent-graft e.g due to holes

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44
Q

Describe type 4 endoleaks

A

Due to graft porosity and usually settles with time

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45
Q

Describe type 5 endoleaks

A

Aneurysm sac continues to expand with time, but no leak is identified (endotension)

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46
Q

What is the 2nd most common site of atherosclerotic aneurysm

A

Popliteal artery

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47
Q

How do popliteal aneurysms present

A
  • Aneurysm thrombosis or distal emboli leading to limb ischaemia
  • Rupture is rare
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48
Q

How are popliteal aneurysms treated

A
  • Ligation and vein bypass graft, OR

- Endovascular stent

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49
Q

What percentage of those with a popliteal aneurysm will also have a AAA

A

30%

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50
Q

What is the most common type of visceral artery aneurysm

A

Splenic artery aneurysm

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51
Q

What are the indications for surgery in popliteal aneurysm

A
  • Symptomatic
  • Limb ischaemia
  • Asymptomatic with thrombus
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52
Q

List the branches of the external iliac artery

A
  • Inferior epigastric artery

- Deep circumflex iliac artery

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53
Q

List the branches of the femoral artery

A
  • Superficial circumflex iliac artery
  • Superficial epigastric
  • Superficial and deep external pudendals
  • Profunda femoris
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54
Q

Describe the course of profunda femoris

A
  • Largest branch of the femoral artery
  • Arises posteriorly/posterolaterally
  • Descends medially to enter adductor compartment
  • Gives of medial and lateral circumflex femoral, then 3 perforators
  • Ends as 4th perforator
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55
Q

Outline the bounds of the popliteal fossa

A
  • Lateral = biceps femoris above, lateral head of gastroc and plantaris below
  • Medial = semimembranosus and semitendinosus above, medial head of gastroc below
  • Floor = popliteal surface of femur, posterior ligament of knee, popliteus mucle
  • Roof = superficial and deep fascia
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56
Q

What is the deepest structure of the popliteal fossa

A

Popliteal artery

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57
Q

What is the most superficial structure of the popliteal fossa

A

Tibial nerve

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58
Q

What flanks the dorsalis pedis artery in the foot

A
  • Medial = EHL tendon

- Lateral = EDL tendons

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59
Q

What does the posterior tibial artery divide into

A

Medial and lateral plantar arteries

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60
Q

What is the most common caused of PVD

A

Atherosclerosis with thrombosis

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61
Q

Outline the structure of an atherosclerotic plaque

A
  • Superficial fibrous cap
  • Intra-intimal area with accumulation of lipids, smooth muscle cells, foam cells
  • Basal zone with lipid accumulation and tissue necrosis
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62
Q

What is thromboangitis obliterans also known as

A

Buerger’s disease

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63
Q

What is the classic demographic of Buerger’s disease

A

Progressive obliteration of distal arteries in young men who smoke heavily

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64
Q

How is Buerger’s disease managed

A
  • Smoking cessation
  • Sympathectomy to relieve arterial spasm
  • Antibiotics
  • Foot care
  • Analgesia
  • Prostaglandins for acute ischaemia
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65
Q

List the symptoms of acute limb ischaemia

A
  • Pain
  • Pulseless
  • Pallor
  • Paraesthesia
  • Paralysis
  • Perishing cold
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66
Q

What is the time-frame for resolution of acute limb ischaemia

A

4-6 hours

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67
Q

Outline the principles of managing acute limb ischaemia

A
  1. Resuscitation
  2. Immediate anticoagulation (5000 units heparin IV)
  3. Analgesia
  4. Restore arterial continuity
  5. Identify and correct any underlying source of embolus
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68
Q

What is the investigation of choice in acute limb ischaemia if diagnosis in doubt

A

Arteriography

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69
Q

Describe the clinical appearance of a limb with <6 hours ischaemia

A

White

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70
Q

Describe the clinical appearance of a limb with 6-12 hours ischaemia

A

Mottled limb with blanching on pressure

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71
Q

Describe the clinical appearance of a limb with 12-24 hours of ischaemia

A

Fixed mottling

72
Q

What is the preferred treatment for acute-on-chronic limb ischaemia

A

Thrombolysis

73
Q

What are the contraindications to thrombolysis in acute limb ischaemia

A
  • Extreme old age
  • Recent surgery (2 weeks)
  • Recent CVA (2 months)
  • Peptic ulceration
  • Bleeding tendencies
74
Q

How should a white leg with sensorimotor deficit be managed

A

Surgery and embolectomy

75
Q

How should a dusky leg with mild anaesthesia be managed

A

Angiography

76
Q

How should a leg with fixed mottling be managed

A

Primary amputation

77
Q

In those with acute limb ischaemia, when should fasciotomy be considered

A

If the time between onset and surgery exceeds 6 hours

78
Q

What are the systemic effects of reperfusion injury

A
  • Rhabdomyolysis
  • Renal failure
  • ARDS
  • Myocardial dysfunction
  • Clotting disorders
79
Q

What are the early signs and symptoms of compartment syndrome

A
  • Pain out of proportion to the condition/injury
  • Pain on passive stretch
  • Absent distal pulse
80
Q

What are the late signs and symptoms of compartment syndrome

A
  • Paralysis
  • Weakness and tenderness
  • Pale, cold limb
  • Sensory loss
81
Q

What incision is used for femoral embolectomy

A

Longitudinal incision in the groin below the inguinal ligament and over femoral artery

82
Q

What incision is used for brachial embolectomy

A

Transverse incision below the skin crease at the elbow

83
Q

What measures should be taken following surgery for acute limb ischaemia

A
  • Check angiogram on table and prior to closure

- Systemic heparinisation should follow surgery which should later be converted to Warfarin

84
Q

What type of catheter is used for embolectomy

A

Fogarty catheter

85
Q

What type of fasciotomy should be performed in lower leg compartment syndrome

A

Four-compartment fasciotomy

86
Q

Describe Leriche syndrome

A

Distal aortic/Proximal iliac stenosis/occlusion causing:

  • Buttock, thigh and calf claudication
  • Erectile dysfunction
  • Proximal muscle wasting
87
Q

Outline the implications of Buerger’s angles

A
  • 50 degrees = severe ischaemia

- 25 degrees = critical ischaemia

88
Q

Outline the assessment of PVD

A
  • Clinical examination
  • ABPI
  • Duplex arterial USS
  • Angiography (only if intervention is planned)
89
Q

What PVD lesions are amenable to angioplasty

A
  • Short lesion
  • Reasonable distal runoff
  • Better for proximal disease
90
Q

What can be used to supplement vein grafts that are not long enough in bypass surgery

A

Miller Cuff (made from PTFE)

91
Q

Why are PTFE grafts unsuitable for distal disease

A

Undergo subintimal hyperplasia early which leads to occlusion and graft failure

92
Q

What suture is used for vascular anastomosis

A

Fine non-absorbable monofilament (e.g. 5/0 prolene)

93
Q

What type of arteriotomy is used in Fem-pop bypass

A

Longitudinal arteriotomy

94
Q

When is fem-fem crossover used

A

Unilateral iliac occlusive disease not amenable to angioplasty or stenting

95
Q

When is axillo-bifemoral grafting used

A

Aortic or bilateral iliac occlusion not amenable to angioplasty or stenting, in the presence of a hostile abdomen, or in a patient not fit for major abdominal surgery

96
Q

When is aorto-bifemoral grafting used

A

Occlusive or stenotic aorto-iliac disease not amenable to stenting or angioplasty

97
Q

What is the most likely cause of mid-term (1 year) graft failure

A

Neointimal hyperplasia causing stenosis of the graft

98
Q

What is the most likely cause of late graft failure

A

Atheromatous disease progression

99
Q

What graft is typically used for PVD

A

Long Saphenous vein used in reverse

100
Q

How much bone should ideally be conserved in BKA

101
Q

What are the indications for amputation (3 D’s)

A
  • Dead - non viable
  • Deadly - tumour, severe infection
  • Damn useless - pain, neurological damage
102
Q

Describe a Gritti-Stokes amputation

A
  • Supracondylar amputation preserving the patella

- Double amputees

103
Q

What type of flaps are used in above knee amputation

A

Anterior and posterior semicircular skin flaps

104
Q

What type of flaps are used in below-knee amputations

A
  1. Burgess flap - long posterior flap using posterior calf muscles to cover the bone ends 15cm below the tibial tuberosity
  2. Skew Flap (MOST POPULAR)
105
Q

When is a trans-metatarsal amputation indicated

A

Diabetic gangrene of the forefoot

106
Q

What is the general rule for flap length:diameter ratio in amputation

A

1.5x diameter

107
Q

What type of prosthesis can aide early mobilisation in amputation

108
Q

Describe the appearance of a neuropathic ulcer

A
  • Punched-out lesion

- Surrounded by a ridge of hard calloused skin

109
Q

Define a Carcot’s joint

A

Painless, disorganised joint due to decreased pain sensation and proprioception

110
Q

What proportion of strokes are caused by carotid artery disease

111
Q

Describe stroke presentation of the carotid territory

A
  • Contralateral hemiparesis

- Dysphasia if dominant hemisphere

112
Q

Describe stroke presentation of the vertebral hemisphere

A
  • Vertigo
  • Diplopia
  • Blurred vision
  • LOC
  • Facial involvement
  • Cerebellar signs
113
Q

Who should be offered elective carotid endarterectomy

A

Patients with ipsilateral stenosis >70% that have caused symptoms in the previous 6 months

114
Q

What is the GOLD standard assessment tool for carotid stenosis

A

Duplex doppler USS

115
Q

What incision is used for carotid endarterectomy

A

Longitudinal incision at the anterior border of SCM

116
Q

What nerves are at risk of damage in carotid endarterectomy

A
  • Marginal mandibular
  • Superior laryngeal
  • Hypoglossal
  • Great auricular
117
Q

Histology of carotid body tumours

A

Paraganglionic cells of neural crest origin

118
Q

Characteristic signs of carotid body tumours

A
  • Mass adjacent to hyoid
  • Smooth, compressible, pulsatile
  • Red-brown appearance
119
Q

What causes subclavian steal syndrome

A

Stenosis of the subclavian artery, proximal to the origin of the vertebral artery

120
Q

What is the physiological result of subclavian steal syndrome

A

Any increase in the demand for blood to the arm causes reverse flow of blood from the cerebral circulation, through the vertebral artery, to supply the subclavian post-stenosis

121
Q

What are the symptoms of subclavian steal syndrome

A
  • Dizziness
  • LOC
  • Ataxia
  • Visual loss
122
Q

Explain the likely distribution of upper limb emboli

A
  • 50% lodge in the brachial artery

- 30% lodge in the axillary artery

123
Q

What are the sources of upper limb emboli

A
  • Left atrium from AF

- Mural thrombus

124
Q

Outline the management of upper limb emboli

A
  • IV heparin
  • Angiography/duplex
  • Brachial embolectomy under GA
125
Q

Describe the 3 clinical phases of Raynaud’s syndrome

A
  1. Digital blanching due to arterial spasm (white)
  2. Cyanosis/pain due to stagnant anoxia (blue)
  3. Reactive hyperaemia due to accumulation of vasoactive metabolites (red)
126
Q

Drugs used to treat idiopathic Raynaud’s syndrome

A
  • Nifedipine

- Prostacyclin

127
Q

Where are the most common sites of hyperhidrosis

A
  • Palms
  • Axilla
  • Feet
128
Q

List the causes of secondary hyperhidrosis

A
  • Hyperthyroidism
  • Phaeochromocytoma
  • Hypothalamic tumours
129
Q

List the non-surgical interventions for hyperhidrosis

A
  • Topical ammonium chloride
  • Iontophoresis (elective current to incapacitate sweat glands)
  • Botox (decreases sympathetic activity)
130
Q

How is palmar hyperhidrosis treated surgically

A
  • Laparoscope inserted into the pleural space via the axilla
  • 2nd and 3rd thoracic ganglia are removed
131
Q

Why is the first thoracic ganglia not removed in sympathectomy

A

Will cause Horner’s syndrome

132
Q

What is the best treatment for axillary hyperhidrosis

133
Q

How is plantar hyperhidrosis treated

A

Chemical lumbar sympathectomy

134
Q

What must be divided to perform a thoracic sympathectomy

A

Parietal pleura

135
Q

Define thoracic outlet syndrome

A

Compression of the subclavian branches of the brachial plexus as they pass from the thorax into the arm

136
Q

List the causes of thoracic outlet syndrome

A
  • Cervical rib
  • Abnormal muscle insertions or muscle hypertrophy
  • Fibrous band
  • Callus from old clavicular fracture
  • Neck trauma
  • Malignancy
137
Q

What test may precipitate symptoms of thoracic outlet obstruction

A

Roos’ test = abduction and external rotation of the arm may precipitate symptoms

138
Q

How may thoracic outlet syndrome be surgically corrected

A

Decompression:

  • Resection of 1st part of 1st rib
  • Divide anterior scalene muscle
139
Q

Where is upper limb venous occlusion likely to occur

A
  • Axillary vein

- Subclavian vein

140
Q

What is the investigation of choice for diagnosing axillary vein thrombosis

A

Duplex scan

141
Q

What is the best treatment for axillary vein thrombosis

A

Local catheter directed TPA

142
Q

Describe cervical rib

A

Elongation of the 7th cervical vertebrae transverse process

143
Q

List the causes of congenital AV fistulas

A
  • Cirsoid
  • Parkes-Weber syndrome
  • Klippel-Trenaunay syndrome
144
Q

Describe a Cirsoid aneurysm

A

Localised arteriovenous fistula typically occurring in the scalp

145
Q

Describe Parkes-Weber Syndrome

A

Congenital condition of multiple AV malformation associated with increased limb size, dilated superficial veins with ulceration, and high-output cardiac failure

146
Q

Describe Klippel-Trenaunay syndrome

A

Combination of:

  • Port-wine staining
  • Varicose veins
  • Hypertrophy of bony and soft tissues
  • Improperly developed lymphatic system
147
Q

List the deep veins of the leg

A
  • Posterior tibial
  • Anterior tibial
  • Peroneal
  • Soleal
  • Gastrocnemius
148
Q

List the deep veins of the thigh

A
  • Popliteal
  • Superficial femoral vein
  • Deep (profunda) femoral vein
  • Iliac
149
Q

List the superficial veins of the lower limb

A
  • Long saphenous

- Short saphenous

150
Q

Where does the long saphenous vein communicate with the deep venous system of the leg

A
  • Saphenofemoral junction
  • Mid-thigh perforator
  • Medial calf perforators (3 or 4)
151
Q

Where does the short saphenous vein join the deep circulation

A

Enters popliteal vein after piercing deep fascia

152
Q

Where does the short saphenous vein communicate with the deep venous system

A
  • Popliteal vein
  • Gastrocnemius communicating veins
  • Lateral calf communicating veins
153
Q

Most common site of varicose veins

A

Long saphenous system

154
Q

Describe primary varicose veins

A

Form due to gravitational venous pooling and vein wall laxity causing venous dilatation and valve leakage

155
Q

Describe secondary varicose veins

A

Caused by obstruction of deep venous outflow (e.g. DVT, pelvis malignancy) resulting in blood being forced to the superficial system

156
Q

How may sites of venous incompetence be formally assessed

A

USS doppler

157
Q

Define Saphena Varix

A

Reducible swelling in the groin due to a dilated varix at the saphenofemoral junction

158
Q

List the indications for surgery to treat varicose veins

A
  • Cosmetic (majority)
  • Lipodermatosclerosis causing venous ulceration
  • Recurrent superficial thrombophlebitis
  • Bleeding from ruptured varix
159
Q

List the surgical options for symptomatic uncomplicated varicose veins

A
  • Endothermal ablation
  • Foam sclerotherapy
  • Saphenofemoral/popliteal disconnection
  • Stripping and avulsions
160
Q

What structures are at risk during long saphenous vein surgery

A

Saphenous nerve (sensory loss)

161
Q

What structures are at risk with short saphenous vein surgery

A
  • Sural nerve (sensory loss)

- Common peroneal nerve (foot drop)

162
Q

Outline the two theories of venous ulcer formation

A
  1. Leucocyte trapping theory

2. Fibrin cuff theory

163
Q

How are chronic venous ulcers managed

A

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

164
Q

Describe 4-layer compression bandaging

A
  1. Cotton wool
  2. Crepe
  3. Elastic bandage
  4. Cohesive bandage
165
Q

What parasite is responsible for filariasis

A

Wuchereria bancrofti (usually transmitted by mosquitos)

166
Q

What does lymphoedema involve

A
  • Accumulation of protein-rich fluid
  • Subdermal fibrosis
  • Dermal thickening
167
Q

Where is fluid confined to in lymphoedema

A

Epifascial space (skin and subcutaneous tissues)

168
Q

Cause of primary lymphoedema in those aged <1

A

Milroy’s disease (congenital)

169
Q

Cause of primary lymphoedema in those aged 1-35

A

Meige’s disease

170
Q

Cause of primary lymphoedema in those >35

171
Q

List the 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
172
Q

How can the diagnosis of lymphoedema be confirmed

A

Lymphoscintigraphy

173
Q

How can detailed anatomy fo the lymphatic system be detailed prior to lymphatic reconstruction

A

Lymphangiography

174
Q

What procedure is indicated for those with proximal lymphatic obstruction and normal distal lymphatics

A

Lymphovenous anastamosis

175
Q

Which procedure is indicated in lymphoedema with good overlying skin

A

Homan’s operation

176
Q

Which procedure is indicated in lymphoedema with poor overlying skin

A

Charles operation

Vascular Surgery (1 decks)

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