Vascular Surgery Flashcards
What are the 6 Ps of limb ischemia?
Pain (sudden) Paraesthesia Pulselessness Pallor Paralysis Perishing cold
How do you treat acute limb ischemia?
Urgent revascularisation - angioplasty or open surgery within 4-8 hours to save limb
In the case of acute limb ischemia + irregular pulse what is the likely cause of limb ischemia?
Embolus
Irregular pulse - likely due to AFIB
Painless pulsatile mass near the groin , what would be your diagnosis?
Femoral artery aneurysm
A male patient with known renal cell carcinoma develops painful scrotal swelling and mentions it is bluish and feels like a bag of worms
What is your diagnosis?
What is the treatment?
Reassure
Or
Do surgery if severe persistent pain to infertility
A known case of renal cell carcinoma developed non tender pitting edema of the lower limbs and dilate veins on the lower abdomen
What could this be?
Occlusion of the IVC - inferior vena cava syndrome
What is buerger’s disease?
What is it strongly associated with?
Thrombangiitis obliterans
Small and medium vessel vasculitis
Assoc w/ SMOKING
Young men - 25 - 45 yrs old.
*** do not confuse with BERGERS - IgA Nephropathy - young adult with hematuria 1-2 days after URTI
Features of buergers
Treatment?
Extremity ischemia - intermittent claudication, rest pain , ischemia ulcers.
Superficial thrombophlebitis
Raynauds
Tx - stop smoking
Case of TIA - what is the nest next modality?
What should be done to check for carotid artery stenosis - when? Why?
Carotid Doppler scanning
Carotid duplex - within 2 weeks of admission, check for carotid artery stenosis to assess need of carotid endarterectomy
When should a carotid endarterectomy be performed in men and women?
Men - >= 50% ICA stenosis
Women - >= 70% ICA stenosis
An elderly woman has recurrent TIAs and loss of consciousness
What is the likely cause?
Carotid artery stenosis
What is usually the Underlying cause of strokes, TIA?
Atrial Fib - stroke
Carotid stenosis - TIA
What are the 3 main types of TOS
Thoracic outlet syndrome
1.Neurogenic - most common
= pain weakness, occasionally loss of muscle at the base of the thumb
2.Venous
= swelling, pain , bluish discolouration of arm
3.Arterial
= pain, coldness, paleness of arm
*sometimes has pulsatile mass - subclavian aneurysm
What is the most important risk factor of aortic dissection?
What are other causes?
Hypertension
- trauma = RTA
- bicuspid aortic valve
- collagens: Marian , EDS, Turners, Noonan’s
- pregnancy
- syphilis
What features can be seen in involvement of other arteries in aortic dissection?
Coronary arteries — angina
Spinal arteries - paraplegia
Distal aorta - limb ischemia
What is the classification of aortic dissection?
- Stanford
A - Ascending
B - Descending - DeBakey
I- ascending aorta to at least the aortic arch, possibly beyond
II - confined ONLY to ascending aorta
III - descending aorta - will extend distally
A patient had axillary lymph nodes removed during a radical mastectomy,
what is a possible complication of axillary node clearance ?
How would you treat it?
Upper limb lymphoedema +/- Frozen shoulder
Treatment - Physiotherapy + Excercise
Patient has pain in the buttocks thighs and erectile dysfunction
Where is the level of ischemia?
What is the the name of the syndrome?
Aorta-iliac artery occlusion
Leriche syndrome
Patient has claudication pain that extends to just above the inguinal ligament
Where is the level of ischemia?
Common iliac artery occlusion
Patient has claudication pain that extends to just below the inguinal ligament. The femoral pulse is palpable but the pulses below it are not
Where is the level of ischemia?
Femoral artery occlusion
Patient has claudication pain that extends to just below knee
Where is the level of ischemia?
Femoro-popliteal
Features of PAD
Intermittent claudication - relieved within minutes of stopping
Pain not present at rest - unless late or severe PAD
How do you assess PAD?
Pulses - femoral, popliteal, posterior tibial, dorsal is pedis
Check ABPI - ankle brachial pressure index
= 0.6 - 0.9 = claudication, if below 0.6 pain at rest
Duplex ultrasound***** - 1ST LINE INVESTIGATION
MRA - should be done before any interventions
What meds should a person with established cardiovascular disease be taking?
Statin
Regardless of cholesterol level
Atorvastatin 80 mg recommended
A patient arrives to the ER with complaints of severe abdominal pain
On examination was found to be hypotensive with a pulsatile tender abdominal mass
Lower limb pulses were absent
What is your diagnosis?
Ruptured abdominal aortic aneurysm
Treatment of RAA
Treat shock - hypotensive so IV NS to bring systolic BP to 90
Immediate ultrasound - initial investigation
If no US do CT abdomen
Renal function tests deteriorate after starting ACEi in hypertensive patient
What is your diagnosis?
Bilateral renal artery stebosis
= bilateral small kidneys + hypertension
Features of coarctation of the aorta
Infancy - heart failure
Adulthood - hypertension
**** Radio-femoral delay Mid systolic murmur Nosebleeds head aches, LL pain on exertion Apical click of aortic valve
Important associations of coarctation of the aorta
more common in males
Turners syndrome
Berry aneurysm
Neurofibromatosis
Major aetiology of
- aortic aneurysm
- aortic dissection
AA - Atheroma, atherosclerosis
AD - HTN
What should be given to reduce the risk of VTE in immobile patients ex// hip fracture underwent surgery
LMWH prophylactic dose
= fondaparinux, enoxaparin
What are the long term meds for TIA?
Statin
Clopidogrel
Femoral and popliteal pulses not felt - where is the occlusion?
External iliac
Popliteal, dorsalis and posterior tibial pulse not felt
What is the most likely damaged artery?
Superficial femoral artery
Continuation of arteries starting from common iliac
Common iliac - external iliac - common femoral - sup femoral - popliteal - posterior tibial artery
DVT diagnosis
Wells criteria** see table
Score > 2 - dvt likely
Management of DVT
Anticoagulant therapy - DOACS
Apixaban or rivaroxaban - 1st line
Start once diagnosis is suspected, continue if confirmed
If neither is suitable - give LMWH + dabigatran/edoxaban
OR
LMWH + vitamin k antagonist (warfarin)
- active ca = DOAC unless CI
- Renal impairment GFR <15/min - LMWH or LMWH + Warfarin
- if anticoagulant therapy is CI e.g recent haemorrhaging stroke — surgical thrombectomy **
How long should anticoagulants be used in DVT?
3 months at least
3-6 months
Ulcer on medial malleolus + hemosiderin spots + painful
No loss of sensation
What is the nature of this ulcer?
Causes?
Treatment
Venous ulcer
Causes - varicose veins , dvt, pregnancy , increased weight
Tx - compression stockings, dressing, leg elevation , mild excercise
Ulcer on toes/lateral malleolus , tibia
Irregular deep and necrotic
Unilateral weak/absent pulse
What ulcer?
Cause?
Tx?
Arterial ischemia ulcer
Cause: PAD - risk factors coming HTN dm
Tx - ABPI, manage PAD - anti platelets, statin
