Vascular surgery Flashcards by Helen Lashwood

What is an aortic dissection?

Tear in the tunica intima

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What is the biggest RF for aortic dissection?

HTN

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Recall 2 ways in which aortic dissection can be classified and what these entail

Stanford classification
- Type A is in ascending aorta, type B is in descending aorta

De Bakey classification
Type 1 originates in ascending aorta but extends to arch and possibly beyond
Type 2 is confined to the ascending aorta
Type 3 originates in the descending aorta

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How should aortic dissection be managed?

Aortic root replacement surgery

Bed rest and beta blockers

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What are the main symptoms of aortic dissection?

Tearing chest pain, radiates to back, 20mmHg BP difference between arms
Possible Horner’s

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How should aortic dissection be imaged?

If stable –> CT CAP

If unstable –> TOE/TTE (transoesophageal echo/ transthoracic echo)

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In which type of aortic dissection is surgery not indicated?

Descending

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What are the 3 subtypes of peripheral artery disease?

Intermittent claudication
Critical limb ischaemia
Acute limb-threatening ischaemia

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How can you differentiate between critical and acute limb-threatening limb ischaemia clinically?

Onset
CLI = >2 weeks
ALI = <2 weeks

Colour:
CLI = pink
ALI = marble white
nb. can’t find info on how this works in non-white skin tones

Temp:
CLI: warm
ALI: cold

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What are the 6 Ps of acute limb ischaemia?

Pain
Perishingly cold 
Pallor 
Pulseless
Paralysis 
Paraesthesia

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What is the expected ankle arterial pressure in critical limb ischaemia?

<40mmHg

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What are the causes of limb ischaemia?

TRIED to walk: 
Thromboangiitis obliterans 
Raynaud's 
Injury 
Embolism/thrombosis 
Diabetes

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How should ischaemic limb be investigated?

1st: ABPI
2nd: duplex USS
3rd: MRA/CTA

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What ABPI result is indicative of critical limb ischaemia?

<0.5

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At what ABPI would you refer to vascular surgeons?

<0.8 or >1.3

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How should asymptomatic limb ischaemia/intemittent claudication be managed?

Conservative: (WL, quit smoking etc)
Medical: statin + anti-platelet (1st line is atorvastatin 80mg + clopidogrel 75mg)
Rarely used - naftidrofuryl oxalate (vasodilator)

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How is critical limb ischaemia managed?

1st: Angioplasty, stenting, bypass, embolectomy
2nd: Amputation

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What are the indications for amputation in critical limb ischaemia?

Dead (eg severe PAD/ thromboangiitis obliterans)
Dangerous (sepsis, NF)
Damaged (trauma, burns, frostbite)
Darned nuisance (pain, neurological damage)

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What is thromboangiitis obliterans also known as?

Buerger’s disease

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What is thromboangiitis obliterans?

A smoking-related condition that results in thrombosis in small and medium-sized arteries, and less commonly veins
Ends of digits look all necrotic and nasty

Recall 2 classification systems used to classify limb ischaemia

Fontaine

Rutherford

What are the 3 stages of venous insufficiency?

Phlegmasia alba dolens (white leg)
Phlegmasia cerulea dolens (blue/red leg)
Gangrene (secondary to acute ischaemia)

How can venous insufficiency be managed?

Conservative: compression bandages (ABPI >0.8 required)
Surgical: grafts

What % of varicose veins are primary?

95%

How should varicose veins be investigated?

Cough impulse (should be neg in varicose pathology) Tap test - tap proximally and feel for an impulse distally Tourniquet test

How is the tourniquet test for varicose veins performed?

Patient supine, elevate legs, milk veins Apply tourniquet high to compress saphenofemoral junction Stand patient Repeat distally until controlled filling Controlled filling = distal veins do not fill Uncontrolled filling = distal veins full - meaning there is an incompetent valve below the tourniquet

How can varicose veins be managed?

Conservative: WL, avoid prologed standing, compression stockings, emollients Medical: injection sclerotherapy, radiofrequency ablation Surgical: various types of ligation

What investigations should be done in suspected DVT?

First do a Well's score If 2 or more --> USS leg If 0 or 1 --> D-dimer within 4 hours --> USS if pos, other diagnosis if neg If DVT is confirmed and unprovoked do a CT AP to help identify possible malignancy

How should DVT be managed?

DOAC (if renal impairment --> LMWH + warfarin)

Recall the components of the Wells score

Mnemonic: DVT SCORES DVT previous [+1] Veins - superficial collateral [+1] Three cm difference in calf diameter [+1] Static (paralysis/paresis/plaster immobilisation) [+1] Cancer (active within 6 months) [+1] Oedema (pitting, confined to the symptomatic leg) [+1] Recently bedridden for 3 days [+1] Entire leg swollen [+1] Something else equally likely [-2]

What is the most common site of superficial thrombophlebitis?

Saphenous vein

What are the symptoms of superficial thrombophlebitis?

Palpable/nodular cord Inflammation Varicose veins

How should superficial thrombophlebitis be investigated?

Doppler USS

How should superficial thrombophlebitis be managed?

``` Compression stockings + 1st line = NSAIDs 2nd line (if SVT >5cm long/<5cm from SFJ) = DOAC 3rd line = varicose vein surgery ```

How should venous ulcers be investigated?

Doppler USS, ABPI (to exclude arterial)

How should venous ulcers be managed?

1st - graded compression stockings | 2nd line - skin grafting (if not resolved in 12w or area >10cm^2)

Where do arterial ulcers typically appear?

Toes and heel

How should arterial ulcers be managed?

Pain mx IV prostaglandins RF modification Chemical lumbar sympathectomy

Where do neuropathic ulcers typically appear?

Over plantar surface of metatarsal head and plantar surface of hallux

How can neuropathic ulcers be managed?

Cushioned shoes to reduce callous formation

How should popliteal aneurysms be managed?

If stable: femoral-distal bypass | If acute: embolectomy +/- femoral-distal bypass

What is an abdominal aortic aneurysm?

DIlation of the abdominal aorta to >50% of normal diameter/ 3cm, involving all layers of the endothelium

What are the 2 types of AAA?

Fusiform (equally round) | Saccular (outpouching)

What is the process for AAA screening?

``` In males >65y --> single abdominal USS If AAA: 3-4.5cm --> f/u scan in 12m 4.5-5.5cm --> f/u scan in 3m >5.5cm --> 2ww to vascular ```

What is the elective operation used for AAA repair?

EVAR | If particularly young you can do an open replacement - has longer recovery time but lower chance of further procedures

What are the complications of AAA?

Rupture Embolism (trash foot) Thrombus Fistulation

What is the 1st line treatment for SVCO?

Dexamethosone

How should stridor due to SVCO be managed?

Intubation --> endovascular stenting