Vascular Surgery Flashcards
Thoracic Outlet Syndrome
Thoracic outlet syndrome is a condition in which there is compression of the trunk of the brachial plexus, or the subclavian artery or vein at the superior aperture of the chest resulting in pain or numbness in the hand or forearm often on the ulnar side.
It presents UNI LATERALLY .
Depending on which neurovascular structures are involved, it may be seen together with a weak radial pulse, forearm cyanosis, or thenar muscles weakness.
Ruptured Aortic Aneurysm Mgx
This scenario describes a ruptured aortic aneurism. Immediate intravenous normal saline to raise the blood pressure to 90 mmHg to keep the vital organs perfused till definitive measures are taken. The idea here is to treat major hypovolaemia, but accept moderate degrees of hypotension which is a systolic BP > 90 mmHg.
In such a given case, assume that the problem is a ruptured abdominal aortic aneurysm and commence resuscitative measures, whilst appropriate experts are summoned and
relevant ‘emergency confirmato,y investigations like an ultrasound or CT scans are performed
Before taking patient to any imaging follow ABC resuscitation guidelines
3 day post hemorrhagic stroke pt Complicated with Left leg DVT treatment ?
Recent Hemorrhagic Stroke - Do NOT give LMWH, DOAC, Warfarin
Give Percutaneous Mechanical Thrombectomy
Thoracic Aortic Dissection (after car accident and different BP reading in respective arms )
Poorly controlled hypertensive patients(70%)
Episode resembles MI
Large difference in BP in Upper Extremities (radio- radial delay)
DX- CXR- Widen Media sternum
MGx- IV labetalol (BP to 100-120)
and then Surgical tx
Renal Vascular Disease (artery stenosis)
Cause: arthrosclerosis / fibromuscular disease
Presentation: Htension resistant to Tx
ACEi ARB worsen the renal function (renal stenosis )
Tests: USG small renal on effected side
Gold Standard: renal angiography (invasive) , usually done after CT/MRI angiography
Treatment : angioplasty and stent placement surgery
comprehensive antihypertensive regime
Ulcers of the FOOT
Venous Ulcers: +Painful+, Superficial,on Medial distal leg ie around medial malleolus, Hemosiderin are characteristics.
Neuropathic ulcers: Painless, toes and sole of foot.(Diabetics are asked to examine foot).
Arterial Ulcers: lateral malleolus, dorsum of foot, Deep ,6Ps ( severe pain, paralysis, paranesthesia , pulseless , perishably cold ,pale )
DDx of acute chest pain
Acut coronary syndrome
Pain>10 minutes
Onset with minimal activity or at rest
Radiation to left arm /jaw
Aortic dissection Sudden tearing chest pain Radiate to back between scapulas Hypotensive / Tachycardic Difference in BP and/ pulses (abnormal peripheral pulses)
Pneumothorax Sudden breathlessness Tall male / COPD Trauma Hyperresonance / Diminish breath sounds
Pneumonia
Fever/ cough / Plurulant Sputum
GERD
Indigestion/ acid taste /
Buring pain when SUPINE
Pericarditis
Fever / Sharp pain / cough
Pain relieve by sitting forward
Anxiety
Tingling in fingers
Tight chest / SOB
Musculoskeletal
Sharp / Positional / Pleuritic
Aggrevated by movement ( cough, inspiration,twisting of neck or thoracic cage )
Cause of AAA
1.Most Common Atherosclerosis
Reduce elastic recoil
Degenrative ischaemic changes
2.Infection
Mycotic aneurysm
3.Elastin and Collagen abnormalities
Marfan’s and Ehlers-Danlos synd
Bilateral pain in Calf muscles in Chronic Smoker .. relieved by rest
1.PAD(peripheral arterial disease )
Doppler USG measure Ankle Brachial Pressure index (ABPI) arm-leg P diff
- 1 st line
- measure the systolic BP by using a compression cuff . like normal doctors do / but the Doppler do the work of stetho
Duplex USG (do this if the patient require Revascularization )
- large USG device done by sonographers
- Color flow
MRI/CT angiography
considered only if intervension is necessary
Intermittent claudication-Pain is due to lactic acid build up by Calf muscles due to poor oxygen supply due to Atherosclerosis due to smoking .
2. Burger's Disease Male / 40 / Strong Smoking History Severe claudication Affects the small arteries
Lower Limb Occluded Artery Anatomical Site and associated symptoms
Aorto-iliac Artery: Lereiche Syndrome:
(Claudication +Pain in buttock and thigh+ Erectile dysfunction.)
Common iliac artery bifurcates into internal iliac artery that moves to the groin and the common iliac continue as external iliac artery. As external crosses the inguinal ligament, it becomes femoral and its called popliteal below the knee.
So, Internal iliac ⏭️ Pain in the Buttock Groin region.
External iliac ⏭️ above inguinal ligament.
Femoral⏭️ below inguinal ligament
Femero-popliteal ⏭️ below knee.
Pain in groin/buttock+ above inguinal ligament= common iliac ie internal plus external
Inferior Vena Cava Syndrome
Causes (compression of IVC)
RCC
Pregnancy
Thrombosis
Inferior vena cava occlusion results in reduced venous return to the heart, which may lead to peripheral oedema and tachycardia. Possible causes include pregnancy(supine position), renal cell carcinoma or thrombosis.
Well established case for IVC S is RCC
Present with wide variety of symptoms making it difficult to diagnose
Odema of the lower extremities and Tachycardia are frequently seen .
Dilated lower abdominal veins
Thromboangiitis obliterans (40 young age , non healing ulcer in base of the toe , chronic 3 months pain is the legs )
5 S of Buerger’s disease : Sex-Male Smoking history Small vessels
Severe claudication Stop smoking is treatment
Thromboangiitis obliterans describes thrombosis formation in small and medium sized arteries normally in the hands and feet. This occurs almost exclusively in smokers and presents with painful purple or blue areas on the fingers and toes.
Associated “Superficial Thromophlelibitis” and “Raynouds Phenomena” can happen.
Repeated LOC and TIA
Answer :Carotid Artery Stenosis
AF causes Stroke >24hr (not TIA <24hr)
A stable atheromatous plaque in the: Carotid a => TIA Ophthalmic a => amurosis fugax Coronary a => stable angina Mesenteric arterial system => abdominal angina Iliofemoral => intermittent claudication
Stroke: Sudden onset of focal neurological loss of presumed Vascular origin >24 hours
TIA : <24 hours
70 women painless visual loss + slurred speech for 15 minutes for 2 times
Carotid artery stenosis 80% Best tx
1st line is Endarterectomy(surgery) but more invasive than Angioplasty and Stent
if not fit : angioplasty + stent (downside is high mortality rate)
NB: surgery within 2 wks
Endarterectomy is a surgical procedure used to clear atherosclerotic plaques from arteries in order to reestablish flow. It entails the physical separation of the plaque from the arterial endothelial and its extraction from the artery altogether. The arterial incision is repaired with stitching or patches.
always consider Carotid endarterectomy as secondary prevention in Ischaemic stroke if internal carotid artery is stenosed (>50% in men, >70% in women)
Secondary prevention after TIA/Stroke: Anti hypertensive according to age ( target BP 130/80) ,
do not try to control BP in first 48 hours as this may cause extension of stroke
Statin regardless of baseline cholesterol level (80mg atrovastatin)
Anticoagulation if Afibrillation: Warfarin (target INR 2.0-3.0)
No afibrillation: antiplatelet using Clopidogrel for long term. If not tolerated, give Aspirin+Dipyridamol
