Vascular Surgery Flashcards
Abdominal Aortic Aneurysms - define, RFs, S&S, invx & management
an abnormal dilatation of the abdominal aorta over 3cm or >50% of normal diameter
Likely cause - elastin or collagen degeneration in arterial wall
Often a/w atherosclerosis, CTD, trauma
• Advancing age
• Men (3-6x more likely & occurs at younger ages)
• Smoking
• Family history (10x risk for 1st degree relative)
• Popliteal artery aneurysm
• Coronary artery disease
• Hypertension
First presentation can be at rupture or can be incidental finding
• Back pain
• Abdominal pain - non specific, generalised
• Collapse
• Pulsatile mass in abdomen
Differentials - back pain (msk), renal colic
Investigations & Diagnosis: Bloods • FBC - Hb • U&Es - urea meal? • LFTs - clotting • Clotting panel • Urgent X-match or G&S
Imaging
• USS - bedside
• CT or MRI if stable
Bedside
• ECG
• USS
• CXR
Management:
Conservative & Follow-up
• asymptomatic aneurysms (<5.5cm) should be managed conservatively with regular follow-up by ultrasound (3–4cm yearly, or 6-monthly if enlargement >10% per year, 4–5.5cm 3–6-monthly scanning) and management of cardiovascular risk factors.
Surgical repair
• Symptomatic or 5.5cm or >1cm increase in diameter over a year
• EVAR vs Open
Prognosis - 80% mortality in rupturew
Acute Lower Limb Ischaemia - definition, aetiology, S&S, investigations & management
Limb ischaemia due to sudden occlusion of supplying artery
Causes - thrombosis (AS, aneurysm, hypovol), embolism, vascular injury (trauma, dissection)
RFs - smoking, diabetes, age, HTN, hyperlipidaemia, obesity
S&S - 6Ps
Investigations
- bedside: examination, doppler, ECG (arrhythmias), BM
- bloods: FBC, U&Es, LFTs, clotting, ABG/VBG
- imaging: USS, CT-A
Management
- immediate: ABC, analgesia, heparin (anti coag)
- medical: anticoagulant
- surgical: intra-arterial catheter thrombolysis, thrombectomy, bypass
Chronic Limb Ischaemia - definition, causes, S&S, investigation & management
Definition: Chronic arterial insufficiency to lower limbs results in consequences ranging from pain on exercise (intermittent claudication) to ulceration or gangrene
Aetiology & Risk factors:
• Atherosclerosis
○ Risk factors: diabetes, smoking, age, obesity, diet
Presentation/Clinical Features:
• Intermittent claudication - crampy pain in calf, same distance, relieved by rest
• Rest pain - in more severe cases
• Limb ulceration or grangrene
Critical ischaemia: When there is rest pain >2 weeks, ulceration or gangrene, indicating
severe arterial insufficiency threatening the viability of the limb.
On examination:
• Burger’s test - elevation of the leg results in pallor, venous guttering, followed by dependent rubor.
• Ankle-brachial pressure index (ABPI): Measured using a handheld Doppler; determined as the systolic ankle pressure divided by the brachial pressure.
○ Normal >0.9; claudication 0.8–0.6.
• Critical ischaemia: <0.5 or ankle systolic <50 mmHg or toe systolic <30 mmHg (values may be falsely high in diabetics due to poorly compressible vessels).
Investigations & Diagnosis:
• Imaging:
○ Arterial duplex, CT or MR angiography.
○ Digital subtraction angiography in those having intervention.
• Bloods:
○ FBC, lipids, glucose, clotting and group and save preintervention.
Management:
Medical
• Stop smoking, encourage exercise, treat CV risks
Surgery
• Balloon angioplasty and/or stenting of arterial stenoses.
• Revascularisation - for critical ischaemia
• Amputation for end stage
define critical limb ischaemia
Critical Ischaemia – rest pain and/or tissue loss in the foot from vascular disease
Arterial Ulcers - pathophysiology, features & management
Due to insufficient blood supply due to underlying PVD
Occur distally, smaller & deeper, punched out, regular shape, less likely to bleed, painful (esp on elevation), pale, a/w absence pulses, intermittent claudication
Refer to vascular for management of PVD & revascularisation
Venous Ulcers - pathophysiology, features & management
Venous insufficiency leads to pooling of blood
Occur in gaiter area, bigger, more superficial, irregular boarders, bleed, less painful, occur after minor injury to leg, pain better on elevation & worse on lowering leg
May need vascular or TVN input for cleaning, debridement & dressings, compression dressing (once ABPI excludes arterial ulcers), pentoxifylline (taken orally) can improve healing in venous ulcers (but is not licensed).
• Antibiotics are used to treat infection.
• Analgesia is used to manage pain (avoid NSAIDs as they can worsen the condition).
Aortic dissection - define, causes/RFs, S&S, invx & management
Tear in aortic intima which allows blood to flow in aortic wall, creates false lumen
Degeneration of aortic wall - hypertension, atherosclerosis (age, men, smoking, diet), CTD (SLE, ED, Marfan’s), aortitis, congenital cardiac abnormalities, trauma, cocaine, iatrogenic
tearing/ripping sudden severe chest pain, collapse, radiating to back, hypertensive, radial pulse deficit, diastolic murmur, differences in BP between arms, focal neurological deficits
Obs, cardiac exam, ECG, bloods (FBC, U&Es, X match), CXR (widened mediastinum, bulge in aorta), CT angiogram
SURGICAL EMERGANCY - analgesia, beta blockers to control BP
Pulmonary Embolism - define, RFs, S&S, invx & management
occlusion of pulmonary vessels usually from thrombus - 95% DVT
RFs: surgery, immobility, pregnancy, active cancer, obesity, haematological conditions
S&S; small may be asymptomatic, tachycardia, sudden SOB, haemoptysis, pleuritic chest pain, shock & collapse if massive
Inv: observations, ECG, FBC, d-dimer, ABG, Well’s score, CXR & CTPA, doppler of LL
Management - analegsia & oxygen if needed
initial - apixiban or rivaroxaban start immediately, if contra LMWH
long term anticoagulation needed - warfarin, NOAC/DOAC, LMWH
prevention important
thrombolysis (alteplase, streptokinase)if massive & haemodynamically unstable
Simplified Well’s Score Criteria (6)
Clinical S&S of DVT Most likely diagnosis active cancer immobility or recent surgery HR >100bpm haemopytsis
> 1 - likely
Long term anticoagulant options & reasons
○ Warfarin (target 2-3); need to continue LMWH for 5 days or until in range
○ NOAC/DOAC e.g. apixaban, rivaroxaban
○ LMWH; first line in pregnancy & cancer
• Continue anti-coagulation for:
○ 3mths if reversible cause
○ >3mths (usually 6mths) if cause unclear, recurrent VTE or irreversible cause
6mths in active cancer, then review
DVT - define, RFs, S&S
Partial or total occlusion of a deep vein - formation of thrombus (blood clot) that develops in a deep vein, usually lower limb. If not treated at risk of embolises & causing a PE
Virchows traid, RFs: hx of DVT, cancer, thrombophilia, inflammatory conditions, varicose veins, smoking, male, age >60, hospitalisation, immobility, recent surgery or trauma, pregnancy, OCP/HRT, acute infection or dehydration
S&S: hot warm half calf, unilateral leg swelling, painful, calf asymmetry, venous dilation, oedema, tenderness
Ivx: well’s score, USS doppler, bloods
Management: apixiban immediately, LMWH if not suitable, long term anticoagulation with NOAC, warfarin or LMWH
