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Vascular surgery Flashcards

1
Q

What is peripheral arterial disease

A

Narrowing of arteries supplying the limbs and periphery

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2
Q

Describe intermittent claudication

A

Symptom of ischaemia of a limb, occurs during exertion and relieved by rest

Crampy, achy pain in the calf, thigh or buttock muscles associated with muscle fatigue when walking beyond a certain intensity

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3
Q

Describe critical limb ischaemia and how it presents

A

End stage of peripheral arterial disease where there is inadequate supply of blood to a vessel to allow it to function normally at rest

Pain at rest, non healing ulcers and gangrene

Pain
Pallor
Pulseless
Paralysis
Paraesthesia
Perishing cold

Risk of limb loss

Burning pain - worse at night when the leg is raised as gravity no longer helps pull blood into the foot

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4
Q

Describe acute limb ischaemia

A

Rapid onset of ischaemia in a limb

Typically due to thrombus blocking the arterial supply of a distal limb

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5
Q

What do atherosclerotic plaques cause

A

Stiffening of the artery walls, leading to hypertension and strain on the heart

Stenosis leading to reduced blood flow

Plaque rupture resulting in a thrombus that can block a distal vessel causing ischaemia

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6
Q

List some risk factors for atherosclerosis

A

Non-modifiable

  • age
  • family history
  • male
Modifiable
- smoking
- alcohol
- poor diet 
Low exercise
- obesity 
-Poor sleep 
- Stress

Medical co-morbidities

  • Diabetes
  • HTN
  • CKD
  • Inflammatory conditions such as RA
  • Atypical antipsychotics
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7
Q

List some end results of atherosclerosis

A 
Angina
MI
TIA
Stroke
PAD
Chronic mesenteric ischaemia
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8
Q

How does peripheral arterial disease

A

Intermittent claudication

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9
Q

Describe Leriche syndrome

A

Occlusion in the distal aorta or proximal common iliac artery

Thigh/buttock claudication
Absent femoral pulses
Male impotence

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10
Q

What do you look for on examination for peripheral arterial disease

A

RF - tar staining and xanthomata
CVD - missing limbs/digits, midline sternotomy scar (previous CABG), scar on inner calf for saphenous vein harvesting , focal weakness from previous stroke
Weak peripheral pulses

PAD
Pallor, cyanosis, dependent rubor (deep red colour when the limb is lower than the rest of the body) 
Muscle wasting 
Hair loss
Ulcers
Poor wound healing 
Gangrene

On examination 0- reduced skin temperature, reduced sensation, prolonged CRT, changes during buergers test

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11
Q

Describe Buerger’s test

A

Used to assess for PAD

Lay the patient on their back, lift leg to 45 degrees at the hip for 1-2 mins, looking for pallor. Pallor indicates arterial supply not adequate to overcome gravity, suggesting OAD. Beuergers angle refers to the angle at which the leg is pale due to inadequate blood supply

Sit the patient up with their legs hanging over side of the bed. Blood flow back to legs assisted by gravity. Healthy patient, legs go a normal pink colour. In a person with PAD the legs will initially go blue as the ischaemic tissue deoxygenates the blood and then a dark red (rubor) due to vasodilation in response to waste products of anaerobic respiration

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12
Q

What do leg ulcers indicate

A

The skin and tissues are struggling to heal due to impaired blood flow

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13
Q

Give the features of arterial ulcers

A

Ischaemia secondary to inadequate blood supply

  • Smaller
  • Deeper
  • Well defined borders
  • Punched out appearance
  • Occur peripherally (toes)
  • Have reduced bleeding
  • Painful
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14
Q

Give the features of venous ulcers

A

Impaired drainage and pooling of blood in the legs

  • Occur after a minor injury to the leg
  • Larger than arterial ulcers
  • More superficial than arterial ulcers
  • Have irregular, gently sloping borders
  • Affect the gaiter area of the leg (mid calf down to the ankle)
  • Less painful than arterial ulcers
  • Occur with other signs of chronic venous insufficiency
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15
Q

How do you investigate for peripheral arterial disease

A

Ankle-branchial pressure index (ABPI)
Duplex ultrasound
Angiography (CT/MRI)

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16
Q

Describe ankle-branchial pressure index

A

Ratio of SBP in the ankle compared with SBP in the arm - these readings are taken manually

0.9-1.3 is normal
0.6-0.9 indicates mild peripheral arterial disease
0.3-0.6 indicates moderate to severe peripheral arterial disease
<0.3 indicates severe disease to critical ischaemia

An ABPI >1.3 can indicate calcification of the arteries, making them difficult to compress - more common in diabetic patients

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17
Q

Describe the management of intermittent claudication

A

Lifestyle changes - manage modifiable risk factors and optimise medical treatment of co-morbidities

Exercise training - involving a structured and supervised programme of regularly walking to the point of near maximal claudication and pain, then resting and repeating

Medical treatments - atorvastatin 80mg, clopidogrel 75mg OD

Surgical - endovascular angioplasty and stenting, endarterectomy, bypass surgery

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18
Q

Describe the management of critical limb ischaemia

A 
Urgent vascular referral 
Analgesia 
Endovascular angioplasty and stenting 
Endarterectomy
Bypass surgery 
Amputation if not possible to restore the blood supply
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19
Q

Describe the management of acute limb ischaemia

A

Urgent referral to vascular team for assessment

IV heparin

Endovascular thrombolysis 
Endovascular thrombectomy
Surgical thrombectomy 
Endarterectomy 
Bypass surgery 
Amputation
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20
Q

What are varicose veins

A

Distended superficial veins measuring >3mm in diameter, usually affecting the legs

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21
Q

What are reticular veins

A

Dilated blood vessels in the skin measuring <3mm

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22
Q

What are telangiectasia

A

Dilated blood vessels in the skin measuring <1mm in diameter - spider veins or thread veins

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23
Q

Describe how varicose veins form

A

When the valves in the veins connecting the superficial and deep veins are incompetent

Blood flows from the deep veins into the superficial veins and overloads them - dilation and engorgement of the superficial veins

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24
Q

Describe chronic venous insufficiency and its features

A

When blood pools in the distal veins, the pressure causes the veins to leak small amounts of blood into the nearby tissues. The Hb in the leaked blood breaks down into hemosiderin which is deposited around the shins in the legs giving a brown discolouration of the legs

Pooling of blood results in inflammation, the skin becomes dry and inflamed, venous eczema

The skin and soft tissues become fibrotic and tight causing the lower legs to become narrow and hard - lipodermatosclerosis

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25
List some risk factors for varicose veins
``` Old age FH Female Pregnancy Obesity Prolonged standing DVT ```
26
How do varicose veins present
Engorged and dilated superficial leg veins Asymptomatic o have a heavy/dragging sensation in the legs, aching, itching, burning, oedema, muscle cramps, restless legs
27
Name and describe some special tests for varicose veins
Tap test - apply pressure to the saphenofemoral junction and tap the distal varicose vein, feeling for a thrill at the SFJ - incompetent valve Cough test - apply pressure to the SFJ and ask the patient to cough feeling for thrills - suggests dilated vein - saphenous varix Trendelenburg's test - with the patient lying down, lift the affected leg to drain the veins completely, apply tourniquet to the thigh and stand the patient up. The tourniquet should prevent the varicose veins reappearing if placed distally to incompetent valve. Repeat the test at different levels to locate the incompetent valve
28
How are varicose veins managed?
If due to pregnancy - improve after delivery Weight loss Physical activity Keep the leg elevated Compression stockings Endothermal ablation Sclerotherapy - irritant foam causes closure of the vein Stripping - vein is ligated and pulled out of the leg
29
List some complications of varicose veins
Prolonged and heavy bleeding after trauma Superficial thrombophlebitis DVT Chronic venous insufficiency - skin changes and ulcers
30
Describe venous eczema
Dry, itchy, flaky, scaly, red, cracked skin - chronic inflammatory response by the skin
31
Describe the classic presentation of lipoodermatosclerosis
Hardening and tightening of the skin and tissue benerath the skin. Chronic inflammation causes the SC tissue to become fibrotic. Inflammation of the sc fat causes panniculitis. Inverted champagne bottle appearance - narrowing of the lower legs
32
Describe atrophie blanche
Patches of smooth, porcelian-white scar tissue on the leg
33
List some chronic venous changes
``` Venous ulcers Venous eczema Lipodermatosclerosis - inverted champagne bottle leg Atrophie blanche Cellulitis Poor healing after surgery Pain ```
34
Describe the management of chronic venous insufficiency
Keep the skin healthy - monitor skin health and avoid damage, regular emollient use, topical steroids to treat flares of venous eczema, potent topical steroids for lipodermatosclerosis flares Improve drainage - weight loss if obese, keep active, keep the legs elevated when resting, compression stockings (Exclude PAD first) Manage the complications - antibiotics for infection, analgesia for pain, wound care for ulcers complications
35
Describe diabetic ulcers
Feet of people with diabetes who have lost sensation and do not realise they have injured their feet/poorly fitting shoes Damage to small and large blood vessels impairs the supply and wound healing Raised blood sugar immune system changes and autonomic neuropathy also contribute to the ulceration and poor healing
36
What is an important complication of diabetic foot ulcers
Osteomyelitis
37
Describe pressure ulcers
Reduced mobility, where prolonged pressure on particular areas lead to skin break down due to reduced blood supply, localised ischaemia, reduced lymph drainage and abnormal change in shape of tissues under pressure
38
What scoring system is used to identify those at risk and prevent pressure ulcers
Waterlow score
39
What is lymphoedema
Chronic condition caused by impaired lymphatic drainage of an area
40
List the two types of lymphoedema
Primary - rare, genetic disorder, presents <30yo, faulty lymphatic development Seconary - most commonly after breast cancer surgery due to axillary lymph nodes in the armpit removal
41
What is an important differential for lymphoedema
Lipoedema - build up of fat in limbs, often the legs | Affects women more than men
42
Which sign is used for lymphodema assessment
Stemmer's sign - skin at the bottom of the second toe or middle finger is pinched together. If it is possible to lift and tent the skin, stemmers sign is negative. If it is not possible to pinch the skin together, lift and tent it then stemmers sign is positive and lymphoedema may be present
43
List some investigations for lymphoedema
Limb volume Bioelectric impedance spectrometry Lymphoscintigraphy
44
Describe the management for lymphoedema
``` Specialist lymphoedma service Massage techniques Compression bandage Specific lymphoedema exercises to improve drainage Weight loss if overweight Good skin care Lymphaticovenular anastomosis - allow lymph to drain into venous system Antibiotics CBT and antidepressants ```
45
Define abdominal aortic aneurysm
>3cm diameter
46
List some risk factors for abdominal aortic aneurysm
``` Men Increased age Smoking FH CVD ```
47
Describe AAA screening in england
Men aged >65 Asymptomatic early detection Routine screening considered in women >70yo with RF
48
How do AAA present
``` Ruptures Screening Non-specific abdo pain Pulsatile and expansile mass Incidental finding - CT/USS ```
49
How is AAA diagnosed
USS | CTA
50
Describe the classification of AAA
Normal <3cm Small 3-4cm Medium 4.5-5.4cm Large >5.5
51
How are AAA managed
Treat reversible factors - stop smoking, healthy diet and exercise, optimise the management of HTN, DM and hyperlipidaemia
52
How often are people with AAA followed up
Yearly for those with 3-4.4cm AAA | 3 monthly for people with aneurysms 4.5-5.4
53
When is elective repair of AAA recommended
Symptomatic Diameter growing >1cm a year Diameter >5.5
54
Describe elective repair of AAA
Open repair via laparotomy | Endovascular aneurysm repair (EVAR) using a stent inserted via the femoral arteries
55
Describe the link between driving and AAA
Inform the DVLA if >6cm Stop driving if >6.5cm Stricter rules apply to heavy vehicle drivers
56
How does a ruptured AAA present
Severe abdominal pain that may radiate to the back or groin Haemodynamic instability - hypotension or tachycardia Pulsatile and expansive mass in the abdomen Collapse Loss of consciousness
57
How is a ruptured AAA managed
Permissive hypotension - aim for lower than normal BP when performing fluid resuscitation Transfer to theatre for surgical repair CT angiogram can be used to diagnose or exclude ruptured AAA in haemodynamically stable patients
58
List the layers of the wall of an artery
Tunica intima - innermost Tunica media - middle Tunica adventitia - outermost layer
59
What is an aortic dissection
Tear in the intimal lining, causing blood to flow between the intima and media creating a false lumen filled with blood
60
List some risk factors for aortic dissection
``` Ehlers Danlos syndrome Marfans syndrome HTN Male Smoking Poor diet Reduced physical activity Raised cholesterol Old age Bicuspid aortic valve Aortic valve replacement CABG Coarctation of aorta ```
61
What is a retrograde dissection and how can it progress
Propagates towards the aortic valve at the root of the aorta - results in prolapse of the aortic valve, bleeding into the pericardium and cardiac tamponade
62
Give the classification of aortic dissections
Stanford system Type A - affects the ascending aorta, before the brachiocephalic artery Type B - affects the descending aorta, after the left subclavian DeBakey system 1) Begins in the ascending aorta and involves the arch 2) isolated to the ascending aorta 3a) begins in descending aorta and involves section above diaphragm 3b) beings in descending aorta and involves the aorta below the diaphragm
63
Describe how aortic dissections present
Sudden onset, severe, ripping or teating chest pain (anterior - ascending or back if descending). The pain may migrate ``` HTN Differences in BP between the arms >20mmHg Radial pulse deficit Early diastolic murmur - aortic regurgitation murmur Focal neurological deficit Chest and abdominal pain Collapse Hypotension as progression occurs ```
64
How are aortic dissections diagnosed
ECG and CXR to exclude other causes - may be normal or false reassuring since MI can present alongside aortic dissection and MI treatment will worsen dissection CT angiogram - initial investigation to confirm diagnosis MR angiogram - greater detail and can help plan management but often takes longer to get
65
Describe the management of aortic dissections
Analgesia BP and HR control - IV beta blockers (labetalol) or calcium channel blockers as 2nd line Type A - surgery - cardiothoracic as may need aortic valve replacement Type B - medical management with blood pressure control unless complications such as rupture, renal, visceral or limb ischaemia
66
List some complications of aortic dissection
``` MI Stroke Paraplegia Cardiac tamponade Aortic valve regurgitation Death ```
67
What is seen on CXR of patients with aortic dissection
Widened mediastinum
68
Which investigation is used to diagnose aortic dissection in those too unwell for CTA
Transoesophageal echo
69
What causes carotid stenosis
Atherosclerosis
70
Give the RF for carotid stenosis
``` Male Age Diet Smoking HTN Reduced physical activity ```
71
What is the risk of having carotid stenosis
TIA/Stroke | Also because of the atherosclerosis, may have this elsewhere so at risk of MI/CAD
72
Classify the severity of carotid stenosis
Mild = <50% reduction Moderate 50-69% reduction Severe = >70% reduced
73
How does carotid stenosis present
Asymptomatic Screened for after stroke or TIA Carotid bruit may be heard
74
How is carotid stenosis diagnosed
Carotid ultrasound | CT/MRA
75
How is carotid stenosis managed
Modifiable RF management Medical - aspirin, Clopidogrel or ticagrelor Surgery - carotid endarterectomy or carotid angioplasty and stenting
76
List the complications of carotid endarterectomy
Facial nerve injury - weakness - marginal mandibular branch - drooping of lower lip Glossopharyngeal nerve - swallowing difficulty Recurrent laryngeal nerve - hoarse voice Hypoglossal nerve injury - unilateral tongue paralysis
77
When is surgery offered for carotid stenosis
Stenosis >70% reduction
78
What is Buerger's disease
Thromboangitis obliterans Inflammatory condition that causes thrombus formation in the small and medium sized blood vessels in the distal arterial system (hands and feet)
79
Who does Buerger's disease typically affect
Men Aged 25-35 Smoking
80
How do Buerger's disease patients present
Painful, blue discolouration to the fingertips or toes Pain worse at night
81
What can be seen on angiograms in Buerger's
Corkscrew collaterals - finding on angiograms where new vessels form to bypass the affected arteries
82
Describe the management of Buerger's
Stop smoking IV iloprost - dilated blood vessels
83
Which veins are most implicated in varicose veins
Long saphenous - medial thigh and calf
84
Why is an abdominal CT a good idea if the patient is stable enough with ruptured AAA
Give surgeons idea of size of Teflon graft needed, if there is rupture, involvement of iliac and renal arteries
85
At what vertebral level does the aorta birfucate
L4 - level of the umbilicus
86
What size AAA is offered elective surgery
>5.5cm

Finals (18 decks)

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