Vascular surgery Flashcards
What is peripheral arterial disease
Narrowing of arteries supplying the limbs and periphery
Describe intermittent claudication
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
Describe critical limb ischaemia and how it presents
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
Describe acute limb ischaemia
Rapid onset of ischaemia in a limb
Typically due to thrombus blocking the arterial supply of a distal limb
What do atherosclerotic plaques cause
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
List some risk factors for atherosclerosis
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
List some end results of atherosclerosis
Angina MI TIA Stroke PAD Chronic mesenteric ischaemia
How does peripheral arterial disease
Intermittent claudication
Describe Leriche syndrome
Occlusion in the distal aorta or proximal common iliac artery
Thigh/buttock claudication
Absent femoral pulses
Male impotence
What do you look for on examination for peripheral arterial disease
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
Describe Buerger’s test
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
What do leg ulcers indicate
The skin and tissues are struggling to heal due to impaired blood flow
Give the features of arterial ulcers
Ischaemia secondary to inadequate blood supply
- Smaller
- Deeper
- Well defined borders
- Punched out appearance
- Occur peripherally (toes)
- Have reduced bleeding
- Painful
Give the features of venous ulcers
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
How do you investigate for peripheral arterial disease
Ankle-branchial pressure index (ABPI)
Duplex ultrasound
Angiography (CT/MRI)
Describe ankle-branchial pressure index
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
Describe the management of intermittent claudication
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
Describe the management of critical limb ischaemia
Urgent vascular referral Analgesia Endovascular angioplasty and stenting Endarterectomy Bypass surgery Amputation if not possible to restore the blood supply
Describe the management of acute limb ischaemia
Urgent referral to vascular team for assessment
IV heparin
Endovascular thrombolysis Endovascular thrombectomy Surgical thrombectomy Endarterectomy Bypass surgery Amputation
What are varicose veins
Distended superficial veins measuring >3mm in diameter, usually affecting the legs
What are reticular veins
Dilated blood vessels in the skin measuring <3mm
What are telangiectasia
Dilated blood vessels in the skin measuring <1mm in diameter - spider veins or thread veins
Describe how varicose veins form
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
Describe chronic venous insufficiency and its features
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
List some risk factors for varicose veins
Old age FH Female Pregnancy Obesity Prolonged standing DVT
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
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
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
List some complications of varicose veins
Prolonged and heavy bleeding after trauma
Superficial thrombophlebitis
DVT
Chronic venous insufficiency - skin changes and ulcers
Describe venous eczema
Dry, itchy, flaky, scaly, red, cracked skin - chronic inflammatory response by the skin
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
Describe atrophie blanche
Patches of smooth, porcelian-white scar tissue on the leg
List some chronic venous changes
Venous ulcers Venous eczema Lipodermatosclerosis - inverted champagne bottle leg Atrophie blanche Cellulitis Poor healing after surgery Pain
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
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
What is an important complication of diabetic foot ulcers
Osteomyelitis
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
What scoring system is used to identify those at risk and prevent pressure ulcers
Waterlow score
What is lymphoedema
Chronic condition caused by impaired lymphatic drainage of an area
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
What is an important differential for lymphoedema
Lipoedema - build up of fat in limbs, often the legs
Affects women more than men
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
List some investigations for lymphoedema
Limb volume
Bioelectric impedance spectrometry
Lymphoscintigraphy
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
Define abdominal aortic aneurysm
> 3cm diameter
List some risk factors for abdominal aortic aneurysm
Men Increased age Smoking FH CVD
Describe AAA screening in england
Men aged >65
Asymptomatic early detection
Routine screening considered in women >70yo with RF
How do AAA present
Ruptures Screening Non-specific abdo pain Pulsatile and expansile mass Incidental finding - CT/USS
How is AAA diagnosed
USS
CTA
Describe the classification of AAA
Normal <3cm
Small 3-4cm
Medium 4.5-5.4cm
Large >5.5
How are AAA managed
Treat reversible factors - stop smoking, healthy diet and exercise, optimise the management of HTN, DM and hyperlipidaemia
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
When is elective repair of AAA recommended
Symptomatic
Diameter growing >1cm a year
Diameter >5.5
Describe elective repair of AAA
Open repair via laparotomy
Endovascular aneurysm repair (EVAR) using a stent inserted via the femoral arteries
Describe the link between driving and AAA
Inform the DVLA if >6cm
Stop driving if >6.5cm
Stricter rules apply to heavy vehicle drivers
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
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
List the layers of the wall of an artery
Tunica intima - innermost
Tunica media - middle
Tunica adventitia - outermost layer
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
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
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
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
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
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
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
List some complications of aortic dissection
MI Stroke Paraplegia Cardiac tamponade Aortic valve regurgitation Death
What is seen on CXR of patients with aortic dissection
Widened mediastinum
Which investigation is used to diagnose aortic dissection in those too unwell for CTA
Transoesophageal echo
What causes carotid stenosis
Atherosclerosis
Give the RF for carotid stenosis
Male Age Diet Smoking HTN Reduced physical activity
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
Classify the severity of carotid stenosis
Mild = <50% reduction
Moderate 50-69% reduction
Severe = >70% reduced
How does carotid stenosis present
Asymptomatic
Screened for after stroke or TIA
Carotid bruit may be heard
How is carotid stenosis diagnosed
Carotid ultrasound
CT/MRA
How is carotid stenosis managed
Modifiable RF management
Medical - aspirin, Clopidogrel or ticagrelor
Surgery - carotid endarterectomy or carotid angioplasty and stenting
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
When is surgery offered for carotid stenosis
Stenosis >70% reduction
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)
Who does Buerger’s disease typically affect
Men
Aged 25-35
Smoking
How do Buerger’s disease patients present
Painful, blue discolouration to the fingertips or toes
Pain worse at night
What can be seen on angiograms in Buerger’s
Corkscrew collaterals - finding on angiograms where new vessels form to bypass the affected arteries
Describe the management of Buerger’s
Stop smoking
IV iloprost - dilated blood vessels
Which veins are most implicated in varicose veins
Long saphenous - medial thigh and calf
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
At what vertebral level does the aorta birfucate
L4 - level of the umbilicus
What size AAA is offered elective surgery
> 5.5cm
