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Finals > Vascular surgery > Flashcards

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
Q

List some risk factors for varicose veins

A 
Old age
FH
Female
Pregnancy
Obesity
Prolonged standing
DVT
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26
Q

How do varicose veins present

A

Engorged and dilated superficial leg veins
Asymptomatic o have a heavy/dragging sensation in the legs, aching, itching, burning, oedema, muscle cramps, restless legs

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27
Q

Name and describe some special tests for varicose veins

A

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

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28
Q

How are varicose veins managed?

A

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

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29
Q

List some complications of varicose veins

A

Prolonged and heavy bleeding after trauma
Superficial thrombophlebitis
DVT
Chronic venous insufficiency - skin changes and ulcers

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30
Q

Describe venous eczema

A

Dry, itchy, flaky, scaly, red, cracked skin - chronic inflammatory response by the skin

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31
Q

Describe the classic presentation of lipoodermatosclerosis

A

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

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32
Q

Describe atrophie blanche

A

Patches of smooth, porcelian-white scar tissue on the leg

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33
Q

List some chronic venous changes

A 
Venous ulcers
Venous eczema 
Lipodermatosclerosis - inverted champagne bottle leg 
Atrophie blanche 
Cellulitis
Poor healing after surgery 
Pain
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34
Q

Describe the management of chronic venous insufficiency

A

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

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35
Q

Describe diabetic ulcers

A

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
Q

What is an important complication of diabetic foot ulcers

A

Osteomyelitis

37
Q

Describe pressure ulcers

A

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
Q

What scoring system is used to identify those at risk and prevent pressure ulcers

A

Waterlow score

39
Q

What is lymphoedema

A

Chronic condition caused by impaired lymphatic drainage of an area

40
Q

List the two types of lymphoedema

A

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
Q

What is an important differential for lymphoedema

A

Lipoedema - build up of fat in limbs, often the legs

Affects women more than men

42
Q

Which sign is used for lymphodema assessment

A

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
Q

List some investigations for lymphoedema

A

Limb volume
Bioelectric impedance spectrometry
Lymphoscintigraphy

44
Q

Describe the management for lymphoedema

A 
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
Q

Define abdominal aortic aneurysm

A

> 3cm diameter

46
Q

List some risk factors for abdominal aortic aneurysm

A 
Men 
Increased age
Smoking
FH
CVD
47
Q

Describe AAA screening in england

A

Men aged >65
Asymptomatic early detection
Routine screening considered in women >70yo with RF

48
Q

How do AAA present

A 
Ruptures
Screening
Non-specific abdo pain 
Pulsatile and expansile mass
Incidental finding - CT/USS
49
Q

How is AAA diagnosed

A

USS

CTA

50
Q

Describe the classification of AAA

A

Normal <3cm
Small 3-4cm
Medium 4.5-5.4cm
Large >5.5

51
Q

How are AAA managed

A

Treat reversible factors - stop smoking, healthy diet and exercise, optimise the management of HTN, DM and hyperlipidaemia

52
Q

How often are people with AAA followed up

A

Yearly for those with 3-4.4cm AAA

3 monthly for people with aneurysms 4.5-5.4

53
Q

When is elective repair of AAA recommended

A

Symptomatic
Diameter growing >1cm a year
Diameter >5.5

54
Q

Describe elective repair of AAA

A

Open repair via laparotomy

Endovascular aneurysm repair (EVAR) using a stent inserted via the femoral arteries

55
Q

Describe the link between driving and AAA

A

Inform the DVLA if >6cm
Stop driving if >6.5cm
Stricter rules apply to heavy vehicle drivers

56
Q

How does a ruptured AAA present

A

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
Q

How is a ruptured AAA managed

A

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
Q

List the layers of the wall of an artery

A

Tunica intima - innermost
Tunica media - middle
Tunica adventitia - outermost layer

59
Q

What is an aortic dissection

A

Tear in the intimal lining, causing blood to flow between the intima and media creating a false lumen filled with blood

60
Q

List some risk factors for aortic dissection

A 
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
Q

What is a retrograde dissection and how can it progress

A

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
Q

Give the classification of aortic dissections

A

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
Q

Describe how aortic dissections present

A

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
Q

How are aortic dissections diagnosed

A

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
Q

Describe the management of aortic dissections

A

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
Q

List some complications of aortic dissection

A 
MI
Stroke
Paraplegia
Cardiac tamponade
Aortic valve regurgitation
Death
67
Q

What is seen on CXR of patients with aortic dissection

A

Widened mediastinum

68
Q

Which investigation is used to diagnose aortic dissection in those too unwell for CTA

A

Transoesophageal echo

69
Q

What causes carotid stenosis

A

Atherosclerosis

70
Q

Give the RF for carotid stenosis

A 
Male
Age
Diet
Smoking
HTN
Reduced physical activity
71
Q

What is the risk of having carotid stenosis

A

TIA/Stroke

Also because of the atherosclerosis, may have this elsewhere so at risk of MI/CAD

72
Q

Classify the severity of carotid stenosis

A

Mild = <50% reduction
Moderate 50-69% reduction
Severe = >70% reduced

73
Q

How does carotid stenosis present

A

Asymptomatic
Screened for after stroke or TIA
Carotid bruit may be heard

74
Q

How is carotid stenosis diagnosed

A

Carotid ultrasound

CT/MRA

75
Q

How is carotid stenosis managed

A

Modifiable RF management
Medical - aspirin, Clopidogrel or ticagrelor
Surgery - carotid endarterectomy or carotid angioplasty and stenting

76
Q

List the complications of carotid endarterectomy

A

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
Q

When is surgery offered for carotid stenosis

A

Stenosis >70% reduction

78
Q

What is Buerger’s disease

A

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
Q

Who does Buerger’s disease typically affect

A

Men
Aged 25-35
Smoking

80
Q

How do Buerger’s disease patients present

A

Painful, blue discolouration to the fingertips or toes

Pain worse at night

81
Q

What can be seen on angiograms in Buerger’s

A

Corkscrew collaterals - finding on angiograms where new vessels form to bypass the affected arteries

82
Q

Describe the management of Buerger’s

A

Stop smoking

IV iloprost - dilated blood vessels

83
Q

Which veins are most implicated in varicose veins

A

Long saphenous - medial thigh and calf

84
Q

Why is an abdominal CT a good idea if the patient is stable enough with ruptured AAA

A

Give surgeons idea of size of Teflon graft needed, if there is rupture, involvement of iliac and renal arteries

85
Q

At what vertebral level does the aorta birfucate

A

L4 - level of the umbilicus

86
Q

What size AAA is offered elective surgery

A

> 5.5cm

Finals (18 decks)

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