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Vascular surgery Flashcards

1
Q

Causes of acute limb ischemia

A

Atherosclerosis
Thrombotic: malignancy, infection, shock ( low flow)
Embolic: AF, aneurysm, bacterial endocarditis

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2
Q

Risk factors for peripheral arterial disease

A

obesity, smoking, diabetes, age, hypercholesterolaemia, hypertension

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3
Q

Symptoms of acute limb ischaemia

A

Pain
Paresthesia
Paralysis
Pallor
Pulselessness
Perishingly cold

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4
Q

Vascular exam

A

CVS/PAD orientated
Inspection - comparing both sides, looking for pallor, mottling, skin changes, loss of hair, ulcers, gangrene
Palpate- temperature, pulses
Auscultate - bruit
sensory and motor function of leg
Muscle tenderness

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5
Q

Acute limb ischaemia blood test Ix

A

FBC, U&E, including a serum lactate (to assess the level of ischaemia), Coag, thrombophilia screen (if <50yrs without known risk factors), Group and Save, Creatine kinase (marker of rhabdomyolysis), elevated CRP

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6
Q

Acute limb iscaemia Ix

A

ECG
Handheld doppler US to detect both arterial and venous flow on both limbs
CT angiography
ABPI

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7
Q

Classification system for acute limb ischaemia

A

Rutherford

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8
Q

Acute limb ischaemia Mx

A

•Oxygen, IV access/ fluids and analgesia
•5000 units of unfractionated heparin
•+/- heparin infusion (if not immediately going to theatre)

Surgical:
endovascular- revascularisation with percutaneous transluminal angioplasty/stenting,Catheter-directed thrombolysis
open- embolectomy, arterial bypass

Amputation if limb not salvageable

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9
Q

Acute limb ischaemia Cx

A

Compartment syndrome
Release of substances from the damaged muscle cells :
K+ ions causing hyperkalemia
H+ ions causing acidosis
Myoglobin, resulting in significant AKI

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10
Q

Compartment syndrome

A

Acute increase in pressure within a compartment which endangers the perfusion of tissues, requiring emergency decompression

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11
Q

Compartment syndrome symptoms

A

Disproportionate ’Crescendo pain’, unresponsive to analgesia
Have high suspicion if after surgery day 3/4 they still need oral morphine and if their ability to do any physio rapidly decreases

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12
Q

Compartment syndrome signs

A

affected compartment may feel tense
Dorsiflex will tense muscle further and may be too painful for patient to do it will test the ant/post compartment of leg
Eversion/inversion will test the other 2 leg compartments

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13
Q

Causes of compartment syndrome

A

Reperfusion injury post revascularization in acute limb ischaemia
fractures, crush injuries, burns, rhabdomyolysis

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14
Q

Compartment syndrome Pathophysiology

A
  1. Release of free radicals, K+, Ca++, Toxins , cytokines, lactate, leached into local tissue
  2. it will swell in compartment, increase in intra compartmental pressure
  3. veins compressed causing fluid to move out into compartment, also venous drainage impaired
  4. reduced perfusion to area leads to secondary ischaemia episode
  5. nerves compressed
  6. ischemia in muscle tissue
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15
Q

Compartment syndrome Ix

A

clinical dx
If diagnostic uncertainty:
Compartment pressures
pH
A creatine kinase (CK) level

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16
Q

Compartment syndrome Mx

A

Keep the limb at a neutral level with the patient
High flow oxygen
Augment blood pressure with bolus of IV crystalloid fluids
Remove all dressings / splints / casts, down to the skin
Treat symptomatically with opioid analgesia (usually IV)

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17
Q

Compartment syndrome definitive Mx

A

Urgent fasciotomy! (double incision to release compartments)

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18
Q

Intermittent claudication

A

Cramping muscular pain, often in the calf, which is brought on by exertion, relieved by rest and reproducible on walking that distance again.

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19
Q

Critical limb ischemia definition

A

Ischaemic rest pain >2w despite analgesia or the presence of tissue loss
ABPI <0.5

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20
Q

Critical ischaemia symptoms

A

Rest pain
Pain is felt in the toes/forefoot as its the most distal
Pain often wakes the patient up at night (loss of gravity’s help in perfusing)
Patients typically hang their legs from the side of the bed

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21
Q

Critical ischaemia signs

A

limbs may be pale and cold
weak or absent pulses
limb hair loss
skin changes (atrophic skin, ulceration, or gangrene which represents death of tissue)
thickened nails

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22
Q

Buerger’s test

A

The angle at which the leg becomes pale when you elevate it against gravity
angle of less than 20 degrees indicates severe ischaemia
then swing the patient’s leg over the side and watch out for a “sunset foot”

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23
Q

Ankle-brachial pressure index

A

measurement of the cuff pressure at which blood flow is detectable by doppler in the posterior tibial or anterior tibial arteries compared to the brachial artery (ankle/brachial pressure)

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24
Q

Mx of chronic limb ischemia

A

Lifestyle management:
- smoking cessation advice +/- nicotine replacement therapy / further intervention
- Supervised Exercise programmes
- healthy eating,
control of hyperlipidaemia
- weight reduction
- Control of bp
Screen for and Optimise diabetes control
Statin therapy (ideally atorvastatin 80mg OD)
Antiplatelet therapy

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25
Symptomatic relief for IC
Naftidrofuryl oxalate
26
Peripheral arterial disease differentials
Spinal canal claudication ( but all pulses present) Spinal cord compression ( calf pain) Malignancy can cause embolus in acute limb ischemia Peripheral neuropathy ( associated with numbness and tingling) Popliteal artery entrapment (young patients who may have normal pulses) Venous claudication ( bursting pain on walking with previous history of DVT) Fibromuscular dysplasia Buerger's disease
27
Buerger's disease/Thromboangiitis obliterans
disease of the small and medium arteries and veins that restricts blood flow to the hands and feet. Clots (thrombus) develop inside the blood vessels. This in turn leads to skin ulcers and gangrene in the fingers and toes and numbness and tingling if the nerves are affected.
28
Buerger's disease/Thromboangiitis obliterans epidemiology
The disease is seen almost exclusively in smokers, mainly in young men aged 20-40 years.
29
Raynauds
Episodic vasospasm of the arteries of the extremities resulting in digital ischaemia, can be induced by cold or emotional stres
30
Primary Raynaud's
Idiopathic, majority of cases, typically young women in 20s – 30s
31
Secondary Raynaud's
Older age group, men and women affected equally •Associated with connective tissue disease especially Scleroderma,SLE,Sjogen’s,RA •Drugs e.g. amphetamines, cocaine, beta blockers, chemotherapy, COCP •Vascular occlusive disease e.g. Buerger’s, Atherosclerosis, •Haematological e.g. polycythemia, leukaemia, •Environmental/occupational e.g. frostbite •Anatomical e.g. carpal tunnel •Infections e.g. Hep B & C, parvovirus B19 •Endocrine e.g. hypothyroidism, phaeochromocytoma, carcinoid syndrome
32
Raynaud symptoms
•Pallor of distal part of fingers •Numbness •Pain •Blue fingers (cyanosis) •Hyperaemic phase – red and warm fingers burning/severe as warm up Smoking can aggravate symptoms
33
Raynaud Ix
•Full blood count •ESR •Plasma viscosity •Autoimmune screen •Investigating underlying disease
34
Raynaud Imaging
•Infrared thermography (cold provocation test) •Laser doppler flowmetry •Digital plethysmography
35
Raynaud Dx
•Clear demarcated digital pallor •At least one colour change e.g. cyanosis/erythema •Identified cold/emotion triggers •Exclude cervical rib/ thoracic outlet syndrome
36
Raynaud Mx
General measures: •Smoking cessation •Maintain body warmth •Minimize stress •Regular exercise •Stop drug if SE Surgical (uncommon) •Digital/thoracoscopic sympathectomy Medical •Calcium channel blockers esp. Nifedipine •IV prostacyclin (epoprostenol) infusions: effects may last several weeks/months (antiplatelet) •Admit for IV iloprost if conservative and nifedipine not controlling symptoms •Consider immunosuppression for autoimmune associated raynaud’s In extreme cases nerve blocks or digital amputation might be necessary.
37
Risk Factors chronic venous disease
•Obesity •Increasing age •Family history / genetics •Pregnancy (hormonal factors increase the laxity of venous walls and valves) • women more at risk • prolonged standing/crossing knees
38
Features of chronic venous disease
• varicose veins • Itching, aching discomfort and heaviness of the legs • leg oedema •“Restless” legs •Symptoms typically worse after prolonged standing / towards end of day • hemosiderin pigmentation • lipodermatosclerosis • ulcers
39
Mx chronic venous disease
Conservative: - Manual compression to help blood flow - Compression bandages/stocking - Legs above heart 1. Endovenous thermal ablation (laser or radiofrequency) involves sealing the lumen of the incompetent vein 2. Ultrasound-guided foam sclerotherapy 3. Conventional Surgery
40
Virchow's triad
1. Slowed blood flow in veins 2. Hypercoagulation 3. Damage to blood vessel endothelium
41
Risk factors for venous ulcers
underlying mechanism is venous hypertension & inflammation •Superficial venous incompetence (e.g. Varicose veins) •Previous deep vein thrombosis in the affected leg ( increases pressure in leg, scarring to valve) •Phlebitis in the affected leg •Previous fracture, trauma, or surgery to leg •Family history of venous disease. •Pregnancy •Obesity or physical inactivity •Severe leg injury or trauma •Increasing age
42
Venous ulcer features
Most common elevation helps top of sock area( gaiter) ulcers are large shallow irregular border exudative granulating base warm skin normal peripheral pulses
43
Risk factors for arterial ulcers
•Peripheral arterial disease. •Coronary heart disease. •History of stroke or TIA •Diabetes mellitus. •Obesity and immobility.
44
Arterial ulcer features
worse when elevated affect pressure/trauma sites ulcers are small, deep punched out, necrotic base, cold skin, weak absent peripheral pulses
45
Diabetic ulcer
most commonly caused by poor circulation, hyperglycemia and nerve damage •Usually younger patients •Usually foot ulcer,pressure sites •Often painless with abnormal or absent sensation •Underlying pathology is peripheral neuropathy secondary to diabetes •warm skin •normal peripheral pulses
46
Diabetic ulcer Ix
Assess sensation – monofilament test. Check HBA1C & optimise Foot x-rays to look for underlying osteomyelitis Arterial imaging as for PAD if neuroischaemic
47
Mx venous leg ulcer
If ABPI >0.8 apply compression bandaging leg elevation and increased exercise,weight reduction, improved nutrition pentoxifylline (peripheral vasodilator) is an effective adjunct to compression bandaging
48
Mx arterial leg ulcer
Conservative- lifestyle changes Medical – statin therapy, anti-platelet agent, optimisation of blood pressure and glucose Surgical vascular reconstruction. – Angioplasty Flucloxacillin if there's an infection
49
Mx diabetic foot ulcer
•Podiatry & orthotists: debridement, offloading/pressure relieving footwear (e.g. non-weight bearing shoes). •Diabetology: management of diabetes, targeting HbA1c <7%. •Vascular surgeon: improving perfusion, controlling infection soft tissue, osteomyelitis, debridement Any signs of infection will warrant swabs taken and antibiotics (e.g. flucloxacillin)
50
Charcots foot
commonest cause is diabetes loss of joint sensation results in continual unnoticed trauma and deformity occurring causes neuropathic ulcers
51
Charcots foot presentation
swelling, distortion, pain, loss of function deformity causing the loss of the transverse arch is termed a “rocker-bottom” sole
52
Risk factors for venous ulcers
underlying mechanism is venous hypertension & inflammation •Superficial venous incompetence (e.g. Varicose veins) •Previous deep vein thrombosis in the affected leg ( increases pressure in leg, scarring to valve) •Phlebitis in the affected leg •Previous fracture, trauma, or surgery to leg •Family history of venous disease. •Pregnancy •Obesity or physical inactivity •Severe leg injury or trauma •Increasing age
53
Superficial thrombophlebitis
blood clot lodged in vein causing inflammation in vein, most commonly involves the saphenous veins, often associated with varicosities
54
Superficial thrombophlebitis clinical presentation
painful, tender, cord like structure ( vein hardening) with associated redness and swelling. Most commonly in lower leg
55
Mx Superficial thrombophlebitis
symptomatic tx with rest, elevation of limb and analgesics eg NSAIDS. Preventive treatment of blood clot like anticoagulant and prevention of DVT steps
56
dvt Wells score
- cancer - recent immobilisation - major surgery - localised tenderness in deep venous system location - entire leg swollen - calf swelling - pitting oedema - collateral superficial veins ( non varicose) - prev DVT - Alternative diagnosis less likely as DVT (-2)
57
Risk factors dvt
Pregnancy, pelvic and orthopaedic surgery, malignancy, history , long air travel,age >60, dehydration, obesity, previous or family history VTE, Combined oral contraceptives and hormone replacement therapy thrombophilias
58
factor V Leiden
most common thrombophilic disorder 4-5%, of a Northern European population might be expected to be heterozygous increased risk of venous thrombosis
59
DVT clinical presentation
features of PE pain and swelling redness warmth and engorged superficial veins in the calf Pitting oedema Homan’s sign ( pain in calf on dorsiflexion of foot)
60
DVT Ix
Wells score if likely to have DVT- leg US, or d dimer and anticoagulation if US can't be done in 4 hours if unlikely to have DVT - d dimer
61
DVT interim anticoagulation
1. apixaban or rivaroxaban or 2. low molecular weight heparin (LMWH) for at least 5 days followed by dabigatran or edoxaban or 3. LMWH concurrently with a vitamin K antagonist for at least 5 days.
62
For people starting interim anticoagulation therapy
Carry out baseline blood tests including full blood count, renal and hepatic function, prothrombin time (PT), and activated partial thromboplastin time (APTT)
63
DVT Cx
PE Venous insufficiency Recurrent DVT Post-thrombotic syndrome - pain, swelling, hyperpigmentation, dermatitis, ulcers, gangrene and lipodermatosclerosis caused by chronic venous hypertension
64
Abdominal aortic aneurysms Screening
offered at age 65 using abdominal ultrasound scan.
65
AAA repeat screening principles if small
If small AAA (3-4.4cm) – offered yearly repeat ultrasound
66
AAA repeat screening principles if medium
If medium AAA (4.5-5.4cm) – offered repeat ultrasound every 3 months
67
AAA repeat screening principles if large
If large AAA (>5.5cm) – surgery generally recommended. main surgical options are open repair or Endovascular Aneurysm repair (EVAR).

Medicine (72 decks)

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