Vascular Surgery Flashcards
1
Q
A
2
Q
What is PAD?
A
Peripheral arterial disease (PAD) refers to the narrowing of the arteries supplying the limbs and periphery, reducing the blood supply to these areas.
3
Q
What is the main symptom seen with PAD?
A
claudication
4
Q
What are the different types of ischaemia?
A
Intermittent claudication
Critical limb ischaemia
Acute limb ischaemia
5
Q
What is ischaemia
A
refers to an inadequate oxygen supply to the tissues due to reduced blood supply.
6
Q
WHat is necrosis?
A
refers to the death of tissue.
7
Q
WHat is gangrene?
A
Gangrene refers to the death of the tissue, specifically due to an inadequate blood supply.
8
Q
WHat is Intermittent claudication
A
is a symptom of ischaemia in a limb, occurring during exertion and relieved by rest. It is typically a crampy, achy pain in the calf, thigh or buttock muscles associated with muscle fatigue when walking beyond a certain intensity.
9
Q
What si critcial ischaemia?
A
s the end-stage of peripheral arterial disease, where there is an inadequate supply of blood to a limb to allow it to function normally at rest
There is a significant risk of losing the limb.
10
Q
How does critcial limb ischaemia present as?
A
The features are pain at rest, non-healing ulcers and gangrene.
11
Q
What is acute limb ischaemia?
A
refers to a rapid onset of ischaemia in a limb. Typically, this is due to a thrombus (clot) blocking the arterial supply of a distal limb, similar to a thrombus blocking a coronary artery in myocardial infarction.
12
Q
Cause of PAD
A
Atherosclerosis
13
Q
WHat is Atherosclerosis
WHich arteries does it affect
A
Atherosclerosis is a combination of atheromas (fatty deposits in the artery walls) and sclerosis (the process of hardening or stiffening of the blood vessel walls).
Atherosclerosis affects the medium and large arteries. It is caused by chronic inflammation and activation of the immune system in the artery wall.
Lipids are deposited in the artery wall, followed by the development of fibrous atheromatous plaques.
14
Q
Non modifiable risk factors for Atherosclerosis
A
Older age
Fhx
Male
15
Q
Modifiable risk factors for Atherosclerosis
A
- Smoking
- Alcohol consumption
- Poor diet (high in sugar and trans-fat and low in fruit, vegetables and omega 3s)
- Low exercise / sedentary lifestyle
- Obesity
- Poor sleep
- Stress
16
Q
Medical Co-Morbidities for atherosclerosis
A
Diabetes
Hypertension
Chronic kidney disease
Inflammatory conditions such as rheumatoid arthritis
Atypical antipsychotic medications
17
Q
What are the End Results of Atherosclerosis
A
- Angina
- Myocardial infarction
- Transient ischaemic attack
- Stroke
- Peripheral arterial disease
- Chronic mesenteric ischaemia
18
Q
What are the features of Critical Limb Ischaemia
A
6Ps
Pain
Pallor
Pulseless
Paralysis
Paraesthesia (abnormal sensation or “pins and needles”)
Perishing cold
causes burning pain, worse at night when the leg is raised, as gravity no longer helps pull blood into the foot.
19
Q
WHat is Leriche Syndrome
Name the clinical traid?
A
Leriche syndrome occurs with occlusion in the distal aorta or proximal common iliac artery. There is a clinical triad of:
- Thigh/buttock claudication
- Absent femoral pulses
- Male impotence
20
Q
What are the signs of arterial disease on general inspection ?
A
- Skin pallor
- Cyanosis
- Dependent rubor (a deep red colour when the limb is lower than the rest of the body)
- Muscle wasting
- Hair loss
- Ulcers
- Poor wound healing
- Gangrene (breakdown of skin and a dark red/black change in colouration)
- Missing limbs or digits after previous amputations
- Midline sternotomy scar (previous CABG)
- A scar on the inner calf for saphenous vein harvesting (previous CABG)
- Focal weakness suggestive of a previous stroke
21
Q
On examination aterial disease would show?
A
- Tar staining on the fingers
- Xanthomata (yellow cholesterol deposits on the skin)
- Reduced skin temperature
- Reduce sensation
- Prolonged capillary refill time (more than 2 seconds)
- Changes during Buerger’s test
22
Q
What disease does Buerger’s Test test for
A
peripheral arterial disease in the leg.
23
Q
Explain how to perform a Buerger’s test?
A
The first part involves the patient lying on their back (supine). Lift the patient’s legs to an angle of 45 degrees at the hip. Hold them there for 1-2 minutes, looking for pallor. Pallor indicates the arterial supply is not adequate to overcome gravity, suggesting peripheral arterial disease. Buerger’s angle refers to the angle at which the leg is pale due to inadequate blood supply. For example, a Buerger’s angle of 30 degrees means that the legs go pale when lifted to 30 degrees.
The second part involves sitting the patient up with their legs hanging over the side of the bed. Blood will flow back into the legs assisted by gravity. In a healthy patient, the legs will remain a normal pink colour. In a patient with peripheral arterial disease, they will go:
- Blue initially, as the ischaemic tissue deoxygenates the blood
- Dark red after a short time, due to vasodilation in response to the waste products of anaerobic respiration
The dark red colour is referred to as rubor
24
Q
What is the difference between aterial ulcers and venous ulcers on definition
A
Arterial ulcers are caused by ischaemia secondary to an inadequate blood supply
Venous ulcers are caused by impaired drainage and pooling of blood in the legs.
25
What are the features of arterial ulcers?
* Are smaller than venous ulcers
* Are deeper than venous ulcers
* Have well defined borders
* Have a “punched-out” appearance
* Occur peripherally (e.g., on the toes)
* Have reduced bleeding
* Are painful
* Are pale colour due to poor blood supply
* Have pain worse at night (when lying horizontally
* Have pain is worse on elevating and improved by lowering the leg (gravity helps the circulation)
26
WHat are the features of Venous ulcers
* Occur after a minor injury to the leg
* Are larger than arterial ulcers
* Are more superficial than arterial ulcers
* Have irregular, gently sloping borders
* Affect the gaiter area of the leg (from the mid-calf down to the ankle)
* Are less painful than arterial ulcers
* Occur with other signs of chronic venous insufficiency (e.g., haemosiderin staining and venous eczema)
* Have pain relieved by elevation and worse on lowering the leg
27
What can you use to accurately assess the pulses when they are difficult to palpate.
hand-held Doppler
28
Ix for PAD?
* **Ankle-brachial** pressure index (ABPI)
* **Duplex ultrasound** – ultrasound that shows the speed and volume of blood flow
* **Angiography** (CT or MRI) – using contrast to highlight the arterial circulation
29
What is an Ankle-Brachial Pressure Index
Ankle-brachial pressure index (ABPI) is the ratio of systolic blood pressure (SBP) in the ankle (around the lower calf) compared with the systolic blood pressure in the arm.
30
What do you use to measure Ankle-Brachial Pressure Index
Doppler probe
31
How do you calculate Ankle-Brachial Pressure Index
Divide the highest ankle systolic pressure in each of the posterior tibial and dorsalis pedis arteries\* in both feet by the highest brachial systolic pressure from each arm; the lowest resulting value is the patient's overall ABPI.
For example, an ankle SBP of 80 and an arm SBP of 100 gives a ratio of 0.8 (80/100).
32
What do the ratio from ABPI indicate
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
Less than 0.3 indicates severe disease to critical ischaemic
An ABPI above 1.3 can indicate **calcification** of the arteries, making them difficult to compress. This is more common in **diabetic patients**
33
Management of Intermittent Claudication are usually lifestyle changes and exercise training
Medication can also be used as treatment
What medication can be given?
* Atorvastatin 80mg
* Clopidogrel 75mg once daily (aspirin if clopidogrel is unsuitable)
* Naftidrofuryl oxalate (5-HT2 receptor antagonist that acts as a peripheral vasodilator)
34
What are some surgical options for management for intermittent claudication?
* Endovascular angioplasty and stenting
* Endarterectomy – cutting the vessel open and removing the atheromatous plaque
* Bypass surgery – using a graft to bypass the blockage
Endovascular angioplasty and stenting involve inserting a catheter through the arterial system under x-ray guidance. At the site of the stenosis, a balloon is inflated to create space in the lumen. A stent is inserted to keep the artery open. Endovascular treatments have lower risks but might not be suitable for more extensive disease.
35
Management of Critical Limb Ischaemia
Patients with critical limb ischaemia require **urgent referral** to the vascular team. They require **analgesia** to manage the pain.
Urgent revascularisation can be achieved by:
* Endovascular angioplasty and stenting
* Endarterectomy
* Bypass surgery
* Amputation of the limb if it is not possible to restore the blood supply
36
Management of Acute Limb Ischaemia
Patients with acute limb ischaemia need an **urgent referral to the on-call vascular team for assessment.**
Management options include:
* **Endovascular thrombolysis** – inserting a catheter through the arterial system to apply thrombolysis directly into the clot
* **Endovascular thrombectomy** – inserting a catheter through the arterial system and removing the thrombus by aspiration or mechanical devices
* **Surgical thrombectomy** – cutting open the vessel and removing the thrombus
* **Endarterectomy**
* **Bypass surgery**
* **Amputation** of the limb if it is not possible to restore the blood supply
37
What is VTE
Venous thromboembolism (VTE) is a common and potentially fatal condition. It involves blood clots (thrombi) developing in the circulation. This usually occurs secondary to stagnation of blood and hyper-coagulable states
38
How does something like atrual septal defect cause a person to have a stroke if they have a DVT
If the patient has a hole in their heart (for example, an atrial septal defect), the blood clot can pass through to the left side of the heart and into the systemic circulation. If it travels to the brain, it can cause a large stroke.
39
Risk Factors for DVT or PE
* Immobility
* Recent surgery
* Long haul travel
* Pregnancy
* Hormone therapy with oestrogen (combined oral contraceptive pill and hormone replacement therapy)
* Malignancy
* Polycythaemia
* Systemic lupus erythematosus
* Thrombophilia
**TOM TIP: In your exams, when a patient presents with possible features of a DVT or PE, ask about risk factors such as periods of immobility, surgery and long haul flights to score extra points.**
40
What is Thrombophilias
Name examples?
Thrombophilias are conditions that predispose patients to develop blood clots. There are a large number of these:
* **Antiphospholipid syndrome**
* Factor V Leiden
* Antithrombin deficiency
* Protein C or S deficiency
* Hyperhomocysteinaemia
* Prothombin gene variant
* Activated protein C resistance
OM TIP: If you remember one cause of recurrent venous thromboembolism, remember **antiphospholipid syndrome.** The common association you may come across in exams is recurrent miscarriage. The diagnosis can be made with a blood test for antiphospholipid antibodies.
41
What does Prophylaxis consist of for risk of VTE
Every patient admitted to hospital should be assessed for their risk of venous thromboembolism (VTE). If they are at increased risk of VTE, they should receive prophylaxis unless contraindicated.
Prophylaxis is usually with **low molecular weight heparin**, such as **enoxaparin**. Contraindications include **active bleeding or existing anticoagulation with warfarin or a DOAC.**
**Anti-embolic compression stockings** are also used, unless contraindicated. The main contraindication for compression stockings is significant peripheral arterial disease
42
Presentation of DVT
DVTs are almost always **unilateral**. DVTs can present with:
* Calf or leg swelling
* Dilated superficial veins
* Tenderness to the calf (particularly over the site of the deep veins)
* Oedema
* Colour changes to the leg
43
Bilateral DVT is rare and bilateral symptoms are more likely due to an alternative diagnosis such as
chronic venous insufficiency or heart failure.
44
To examine for leg swelling, measure the circumference of the calf 10cm below the tibial tuberosity. More than \_cm difference between calves is significant.
3
45
Diagnosis of DVT
**D-dimer**
**Doppler ultrasound** of the leg is required to diagnose deep vein thrombosis. NICE recommends repeating negative ultrasound scans after 6-8 days if a positive D-dimer and the Wells score suggest a DVT is likely.
CTPA
46
Pulmonary embolism can be diagnosed with
CT pulmonary angiogram (CTPA) or ventilation-perfusion (VQ) scan.
CTPA is usually preferred, unless the patient has significant kidney impairment or a contrast allergy.
47
What other conditions can raise a D-Dimer
Pneumonia
Malignancy
Heart failure
Surgery
Pregnancy
48
Initial Management for DVT or PE?
anticoagulation: apixaban or rivaroxaban
consider catheter-directed thrombolysis in patients with a symptomatic iliofemoral DVT
49
WHat are the options for Long Term Anticoagulation DVT/PE patients
The options for long term anticoagulation in VTE are a DOAC, warfarin, or LMWH.
50
What are DOACs
DOACs are oral anticoagulants that do not require monitoring. They were called “novel oral anticoagulants” (NOACs), but this has been changed to “direct-acting oral anticoagulants” (DOACs)
They are suitable for most patients, including patients with cancer.
51
Examples of DOACS?
apixaban, rivaroxaban, edoxaban and dabigatran
52
Mechanism of Warfarin?
vitamin K antagonist
53
What is the target INR for warfarin when treating patients with DVT/PE
between 2 and 3
54
Warfarin is first line for which patients with DVT/PE
patients with antiphospholipid syndrome (who also require initial concurrent treatment with LMWH).
55
WHat is the first line anticoagulant for **pregnant ladies** with DVT or PE
Low molecular weight heparin (LMWH)
56
With people with Unprovoked DVT it is good for them to test for?
**Antiphospholipid syndrome** (check antiphospholipid antibodies)
**Hereditary thrombophilias** (only if they have a first-degree relative also affected by a DVT or PE)
57
WHat are varicose veins?
Varicose veins are distended superficial veins measuring more than 3mm in diameter, usually affecting the legs.
58
NAme two different types of dilated blood vessles?
Reticular veins
Telangiectasia
59
What is the difference between **Reticular veins** and **Telangiectasia**
**Reticular veins** are dilated blood vessels in the skin measuring less than 1-3mm in diameter.
**Telangiectasia refer**s to dilated blood vessels in the skin measuring less than 1mm in diameter. They are also known as spider veins or thread veins.
60
The deep and superficial veins are connected by vessels called the _________ veins, which allow blood to flow from the superficial veins to the deep veins
The deep and superficial veins are connected by vessels called the **perforating veins** (or perforators),
61
Patho of varicose veins?
When the valves are incompetent in these perforators, blood flows from the deep veins back into the superficial veins and overloads them. This leads to dilatation and engorgement of the superficial veins, forming varicose veins.
62
Chronic Venous Insufficiency
What cause **brown discolouration** to the lower legs.
When blood pools in the distal veins, the pressure causes the veins to leak small amounts of blood into the nearby tissues. The haemoglobin in this leaked blood breaks down to haemosiderin, which is deposited around the shins in the legs. This gives a brown discolouration to the lower legs.
63
Pooling of blood in the distal tissues results in inflammation. The skin becomes dry and inflamed, referred to as
venous eczema.
64
The skin and soft tissues become fibrotic and tight, causing the lower legs to become narrow and hard, referred to as
lipodermatosclerosis.
65
Risk Factors for varicose veins?
* Increasing age
* Family history
* Female
* Pregnancy
* Obesity
* Prolonged standing (e.g., occupations involving standing for long periods)
* Deep vein thrombosis (causing damage to the valves)
66
Presentation of varicose veins
* Heavy or dragging sensation in the legs
* Aching
* Itching
* Burning
* Oedema
* Muscle cramps
* Restless legs
Patients may also have signs and symptoms of chronic venous insufficiency (e.g., skin changes and ulcers).
67
Name tests you can for varicose veins
Tap test
Cough test
Trendelenburgs test
Perthes test
Duplex ultrasound
68
WHat is a tap test?
apply pressure to the saphenofemoral junction (SFJ) and tap the distal varicose vein, feeling for a thrill at the SFJ. A thrill suggests incompetent valves between the varicose vein and the SFJ
69
WHat is a cough test?
apply pressure to the SFJ and ask the patient to cough, feeling for thrills at the SFJ. A thrill suggests a dilated vein at the SFJ (called saphenous varix).
70
What is Trendelenburg’s test
with the patient lying down, lift the affected leg to drain the veins completely. Then apply a tourniquet to the thigh and stand the patient up. The tourniquet should prevent the varicose veins from reappearing if it is placed distally to the incompetent valve. If the varicose veins appear, the incompetent valve is below the level of the tourniquet. Repeat the test with the tourniquet at different levels to assess the location of the incompetent valves.
71
what is Perthes test
apply a tourniquet to the thigh and ask the patient to pump their calf muscles by performing heel raises whilst standing. If the superficial veins disappear, the deep veins are functioning. Increased dilation of the superficial veins indicates a problem in the deep veins, such as deep vein thrombosis.
72
Management of varicose veins?
Weight loss if appropriate
Staying physically active
Keeping the leg elevated when possible to help drainage
Compression stockings (exclude arterial disease first with an ankle-brachial pressure index)
73
What are some surgical options for varicose veins?
* **Endothermal ablation –** inserting a catheter into the vein to apply radiofrequency ablation
* **Sclerotherapy** – injecting the vein with an irritant foam that causes closure of the vein
* **Stripping** – the veins are ligated and pulled out of the leg
74
Complications of varicose veins
* Prolonged and heavy bleeding after trauma
* Superficial thrombophlebitis (thrombosis and inflammation in the superficial veins)
* Deep vein thrombosis
* All the issues of chronic venous insufficiency (e.g., skin changes and ulcers)
75
WHat is Chronic venous indufficiency?
Chronic venous insufficiency occurs when blood does not efficiently drain from the legs back to the heart. Usually, this is the result of damage to the valves inside the veins
often associated with varicose veins
76
Chronic pooling of blood in the legs leads to skin changes
WHere are the common skin changes?
What are these areas called?
The area between the top of the foot and the bottom of the calf muscle is the area most affected by these changes. This is known as the **gaiter area**
77
What is Haemosiderin staining
is a red/brown discolouration caused by haemoglobin leaking into the skin.
78
WHat are Atrophie blanche
refers to patches of smooth, porcelain-white scar tissue on the skin, often surrounded by hyperpigmentation.
79
chronic venous insufficiency can lead to:
Cellulitis
Poor healing after injury
Skin ulcers
Pain
80
Chronic venous changes are very common in ____ \_\_\_\_\_\_
older patients
81
skin changes in chronic venous Insufficiency are often misdiagnosed as
cellulitis
82
Management for chronic venous Insufficiency
* Monitoring skin health and avoiding skin damage
* Regular use of emollients (e.g., diprobase, oilatum, cetraben and doublebase)
* Topical steroids to treat flares of venous eczema
* Very potent topical steroids to treat flares of lipodermatoscleros
* Weight loss if obese
* Keeping active
* Keeping the legs elevated when resting
* Compression stockings (exclude arterial disease first with an ankle-brachial pressure index)
83
What is an important complicaiton of diabetic foot ulcer?
Osteomyelitis
infection in the bone
84
Who are pressure ulcer more common in
ypically occur in patients with reduced mobility, where prolonged pressure on particular areas (e.g., the sacrum whilst sitting) lead to the skin breaking down.
85
What causes pressure ulcers?
This happens due to a combination of reduced blood supply and localised ischaemia, reduced lymph drainage and an abnormal change in shape (deformation) of the tissues under pressure.
86
What risk assessment is used for estimating an individual patient’s risk of developing a pressure ulcer.
Waterlow Score
87
Ix for leg ulcers
**Ankle-brachial pressure index (ABPI)** is used to assess for arterial disease. This is required in both arterial and venous ulcers.
**Blood tests** may help assess for infection (FBC and CRP) and co-morbidities (HbA1c for diabetes, FBC for anaemia and albumin for malnutrition).
**Charcoal swabs** may be helpful where infection is suspected, to determine the causative organism.
**Skin biopsy** may be required in patients where skin cancer (e.g., squamous cell carcinoma) is suspected as a differential diagnosis. This will require a two week wait referral to dermatology.
88
What does Good wound care involve?
Cleaning the wound
Debridement (removing dead tissue)
Dressing the wound
89
Is Compression therapy is used to treat arterial or venous ulcers
venous ulcers
90
What can be taken orally to imporve venous ulcers\>
Pentoxifylline
91
What is aortic dissection?
Aortic dissection refers to when a break or tear forms in the inner layer of the aorta, allowing blood to flow between the layers of the wall of the aorta.
With aortic dissection, blood enters between the intima and media layers of the aorta. A false lumen full of blood is formed within the wall of the aorta. Intramural refers to within the walls of the blood vessel.
92
Classifciation of aortic dissection?
Standford
The **Stanford** system:
Type A – affects the ascending aorta, before the brachiocephalic artery
Type B – affects the descending aorta, after the left subclavian artery
93
Classification of aortic dissection?
Debakey?
The DeBakey system:
* Type I – begins in the ascending aorta and involves at least the aortic arch, if not the whole aorta
* Type II – isolated to the ascending aorta
* Type IIIa – begins in the descending aorta and involves only the section above the diaphragm
* Type IIIb – begins in the descending aorta and involves the aorta below the diaphragm
94
Risk Factors for aortic dissection?
ge, male sex, smoking, hypertension, poor diet, reduced physical activity and raised cholesterol.
Hypertension is a big risk factor
95
Conditions or procedures that affect the aorta increase the risk of a dissection, such as:
Bicuspid aortic valve
Coarctation of the aorta
Aortic valve replacement
Coronary artery bypass graft (CABG)
96
Conditions that affect the connective tissues can also increase the risk of a dissection, notably:
Ehlers-Danlos Syndrome
Marfan’s Syndrome
97
Presentation of aortic dissection?
, severe, “ripping” or “tearing” chest pain
* Hypertension
* Differences in blood pressure between the arms (more than a 20mmHg difference is significant)
* Radial pulse deficit (the radial pulse in one arm is decreased or absent and does not match the apex beat)
* Diastolic murmur
* Focal neurological deficit (e.g., limb weakness or paraesthesia)
* Chest and abdominal pain
* Collapse (syncope)
* Hypotension as the dissection progresses
98
Diagnosis of aortic dissection
An ECG and chest x-ray are often used to exclude other causes (such as myocardial infarction),
CT angiogram is usually the initial investigation to confirm the diagnosis and can generally be performed very quickly.
MRI angiogram provides greater detail and can help plan management but often takes longer to get.
99
Management for aortic dissection
SUrgery option
Surgical intervention from the vascular team will depend on the type of aortic dissection.
**Type A** may be treated with **open surgery (midline sternotomy)** to remove the section of the aorta with the defect in the wall and replace it with a synthetic graft. The aortic valve may need to be replaced during the procedure.
**Type B** may be treated with **thoracic endovascular aortic repair (TEVAR),** with a catheter inserted via the femoral artery inserting a stent graft into the affected section of the descending aorta. Complicated cases may require open surgery.
100
Does Aortic dissection have a high or low mortality?
high
101
Complications of aortic dissection?
There is a long list of complications. Some of the key ones to remember are:
* Myocardial infarction
* Stroke
* Paraplegia (motor or sensory impairment in the legs)
* Cardiac tamponade
* Aortic valve regurgitation
* Death
102
What is Carotid artery stenosis?
Carotid artery stenosis refers to narrowing of the carotid arteries in the neck, usually secondary to atherosclerosis.
103
Carotid artery stenosi could lead to
emobolic stroke
104
Patients with a _______ \_\_\_\_\_\_ _____ or _____ are investigated for carotid artery stenosis, usually with a _____ \_\_\_\_\_\_.
Patients with a **transient ischaemic attack (TIA)** or stroke are investigated for carotid artery stenosis, usually with a **carotid ultrasound.**
105
Patients with cartoid artery disease are high risk of
coronary artery disease and myocardial infarction (heart attacks).
106
The severity of carotid artery stenosis is categorised as:
Mild – less than 50% reduction in diameter
Moderate – 50 to 69% reduction in diameter
Severe – 70% or more reduction in diameter
107
Presentation of Carotid artery stenosis
usually **asymptomatic**. Usually, it is diagnosed after a TIA or stroke.
A **carotid bruit** may be heard on examination. This is a whooshing sound heard with a stethoscope over the affected carotid artery, caused by turbulent flow around the stenotic area during systole (contraction of the heart).
108
Diagnosis of caotid artery stenosis
Carotid ultrasound is usually the initial investigation to diagnose and assess carotid artery stenosis.
CT or MRI angiogram may be used to assess the stenosis in more detail before surgical interventions.
109
Management of carotid artery stenosis?
* Healthy diet and exercise
* Stop smoking
* Management of co-morbidities (e.g., hypertension and diabetes)
* **Antiplatelet medications (e.g., aspirin, clopidogrel and ticagrelor)**
* **Lipid-lowering medications (e.g., atorvastatin)**
110
Surgical interventions are considered where there is significant carotid artery stenosis. The options are:
Carotid endarterectomy
Angioplasty and stenting
111
WHat is Endarterectomy
Endarterectomy involves an incision in the neck, opening the carotid artery and scraping out the plaque. This is the first-line treatment for most patients requiring surgical intervention. A key complication of the procedure is stroke (around 2%).
112
During endarterectomy, nearby nerves can be injured. This may be temporary or permanent.
What are symptoms depending on the nerve being affected?
* Facial nerve injury causes facial weakness (often the marginal mandibular branch causing drooping of the lower lip)
* Glossopharyngeal nerve injury causes swallowing difficulties
* Recurrent laryngeal nerve (a branch of the vagus nerve) injury causes a hoarse voice
* Hypoglossal nerve injury causes unilateral tongue paralysis
113
What is an alternaitve to endarterectomy?
Angioplasty and stenting is an alternative to endarterectomy
114
Buerger disease is also known as
thromboangiitis obliteran
115
What is thromboangiitis obliteran/Beruger disease?
It is an inflammatory condition that causes thrombus formation in the small and medium-sized blood vessels in the distal arterial system (affecting the hands and feet).
116
Who does Buergers disease affect
Buerger disease typically affects men aged 25 – 35 and has a very strong association with smoking.
Notable features (included in the diagnostic criteria) are:
* Younger than 50 years
* Not having risk factors for atherosclerosis, other than smoking
117
Presentaiton of Buergers disease
The typical presenting feature i**s painful, blue discolouration to the fingertips or tips of the toes**. The pain is often **worse at night.** This may progress to ulcers, gangrene and amputation.
**Corkscrew collaterals** are a typical finding on angiograms, where new collateral vessels form to bypass the affected arteries.
118
Key presentation of buerguers disease
a young male smoker with painful blue fingertips.
119
Important management of Buerger disease
Completely stop smoking
120
What is Lymphoedema
chronic condition caused by impaired lymphatic drainage of an area.
121
What would you avoid with people with lumphoedema
Avoid taking blood, inserting a cannula, giving injections or performing a blood pressure reading in a limb with lymphoedema.
122
What is Lymphatic Filariasis
Lymphatic filariasis is an infectious disease caused by **parasitic worms** spread by **mosquitos**
123
What is more common primary or secondary lymphoedema?
Secondary
124
The most common example is when patients develop lymphoedema is after...
breast cancer surgery, due to the removal of axillary lymph nodes in the armpit
125
Differential of lymphodema
Lipoedema
126
