Vascular Surgery Flashcards
what is an aneurysm?
focal dilatation of a blood vessel to more than 1.5x its normal diameter
what sex is most commonly affected by AAA?
males
what co-exists in around 25% of patients with a AAA?
femoral or popliteal aneurysms
what is the main cause of an AAA?
degenerative changes
Describe the 369 rule for bowel obstruction on AXR
Describes the cm of dilation that suggests diagnosis on a scan
Small bowel >3cm
Large bowel >6cm
Caecum >9cm
What investigation is done in the case of a suspected AAA rupture, and when would this not ne done?
CT angiography
Not done if the patient is haemo-dynamically unstable = straight to theatre
What are the two surgical options for managing a ruptured AA?
Open surgical repair
EVAR
What is the target systolic BP in patients with a ruptured AAA?
70-80mmHg
What is an aneurysm?
Abnormal dilatation of a blood vessel by more than 50% of its normal diameter
At what diameter is a AAA diagnosed?
> 3cm (normal is 2cm)
What effect does diabetes have on the risk of AAA?
Reduces
Name three risk factors for AAA?
Smoking
Male sex
Hyperlipidaemia
How do the vast majority of AAA’s present?
Asymptomatic, found at screening (75%)
What triad of symptoms can be seen in symptomatic, inflammatory AAA?
Low back pain
Weight loss
Raised ESR
What is the mortality rate for AAA rupture?
90%
What is the classic triad of symptoms of a ruptured AAA?
Abdominal or back pain
Hypovolaemia
Pulsatile abdominal mass
What test is done for AAA screening?
Abdominal USS
What size of AAA should be rescreened and when?
25-39mm
At 5-10 years
What is the gold standard investigation when planning management for AAA?
CTA
What medications should a patient with a AAA be put on to minimise risk factors?
Anti-platelet
Statin
Anti-hypertensives
What medication may have an effect on AAA growth rate?
Metformin
When should a AAA that is 30-44mm be measured?
Anually
When should a AAA that is 45-54mm be measured?
3 monthly
When is repair of a AAA indicated?
Diameter >55mm
Symptomatic = urgent repair
Rapid expansion (>10mm/year)
What are the two options for surgical repair fo a AAA?
OSR
EVAR
What is an endoleak?
A surgical complication
The persistence of blood flow outside the lumen of an endo-vascular stent graft
What are the rules about driving with a AAA for car drivers?
Inform DVLA when >60mm
Suspended when >65mm
What are the rules about driving with a AAA for HGV drivers?
Inform when >55mm, suspended until repaired
What are acute aortic syndromes?
A group of conditions that affect the thoracic aorta
Name the three acute aortic syndromes?
Aortic dissection
Intra-mural haematoma (IMH)
Penetrating aortic ulcer (PAU)
What is an aortic dissection?
A tear in the intima of the aorta, allowing blood to form a false lumen between the intima and the adventitia
What are the two classification systems for aortic dissection?
Stanford system
DeBakey system
Describe the Stanford system for classifying aortic dissection
A = proximal to the left subclavian
B = distal to the left subclavian
Which type of aortic dissection, according toe the Stanford system, is an acute emergency?
A
Describe the DeBakey system for classifying aortic dissection
1 = ascending to descending aorta
2 = ascending only
Describe the DeBakey system for classifying aortic dissection
1 = ascending to descending aorta
2 = ascending only
3a = beyond the origin of the LSA, above the diaphragm
3b = beyond the origin of the LSA, below the diaphragm
What is the best test for an aortic dissection?
CT angiogram
How is a type A aortic dissection managed?
Emergency surgery - usually involves aortic root replacement with bypass
How is an uncomplicated type B aortic dissection managed?
IV beta blockade
How is a complicated type B aortic dissection managed?
TEVAR
How is a chronic type B aortic dissection managed?
Annual surveillance
Beta blocker and CCB
What is an intramural haematoma (IMH)?
Clotted blood in the intramural space in the absence of an obvious intimal tear
What condition is IMH associated with?
Hypertension
What are the possible complications of IMH?
Dissection
Rupture
What is the least common acute aortic syndrome?
Penetrating aortic ulcer (PAU)
What causes a PAU?
Focal ulceration of a plaque into the media
Which has a better prognosis - PAU or dissection?
Dissection
What is acute limb ischaemia?
A sudden reduction in perfusion to a limb, causing a potential threat to limb viability
What classification system is used for acute limb ischaemia?
Rutherford classification
What is the classical presentation of acute limb ischaemia (the 6 P’s)?
Pain
Pallor
Paraesthesia
Paralysis
Perishingly cold
Pulseless
Why is calf tenderness in acute limb ischaemia concerning?
Suggests there is severe muscle ischaemia
What bloods should be done for acute limb ischaemia?
FBC
U+Es
Coagulation
What is the first line imaging for acute limb ischaemia?
CTA
What medication should be given initially for acute limb ischaemia?
Unfrac1tionated heparin - 5000 unit bolus followed by an infusion
What is the first line imaging for carotid disease?
Duplex scan
What is the primary intervention in carotid disease?
Risk factor control
What medications should be started in carotid artery disease?
Low dose aspirin (clopidogrel if intolerant)
Atorvastatin 40-80mg
How does diabetic peripheral neuropathy present?
Progressive, symmetrical loss of sensation in the distal lower extremities
Can be painful
What classification systems can be used for diabetic foot ulcers?
SINBAD
WIFI system
Describe the foot of a patient with a neuropathic ulcer
Warm, well perfused
Bounding pulse
Distended veins
Callus present
Where do neuropathic ulcers tend to form?
Sites of repetitive trauma
What is the most important initial step in neuropathic ulcers?
Pressure offloading - best method is with a total contact cast
What can precipitate an ischaemic ulcer?
A minor infection
How is osteomyelitis in a diabetic foot managed?
Up to 6 weeks of antibiotics
Amputation if this fails
