Vascular Surgery Flashcards
define ulcers
abnormal breaks in the skin or mucous membranes
what are the common causes of lower limb ulcers?
venous origin (80%)
arterial insufficiency
diabetic related neuropathy
immobilisation - pressure over bony prominence
rare - infection, trauma, vasculitis or malignancy
what is a venous ulcer caused by?
venous insuffiency…due to valvular incompetence or venous outflow obstruction…impaired venous return…venous hypertension causes trapping of white blood cells in capillaries and forms fibrin cuff hindering oxygen transportation into the tissue..activating white cells to release inflammatory mediators
what are the clinical features of a venous ulcer?
shallow and irregular borders and a granulating base
usually over medial malleolus
painful (worse at end of day)
aching
itching
bursting sensation
may be varscose veins and oedema, and other signs of venous insuffiency - varicose eczema, thrombophlebitis, haemosiderin skin staining, lipodermatosclerosis, atrophie blanche
what is a common complication of a venous ulcer?
prone to infection and can present with associated cellulitis
what are the risk factors for developing a venous ulcer?
increasing age
pre existing venous incompetence or history of venous embolism
pregnancy
obesity
severe leg injury/trauma
which investigations are required for venous ulcers?
duplex USS
insuffiency usually at sapheno-femoral or sapheno-popliteal junctions
Ankle brachial pressure index - arterial component to the ulcers
swabs - infection
thrombophilia and vasculitic screening in young patients
how do you manage venous ulcers?
conservative - leg elevation, increased exercise (aids venous return due to calf muscle), weight reduction and better nutrition
if infection - abx
multicomponent compression bandaging
if varicose veins too - surgery
what is an arterial ulcer caused by?
reduction in arterial blood flow…decreased perfusion of tissues and poor healing
what are the clinical features of arterial ulcers?
small deep lesions, well defined borders and necrotic base
occur distally at sites of trauma and in pressure areas like a heel
intermittent claudication
pain at night - limb ischaemia
long period of time
no granulation tissue as no healing
cold limbs
thickened nails
necrotic toes
hair loss
absent pulses
what are the risk factors for arterial ulcers?
same risk factors for peripheral arterial disease - smoking, DM, hypertension, hyperlipidaemia, increasing age, family history, obesity, physical inactivity
which investigations are required for arterial ulcers?
ankle brachial pressure index
if low - more severe (less than 0.5- severe, >0.9 normal)
location of arterial disease - imaging such as duplex uss
how are arterial ulcers managed?
critical limb ischaemia
so
conservative - smoking cessation, weight loss, increased exercise
medical - CV risk so statin, antiplatelet such as aspirin
surgical - angioplasty or bypass grafting
what are neuropathic ulcers caused by?
peripheral neuropathy…loss of protective sensation which leads to repetitive stress and unnoticed injury forming…painless ulcers forming on pressure points…usually DM and B12 defiency
what are the clinical features of neuropathic ulcers?
burning/tingling in legs
single nerve involvement
amotrophic neuropathy (painful wasting of proximal quadriceps)
variable size
punched out appearance
sites of pressure - metatarsal head or heel
peripheral neuropathy
warm feet and good pulses
which investigations are required for neuropathic ulcers?
blood glucose levels and serum b12 level
concurrent arterial disease checked- ABPI and maybe duplex
swab - infection
x ray - osteomyelitis
test of peripheral neuropathy
how do you manage neuropathic ulcers?
diabetic foot clinic
hba1c less than 7%
improved diet and exercise
chiropody - foot hygeine and footwear
abx if infection
ischaemic or necrotic tissue - surgical debridement
what can be seen alongside neuropathic ulcers?
charcot’s foot - loss of joint sensation results in continual unnoticed trauma and deformity…predisposes to ulceration
charcots - swelling, distortion, pain, loss of function, rocker bottom sole
a patient presents with an acutely painful limb that is cold and pale, what is your top diagnosis?
acute limb ischaemia
what are the clinical features of acute limb ischaemia?
pain
pallor
pulseless
perishingly cold
paraesthesia
paralysis
how do you examine a patient with suspected acute limb ischaemia?
both limbs - if full pulses in one leg and none in other…urgent intervention
what risk factors should be asked about for acute limb ischaemia?
a fib
hypertension
smoking
DM
recent MI
which investigation is required for acute limb ischaemia?
CT angiogram
urgent vascular review
what initial management is required for acute limb ischaemia?
emergency - irreversible tissue damage occurs within 6 hours
fluid resuscitated
IV heparin
what is the top differential for a hot and swollen limb?
DVT
localised to calf with tenderness or firmness
or cellulitis
how is a DVT diagnosed?
history of pro thrombotic disease
well’s score calculation, >1 = USS doppler
how is a DVT initially managed?
therapeutic doses of LMWH and then swapped to DOAC for 3-6 months
if iliofemoral DVT with severe sx- urgent vascular review
what are some neurological causes of acutely painful limb?
radiculopathies - back pain that radiates to affected area and worse on movement, muscle weakness,paraesthesia, altered reflexes
central causes -MS
spinal causes - disc herniation
peripheral - infective or trauma
what is an abdominal aortic aneurysm?
permanent localised dilation of the abdominal aorta of more than 50% of the artery..more than 3cm in diameter
what are the risk factors for AAA?
hypertension
hyperlipidaemia
family history
male
increasing age
DM is a negative risk factor
what is the aetiology of AAA?
unknown…
atherosclerosis
trauma
infection
CT diseases - marfans, ehler’s danlos
inflammatory disease
what are the clinical features of AAA?
abdo pain
back or loin pain
general malaise
distal emboli producing limb ischaemia - 6P’s
pulsatile mass in abdomen
shock/syncope
what is the screening programme for AAA?
national abdominal aortic aneurysm - when 65, men have uss…50% reduction in mortality
what is the main differentials for AAA?
main one - renal colic - back pain with no other sx
others - diverticulitis, IBD, IBS, GI haemorrhage, appendicitis, ovarian torsion or rupture
which investigations are required for AAA?
USS - to confirm diagnosis
then CT with contrast
how do you manage AAA?
medical - if less than 5.5cm monitored with duplex USS, either yearly or 3 monthly. Also conservative tx to reduce CV risk factors - smoking cessation, improved BP control, aspirin and statin, weight loss and increased exercise
surgery - if more than 5.5cm or expanding >1cm/year or symptomatic AAA (if patient unfit left until 6cm before surgery)
–open repair: midline laparotomy or long transverse incision, exposing aorta, clamp proximally and iliac arteries distally, remove segment and replace with graft
— endovascular repair: introduce graft via femoral arteries and fix stent across the aneurysm
what is a complication of endovascular repair of AAA?
endovascular leaking - an incomplete seal forms around aneurysm resulting in blood leaking around graft
what are the complications of AAA?
rupture (top)
retroperitoneal leak
embolism
aortoduodenal fistula
what are the risk factors for a ruptured AAA?
increased risk exponentially with diameter of aneurysm
smoking
hypertension
female
what are the clinical features of a ruptured AAA?
sudden onset of abdo pain and back pain associated with collapse…or mild abdo sx and tenderness over aneurysm - indicate contained retroperitoneal rupture
syncope
vomit
haemodynamically compromised
pulsatile abdo mass and tender
classic triad - flank/back pain,hypotension and pulsatile abdo mass
how do you manage a ruptured AAA?
high flow oxygen
IV access (2 large bore cannulae)
urgent bloods - FBC, U and E, clotting, crossmatch for minimum 6U units
BP should be kept below 100mmHg systolic to prevent dislodging the clot and precipitating further bleeding
transferred to local vascular unit
medical (if small AAA) - treat risk fx - smoking, hypertension, hypercholesteraemia, doxycycline (matrix metalloproteinase inhibitor) ans stains can reduce expansion
what us the pathway of the femoral catheter for an endovascular repair?
femoral, external, common, abdo aorta, aortic arch
what are the differentials for a ruptured aaa?
massive MI or acute pancreatitis - ecg and serum amylase
which two factors are considered in treating a ruptured aaa?
size of aneurysm and the general health of patient
which two factors are considered in treating a ruptured aaa?
size of aneurysm and the general health of patient
if more than 5.5cm or with an expansion of 1cm/year
what is involved in the pre operative assessment of patients with asymptomatic AAA?
- CT or MRI
- haematological and bichemical tests
- chest radiograph and ECG (if ischaemic HD)
- renal assessment if have impairment
- anaesthetic assessment
what is the aetiology of peripheral vascular disease?
about 20% of the middle aged population (65-75), only a quarter have sx (intermittent claudication)
what do people with severe peripheral vascular disease present with?
critical limb ischaemia
what is the pathophysiology of peripheral vascular disease?
atheromatous plaques - atherosclerosis…causes development of atheroma that produces area of narrowig or leads to occlusion of the affected artery
what are the risk factors of peripheral vascular disease?
smoking
hypercholesteraemia
hypertension
DM
family history
cardiac disease, cerebrovascular disease - caused by atherosclerosis
what is intermittent claudication?
pain in the muscles of lower limbs elicited by walking
affects men over age of 50 the msot
what artery is most likely to be affected by intermittent claudication?
superficial femoral artery in adductor canal region