Vascular Surgery Flashcards
Indications for surgery to revascularise the lower limb?
Intermittent claudication
Critical ischaemia
Ulceration
Gangrene
assessment of PVD?
Ankle brachial pressure index measurement
Duplex arterial ultrasound
Angiography (standard, CT or MRI): usually performed only if intervention being considered.
Bypass surgery procedure?
Artery dissected out, IV heparin 3,000 units given and then the vessels are cross clamped
Longitudinal arteriotomy
Graft cut to size and tunneled to arteriotomy sites
Anastomosis to femoral artery usually with 5/0 ‘double ended’ Prolene suture
Distal anastomosis usually using 6/0 ‘double ended’ Prolene
What is a Miller Cuff?
If there is insufficient vein for the entire conduit then vein can be attached to the end of the PTFE graft and then used for the distal anastomosis. This type of ‘vein boot’ is technically referred to as a Miller Cuff and is associated with better patency rates than PTFE alone.
When does sub intimal hyperplasia occur?
Sub intimal hyperplasia occurs early when PTFE is used for the distal anastomosis and will lead to early graft occlusion and failure.
Classical presenting features of acute mesenteric infarction?
Sudden onset of abdominal pain followed by forceful evacuation
Best investigated by CT angiogram
Which patients may have false ABPI readings?
calcified vessels such as diabetics
What is a Gritti Stokes amputation?
Gritti - Stokes operation the patella is conserved and swung posteriorly to cover the distal femoral surface.
When is amputation indicated?
Dead non viable
Deadly where it is posing a major threat to life
Dead useless where it is viable but a prosthesis would be preferable
What are the main categories of amputation?
The main categories of amputations are:
Pelvic disarticulation (hindquarter)
Above knee amputation
Gritti Stokes (through knee amputation)
Below knee amputation (using either Skew or Burgess flaps)
Syme’s amputation (through ankle)
Amputations of mid foot and digits
What does choosing the level of amputation depend on ?
The disease process being treated
Desired functional outcome
Co-morbidities of the patient
Features of above knee amputation?
Quick to perform
Heal reliably
Patients regain their general health quickly
For this benefit, a functional price has to be paid and many patients over the age of 70 will never walk on an above knee prosthesis.
Above knee amputations use equal anterior-posterior flaps
Features of below knee amputation?
Technically more challenging to perform
Heal less reliably than their above knee counterparts.
However, many more patients are able to walk using a below knee prosthesis.
In below knee amputations the two main flaps are Skew flaps or the Burgess long posterior flap. Skew flaps result in a less bulky limb that is easier to attach a prosthesis to.
Typical symptoms of varicose veins?
Cosmetic appearance
Aching
Ankle swelling that worsens as the day progresses
Episodic thrombophlebitis
Bleeding
Itching
Symptoms of chronic venous insufficiency?
Dependant leg pain
Prominent leg swelling
Oedema extending beyond the ankle
Venous stasis ulcers
Typical venous stasis ulcer?
Located above the medial malleolus
Indolent appearance with basal granulation tissue
Variable degree of scarring
Non ischaemic edges
Haemosiderin deposition in the gaiter area (and also lipodermatosclerosis).
Differential for chronic venous insufficiency?
Lower limb arterial disease
Marjolins ulcer
Claudication
Spinal stenosis
Swelling due to medical causes e.g. CCF.
Indications for venous surgery?
Indications for surgery:
Cosmetic: majority
Lipodermatosclerosis causing venous ulceration
Recurrent superficial thrombophlebitis
Bleeding from ruptured varix
How to perform the trendelenberg procedure?
Head tilt 15 degrees and legs abducted
Oblique incision 1cm medial from artery
Tributaries ligated (Superficial circumflex iliac vein, Superficial inferior epigastric vein, Superficial and deep external pudendal vein)
SF junction double ligated
Saphenous vein stripped to level of knee/upper calf. NB increased risk of saphenous neuralgia if stripped more distally
Therapy for symptomatic uncomplicated varicose veins?
In those without deep venous insufficiency options include; endothermal ablation, foam sclerotherapy, saphenofemoral / popliteal disconnection, stripping and avulsions, compression stockings
Therapy for minor varicose veins?
Reassure/ cosmetic therapy
Therapy for varicose veins with skin changes?
Therapy as above (if compression minimum is formal class I stockings)
Therapy for chronic venous insufficiency or ulcers?
Class 2-3 compression stockings (ensure no arterial disease).
Causes of venous leg ulcers?
venous hypertension, secondary to chronic venous insufficiency (other causes include calf pump dysfunction or neuromuscular disorders)
Features of venous leg ulcers?
Ulcers form due to capillary fibrin cuff or leucocyte sequestration
Features of venous insufficiency:
-oedema
-brown pigmentation
-lipodermatosclerosis, eczema
Location above the ankle, painless
Associations of venous leg ulcers?
Deep venous insufficiency is related to previous DVT
superficial venous insufficiency is associated with varicose veins
Management of venous leg ulcers?
Management: 4 layer compression banding after exclusion of arterial disease or surgery
If fail to heal after 12 weeks or >10cm2 skin grafting may be needed
What is a Marjorlins ulcer?
Squamous cell carcinoma
Occurring at sites of chronic inflammation e.g; burns, osteomyelitis after 10-20 years
Mainly occur on the lower limb
Features of arterial ulcers?
Occur on the toes and heel
Painful
There may be areas of gangrene
Cold with no palpable pulses
Low ABPI measurements
Features of neuropathic ulcer?
Commonly over plantar surface of metatarsal head and plantar surface of hallux
The plantar neuropathic ulcer is the condition that most commonly leads to amputation in diabetic patients
Due to pressure
Management includes cushioned shoes to reduce callus formation
Features of pyoderma gangrenosum?
Associated with inflammatory bowel disease/RA
Can occur at stoma sites
Erythematous nodules or pustules which ulcerate
How is ABPI calculated?
Lower limb pressure/highest upper limb pressure
Results of ABPI?
1.2 or greater Usually due to vessel calcification
1.0- 1.2 Normal
0.8-1.0 Minor stenotic lesion
Initiate risk factor management
0.50-0.8 Moderate stenotic lesion
Consider duplex
Risk factor management
If mixed ulcers present then avoid tight compression bandages
0.3 - 0.5 Likely significant stenosis
Duplex scanning to delineate lesions needed
Compression bandaging contra indicated
Less than 0.3 Indicative of critical ischaemia
Urgent detailed imaging required
What is lymphangiosarcoma?
a rare condition arising as a result of chronic oedema. It is an aggressive malignancy.
what type of tumour is a carotid body tumour?
paraganglionoma.
Types of carotid body tumour?
Sporadic - Accounts for 85% of cases
Familial - Seen in around 10% of cases and usually in younger patients
Hyperplastic - Seen in those at high altitude or in those with COPD
Features of carotid body tumours?
-60% of head and neck paraganglionomas
- tumours of middle age
- 5% are bilateral
- 5% are malignant
They typically present as an asymptomatic neck mass in the anterior triangle of the neck. They are typically slow growing lesions.
Imaging of carotid body tumours?
Duplex ultrasonography
CT angiography is sometimes helpful.
Treatment of carotid body tumours?
surgical resection. This is preceded by embolization in selected cases.
what is a Klippel-Trenaunay vein?
a large, lateral, superficial vein sometimes seen at birth. This vein begins in the foot or the lower leg and travels proximally until it enters the thigh or the gluteal area
Treatment of aortic dissection?
Type A (Ascending aorta/ aortic root):Surgery- aortic root replacement
Type B (Descending aorta): Medical therapy with antihypertensives
In what operation are skew flaps created?
Below knee amputation (also burgess flaps)
Characteristics of tetralogy of fallot?
Right-to-left shunting
overriding aorta
VSD
RVH
pulmonary stenosis
The four characteristic features are:
ventricular septal defect (VSD)
right ventricular hypertrophy
right ventricular outflow tract obstruction, pulmonary stenosis
overriding aorta
symptoms of TOF?
cyanosis
causes a right-to-left shunt
ejection systolic murmur due to pulmonary stenosis (the VSD doesn’t usually cause a murmur)
a right-sided aortic arch is seen in 25% of patients
chest x-ray shows a ‘boot-shaped’ heart, ECG shows right ventricular hypertrophy
Management of TOF?
surgical repair is often undertaken in two parts
cyanotic episodes may be helped by beta-blockers to reduce infundibular spasm
