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