Vascular surgery Flashcards
1
Q
What is an aneurysm ?
A
Bulging or ballooning of the artery due to weakness in the wall of the vessel that supply’s blood to the brain.
2
Q
What is an arterial thrombosis ?
A
A blood clot in an artery. Usually in patients with atherosclerosis.
3
Q
What conditions are caused by arterial thrombus ?
A
-MI
- TIA ( Blockage of blood supply of the heart causing short lived stroke symptoms)
- Stroke
- Critical limb ischemia
4
Q
What are some of the RF for thrombus formation ?
A
- Smoking
- Atherosclerosis
- Obesity
- Hypertension
- Diabetes
- Hypercholesterolemia
5
Q
What causes an arterial ulcer ?
A
Insufficient blood supply to the skin due to PAD
6
Q
What are some of the definitive clinical features on inspection of an arterial ulcer ?
A
- Often occur more distal on the toes or the dorsum of the foot/lateral malleolus
-Small and deep - Well defined, punched out borders
- Pale colour due to poor blood supply.
- Painful
- Hair loss and shiny legs may indicate PAD
7
Q
What symptoms may a patient with PAD experience ?
A
- PAD symptoms and RF
- Absent pulses, pale limb
- Intermittent claudication
- Pain worse when lying down and elevating the leg
- Loss of sensation in the leg
- Diabetes
8
Q
What are the risk factors for an arterial ulcer ?
A
- Diabetes
- PAD
- Vasculitis
- Arteriosclerosis
- Renal failure
- DM
- Hypertension/cholesterol
9
Q
What can be used to differentiate between an arterial and a venous ulcer ?
A
ABPI ( Will be low in sig arterial disease)
10
Q
What is the treatment of an arterial ulcer ?
A
- Vascular referral for possible revascularization
- Treatment of the underlying disease and he ulcer will heal rapidly
- Compression and debridement are NOT CONDUCTED.
11
Q
A type A Stanford system Aortic dissection effects what part of the aorta ?
A
- Ascending aorta
12
Q
A type B Stanford system Aortic dissection effects what part of the aorta ?
A
- Descending aorta
13
Q
What is the typical clinical presentation of an aortic dissection ?
A
Typical presentation is a sudden onset severe, ripping or tearing chest pain.
Pain may migrate
Some patients will not have any pain at all
Anterior chest wall pain = Ascending aorta is effected
Posterior chest wall pain = Descending aorta is affected.
Some patients will not have any pain.
14
Q
What are the clinical signs of aortic dissection ?
A
Hypertension
Difference in BP between the arms ( More than 20mmHg)
Radial pulse deficit ( One arm has a decreased RP or absent)
Diastolic murmur.
DND – Limb weakness or paresthesia
Chest and abdo pain
Syncope
Hypotension as the dissection progresses.
Acute aortic regurgitation – Mid diastolic murmur
Acute HF – suggested by resp distress and CXR of pulmonary oedema.
15
Q
What are the RF for aortic dissection ?
A
Generally share the same risk factors as peripheral arterial disease such as age, male sex, hypertension, poor diet, and hypercholesterolemia.
Hypertension – BIG RF. Dissection can be triggered by events that temporarily cause a dramatic increase in BP like heavy weightlifting or the use of cocaine.
Conditions or procedures that affect the aorta increase the risk of dissection like
Bicuspid aortic valve
Coarctation of the aorta
Aortic valve replacement
CABG
Marfans and Ehlers Danlos syndrome are both RF.
16
Q
What is the typical exam presentation of an aortic dissection ?
A
For your exams, a man aged around 60 with a background of hypertension, presenting with a sudden onset tearing chest pain, has aortic dissection.
17
Q
What are two RF that often come up in exams for an aortic dissection ?
A
Marfan’s and Ehlers-Danlos syndrome are worth remembering as risk factors, as these may be options on an MCQ exam.
18
Q
What is the initial investigation for an aortic dissection ?
A
- CT angio.
19
Q
If a CT is unavailable, what imaging is used in an aortic dissection ?
A
Trans esophageal echocardiography.
20
Q
How is an aortic dissection managed ?
A
- Analgesia
- BP management - BB like IV labetalol
- Type A can be treated with a sternotomy and aortic root replacement
- Type B can be treated with a TEVAR
21
Q
What is a AAA ?
A
Dilation of the abdominal aorta with a diameter of more than 3cm.
22
Q
How does a AAA present ?
A
Most patients are asymptomatic and may present on a routine screening or when it ruptures
- Non specific abdominal pain
- Pulsatile and expansible mass in the abdomen when palpated with both hands
- Incidentaloma
23
Q
What are the RF of a AAA ?
A
- Male sex
- Smoking
- Hypertension
- Increased age
- FHx
- CV disease
24
Q
When does the AAA screening program start ?
A
- Over 65 and male
25
How is progression of a AAA halted ?
- Smoking cessation
- Healthy diet and exercise
- Hypertension, diabetes and hyperlipidemia management.
Management of CV risk factors.
26
What is the management of an aneurysm 3-4.4 cm in diameter ?
Yearly USS scans and referral to vascular team
27
What is the management of an aortic aneurysm 4.5-5.4 cm in size ?
3 monthly scans and referral to vascular
28
When is elective repair indicated in a AAA ?
- Symptomatic
- Diameter growing by more than 1cm per year
- Diameter above 5.5 cm
Graft Is inserted into the aorta via open repair via a laparotomy or an endovascular aneurysm repair using a stent inserted into the femoral arteries.
29
What are the symptoms of a ruptured AAA ?
- Severe abdominal pain that may radiate to the back or groin.
- Hemodynamic instability (Hypotension and tachycardia)
- Pulsatile and expansible mass in the abdomen
- Collapse and loss of consciousness.
30
What is the management of hemodynamically stable patients with a ruptured AAA ?
- CT angio to confirm diagnosis.
- Patients usually have mild epigastric pain and a leaking Aorta
31
What is the management of non hemodynamically stable patents with a ruptured AAA ?
Urgent referral to vascular surgery
32
What aneurysm is common in patients following a AAA
PAA
Popliteal artery aneurysm
33
What is burgers disease ?
Thromboangiitis obliterans. Inflammatory condition that causes thrombus formation in the small and medium size blood vessels in the distal limbs
34
What is the typical exam presentation of burgers disease ?
The key presentation to remember for your exams is a young male smoker with painful blue fingertips. The exam question may ask the diagnosis (Buerger disease or thromboangiitis obliterans) or ask the most important aspect of management (completely stopping smoking).
35
What are the clinical features of burgers disease ?
- Painful blue discoloration of the fingertips
- Pain worse at night
- May be corkscrew collateral on angiograms
36
What is the management of burgers disease ?
- Stop smoking all together
- IV iloprost to dilate blood vessels ( Only in some cases)
37
What is peripheral artery disease ?
Narrowing of the arteries, usually due to PAD, causing limb claudication. Usually caused by atherosclerosis ( affecting the medium and large arteries). Development of atheromatous plaques. This can cause stenosis (Stiffening like in angina), Plaque rupture and stiffening of artery walls leading to hypertension.
38
What is intermittent claudication ?
Symptom of ischemia in the limb, occurring during exertion and relieved by rest . Crampy, achy pain in muscles associated with muscle fatigue.
39
What is critical limb ischemia ?
End stage PAD, where inadequate blood supply to the limb. Pain at rest and non-healing wounds
40
What is acute limb ischemia ?
Rapid onset. Usually due to a thrombus blocking the arterial supply to the distal limb.
41
What are some of the symptoms of PAD ?
- Intermittent claudication
- RF signs like Xanthomata and signs of CVD (midline sternotomy)
- Weak or absent peripheral pulses.
- Skin pallor and cyanosis
- Hair loss and ulcers
- Reduced skin temp and sensation
- Increased cap refill
- Hang legs off the bed for relief
42
What are the RF for PAD ?
Old age
FHX
Male
Smoking and alcohol consumption
Obesity
Poor sleep
Stress
Diabetes and hypertension
CKD
RA
Atypical antipsychotic medications.
43
What is burgers test ?
Patient in a supine position and hold the patients legs at a 45 degree angle. Hole for 1 to 2 minutes and assess for pallor. The angle is the angle at which the leg becomes pale.
Involves the patient sitting up with legs overhanging the bed. Blood will flow back into the leg and in healthy patients this will go pink. In ischemic patients, they will go blue than dark red (Rubor)
44
What investigations are used to investigate suspected PAD ?
ABPI
Duplex USS
Angiography
45
What does a high ABPI indicate ?
Calcification of the vessels like in diabetes
46
What are the ABPI categories ?
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
47
How is intermittent claudication treated ?
Lifestyle changes
Structured exercise training.
Atorvastatin (For high cholesterol), clopidogrel (antiplatelet ) and naftidrofuryl oxalate (5- HT2 receptor antagonist that acts as a peripheral vasodilator)
Endovascular angioplasty and stenting
Endarterectomy or bypass surgery.
48
How is critical limb ischemia treated ?
Urgent revascularization by using endovascular angioplasty and stenting
Enterectomy
Bypass surgery
Amputation if not possible to restore blood supply.
49
How is acute limb ischemia treated ?
Endovascular thrombolysis
Endovascular thrombectomy
Surgical thrombectomy
Endarterectomy.
Bypass surgery
Amputation
50
What is leriche syndrome/how does it occur ?
Occurs with occlusion in the distal aorta or the proximal common iliac artery.
Absent femoral pulses
Impotence
Buttock pain
51
What is the triad of symptoms associated with leriche syndrome ?
- Thigh/buttock pain ( clarification )
- Absent femoral pulses
- Male impotence
52
What is dry gangrene ?
Ischemic gangrene and occur secondary to chronically reduced blood flow. It occurs due to atherosclerosis (PAD), thrombosis (vasculitis and hypercoagulable states) and vasospasm (cocaine use and Raynaud's)
53
What are the clinical features of dry gangrene ?
Necrotic area is well demarcated from the surrounding tissue and patients do not show any signs of infection. In most cases, auto amputation occurs
54
What is gas gangrene ?
After infection of traumatic or surgical wounds, there is a release of alpha and theta toxins. This leads to necrosis and microvascular thrombosis with localized gas production. This can cause rhabdomyolysis, renal failure, red blood cell hemolysis, sepsis and generalized shock.
55
What organism causes gas gangrene ?
clostridium perfingens
56
What is wet gangrene ?
Infectious gangrene and includes necrotizing fasciitis and gangrenous cellulitis.
57
What are the clinical features of gas gangrene ?
Acute onset of severe localized pain, with little inflammation. Skin is darkened and spreading erythema. Patient is hot to touch and infected area gives a distinctive and potent smell. Blistering
58
What is the clinical presentation of wet gangrene ?
The necrotic area is poorly demarcated from the surrounding tissue and patients are pyrexial/septic.
59
How is gas gangrene managed ?
- Debridement
- Antibiotics (Penicillin, gentamycin and metronidazole)
60
How is wet gangrene managed ?
- Surgical debridement
- Amputation
- BS antibiotics (Penicillin, gentamycin and metronidazole)
61
How is dry gangrene managed ?
Most of the time amputation is necessary
62
What is Fournier's gangrene ?
necrotizing fasciitis of the scrotum or the vulva. It is a deep soft tissue infection that is life threatening.
63
Why do venous ulcers occur ?
Occur due to the pooling of blood and waste products in the skin secondary to venous insufficiency.
64
What are the key clinical features of venous ulcers ?
- Occur in the gaiter area (Top of foot and bottom of calf) and medial malleolus
- Chronic venous changes like hyperpigmentation, venous eczema and liperdermatosclerosis.
- often occur after a minor injury to the leg
- Larger than arterial ulcers and more superficial.
- Irregular, sloping border.
- More likely to bleed and less painful than arterial
- Pain is relieved in elevation and worse on leg lowering.
- Swelling
65
What are the RF for venous ulcers ?
Venous eczema
Lipodermatoslerosis
Previous DVT
Varicose veins
66
How are venous ulcers managed (Uncomplicated) ?
District nurses to implement good wound care like cleaning the wound, debridement and dressing of the wound.
Compression therapy – after arterial disease is excluded with ABPI. Most venous ulcers heal well with compression bandaging and it is commonly 1st line of treatment
Pentoxifylline – Oral can improve venous healing
Antibiotics to treat infection
Analgesia to manage pain – CI NSAIDS AS THEY CAN WORSEN THE CONDITION
67
What is first line of treatment in Venous ulcers ?
Compression bandaging
68
What medication is CI in venous ulcers ?
NSAIDS
69
What are some of the management options for complicated venous ulcers ?
Vascular surgery where mixed or arterial ulcers are suspected
Tissue viability in complex or non-healing ulcers
Pain clinics
Diabetic ulcer services
70
What are varicose veins ?
- Distended superficial veins measuring greater than 3cm. Due to a defect in valves causing blood to pool back in the veins. Usually caused by chronic venous insufficiency.
71
What are some of the signs of chronic venous insufficiency ?
- Lipodermatosclerosis
- Browning of the legs
- Venous eczema
72
What are the clinical features of varicose veins ?
Patients often present with enlarged and dilated superficial veins and may be asymptomatic or …..
Heavy or aching sensation in the legs
Aching and burning
Oedema
Muscle cramps
Restless legs
May have signs of chronic venous insufficiency like venous ulcers, lipodermatosclerosis and skin changes.
73
What are the risk factors for varicose veins ?
Increasing age, FHX, Female pregnancy and obesity
Prolonged standing
DVT causing damage to the valves
74
What is the gold standard of investigation for varicose veins ?
Duplex/doppler USS
75
What tests can be used when investigating varicose veins ?
- Tap test
- Cough test
- Trendelburgs test (tourniquet should prevent varicose veins from reappearing if it is placed distally to the incompetent valve)
- Perth's test
76
What are some of the complications of varicose veins ?
Prolonged and heavy bleeding after trauma
Superficial thrombophlebitis ( Inflammatory venous condition in patients with a history of DVT and varicose veins. Usually erythema and inflammation of the effected leg and veins are tender and hard on palpation. 1st line treatment is NSAIDS)
DVT
CVI – skin changes and ulcers
77
What is superficial thrombophlebitis ?
- Inflammatory venous condition that presents in patients with a history of DVT and varicose veins
- Patients usually have erythema and inflammation of the leg and hard and tender veins on palpation
78
What is the first line of treatment for superficial thrombophlebitis ?
NSAIDS
79
What are some simple treatment options for varicose veins ?
Weight loss
Keeping leg elevated
Compression stockings ( ABPI first to exclude arterial disease)
Physically active
Conservative options such as weight loss are always recommended first
80
What are some surgical options for varicose veins ?
Endothermal ablation
Sclerotherapy
Stripping
81
Where do short saphenous vein varicose veins present ?
lateral malleolus. Often presents on the posterolateral malleolus.
82
Where do long saphenous vein varicose veins present ?
Medial malleolus ?
83
What is saphina Varix ?
dilation of the saphenous vein. Bluish tinge groin lump that disappears when lying down and positive cough impulse test. Increased risk when the patient has varicose veins.
84
What is the critical limb ischemia triad ?
- Arterial ulcers
- Gangrene
- Burning pain worse at night and when the leg is elevated.
85
What are red flags in PAD history ?
Pain at night
Pain at rest
Loss of sensation
86
What are the 6ps indicating the symptoms of acute limb ischemia ?
Pain
Pallor
Pulseless
Paralysis
Paraesthesia (abnormal sensation or “pins and needles”)
Perishing cold
87
What would be present OE in a patient with acute limb ischemia ?
Marble white appearance of the skin
Absent limb pulses
Cold limb
Paresthesia
Paralysis
Muscle weakness and gangrene
88
What is a CV risk of acute limb ischemia ?
AF – Can cause embolism from a thrombus in the left atrium or following a MI
89
What is serum lactate used for in acute limb ischemia ?
To assess the severity of ischemia
90
What is important to look at when investigating (e.g investigations)
acute limb ischemia ?
Doppler to confirm the presence of pulses
ECG to look for AF (Emboli)
Serum lactate – To assess severity of ischemia
Group and save for surgery.
CT/MRI to guide revascularization if delaying treatment is not threatening to viability.
91
What system is used when grading the severity of ALI ?
The Rutherford classification is used in grading the severity of ALI and determining limb viability. 1 is most viable and 3 is irreversible damage.
92
How is ALI managed medically ?
Systemic anticoagulation with heparin, analgesia with paracetamol and an opioid
Management of CV Risk factors
93
How is a thrombosis ALI managed ?
PCI directed thrombolysis
94
How is an emboli ALI managed ?
Embolectomy
95
What are the symptoms of embolic ALI ?
Sudden and sever pain
Unlikely to be prior symptoms of PAD
Unlikely to be previous limb interventions
Likely to be a history of AF or a recent MI.
Artery will be soft and tender
Femoral pulses will be present.
96
What are the features of thrombotic ALI ?
Gradual vague pain and onset
Pain is less severe
Usually a history of past PAD symptoms
No cardiac history
Likely to be history of previous vascular surgery or endovascular interventions.
Artery palpation will be hard and calcified
Contelateral leg pulses will be absent.
97
What are the complications of ALI ?
High mortality rate, massive oedema (Compartment syndrome and hypovolemic shock). AKI, ACIDOSIS AND HYPERKALAEMIA.
98
What is the first line treatment of critical limb ischemia (include pharmacological management)?
supervised exercise programmers as well as management of CV RF as well as clopidogrel 75mg daily and atorvastatin 80mg.
99
What treatment is NOT indicated in arterial ulcers ?
Compression and debridement.
100
What are the key features of Fournier's gangrene ?
- Infection of the deep fascia – can be caused by a Indwelling catheter
- Pain out of proportion to what is observed
- Erythema that is poorly demarcated and can appear gangrenous in later stages
- Systemic illness.
- Type 2 diabetes – RF and immunocompromised and alcoholics
- Effects the external genitalia or perineum
101
What does dry gangrene look like ?
- Well demarcated, black, necrotic area.
- No systemic signs of infection
- Auto amputation occurs in most cases.
102
What does gas gangrene look like ?
- Acute onset of severe localized pain
- Small amounts of inflammation
- Skin is darkened
- Systemic fever
- Distinctive smell
103
What does wet gangrene look like ?
- Poorly demarcated necrotic area
- Patient usually septic
104
What is a protected characteristic of AAA ?
Type 2 diabetes.
105
What will be present on angiogram in patients with burgers disease ?
Corkscrew collateral
106
What are the 6 Ps that can indicate critical limb ischaemia ?
-Pain
-Pallor
-Pulselessness
-Paralysis
-Paraesthesia
- Perishingly cold
107
What is the critical limb ischaemia triad ?
- Arterial ulcers
- Gangrene
- Burning pain worse at night and when the leg is elevated
108
What is one of the important CV RF for acute limb ischaemia ?
Atrial fibrillation
109
What is used to anti coagulate in ALI ?
Heparin
110
What is the first line of treatment for chronic limb ischaemia ?
1st like of treatment is supervised exercise programmers as well as management of CV RF as well as clopidogrel 75mg daily and atorvastatin 80mg.
111
What is the gold standard of investigation for varicose veins ?
Duplex USS
112
What are the risk factors for a DVT ?
- Age over 60
- Active cancer
- Dehydration
- Recent Ortho surgery (enoxaparin)
- Obesity
- Previous history of VTE/FHX of VTE.
- Pregnancy
- Combined oral contraceptives/ HRT
113
What are the clinical features of DVT ?
- Unilateral, warm swollen calf or thigh
- Pain on palpation of the deep veins
- Distension of the deep veins and superficial veins
- Pitting odema
114
What Wells score indicates that a DVT is likley ?
More than 2
115
What is the blood test used in DVT assessment and why is it is it not reliable ?
- It can only reliably exclude a DVT and cannot confirm it as it can also be raised in malignancy, infection, pregnancy, stroke, MI and aortic dissection.
116
What is an important investigation that should be used in every patient with suspected DVT ?
Doppler USS
117
What medical management is used in the treatment of a DVT ?
First line DOAC like apixaban for at least 3 months.
Patients with active cancer should be anti-coagulated for at least 3-6 months as well as patients with unprovoked VTEs
118
What can be used in the treatment of a massive DVT ?
PER-CUTANEOUS mechanical thrombectomy.
119
What else should be investigated in patients with unprovoked VTEs ?
Chance of malignancy
120
What are the possible complications of a DVT ?
- PE
- Venous insufficiency
- Recurrent DVT
- Post thrombotic syndrome - Pain, swelling, hyper pigmentation, ulcers, dermatitis ect.
121
What is used in the treatment of acute arm ischaemia due to embolus ?
IV heparin bolus followed by continous infusion
122
A 60 year old male complains of worsening cramping pain in his buttocks and legs. He used to be able to walk to the grocery store, but now has to stop intermittently due to pain. He also reports that he has difficulty getting erections these days. His past history is significant for hypertension and hyperlipidaemia.
Examination shows loss of hair and decreased temperature in the lower legs. The femoral pulses are not felt. The genital examination reveals no abnormalities.
Which of the following is the most likely diagnosis?
Triad of symptoms
- Leg/buttock pain
- Sexual dysfunction
- diminished/absent femoral pulses
Aortoiliac stenosis (Leriche syndrome)
123
What is lipodermatosclerosis characteristic of ?
Chronic venous insufficiency.
124
How does superficial thrombophlebitis present ?
On physical examination, the short saphenous vein is tortuous and appears red. It is warm, tender and hard on palpation along the length of the vessel.
125
What is sensitive and specific in identifying a AAA ?
USS
126
The gold standard of DIAGNOSIS of PAD is angiography. If this is CI due to the use of contrast e.g in CKD, what is used diagnostically ?
MRA
Magnetic resonance angiography
127
What is one of the main risk factors for anal fistulae ?
Crohns
128
How does Henoch - schnlein pupura commonly present ?
Henoch-Schonlein purpura classically presents with abdominal pain, arthritis, haematuria and a purpuric rash over the buttocks and extensor surfaces of arms and legs
Treatment is supportive - analgesia
129
What is the diagnostic criteria for kawasaki disease ?
High grade fevers for more than 5 days and 4/5 of the cream features
- Conjunctivitis
- Rash
- Edema/erythema of the hands
- Adenopathy
- Mucosal involvement (Strawberry tounge, oral fissures ect).
130
What is the main complication of concern in Kawasaki disease ?
Coronary aneurysms and all patients should have an urgent ECHO-cardiogram.
