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!Final Year > Vascular Surgery > Flashcards

Vascular Surgery Flashcards

1
Q

What is critical limb ischaemia?

A

A presentation of peripheral arterial disease
An ankle-brachial pressure index (ABPI) of < 0.5 is suggestive of critical limb ischaemia

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2
Q

What are the causes of critical limb ischaemia?

A

Atherosclerosis is the main cause
Vasculitis and fibromuscular dysplasia is very rare

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3
Q

What is the process of atherosclerosis?

A
  1. Endothelial injury: haemodynamic, HTN, 􏰄 lipids
  2. Chronic inflammation: Lipid-laden foam cells produce GFs, cytokines leading to lymphocyte and SMC recruitment
  3. Smooth muscle proliferation: conversion of fatty streak to
    atherosclerotic plaque
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4
Q

What is the pathology of an atheroma plaque?

A

Fibrous cap: Smooth muscle cells, lymphocytes, collagen
􏰁 Necrotic centre: cell debris, cholesterol, Calcium, foam cells

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5
Q

What are the modifiable risk factors for peripheral arterial disease?

A

Smoking
􏰁Blood pressure
DM control
Hyperlipidaemia
Exercise

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6
Q

What are the non-modifiable risk factors for peripheral arterial disease?

A

Past medical history
Family history (genetics)
Gender -male
Age

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7
Q

What are the three main patterns of peripheral arterial disease?

A
  1. Intermittent claudication
  2. Critical limb ischaemia
  3. Acute limb-threatening ischaemia
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8
Q

What are the features of intermittent claudication?

A

Cramping pain after walking a fixed distance
Pain rapidly relieved by rest
Vessel affected:􏰁
Calf pain = superficial femoral disease (commonest) 􏰁
Buttock pain = iliac disease (internal or common)

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9
Q

What are the features of critical limb ischaemia?

A

Include one or more of:
1. rest pain in foot for more than 2 weeks
2. ulceration
3. gangrene

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10
Q

What is Leriche’s Syndrome?

A

Also known as Aortoiliac Occlusive Disease
Atherosclerotic occlusion of abdominal aorta and iliacs
Triad of:
1. Buttock claudication and wasting
2. Erectile dysfunction
3. Absent femoral pulses

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11
Q

What is Buerger’s Disease?

A

Also known as Thromboangiitis Obliterans
Seen in young, male, heavy smokers
Acute inflammation and thrombosis of arteries and veins in the hands and feet
Leads to ulceration and gangrene

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12
Q

What are the classifications of peripheral arterial disease based on the ankle-brachial pressure index (ABPI)?

A

1 = normal
0.6 - 0.9 = claudication
0.3 - 0.6 = rest pain (critical)
< 0.3 = impending (acute)

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13
Q

What is the most important modifiable risk factor in peripheral arterial disease?

A

Smoking

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14
Q

What are some appropriate investigations for peripheral arterial disease?

A

ABPI
Doppler wave forms:
1. Normal = triphasic
2. Mild stenosis = biphasic
3. Severe stenosis = monophonic
Walk test? Useful to determine maximum claudication distance
Bloods including glucose and lipids
Colour doppler US

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15
Q

What are the management options for peripheral arterial disease in general?

A

Conservative:
1. Treat co-morbidities (HTN, DM and obesity)
2. Exercise training
Medical:
1. For established cardiovascular disease = secondary prevention, atorvastatin 80mg and clopidogrel
Surgical (reserved for severe PAD):
1. Endovascular revascularisation
2. Surgical revascularisation

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16
Q

What is involved in end-vascular revascularisation?

A

Percutaenous transluminal angioplasty +/- stent placement
Endovascular techniques are typically used for short segment stenosis (e.g. < 10 cm), aortic iliac disease and high-risk patients

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17
Q

What is involved in surgical revascularisation?

A

Surgical bypass with an autologous vein or prosthetic material
endarterectomy
Open surgical techniques are typically used for long segment lesions (> 10 cm), multifocal lesions, lesions of the common femoral artery and purely infrapopliteal disease

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18
Q

When would amputation be considered in peripheral arterial disease?

A

Reserved for patients with critical limb ischaemia who are not suitable for other interventions such as angioplasty of bypass surgery

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19
Q

What drug could be used for peripheral arterial disease?

A

Naftidrofuryl oxalate: vasodilator, sometimes used for patients with a poor quality of life

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20
Q

What is acute limb-threatening ischaemia?

A

Surgical emergency
Severe presentation of peripheral arterial disease

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21
Q

What is acute limb-threatening ischaemia characterised by?

A

One or more of the 6 P’s:
1. Pale
2. Pulseless
3. Painful
4. Paralysed
5. Paraesthetic
6. ‘Perishing with cold’

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22
Q

What are the two main causes of acute limb-threatening ischaemia?

A
  1. Thrombus = due to rupture of atherosclerotic plaque
  2. Embolus = e.g. secondary to atrial fibrillation
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23
Q

What are the factors suggestive of a thrombus in acute limb-threatening ischaemia?

A
  1. Pre-existing claudication with sudden deterioration
  2. No obvious source for emboli
  3. Reduced or absent pulses in contralateral limb (bilateral)
  4. Evidence of widespread vascular disease (e.g. MI, stroke, TIA, previous vascular surgery)
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24
Q

What are the factors suggestive of an embolus in acute limb-threatening ischaemia?

A
  1. Sudden onset of painful leg (< 24 hour)
  2. No history of claudication
  3. Clinically obvious source of embolus (e.g. AF, recent MI)
  4. No evidence of peripheral vascular disease (normal pulses in contralateral limb)
  5. Evidence of proximal aneurysm (e.g. abdominal or popliteal)
25
Q

What are the investigations for acute limb-threatening ischaemia?

A

Initial investigations should include a handheld arterial Doppler examination
If Doppler signals are present, an ankle-brachial pressure index (ABI) should also be obtained
Bloods including Group and Save
ECG

26
Q

How is the management for acute limb-threatening ischaemia categorised?

A
  1. Initial management as a surgical emergency which is A to E approach
  2. Definitive management is surgical
27
Q

What is the initial management of acute limb-threatening ischaemia?

A

(duplex US as initial investigation)
1. A to E approach (alert senior)
2. Analgesia: IV opioids are often used
3. IV unfractionated heparin is usually given to prevent thrombus propagation, particularly if the patient is not suitable for immediate surgery
4. Vascular review

28
Q

What is the definitive management of acute limb-threatening ischaemia?

A
  1. Intra-arterial thrombolysis
  2. Surgical embolectomy
  3. Angioplasty
  4. Bypass surgery
  5. Amputation: for patients with irreversible ischaemia
29
Q

What are some complications post-embolectomy in acute limb-threatening ischaemia?

A
  1. Reperfusion injury:
    􏰆a) Local swelling
    b) Compartment syndrome
    c) Acidosis and arrhythmia secondariy to hyperkalaemia
    d) ARDS
    e) GI oedema
    f) Endotoxic shock
  2. Chronic pain syndromes
30
Q

What are the 3 subtypes of peripheral artery disease?

A
  1. Intermittent claudication
  2. Critical limb ischaemia
  3. Acute limb-threatening ischaemia
31
Q

How can you differentiate between critical and acute limb-threatening limb ischaemia clinically?

A

Onset
CLI = >2 weeks
ALI = <2 weeks

Colour:
CLI = pink
ALI = marble white
nb. can’t find info on how this works in non-white skin tones

Temp:
CLI: warm
ALI: cold

32
Q

What are the 6 Ps of acute limb ischaemia?

A

Pain
Perishingly cold
Pallor
Pulseless
Paralysis
Paraesthesia

33
Q

What is the expected ankle arterial pressure in critical limb ischaemia?

A

<40mmHg

34
Q

What are the causes of limb ischaemia?

A

TRIED to walk:
Thromboangiitis obliterans
Raynaud’s
Injury
Embolism/thrombosis
Diabetes

35
Q

How should ischaemic limb be investigated?

A

1st: ABPI
2nd: duplex USS
3rd: MRA/CTA

36
Q

What ABPI result is indicative of critical limb ischaemia?

A

<0.5

37
Q

How should asymptomatic limb ischaemia/intemittent claudication be managed?

A

Conservative: (WL, quit smoking etc)
Medical: statin + anti-platelet (1st line is atorvastatin 80mg + clopidogrel 75mg)
Rarely used - naftidrofuryl oxalate (vasodilator)

38
Q

How is critical limb ischaemia managed?

A

1st: Angioplasty, stenting, bypass, embolectomy
2nd: Amputation

39
Q

What are the indications for amputation in critical limb ischaemia?

A

Dead (eg severe PAD/ thromboangiitis obliterans)
Dangerous (sepsis, NF)
Damaged (trauma, burns, frostbite)
Darned nuisance (pain, neurological damage)

40
Q

What is thromboangiitis obliterans also known as?

A

Buerger’s disease

41
Q

What is thromboangiitis obliterans?

A

A smoking-related condition that results in thrombosis in small and medium-sized arteries, and less commonly veins
Ends of digits look all necrotic and nasty

42
Q

Recall 2 classification systems used to classify limb ischaemia?

A

Fontaine
Rutherford

43
Q

What are the 3 stages of venous insufficiency?

A
  • Phlegmasia alba dolens (white leg)
  • Phlegmasia cerulea dolens (blue/red leg)
  • Gangrene (secondary to acute ischaemia)
44
Q

How can venous insufficiency be managed?

A

Conservative: compression bandages (ABPI >0.8 required)
Surgical: grafts

45
Q

What percentage of varicose veins are primary?

A

95%

46
Q

How should varicose veins be investigated?

A

Cough impulse (should be neg in varicose pathology)
Tap test - tap proximally and feel for an impulse distally
Tourniquet test

47
Q

How is the tourniquet test for varicose veins performed?

A

Patient supine, elevate legs, milk veins
Apply tourniquet high to compress saphenofemoral junction
Stand patient
Repeat distally until controlled filling
Controlled filling = distal veins do not fill
Uncontrolled filling = distal veins full - meaning there is an incompetent valve below the tourniquet

48
Q

How can varicose veins be managed?

A

Conservative: WL, avoid prolonged standing, compression stockings, emollients

Medical: injection sclerotherapy, radiofrequency ablation

Surgical: various types of ligation

49
Q

What are varicose veins?

A

Dilated, tortuous, superficial veins that occur secondary to incompetent venous valves, allowing blood to flow back, away from the heart

50
Q

Where is the most common site for varicose veins?

A

Legs
Due to reflux in the great saphenous vein and small saphenous vein

51
Q

What is the epidemiology of varicose veins?

A

Extremely common but the vast majority of patients do not require any intervention

52
Q

What are the risk factors for varicose veins?

A

Increasing age
Female gender
Pregnancy: the uterus causes compression of the pelvic veins
Obesity

53
Q

What are the features of varicose veins?

A

Cosmetic appearance may prompt presentation
Aching, throbbing
Itching
Complications of varicose veins

54
Q

What are some of the complications of varicose veins?

A

Variety of skin changes may be seen:
1. Varicose eczema (also known as venous stasis)
2. Haemosiderin deposition → hyperpigmentation
3. Lipodermatosclerosis → hard/tight skin
4. Atrophie blanche → hypopigmentation
Bleeding
Superficial thrombophlebitis
Venous ulceration
Deep vein thrombosis

55
Q

What is the investigation of choice for varicose veins?

A

Venous duplex ultrasound: will demonstrate retrograde venous flow

56
Q

What is the main management for varicose veins?

A

Majority of patients do not require surgery and can be treated conservatively
Leg elevation
Weight loss
Regular exercise
Graduated compression stockings

57
Q

What is the criteria for secondary care referral for varicose veins?

A

Significant/troublesome lower limb symptoms e.g. pain, discomfort or swelling
Previous bleeding from varicose veins
Skin changes secondary to chronic venous insufficiency (e.g. pigmentation and eczema)
Superficial thrombophlebitis
An active or healed venous leg ulcer

58
Q

What are some of the surgical management options for varicose veins?

A

Endothermal ablation: using either radiofrequency ablation or endovenous laser treatment
Foam sclerotherapy: irritant foam → inflammatory response → closure of the vein
Surgery: either ligation or stripping

!Final Year (26 decks)

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