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Zero to Finals Decks > Vascular Surgery > Flashcards

Vascular Surgery Flashcards

1
Q

how can peripheral arterial disease (PAD) present?

A
  • intermittent claudication
  • critical limb ischaemia
  • acute limb ischaemia
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2
Q

describe intermittent claudication. which areas are typically affected by this?

A
  • limb pain which comes on with exertion and goes away at rest
  • can cause fatigue on speedwalking
  • calves
  • thighs
  • buttocks
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3
Q

describe the nature of the pain felt in intermittent claudication

A
  • crampy

- achey

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4
Q

describe critical limb ischaemia (CLI)

A
  • the end stage of PAD

- pain in limb at rest

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5
Q

features of CLI?

A
  • pain
  • pallor
  • pulseless
  • paralysis
  • paraesthesia
  • perishingly cold
  • non-healing ulcers
  • gangrene
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6
Q

describe the pain felt in CLI

A
  • burning sensation
  • present at rest
  • worse at night (leg is raised)
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7
Q

triad of leriche syndrome?

A
  • thigh/buttock claudication
  • absent femoral pulses
  • male impotence
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8
Q

what causes leriche syndrome?

A

occlusion of distal aorta / common iliac artery

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9
Q

describe buerger’s test

A
  • with pt laying on their back, lift their leg to 45 degs
  • hold there for 1-2 mins
  • look for pallor
  • then sit the pt up and hang their legs over side of bed
  • look for colour changes
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10
Q

what is buerger’s angle?

A

the angle at which the leg becomes pale

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11
Q

in a healthy pt, what happens at the end of buerger’s test?

A

legs remain pink

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12
Q

in a pt with PAD, what happens at the end of buerger’s test?

A
  • initially legs turn blue

- then go dark red (rubor)

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13
Q

describe an arterial ulcer

A
  • small, deep “punched out” lesion
  • well-defined borders
  • typically on toes
  • no bleeding
  • painful
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14
Q

describe a venous ulcer

A
  • large
  • superficial
  • irregular borders
  • typically on gaiter region
  • less painful
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15
Q

where is the gaiter region?

A

mid-calf down to ankle

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16
Q

investigations for PAD?

A
  • ABPI
  • duplex USS
  • angiography (CT or MRI)
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17
Q

what is the normal range for ABPI?

A

0.9 - 1.3

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18
Q

what would an ABPI of < 0.3 indicate?

A

CLI

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19
Q

what could an ABPI of > 1.3 indicate? who is this more common in?

A
  • arterial calcification

- diabetics

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20
Q

management of intermittent claudication?

A
  • stop smoking
  • optimise comorbidities (HTN, DM)
  • exercise training
  • drugs
  • surgery
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21
Q

drugs offered in intermittent claudication?

A
  • atorvastatin 80mg
  • clopidogrel 75mg OD (alt: aspirin)
  • naftidrofuryl oxalate
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22
Q

surgical options for intermittent claudication?

A
  • endovascular angioplasty and stenting
  • endarterectomy
  • bypass surgery
  • amputation
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23
Q

management of acute limb ischaemia?

A

vascular emergency:

  • endovascular thrombolysis
  • thrombectomy
  • endarterectomy
  • bypass surgery
  • amputation
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24
Q

how could a venous thrombus cause a stroke?

A
  • breaks off to form an embolus
  • in someone with an ASD, travels across the heart into systemic circulation
  • travels up to brain
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25
Q

risk factors for VTE?

A
  • immobility
  • recent surgery
  • long haul flights
  • pregnancy
  • COCP, HRT containing oestrogen
  • malignancy
  • polycythaemia
  • SLE
  • thrombophilia
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26
Q

what is a thrombophilia? give some examples

A

a condition that predisposes you to forming clots

  • antiphospholipid syndrome
  • factor V lieden
  • protein C / S deficiency
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27
Q

which pts are offered VTE prophylaxis? what are they offered?

A
  • anyone with moderate / high risk of a clot
  • LMWH (e.g. enoxaparin)
  • anti-embolic stockings (IPCDs)
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28
Q

contraindications to LMWH?

A
  • active bleeding

- pre-existing anticoagulation with warfarin / DOAC

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29
Q

key contraindication for anti-embolic compression stockings?

A

peripheral arterial disease (PAD)

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30
Q

presentation of a DVT?

A
  • unilateral calf / leg swelling
  • dilated superficial veins
  • calf tenderness
  • oedema
  • colour changes of leg
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31
Q

how is leg swelling measured in suspected DVT? what is significant?

A
  • measure calf circumference 10cm below tibial tuberosity

- > 3cm is significant

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32
Q

which scoring system is used to calculate the risk of the pt having a DVT / PE?

A

wells score

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33
Q

is D-dimer sensitive or specific for VTE? what does this mean?

A
  • sensitive but not specific
  • good at excluding VTE
  • but can be raised for other reasons
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34
Q

causes of a raised D-dimer?

A
  • pneumonia
  • malignancy
  • HF
  • surgery
  • pregnancy
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35
Q

how is DVT diagnosed?

A

doppler USS

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36
Q

what should you do if doppler USS is negative but wells score and D-dimer both suggest DVT?

A

repeat the doppler in 6-8 days

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37
Q

how is pulmonary embolism (PE) diagnosed?

A

either CTPA or ventilation-perfusion (VQ) scan

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38
Q

when would a VQ scan be done instead of CTPA for a pt with a suspected PE?

A
  • significant renal impairment

- contrast allergy

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39
Q

initial management for suspected / confirmed DVT / PE?

A
  • DOAC (apixaban, rivaroxaban)

- start immediately, don’t delay for scans

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40
Q

what management can be considered for a iliofemoral DVT?

A

catheter-directed thrombolysis

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41
Q

drug options for long-term anticoagulation in VTE?

A
  • DOAC
  • warfarin
  • LMWH
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42
Q

first line anticoagulation in VTE in pregnancy?

A

LMWH (dalteparin)

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43
Q

how long should anticoagulation be continued for in VTE:

i) with a reversible cause?
ii) with an unclear cause?
iii) active cancer?

A

i) 3 months
ii) beyond 3 months
iii) 3-6 months, then review

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44
Q

which pts can be offered an inferior vena cava filter? what is this?

A
  • pts with recurrent PEs

- acts like a sieve and catches all the clots

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45
Q

why is it important to investigate an unprovoked DVT?

A

it may indicate an underlying malignancy

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46
Q

how is an unprovoked DVT investigated?

A
  • CT TAP (for Ca)
  • anti-phospholipid antibodies (for APS)
  • screen for thrombophilias
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47
Q

what is a varicose vein? how big are they?

A
  • distended superficial vein
  • typically on legs
  • > 3mm in diameter
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48
Q

what is a reticular vein? how big are they?

A

dilated blood vessels in the skin, measuring 1 - 3mm

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49
Q

how big are telangiectasia?

A

< 1mm in diameter (tiny!)

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50
Q

pathophysiology of varicose veins?

A
  • vein valves become incompetent
  • blood flow back to the heart is disrupted
  • blood pools in the veins
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51
Q

what is chronic venous insufficiency?

A
  • blood that has pooled up in the veins leaks out into surrounding tissue
52
Q

what causes the brown discolouration of skin in chronic venous insufficiency?

A

Hb being broken down

53
Q

what is venous eczema? what causes this?

A
  • dry inflamed skin over the veins

- secondary to chronic venous insufficiency

54
Q

skin changes seen in chronic venous insufficiency?

A
  • brown discolouration
  • venous eczema
  • lipodermatosclerosis
55
Q

RFs for varicose veins?

A
  • ageing
  • FHx
  • female sex
  • pregnancy
  • obesity
  • prolonged standing
  • DVT (causes valve damage)
56
Q

presentation of varicose veins?

A
  • engorged, dilated superficial leg veins
  • heavy / dragging sensation in legs
  • aching
  • itching
  • burning
  • oedema
  • muscle cramps
  • restless legs
57
Q

special tests to check for varicose veins?

A
  • tap test
  • cough test
  • trendelenberg’s test
  • perthes test
58
Q

imaging for varicose veins?

A

duplex USS

59
Q

management of varicose veins?

A
  • if pregnant, they tend to regress after delivery
  • weight loss if needed
  • exercise
  • elevate leg to help drainage
  • compression stockings (r/o PAD first with ABPI)
  • surgery
60
Q

surgical management options for varicose veins?

A
  • endothermal ablation
  • sclerotherapy
  • stripping
61
Q

complications of varicose veins?

A
  • prolonged / heavy bleeding after trauma
  • superficial thrombophlebitis
  • DVT
  • chronic venous insufficiency changes
62
Q

which area of the body is most likely to be affected by chronic venous insufficiency?

A

gaiter area (mid-calf down to ankle)

63
Q

features of chronic venous insufficiency?

A
  • haemosiderin staining
  • venous eczema
  • lipodermatosclerosis
  • atrophie blanche
  • cellulitis
  • poor healing after trauma
  • skin ulcers
  • pain
64
Q

management of chronic venous insufficiency?

A
  • keeping skin healthy
  • emollients
  • weight loss
  • keeping active
  • elevating legs when resting
  • compression stockings
  • TOP steroids for venous eczema
  • stronger TOP steroids for lipodermatosclerosis
65
Q

what is lipodermatosclerosis? which condition is it seen in?

A
  • hardening / tightening of skin over veins

- chronic venous insufficiency

66
Q

how are the complications of chronic venous insufficiency managed?

A
  • ABx for infection
  • analgesia for pain
  • wound car for ulcers
67
Q

what are the 4 types of leg ulcer?

A
  • venous
  • arterial
  • diabetic foot
  • pressure
68
Q

why do arterial ulcers form?

A
  • poor arterial blood supply to the skin

- typically secondary to PAD

69
Q

why do venous ulcers form?

A
  • pooling of venous blood and waste products

- typically secondary to chronic venous insufficiency

70
Q

which condition increases the risk of diabetic foot ulcers?

A

diabetic neuropathy

71
Q

key complication of diabetic foot ulcers?

A

osteomyelitis

72
Q

how can an individual’s risk of pressure ulcers be worked out?

A

using the waterlow score

73
Q

features of an arterial ulcer?

A
  • found distally (e.g. on toes)
  • assoc with: PAD, absent pulses, pallor, IC
  • small
  • deep
  • well-defined border
  • punched-out appearance
  • no bleeding
  • very painful, esp at night
  • pain worse on elevation, improved with gravity
74
Q

features of a venous ulcer?

A
  • found on gaiter region
  • assoc with: hyperpigmentation, venous eczema, lipodermatosclerosis
  • form after a minor injury
  • large
  • shallow
  • irregular, sloping border
  • bleeding
  • less painful
  • pain relieved on leg elevation
75
Q

investigations for leg ulcers?

A
  • ABPI
  • bloods (FBC, CRP)
  • charcoal swabs
  • skin biopsy (r/o Ca)
76
Q

management of arterial ulcers?

A
  • urgent referral to vasc surg for revascularisation

- should heal when underlying PAD is treated

77
Q

management of venous ulcers?

A
  • vasc surg if arterial / mixed ulcers suspected
  • pain clinic / derm/ diabetic ulcer services
  • good wound care
  • compression therapy
  • PO pentoxifylline
  • ABx
  • analgesia (NOT NSAIDs)
78
Q

what does good wound care entail?

A
  • cleaning the wound
  • debriding (removing dead tissue)
  • dressing the wound)
79
Q

key complication of lymphoedema?

A

infection

80
Q

describe lymphoedema

A
  • poor lymph drainage

- leads to protein-rich lymph surrounding the tissue

81
Q

give an example of a cause of secondary lymphoedema

A

breast Ca surgery to remove LNs

82
Q

differential for lymphoedema? how can these be told apart?

A
  • lipoedema

- feet are spared in lipoedema but not in lymphoedema

83
Q

what does a positive stemmer’s sign indicate?

A

lymphoedema

84
Q

how is stemmer’s sign demonstrated?

A
  • pinch the skin at the bottom of the second toe / middle finger
  • if you cannot “tent” the skin, there is lymphoedema
85
Q

assessment and investigations for lymphoedema?

A
  • check for stemmer’s sign
  • calculate limb volume
  • bioelectric impedance spectrometry
  • lymphoscintigraphy
86
Q

methods for calculating limb volume?

A
  • circumferential measurements
  • water displacement
  • perometry
87
Q

management of lymphoedema?

A
  • massage techniques (manual lymph drainage)
  • compression bandages
  • exercises for drainage
  • weight loss if overweight
  • good skin care
  • surgery
  • ABx if cellulitic
  • CBT, antidepressants for psychological impact
88
Q

what is the name of the surgical procedure that is used to treat lymphoedema?

A

lymphaticovenular anastomosis

89
Q

what is lymphatic filariasis?

A

parasitic infectious disease where worms live in lymphatic system

90
Q

how is lymphatic filariasis spread?

A

mosquitos carry the worms

91
Q

presentation of lymphatic filariasis?

A
  • thickened, fibrosed skin and tissue

- called “elephantiasis”

92
Q

globally where is lymphatic filariasis most common?

A

Africa and Asia

93
Q

what is an abdominal aortic aneurysm (AAA)?

A

when the abdominal aorta is dilated by > 3cm

94
Q

mortality rate of ruptured AAA?

A

80%

95
Q

risk factors for AAA?

A
  • male sex
  • ageing
  • smoking
  • HTN
  • FHx
  • existing CVD
96
Q

how is AAA screened for?

A

all men in England get an USS at age 65

97
Q

when should you consider screening women for AAA?

A

aged >70 and one of the following:

  • CVD
  • COPD
  • FHx
  • HTN
  • hyperlipidaemia
  • smoking
98
Q

what is the management of a pt found to have a dilated aorta on AAA screening?

A
  • if > 3cm: refer to vascular

- if > 5.5cm: refer URGENTLY

99
Q

presentation of AAA?

A
  • most pts are asymptomatic, picked up on screening / rupturing
  • non-specific abdo pain
  • pulsatile + expansile mass in abdo when palpated with both hands
  • incidentally found on abdo imaging
100
Q

which investigation is best to diagnose AAA?

A

USS

101
Q

imaging for AAA?

A
  • USS

- CT angiogram for more detail

102
Q

how are AAAs classified?

A
  • normal: < 3cm
  • small aneurysm: 3 - 4.4cm
  • medium aneurysm: 4.5 - 5.4cm
  • large aneurysm: > 5.5cm
103
Q

management of AAA?

A
  • treat reversible RFs
  • follow-up scans
  • elective surgical repair
  • DVLA advice
104
Q

how can reversible RFs be managed in AAA?

A
  • smoking cessation
  • healthy diet
  • exercise
  • optimise HTN / DM management
105
Q

how often are follow-up scans offered after AAA diagnosis?

A
  • if 3 - 4.4cm: annually
  • if 4.5 - 5.4cm: 3-monthly
  • if > 5.5cm: needs elective repair asap
106
Q

indications for elective repair of an AAA?

A
  • symptomatic
  • diameter growing by > 1cm per year
  • diameter > 5.5cm
107
Q

what surgical methods are used for AAA repair?

A
  • open repair, via laparotomy

- endovascular aneurysm repair (EVAR, uses stent via femoral arteries)

108
Q

DVLA guidance for AAAs?

A
  • inform DVLA if > 6cm
  • stop driving if > 6.5cm
  • even stricter if HGV / bus driver
109
Q

what determines the risk of rupture in AAA?

A
  • diameter of the aneurysm

- larger = more likely to rupture

110
Q

presentation of a ruptured AAA?

A
  • severe abdo pain
  • radiates to back / groin
  • shock (high HR, low BP)
  • pulsatile, expansile abdo mass
  • collapse
  • LOC
111
Q

management of ruptured AAA?

A
  • surgical emergency! let vascular + anaesthetists know asap
  • don’t delay surgery for imaging of any form
  • CT angio used to exclude ruptured AAA in pts who are stable
112
Q

pathophysiology of an aortic dissection?

A
  • blood flows between the intima and media layers of the aorta
  • creates a false lumen full of blood
113
Q

how can aortic dissections be classified?

A

stanford system:

  • type A: ascending
  • type B: descending

or debakey system (type I - IIIb)

114
Q

RFs for aortic disssection?

A
  • all the CVD RFs (e.g. smoking, male, poor diet etc)
  • HTN (MAJOR RF)
  • bicuspid aortic valve
  • coarctation of the aorta
  • aortic valve replacement
  • CABG
  • conn tissue disorders
115
Q

which 2 connective tissue disorders particularly increase the risk of aortic dissection?

A
  • ehlers-danlos syndrome

- marfan’s syndrome

116
Q

presentation of aortic dissection?

A
  • severe, tearing chest pain
  • radiates to back
  • migratory pain (moves over time)
  • HTN
  • BP different in each arm
  • radial pulse deficit
  • diastolic murmur
  • focal neuro signs
  • abdominal pain
  • collapse
  • hypotension (late)
117
Q

what is meant by a radial pulse deficit? which condition is this seen in?

A
  • radial pulse in one arm is decreased / absent

- it does not match the apex beat like it should

118
Q

how is aortic dissection diagnosed?

A

on CT angiogram

119
Q

management of aortic dissection?

A
  • surgical emergency
  • morphine for pain relief
  • BBs (to control HR and BP)
  • surgical intervention to insert a graft
120
Q

surgical management of a type A aortic dissection?

A
  • open surgery with midline sternotomy

- then insert a graft

121
Q

surgical management of a type B aortic dissection?

A
  • thoracic endovascular aortic repair (TEVAR)

- then insert a graft

122
Q

complications of aortic dissection?

A
  • MI
  • stroke
  • paraplegia
  • cardiac tamponade
  • aortic regurg (AR)
  • death
123
Q

first line investigation for CLI?

A

duplex USS

124
Q

at what level does the aorta bifurcate?

A

L3 - L4

125
Q

criteria for urgent repair of AAA?

A

if it is growing by >1 cm per year

126
Q

finding on CXR in aortic aneurysm?

A

widened mediastinum

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