Vascular Surgery Flashcards
how can peripheral arterial disease (PAD) present?
- intermittent claudication
- critical limb ischaemia
- acute limb ischaemia
describe intermittent claudication. which areas are typically affected by this?
- limb pain which comes on with exertion and goes away at rest
- can cause fatigue on speedwalking
- calves
- thighs
- buttocks
describe the nature of the pain felt in intermittent claudication
- crampy
- achey
describe critical limb ischaemia (CLI)
- the end stage of PAD
- pain in limb at rest
features of CLI?
- pain
- pallor
- pulseless
- paralysis
- paraesthesia
- perishingly cold
- non-healing ulcers
- gangrene
describe the pain felt in CLI
- burning sensation
- present at rest
- worse at night (leg is raised)
triad of leriche syndrome?
- thigh/buttock claudication
- absent femoral pulses
- male impotence
what causes leriche syndrome?
occlusion of distal aorta / common iliac artery
describe buerger’s test
- 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
what is buerger’s angle?
the angle at which the leg becomes pale
in a healthy pt, what happens at the end of buerger’s test?
legs remain pink
in a pt with PAD, what happens at the end of buerger’s test?
- initially legs turn blue
- then go dark red (rubor)
describe an arterial ulcer
- small, deep “punched out” lesion
- well-defined borders
- typically on toes
- no bleeding
- painful
describe a venous ulcer
- large
- superficial
- irregular borders
- typically on gaiter region
- less painful
where is the gaiter region?
mid-calf down to ankle
investigations for PAD?
- ABPI
- duplex USS
- angiography (CT or MRI)
what is the normal range for ABPI?
0.9 - 1.3
what would an ABPI of < 0.3 indicate?
CLI
what could an ABPI of > 1.3 indicate? who is this more common in?
- arterial calcification
- diabetics
management of intermittent claudication?
- stop smoking
- optimise comorbidities (HTN, DM)
- exercise training
- drugs
- surgery
drugs offered in intermittent claudication?
- atorvastatin 80mg
- clopidogrel 75mg OD (alt: aspirin)
- naftidrofuryl oxalate
surgical options for intermittent claudication?
- endovascular angioplasty and stenting
- endarterectomy
- bypass surgery
- amputation
management of acute limb ischaemia?
vascular emergency:
- endovascular thrombolysis
- thrombectomy
- endarterectomy
- bypass surgery
- amputation
how could a venous thrombus cause a stroke?
- breaks off to form an embolus
- in someone with an ASD, travels across the heart into systemic circulation
- travels up to brain
risk factors for VTE?
- immobility
- recent surgery
- long haul flights
- pregnancy
- COCP, HRT containing oestrogen
- malignancy
- polycythaemia
- SLE
- thrombophilia
what is a thrombophilia? give some examples
a condition that predisposes you to forming clots
- antiphospholipid syndrome
- factor V lieden
- protein C / S deficiency
which pts are offered VTE prophylaxis? what are they offered?
- anyone with moderate / high risk of a clot
- LMWH (e.g. enoxaparin)
- anti-embolic stockings (IPCDs)
contraindications to LMWH?
- active bleeding
- pre-existing anticoagulation with warfarin / DOAC
key contraindication for anti-embolic compression stockings?
peripheral arterial disease (PAD)
presentation of a DVT?
- unilateral calf / leg swelling
- dilated superficial veins
- calf tenderness
- oedema
- colour changes of leg
how is leg swelling measured in suspected DVT? what is significant?
- measure calf circumference 10cm below tibial tuberosity
- > 3cm is significant
which scoring system is used to calculate the risk of the pt having a DVT / PE?
wells score
is D-dimer sensitive or specific for VTE? what does this mean?
- sensitive but not specific
- good at excluding VTE
- but can be raised for other reasons
causes of a raised D-dimer?
- pneumonia
- malignancy
- HF
- surgery
- pregnancy
how is DVT diagnosed?
doppler USS
what should you do if doppler USS is negative but wells score and D-dimer both suggest DVT?
repeat the doppler in 6-8 days
how is pulmonary embolism (PE) diagnosed?
either CTPA or ventilation-perfusion (VQ) scan
when would a VQ scan be done instead of CTPA for a pt with a suspected PE?
- significant renal impairment
- contrast allergy
initial management for suspected / confirmed DVT / PE?
- DOAC (apixaban, rivaroxaban)
- start immediately, don’t delay for scans
what management can be considered for a iliofemoral DVT?
catheter-directed thrombolysis
drug options for long-term anticoagulation in VTE?
- DOAC
- warfarin
- LMWH
first line anticoagulation in VTE in pregnancy?
LMWH (dalteparin)
how long should anticoagulation be continued for in VTE:
i) with a reversible cause?
ii) with an unclear cause?
iii) active cancer?
i) 3 months
ii) beyond 3 months
iii) 3-6 months, then review
which pts can be offered an inferior vena cava filter? what is this?
- pts with recurrent PEs
- acts like a sieve and catches all the clots
why is it important to investigate an unprovoked DVT?
it may indicate an underlying malignancy
how is an unprovoked DVT investigated?
- CT TAP (for Ca)
- anti-phospholipid antibodies (for APS)
- screen for thrombophilias
what is a varicose vein? how big are they?
- distended superficial vein
- typically on legs
- > 3mm in diameter
what is a reticular vein? how big are they?
dilated blood vessels in the skin, measuring 1 - 3mm
how big are telangiectasia?
< 1mm in diameter (tiny!)
pathophysiology of varicose veins?
- vein valves become incompetent
- blood flow back to the heart is disrupted
- blood pools in the veins
what is chronic venous insufficiency?
- blood that has pooled up in the veins leaks out into surrounding tissue
what causes the brown discolouration of skin in chronic venous insufficiency?
Hb being broken down
what is venous eczema? what causes this?
- dry inflamed skin over the veins
- secondary to chronic venous insufficiency
skin changes seen in chronic venous insufficiency?
- brown discolouration
- venous eczema
- lipodermatosclerosis
RFs for varicose veins?
- ageing
- FHx
- female sex
- pregnancy
- obesity
- prolonged standing
- DVT (causes valve damage)
presentation of varicose veins?
- engorged, dilated superficial leg veins
- heavy / dragging sensation in legs
- aching
- itching
- burning
- oedema
- muscle cramps
- restless legs
special tests to check for varicose veins?
- tap test
- cough test
- trendelenberg’s test
- perthes test
imaging for varicose veins?
duplex USS
management of varicose veins?
- 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
surgical management options for varicose veins?
- endothermal ablation
- sclerotherapy
- stripping
complications of varicose veins?
- prolonged / heavy bleeding after trauma
- superficial thrombophlebitis
- DVT
- chronic venous insufficiency changes
which area of the body is most likely to be affected by chronic venous insufficiency?
gaiter area (mid-calf down to ankle)
features of chronic venous insufficiency?
- haemosiderin staining
- venous eczema
- lipodermatosclerosis
- atrophie blanche
- cellulitis
- poor healing after trauma
- skin ulcers
- pain
management of chronic venous insufficiency?
- keeping skin healthy
- emollients
- weight loss
- keeping active
- elevating legs when resting
- compression stockings
- TOP steroids for venous eczema
- stronger TOP steroids for lipodermatosclerosis
what is lipodermatosclerosis? which condition is it seen in?
- hardening / tightening of skin over veins
- chronic venous insufficiency
how are the complications of chronic venous insufficiency managed?
- ABx for infection
- analgesia for pain
- wound car for ulcers
what are the 4 types of leg ulcer?
- venous
- arterial
- diabetic foot
- pressure
why do arterial ulcers form?
- poor arterial blood supply to the skin
- typically secondary to PAD
why do venous ulcers form?
- pooling of venous blood and waste products
- typically secondary to chronic venous insufficiency
which condition increases the risk of diabetic foot ulcers?
diabetic neuropathy
key complication of diabetic foot ulcers?
osteomyelitis
how can an individual’s risk of pressure ulcers be worked out?
using the waterlow score
features of an arterial ulcer?
- 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
features of a venous ulcer?
- 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
investigations for leg ulcers?
- ABPI
- bloods (FBC, CRP)
- charcoal swabs
- skin biopsy (r/o Ca)
management of arterial ulcers?
- urgent referral to vasc surg for revascularisation
- should heal when underlying PAD is treated
management of venous ulcers?
- vasc surg if arterial / mixed ulcers suspected
- pain clinic / derm/ diabetic ulcer services
- good wound care
- compression therapy
- PO pentoxifylline
- ABx
- analgesia (NOT NSAIDs)
what does good wound care entail?
- cleaning the wound
- debriding (removing dead tissue)
- dressing the wound)
key complication of lymphoedema?
infection
describe lymphoedema
- poor lymph drainage
- leads to protein-rich lymph surrounding the tissue
give an example of a cause of secondary lymphoedema
breast Ca surgery to remove LNs
differential for lymphoedema? how can these be told apart?
- lipoedema
- feet are spared in lipoedema but not in lymphoedema
what does a positive stemmer’s sign indicate?
lymphoedema
how is stemmer’s sign demonstrated?
- pinch the skin at the bottom of the second toe / middle finger
- if you cannot “tent” the skin, there is lymphoedema
assessment and investigations for lymphoedema?
- check for stemmer’s sign
- calculate limb volume
- bioelectric impedance spectrometry
- lymphoscintigraphy
methods for calculating limb volume?
- circumferential measurements
- water displacement
- perometry
management of lymphoedema?
- 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
what is the name of the surgical procedure that is used to treat lymphoedema?
lymphaticovenular anastomosis
what is lymphatic filariasis?
parasitic infectious disease where worms live in lymphatic system
how is lymphatic filariasis spread?
mosquitos carry the worms
presentation of lymphatic filariasis?
- thickened, fibrosed skin and tissue
- called “elephantiasis”
globally where is lymphatic filariasis most common?
Africa and Asia
what is an abdominal aortic aneurysm (AAA)?
when the abdominal aorta is dilated by > 3cm
mortality rate of ruptured AAA?
80%
risk factors for AAA?
- male sex
- ageing
- smoking
- HTN
- FHx
- existing CVD
how is AAA screened for?
all men in England get an USS at age 65
when should you consider screening women for AAA?
aged >70 and one of the following:
- CVD
- COPD
- FHx
- HTN
- hyperlipidaemia
- smoking
what is the management of a pt found to have a dilated aorta on AAA screening?
- if > 3cm: refer to vascular
- if > 5.5cm: refer URGENTLY
presentation of AAA?
- 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
which investigation is best to diagnose AAA?
USS
imaging for AAA?
- USS
- CT angiogram for more detail
how are AAAs classified?
- normal: < 3cm
- small aneurysm: 3 - 4.4cm
- medium aneurysm: 4.5 - 5.4cm
- large aneurysm: > 5.5cm
management of AAA?
- treat reversible RFs
- follow-up scans
- elective surgical repair
- DVLA advice
how can reversible RFs be managed in AAA?
- smoking cessation
- healthy diet
- exercise
- optimise HTN / DM management
how often are follow-up scans offered after AAA diagnosis?
- if 3 - 4.4cm: annually
- if 4.5 - 5.4cm: 3-monthly
- if > 5.5cm: needs elective repair asap
indications for elective repair of an AAA?
- symptomatic
- diameter growing by > 1cm per year
- diameter > 5.5cm
what surgical methods are used for AAA repair?
- open repair, via laparotomy
- endovascular aneurysm repair (EVAR, uses stent via femoral arteries)
DVLA guidance for AAAs?
- inform DVLA if > 6cm
- stop driving if > 6.5cm
- even stricter if HGV / bus driver
what determines the risk of rupture in AAA?
- diameter of the aneurysm
- larger = more likely to rupture
presentation of a ruptured AAA?
- severe abdo pain
- radiates to back / groin
- shock (high HR, low BP)
- pulsatile, expansile abdo mass
- collapse
- LOC
management of ruptured AAA?
- 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
pathophysiology of an aortic dissection?
- blood flows between the intima and media layers of the aorta
- creates a false lumen full of blood
how can aortic dissections be classified?
stanford system:
- type A: ascending
- type B: descending
or debakey system (type I - IIIb)
RFs for aortic disssection?
- 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
which 2 connective tissue disorders particularly increase the risk of aortic dissection?
- ehlers-danlos syndrome
- marfan’s syndrome
presentation of aortic dissection?
- 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)
what is meant by a radial pulse deficit? which condition is this seen in?
- radial pulse in one arm is decreased / absent
- it does not match the apex beat like it should
how is aortic dissection diagnosed?
on CT angiogram
management of aortic dissection?
- surgical emergency
- morphine for pain relief
- BBs (to control HR and BP)
- surgical intervention to insert a graft
surgical management of a type A aortic dissection?
- open surgery with midline sternotomy
- then insert a graft
surgical management of a type B aortic dissection?
- thoracic endovascular aortic repair (TEVAR)
- then insert a graft
complications of aortic dissection?
- MI
- stroke
- paraplegia
- cardiac tamponade
- aortic regurg (AR)
- death
first line investigation for CLI?
duplex USS
at what level does the aorta bifurcate?
L3 - L4
criteria for urgent repair of AAA?
if it is growing by >1 cm per year
finding on CXR in aortic aneurysm?
widened mediastinum
