vascular surgery Flashcards
cause of peripheral arterial disease
the narrowing of the arteries supplying thelimbs, reducing blood supply to these areas
sx intermittent claudication
crampy, achy pain in calf/thigh/buttock
associated with muscle fatigue on exertion
relieved by rest
critical limb ischaemia
inadequate blood supply to allow normal function at rest
sx critical limb ischaemia
burning pain- worse at night
pain
pallor
pulselessness
paralysis
paraesthesia
perishing cold
acute limb ischaemia cause
rapid onset usually due to thrombus
gangrene
death of tissue due to inadequate blood supply
cause atherosclerossi
chronic inflammation and activation immune system
lipids deposited-> fibrous atheromatous plaques ->stiffened walls =HTN and strain on heart, stenosis=reduced flow, plaque rupture=thrombus causing ischaemia
RF atherosclerossi
non-modifiable: age, fhx, m
modifiable: smoking, alcohol, sugar, trans fats, sedentary, obesity, poor sleep, stress
conditions: DM, HTN, CKD, RA, atypical antipsychotics
end results atherosclerosis
angina
MI
TIA/stroke
periphral arterial disease
chronic mesenteric ischaemia
leriche syndrome
occlusion of distal aorta or proximal common iliac artery
sx leriche syndrome
thigh/buttock claudication
absent femoral pulses
male impotence
signs arterial disease
skin pallor
cyanosis
dependent rubor
muscle wasting
hair loss
ulcers
poor wound healing
gangrene
reduced skin temp
reduced senssation
increased CRT
buerger changes
buergers test
for PAD
1. lift legs to 45 degrees and hold 1-2m
pallor=inadequate blood supply
buergers angle=angle at which leg is pale
2. hang legs over bed sitting up. in PAD go blue then dark red (rubor)
cause arterial ulcers
due to ischaemia secondary to inadequate blood supply
features arterial ulcers
small
deep
well defined
borders
punched out
peripheral - toes
less bleeding
pain
cause venous ulcers
impaired drainage and blood pooling
features venous ulcers
after minor injury
large
superficial
irregular sloping borders
gaiter area
less painful
ix PAD
ABPI : less than 0.9 in PAD
duplex USS
angiography
ABPI
systolic BP ankle : arm
mx intermitten claudication
lifestyle
exercise
meds: atorvastatin, clopidogrel, naftidofuryl oxalate (5HT2 receptor antagonist=vasodilation)
surgery: endovascular angioplasty and stent, endarterectomy, bypass
mx critical limb ischaemia
vascular surgery to revascularise or amputate
mx acute limb ischaemi
endovascular thrombolysis
endovascular thrombectomy
endarterectomy
bypass
amputation
RF VTE
immobility
recent surgery
long haul travel
pregnancy
oestrogen: HRT and COCP
malignany
polycythaemia
SLE
thrombophilia (antiphospholipid)
VTE prophylaxis
LMWH - enoxaparin
compression stockings (not in PAD)
sx DVT
unilateral calf swelling circumference 10cm below tibial tuberosity is >3cm bigger than other leg
dilated superficial veins
tender calf
oedema
colour changes
ix DVT
wells score
d-dimer
doppler USS
mx DVT
apixaban or rivaroxaban
long term antocoag with DOAC: 3m if reversible cause, 3-6m in cancer, 6, if cause unclear
causes raised d-dimer
VTE
pneumonia
malignancy
HF
surgery
pregnancy
ix unprovoked DVT
baseline bloods
examine for cancer
test for antiphospholipid and hereditary thrombophilias
varicose veins
distended superficial veins >3mm due to icompetent valves
reticular veins
dilated blood vessels in skin 1-3mm
why does chronic venous insufficiency cause skin sx
bloos pools and leaks ->brown discolouration due to haemosiderin, venous eczema, lipodermatosclerosis (fibrotic and tight skin)
RF varicose veins
fhx
F
pregnant
obese
prolonged standing
DVT
sx varicose veins
engorged and dilated
dragging
aching
itching
burning
oedema
muscle cramps
restless legs
tests for chronic venous insufficeincy
tap test
cough test
trendelenburgs
perthes
tap test
pressure on SFJ and tap vein = thrill in chronic venous insufficiency
cough test
pressure on SFJ and cough = thrill in chronic venous insufficiency
trendelenburgs test
lie down
lift leg and drain
tourniquet
stand up
prevents varicose veins reappearing if distal to incompetence
perthes test
tourniquet to thigh and do calf raises
superficial veins disappear means deep veins are functioning
ix chronic venous insufficeincy
duplex USS
mx varicose veins
wt loss
exercise
elevate leg
compression stocking
surgery e.g. endothermal ablation
complication varicose veins
heavy bleeding
superficial thrombophlebitis
DVT
chronic venous insufficiency=ulcers
cause diabetic ulcers
diabetic neuropathy -> injury -> poor healing due to high glucose and neuropathy
complication diabetic ulcers
osteomyeltiis
cause pressure ulcers
immobility-> reduced blood supply and drainage -> skin breaks down
score for pressure ulcers
waterlow
ix ulcers
ABPI
bloods: FBC, CRP, HbA1c, anaemia
charcol swab
biopsy for SCC
mx arterial ulcers
manage PAD
dont debride or compress
mx venous ulcers
clean, debride, dress
compression
pentoxifylline
abx
+/- surgery
lymphoedema
impaired lymphatic drainage
types lymphodema
primary: genetic (presents <30y)
secondary: other conditions, often after axillary node clearance
lipoedema
build up of fat, feet are spares
ix lymphodema
stemmers sign: positive is cant tent skin on 2nd toe/middle finger
limb vol: circumference, water displacemenr
biolectric impedence spectrometry
lymphoscintigraphy: radioactive tracer
mx lymphoedema
massage
compression bandages
skin care
lymphaticovenular anastomosis
lymphatic filanasis cause
=elephantiasis
parasitic worms spread by mosquitos leading to lymphodema and thickening and fibrosis of skin
AAA sizing
smal = 3-4.4cm
med=4.5-5.4cm
large= >5.5cm
RF AAA
M
age
smoking
HTN
Fhx
CVD
screening AAA
all M USS 65y
F at 70y if have RF
presentation AAA
asx
abdi pain
pulsatile mass
sx ruptured AAA
sev abdo pain radiating to back
haemodynamic instability
collapse
LOC
ix AAA
USS
CT angiogram
mx AAA
lifestyle
USS yearly if 3-4.4 cm or 3m if >4.5cm
repair if sx, growing >1cm/yr
cant drive if >6.5cm
rupture=surgical emergency
aortic dissection
tear in aorta-blood enters between intima and media forming a false lumen
stanford classification aortic dissection
A=ascending aorta before brachiocephalic artery
B=descending aorta after L subclavian artery
DeBakey classification aortic dissection
- ascendinf aorta and arch
II. just ascending aoirta
IIIa. descending aorta above diaphragm
IIIb. descending aoirta below diaphragm
RF aortic dissection
HTN
M
smoking
high cholesterol
CABG
bicuspid aortic valve
ehlers danlos
marfans
triggers aortic dissection
wt lifting
cocaine
sx aortic dissection
ripping chest pain that migrates
HTN
BP difference between arms (>20)
radial pulse deficit
diastolic murmur
syncope
focal neuro deficit
ix aortic dissection
ECG
CXR
CT or MRI angiogram
mx aortic dissection
surgical emergency
morphine
BB
complications aortic dissection
MI
stroke
paraplegia
cardiac tamponade
aortic valve regurg
death
carotid artery stenosis severity
mild <50%
mod 50-69%
sev >70%
diagnosis carotid artery stenosis
usually after TIA
USS
CT or MRI angiogram
findings O/E carotid artery stenossi
carotid bruit
mx carotid artery stenossis
lifestyle
aspirin
atorvastatin
carotid endarterectomy
angioplasty and stent
risks carotid endarterectomy
stroke
nerve injury
buerger disease
=thromboangiitis obliterans
inflammatory condition in small and medium sized vessels causing thrombus formation
RF buergers disease
25-35y
M
smoking
sx Buergers disease
blue fingers and toes
pain at night
ix buergers disease
angiogram=corkscrew collaterals
mx buergers disease
stop smoking
IV iloprost (dilates vessel)
