Vascular Surgery Flashcards
ABI values
> 1.4: Calcification –> Refer
1-1.4: Normal
0.9-1: Acceptable
0.8-0.9: Mild Arterial disease –> treat risk factors
0.5-0.8: Moderate Arterial disease –>
- Treat risk factors
- Refer if signs of gangrene or pain on rest.
< 0.5: Severe –> Refer
Heparin ischaemia monitoring
Activated partial thromboplastin time (aPTT)
Maintain 1.5 to 2.5xs the baseline value (21 to 35 seconds)
Warfarin ischaemia monitoring
INR
Abdominal aortic aneurysm (AAA) symptoms
Triad:
1. abdominal and/or back pain
2. pulsatile abdominal mass
3. hypotension
Abdominal aortic aneurysm (AAA) screening
- family history 20%
- >50 years US
Abdominal aortic aneurysm (AAA) mortality rate
- 80%
Abdominal aortic aneurysm (AAA) surgical intervention
- Males > 5.5cm
- Females > 5cm
- Rapid growth > 1cm yearly
- Symptomatic (abdominal/back pain, tenderness, distal embolization)
Abdominal aortic aneurysm (AAA) investigation
- >50 years fast US
- CT angiogram (before elective surgical repair)
Abdominal aortic aneurysm (AAA) size screening
3-3.9cm = 2 yearly US
4-4.5cm = 1 yearly US
4.6-5cm = 6m US
> 5cm = 3m US
> 5.5cm (male) = surgical intervention
Aortic dissection/aneurysm vs myocardial infarction
Check if patient stable
if stable:
Initial: ECG
Best: CT angio
If unstable: fast US
Aortic dissection (AD) confirmation investigation
CT angio
Pseudoaneurysm management
Ultrasound-guided thrombin injection
Pseudoaneurysm complication
femoral artery catheterization 7.5%
Acute limb ischemia most common cause
Thrombosis
- lower limbs 80%
Acute limb ischemia symptoms
1, Paralysis
2. Paraesthesia
3. Pulselessness
4. Pain
5. pallor
6. Poikilothermia
Acute limb ischemia investigation
- Measure ABI
- CT angiogram (gold standard) for surgical
intervention
Acute limb ischemia requiring surgical treatment
- Paralysis
- Paraesthesia
- Rest pain
Acute limb ischemia LMWH vs UFH
- Preceding surgery/renal impairment: UFH
- Medical Mangement only: LMWH (enoxaparin)
Acute limb ischemia treatment
embolectomy
Acute limb ischemia reperfusion injury features
– Acute renal failure
– Hyperkalaemia.
– Myoglobinemia.
– Metabolic acidosis.
– CK elevation
Chronic limb ischemia diagnostic symptoms
-Shiny, hyperpigmented skin.
-Hair loss and ulceration on the legs
-Thickened nails.
-Muscle atrophy.
-Vascular bruits.
-Poor pulses are the hallmark of the chronic obstructive arterial disease
Chronic limb ischemia symptoms that require surgical intervention
– Rest Pain
– Ischemic ulceration
– Gangrene
– Claudication symptoms limiting day to life & work, no improvement
with risk factor modifications, exercises, medical management > 6 months
Peripheral arterial disease (PAD) manifestation of
atherosclerosis
Peripheral arterial disease (PAD) affects ____ of general population
10–15%
How many px with PAD are asymptomatic
approximately 50%
- worse prognosis if symptomatic
Peripheral arterial disease (PAD) symptoms
- calf muscle intermittent claudication (IC) 10%
Peripheral arterial disease (PAD) complications
- AAA 10%
- Popliteal aneurysm (prominent popliteal pulses)
- diabetic foot ulcers
Peripheral arterial disease (PAD) investigation
- Initial: ABI
-
US doppler
-CT angio if aneurysm suspected
Peripheral arterial disease (PAD) management
< 0.9:
-Anti-cholesterol (even in absence of dyslipidaemia)
- Antihypertensives: ACEI or ARBs
- Statins
- Supervised exercise program
NOTE:
-Antiplatelets: aspirin or clopidogrel ONLY is evident cardiovascular disease
- avoid beta-blockers unless for cardio protection
Peripheral arterial disease (PAD) conservative management failed
Revascularization by:
– Endovascular angioplasty or stenting
– Open surgical reconstruction by bypass or endarterectomy
Thrombophlebitis complications
- DVT
- PE
Thrombophlebitis management
- LMWH (spontaneous superficial) 4 weeks
- NSAIDs (superficial)
Varicose veins investigation
Venous duplex ultrasound (gold standard)
Varicose veins referral indications
CEAP > 3
- thrombophlebitis
- chronic venous insufficiency
- Venous ulcer
- Venous eczema
- bleeding
- severe discomfort
Chronic venous ulcers management
compression stockings
Compression sticking contraindications
- ABI < 0.8
- cardiac, renal or liver failure
- cellulitis
- acute DVT
Internal carotid artery stenosis divided into
Asymptomatic
Symptomatic
Asymptomatic internal carotid artery stenosis
< 80% - yearly follow up with CDUS
> 80% = refer
Symptomatic internal carotid artery stenosis
Stroke or TIA
< 49%: medical therapy with antiplatelets + follow up
> 50%: surgery (1-2 weeks after event) + medical therapy
Carotid artery stenosis stroke prevention surgery
Carotid endarterectomy
Fibromuscular dysplasia renal artery stenosis management
Renal artery angioplasty
Atherosclerotic renal artery stenosis management
- unilateral:
ACE inhibitors and ARBs to reach goal blood pressure - if goal blood pressure not reached:
- thiazide diuretic (chlorthalidone or indapamide)
- calcium channel blocker
- mineralocorticoid receptor antagonist
- beta
blocker
Deep Vein Thrombosis (DVT) risk factors
– > 60 years
– Obesity especially BMI > 40
– Smoking
– Prolonged immobilisation due to surgery (total knee replacement)
– Pregnancy
– HRT or OCP
– Malignant diseases
– Congestive cardiac failure
– Inflammatory bowel disease (Crohn’s and ulcerative colitis)
Deep Vein Thrombosis (DVT) investigation
Doppler venous ultrasound
Deep Vein Thrombosis (DVT) prophylaxis
- Enoxaparin 24-48 hours
- Warfarin after 24-48 hours
Thromboembolism risk factors before surgery
- Cardiac failure (VTE)
- acute bowel inflammation
Pulmonary Embolism (PE) symptoms
- Hx of long flight, pregnancy
- acute shortness of breath
- sinus tachycardia
Pulmonary Embolism (PE) investigation
CTPA (radiation risk in pregnancy)
- V/Q (normal chest X-ray), pregancy
Inferior vena cava filter
placement
- Absolute contraindication to therapeutic anticoagulation.
- Failure of anticoagulation when there is acute proximal venous thrombosis (failure to maintain INR)
