Vascular Surgery Flashcards
What is the investigation of choice for varicose veins/chronic venous disease? What would it show?
venous duplex ultrasound
could show retrograde venous flow in varicose veins/chronic venous disease
Conservative management of varicose veins
leg elevation
weight loss
regular exercise
graduated compression stockings
Reasons for referring someone with varicose veins to secondary care
- significant/troublesome lower limb symptoms (pain, discomfort, swelling)
- previous bleeding from varicose veins
- skin changes secondary to chronic venous insufficiency (e.g. pigmentation/eczema)
- superficial thrombophlebitis
- an active or healed venous leg ulcer
What are the treatment options for varicose veins?
- endothermal ablation (either radiofrequency ablation or endovenous laser treatment)
- foam sclerotherapy (irritant foam, chemical reaction -? inflammatory response -> closure of vein)
- surgery (either ligation or stripping)
How can you differentiate arterial and venous ulcers?
Arterial:
- small
- well defined
- deep
- pale, dry, cracked skin
- painful
- typical locations include toe and heel
- associated with weak/absent pulses
Venous:
- typically larger
- shallower
- painless
- usually on lower aspect of the legs
- might also see haemosiderin deposition on the legs
Vascular examination componenes
- Introduce, details, consent, wash hands
- observation from end of the bed (make sure patient is exposed, e.g. take socks off)
- closer inspection (incl. look at the entire legs, look between the toes, look in the popliteal fossa, look at the back of the legs, look under the heel for ulcers)
- (offer to) feel aorta, listen for bruits
- Feel pulses (femoral, popliteal, dorsalis pedis, posterior tibial) - do them at the same time on both sides except popliteal, where you need both hands)
- quick neuro assessment (sensation to light touch, ask them to wiggle toes)
If you don’t feel a pulse - say it
What is the screening programme for AAA in the UK?
males >60 are invited for an abdominal USS
AAA is less common in females, so they are not screened
people with a FH of aneurysms are also screened
What is the ix of choice in suspected ruptured AAA in an unstable and stable patient?
stable: CT angio
unstable: refer to vascular surgery and do a bedside USS
How frequently do you monitor an AAA?
depends on the size
<4.5 cm: 12-monthly
4.5-5.4 cm: 3-monthly
if >5.4 cm you should urgently refer to vascular surgery as there is a high risk of rupture and so should be referred urgently for endovascular or open repair.
What would you classify as a rapidly enlarging AAA?
> 0.5 cm/6 months
or
1 cm/year
-> these patients need urgent endovascular repair (even if asymptomatic)
What are the signs of acute limb ischaemia?
6 Ps
pale
pain
paraesthesia
paralysis
pulseless
perishingly cold
What is the management of acute limb ischaemia?
ABCDE approach
analgesia (IV opioids are often used)
IV unfractionated heparin (to prevent thrombus propagation, especially if patient is not suitable for immediate surgery)
vascular review
what medications should patients with peripheral arterial disease be taking?
statin
clopidogrel
management of a venous ulcer
compression stockings
Signs of venous vs arterial ulcers
What is the difference between acute limb ischaemia and critical limb ischaemia?
critical is a progression of chronic limb ischaemia with intermittent claudication
-> build up over time
acute is usually embolic
sudden onset
Management of chronic limb ischaemia
Managed by GP
lifestyle modification
..
RFs for chronic limb ischeamia
atherosclerosis
diabetes
HTN
AF
smoking
hypercoaguability
recent surgery/fracture
previous DVT
TIA
mx of chronic limb ischaemia
clopidogrel
statin
lifestyle advice (exercise, making cessation)
Surgical:
- angioplasty
+/- stent insertion
- bypass graft
- endartectomy (=embolectomy)
amputation is a last result
Acute management of acute limb ischaemia
- give IV unfractionated heparin
(because it can be reversed quickly when they go to theatre but we need to make sure that it doesn’t get worse)
then IR/theatre
Monitoring clotting which factor fastest?
Factor Xa
What is the reversal agent for unfractionated heparin
t
at what age does the AAA screening programme in the UK start?
65
(single USS in males)
what is superficial thrombophlebitis?
inflammation associated with thrombosis of one of the superficial veins, usually the long saphenous vein of the leg
What is the management according to NICE guidelines of superficial thrombophlebitis?
Patients with clinical signs of superficial thrombophlebitis affecting the proximal long saphenous vein should have an ultrasound scan to exclude concurrent DVT.
Patients with superficial thrombophlebitis should have anti-embolism stockings and can be considered for treatment with prophylactic doses of LMWH for up to 30 days or fondaparinux for 45 days.
If LMWH is contraindicated, 8-12 days of oral NSAIDS should be offered.
Patients with superficial thrombophlebitis at, or extending towards, the sapheno-femoral junction can be considered for therapeutic anticoagulation for 6-12 weeks.
prevalence of AAA >5.5 in screening patients
Only found in 1 per 1,000 screened patients
surgical procedure name for AAA mx
elective endovascular repair (EVAR)
or open repair if unsuitable.
What is Buerger’s test?
a test to assess the adequacy of the arterial supply to the leg
- With the patient positioned supine, stand at the bottom of the bed and raise both of the patient’s feet to 45º for 1-2 minutes.
- Observe the colour of the limbs, if they become pale, note at which angle this occurs e.g. 25 degrees (Buerger’s angle). in a healthy individual the leg should stay pink, even at a 90 degrees)
- Sit the patient up and ask them to hang their legs down over the side of the bed (gravity should aid reperfusion)
RFs for vascular dissesase
HTN
DM
hypercholesterolaemia
smoking
also:
old age
male sex
renal disease
FH
Intermittent claudication pain location
calves
can also be in thighs and buttocks
(gripping, burning, tightening, cramping pain)
What are severe ABMI readings?
<0.5 severe disease
<0.3 critical limb ischaemiaa
