Vascular Surgery Flashcards by Roma Bannon

What are the 6Ps of acute limb ischaemia

Pain, pallor, pulseless, paralysis, paraesthesia perishing cold

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What is Leriche Syndrome

Occlusion in the distal aorta or proximal common iliac artery

Thigh/ bum claudication
Absent femoral pulses
Male impotence

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What is Buerger’s test

Lie patient on back and life legs to 45 degrees at hip - hold 1-2 mins - pale = inadequate arterial supply

Berger’s angle - angle that leg goes pale

Sit patient up with legs hanging over bed - healthy patient- legs will go pink

PAD- Legs will be initially blue- ischaemic tissue deoxygenates blood
Then
Dark red - rubor

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What are the features of arterial leg ulcers

Small, deep, well defined, punched out, peripheral (on toes), reduced bleeding, painful, pale, pain worse at night or on elevating - helps to lower leg

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What are the features of venous ulcers

Happen after minor leg injury, larger than arterial, more superficial, irregular sloping boarders, affect mid calf to ankle, less painful, skin changes, pain worse on lowering leg

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What is a normal Ankle- brachial pressure index

0.9-1.3 - normal

Lower than 0.9= PAD

Above 1.3 = Calcification of arteries- diabetes

Ratio of Systolic BP in ankle compared with arm

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What is the treatment for intermittent claudication

Exercise training

Medical- Statins 80mg , clopidogrel 75mg , peripheral vasodilators

Surgical- endovascular angioplasty and stenting

Bypass surgery

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What is the management of critical limb ischaemia

Urgent revascularisation
Endovascular angioplasty and stenting
Endarterectomy
Bypass surgery
Amputation

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What is the management of acute limb ischaemia

caused by a thrombus

Endovascular thombolysis
Endovascular thombectomy
Surgical thrombectomy
Bypass
Endarterectomy
Amputation

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What are the main risk factors for a DVT

Immobility, surgery, long haul travel, pregnancy, Hormone therapy with oestrogen, malignancy, polycythaemia, SLE, thrombophilia

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What are the two types of VTE prophylaxis

LMWH- enoxaparin - contraindicated (active bleeding or existing anticoagulation with warfarin or DOAC)
Anti-embolic compression stockings

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How do you examine leg swelling

Circumference of the calf 10cm below tibial tuberosity more than 3cm difference between calves is signficiant

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What is used to diagnose a DVT

Doppler USS to diagnose

Repeat negative USS 6-8 days after if D-Dimer is positive and Well’s score suggests that DVT is likely

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What is used to diagnose a PE

CT pulmonary angiogram (preferred) or VQ scan

VQ scan in significant renal impairment

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What is the initial management of a DVT or PE

Treatment dose apixaban or rivaroxaban (10mg) - started immediately

Catheter directed thrombolysis in patients with iliofemoral DVT that symptoms last less than 14 days

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What long term anticoagulation is used in DVT/PE

DOACS- apixaban, rivaroxaban etc - most patients

Warfarin in patients with antiphospholipid syndrome
(APLS= weirdos- warfarin)

LMWH (enoxaparin) in pregnancy

Anticoag for
3 months if reversible cause
over 3 months in unclear cause, recurrent VTE or irreversible cause
3-6 months in active cancer

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What are the features of chronic venous insufficiency

Brown discolouration of legs- blood pools in distal veins causing haemosiderin to leak into legs and get deposited around shins

Venous eczema due to pooling of blood in distal tissues causing inflam

Lipodermatosclerosis- fibrotic tight skin causing lower legs to become hard

Atrophie blanche- smooth white scar tissue

Cellulitis, poor healing, skin ulcers, pain

What special tests are used for varicose veins

Tap test- pressure at saphenofemoral junction and tap distal varicose vein- thrill felt in SFJ suggests incompetent valve between these two points

Trendelenburg’s test- lie down and lift affected leg - apply tourniquet to thigh and stand up - if varicose veins appear then the valve is below the level of the tourniquet - keep moving tourniquet down

Duplex USS to assess extend of varicose vein

What is the management of varicose veins

Weight loss, physically active, keep leg elevated, compression stocking

Endothermal ablation
Scleropathy
Stripping

How is chronic venous insufficiency managed

Keep skin healthy- use emollients, topical steroids for venous eczema flares, potent steroids to treat lipodermatosclerosis

Keep active, compression stockings, keep legs elevated

Abs for infection
Analgesia
Wound care for ulcers

What is the management of an arterial ulcer

Urgent referral for surgical revascularisation

What is the management of venous ulcers

Good wound care
Cleaning, debridement, dressing

Compression therapy
Pentoxifylline to improve healing
Antibiotics to treat infection
Analgesia (not NSAIDs)

How is lymphoedema assessed

Stemmer’s sign- Pinch skin at bottom of middle finger - lymphoedema if you can’t lift and tent the skin

Limb volume - calculated by circumference, water displacement, perometry

BIA

Lymphoscintigraphy

What is the management of lymphoedema

Massage drainage techniques
Compression bandages
Weight loss
Good skin care

Lymphaticovenular anastomosis - attach lymph vessels to veins to help drainage

Don’t take bloods, cannulas or do BP in a limb with lymphoedema

What is lymphatic filariasis

Infectious disease caused by parasitic worms spread by mosquqitoes- worms live in lymphatic system and cause lymphoedema - Africa and Asia

How dilated does a triple A need to be and when are men screened

More than 3cm dilated USS at 65 to detect asymptomatic AAA

How is a AAA investigated and classified

USS urgent 1st line CT angiogram if have time Classification Normal - less than 3 Small- 3-4.4 Medium 4.5-5.4 Large 5.5 <

What is the management of a AAA

Treat modifiable risk factors Yearly follow up scans if 3-4.4cm 3mnthly scans if 4.5-5.4cm Elective repair if -Symptomatic, diameter growing more than 1cm per yr, diameter over 5.5 Open repair or Endovascular aneurysm repair with stent via femoral arteries Inform DVLA if Aneurysm over 6cm and stop driving if over 6.5cm

What is the treatment for a ruptured AAA

Surgical emergency - repair Permissive hypotension- aim for a lower blood pressure when giving fluid resus Only use CT angio to exclude this diagnosis in haemodynamically unstable patients

What are the features of aortic dissection

Tear in the inner layer of aorta Blood enters between intima and media layers creating a false lumen

What are the classifications for aortic dissection

Stanford system A- Ascending aorta before brachiocephalic artery b-Descending aorta after left subclavian

What are the risk factors for aortic dissection

HTN Weight lifting, cocaine- anythign that causes quick increase in BP Bicuspic aortic valve, coartation of aorta, CABG, aortic valve replacement - anything that affects the aorta Ehlers-Danlos Syndrome Marfans syndrome Think CT issues

What are the features of aortic dissection, how is it investigated

Ripping/ tearing chest pain HTN, differences in BP in arms , radial pulse deficit, diastolic murmur, focal neuro deficit, chest and abdo pain, syncope, hypotension as it progresses CT angiogram first line

What is the management of aortic dissection

Surgical emergency Analgesia BP and HR controlled on beta blockers - reduce stress on aorta Type a- open surgery to remove section and replace with synthetic graft Type b- Thoracic endovascular repair with a catheter in femoral vein

How is carotid artery stenosis investigated

Usually diagnosed after TIA or stroke- carotid USS Can do a CT or MRI angiogram to assess stenosis before surgical intervention Can hear carotid bruit on examination

What is the classification of carotid artery stenosis

Mild less than 50% reduction Moderate 50-69% reduction Severe 70% or more

How do you manage carotid artery stenosis

Lifestyle choices Anti-platelet meds - aspirin, clopidogrel, statins Surgical when significant Carotid endarterectomy <70% stenosis - first line and scapes out plaques- risk of stroke with this and nerve damage- facial nerve palsies etc Angioplasty and stenting

What are the features of Buerger disease

Inflam condition causing thrombus formation in small and medium vessels in hands and feet Men aged 25-35 and associated with smoking Features Men under 50 No risk factors for atherosclerosis except smoking

How does buerger's disease present

Painful, blue discolouration of fingertips and toes, worse at night, ulcers, gangrene Corkscrew collaterals found on angiograms - collateral vessels form to bypass affected arteries

How is Buerger's disease managed

Stopping smoking completely- no nicotine replacements IV iloprost to dilate blood vessels

What is the difference between acute limb ischaemia and critical limb ischaemia

Critical limb ischaemia- end stage PAD- inadequate blood supply to sustain limb- pain worse at night- risk of loosing limb Acute limb ischaemia- rapid onset ischaemia caused by a clot

What are some types of thrombophillias and what is a thrombophilia

Thrombophilia- predisposition to clotting Factor V leiden- most common Antiphospholipid Antithrombin deficiency Portein C/ S deficiency