Vascular Surgery

Question 1

Thrombosis is

Answer 1

Perf used using alteplase

Adverse events
Minor hemorrhage from catheter site in 40%
CVA in 1-2%
Distal trashing in 4%
Re-perfusion injury in 2%

Contraindications
Total limb anaesthesia
Mottling
Paralysis
Swollen or tense muscle

Question 2

How do cervical ribs occur

Answer 2

Cervical ribs occur as a result of the elongation of the transverse process of the 7th cervical vertebra. It is usually a fibrous band that attaches to the first thoracic rib.

Question 3

Vascular graft infection

Answer 3

Over 50% of vascular prosthetic infections are associated with staphylococcus. In the majority of cases methicillin resistance is present. It is interesting to note that much of the data relating to this topic is becoming a little dated and with the decline in MRSA in UK hospitals in the past few years it will be interesting to see whether this demographic changes. *

Question 4

5 year patency of grafts

Answer 4

5 year patency rates with vein = 66%
5 yelf patency rates with PTFE = 47% (above knee)

Question 5

Failure of hyper hydros is surgery

Answer 5

The nerve of Kuntz, a connection from the second intercostal nerve to the first thoracic ventral ramus is a potential cause of failure of the procedure and can result in persistence of symptoms even though the T2 ganglion is divided

Surgical sympathectomy may be beneficial in resistant cases. Division of the T1 ganglia for facial symptoms, T2 and T3 for palmar, T4 for axillary disease

Question 6

Minium length of bone left for below knee amputation

Answer 6

10cm is the minimum, if removing less than this then consider complete removal of the fibula

Question 7

In the MRC trial what was the over all stroke rate in those who underwent surgery in past 5 years

Answer 7

6%

Half the risk

Question 8

Popliteal artery aneurysm

Answer 8

Popliteal artery aneurysms are the commonest type of aneurysmal disease encountered in the extremities
The disease is bilateral in 50%
Abdominal aortic aneurysm is present in 50%
They have a high rate of distal embolisation and therefore most advocate treating aneurysms greater than 2cm in diameter
Electively the gold standard is aneurysm exclusion and bypass

Question 9

Crisoid aneurysm

Answer 9

These rare aneurysms occur at sites where superficially located vessels become complexed with arteriovenous malformations. They occur most commonly on the scalp and may cause cardiac problems secondary to high flow rates. They are also cosmetically disfiguring.
Standard investigation is with doppler studies complemented with both MRA and CT angiography.
Treatments range from cosmetic camouflage through to surgical excision

Question 10

Timing for fasciotomy

Answer 10

Should be considered if time exceeds 6 hours

Question 11

Leriche syndrome

Answer 11

Atheromatous disease involving the iliac vessels. Blood flow to the pelvic viscera is compromised. Patients may present with buttock claudication and impotence (in this particular syndrome). Diagnostic work up will include angiography, where feasible, iliac occlusions are usually treated with endovascular angioplasty and stent insertion.

Question 12

Carotid endarterectomy

Answer 12

Makes 50-99%
Females 70-99%

Question 13

Roos test

Answer 13

Used to exam for thoracic outlet obstruction

Question 14

Size for iliac aneurysm intervention

Answer 14

Most intervene between 3.5-4cm

Risk of spontaneous rupture below 4 is low

1/3-1/2 bilateral
70% in comman iliac
20% in thr internal

Question 15

Commonest site for type 2 endo leak

Answer 15

Back bleeding for IMA

Question 16

Half-life of Alta please

Answer 16

5mins

Question 17

Compressions stocking grades

Answer 17

Question 18

Homans operation

Answer 18

Reduction procedure with preservation of overlying skin (which must be in good condition). Skin flaps are raised and the underlying tissue excised. Limb circumference typically reduced by a third.

Question 19

Charles operation

Answer 19

All skin an subcutaneous tissue around the calf is excised down to the deep fascia. Split skin grafts are placed over the site. May be performed if overlying skin is not in good condition. Larger reduction in size than with Homans procedure.

Question 20

Lymphovenous anastamosis

Answer 20

Identifiable lymphatics are anastomosed to sub dermal venules. Usually indicated in 2% of patients with proximal lymphatic obstruction and normal distal lymphatics.

Question 21

AAA screening

Answer 21

Aortic size Screening category Outcome

2.9mm or less Normal No further imaging
30-44mm Small aneurysm Repeat annual USS

45-54mm Medium aneurysm USS at three monthly intervals

55mm or greater Large aneurysm Urgent vascular surgical referral (within 2 weeks) for CT angiography

Question 22

Risk of AAA rupture

Answer 22

30-39 0%
40-49 1%
50-59 11%
60-69 11-22%
70mm or greater 33%

Question 23

Superior mesenteric artery syndrome

Answer 23

SMA syndrome is a rare disorder in which the SMA and aorta take an angle of 6-25o as opposed to 38-56o. There is also a component of mesenteric shortening. The result of this is that the 3rd portion of the duodenum becomes constricted. Symptoms include colicky upper abdominal pain, early satiety, nausea and weight loss (which exacerbates the problem).
The condition may be congenital with a high insertion of the 4th part of the duodenum being partly to blame or acquired, as a result of trauma, extreme weight loss or surgery.

Diagnosis
This can be challenging. It is a rare disorder and endoscopic studies are often normal or show non specific features. Contrast studies may demonstrate reversed peristalsis and hold up at the third part of the duodenum. Confirmatory angiographic studies are then needed to demonstrate the arterial lesion.

Treatment
Initially with nutritional support (N-J feeding if possible) and then surgical bypass. The correlation between disease and surgical outcomes can be variable.

Question 24

Aberrant subclavian artery

Answer 24

This is the most common congenital abnormality affecting the aortic arch. The aberrant artery usually arises just distal to the left subclavian artery and crosses in the posterior part of the mediastinum usually behind the oesophagus on its way to the right upper extremity. Such course of this aberrant vessel may cause a vascular ring around the trachea and oesophagus. Dysphagia due to an aberrant right subclavian artery is termed dysphagia lusoria. Palsy of the recurrent laryngeal nerve is termed Ortner’s syndrome.

The aberrant right subclavian artery frequently arises from a dilated segment of the proximal descending aorta, the so-called Diverticulum of Kommerell. It is alternatively known as lusorian artery.

Question 25

Leriche syndrome

Answer 25

Aortioiliac occlusive disease. Consists of a triad of symptoms; impotence, buttock/ thigh claudication and absent or decreased femoral pulses. It is usually treated using endovascular techniques. For those patients with unfavorable anatomy an aorto-bifemoral bypass may be needed.

Question 26

May- Thurner syndrome

Answer 26

This occurs as a result of the compression of the left iliac vein by the right iliac artery. This overrides the vein and may compress it along its course. It is a recognised cause of spontaneous DVT where no underlying hypercoagulable state exists. Because the condition may be long standing, some patients may present with signs of left sided chronic venous insufficiency. Some cases may be treated by stent placement to minimise the compressive effect.

Question 27

Options for managing iliac occlusive disease

Answer 27

• Stenosis <3cm angioplasty
• Stenosis 3-10cm angioplasty
• Complex disease, associated aortic occlusions, external and common iliac occlusions- surgery