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Vascular Surgery Flashcards

1
Q

What is peripheral arterial disease?

A

Significant narrowing of arteries distal to the arch of aorta, usually due to atherosclerosis

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2
Q

What are the RF of peripheral arterial disease?

A

Smoking, DM, hypertension, hyperlipidaemia, physical inactivity and obesity.

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3
Q

What are the symptoms of peripheral arterial disease?

A

Walking impairment, pain in buttocks and thighs relieved at rest.

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4
Q

What are the signs of peripheral arterial disease (PAD)?

A

Pale, cold leg
Hair loss
Ulcers
Poor wound healing
Weak or absent pulses

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5
Q

What are the investigations for PAD?

A

Full CVS risk assessment incl BP, FBC, blood glucose, lipids and ECG.

Ankle-brachial pressure index- uses doppler probe to find the systolic brachial blood pressure of the arms and comparing to ankle blood pressures

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6
Q

How do you non-surgically manage a patient with PAD?

A

Non-surgical: RF modification, supervised exercise program, smoking cessation and weight management

Managing CVS risk- clopidogrel 75mg, atorvastation 80mg, diabetes and HTN should be well controlled
Managing pain- Naftidrofuryl oxalate- vasodilator, only if exercise is ineffective and the pt does not want angioplasty or bypass

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7
Q

How do you surgically management a patient with PAD?

A

Intermittent claudication: endovascular revascularisation or surgical revascularisation, when RF modification has not improved sx

Critical limb ischaemia (rest pain, tissue loss etc.), referral to vascular MDT. Endovascular methods for small stenosis, surgical bypass for larger and more extensive stenosis and amputation if there no other option.

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8
Q

Define gangrene

A

Death of tissue specifically due to an inadequate blood supply

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9
Q

Define necrosis

A

Tissue death

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10
Q

Define ischaemia

A

Inadequate O2 supply due to inadequate blood supply

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11
Q

How does atherosclerosis cause ACS?

A

Plaques cause:

  1. stiffening of artery walls —> HTN and strain on the heart due to increased resistance
  2. stenosis —> reduced blood flow e.g. angina.
  3. plaque ruptures —> get thrombus in distal vessel —> cause ischaemia/ACS
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12
Q

What are non-modifiable RF for atherosclerosis?

A

Male gender, older age, FHx

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13
Q

What are modifiable RF for atherosclerosis?

A

Smoking
Alcohol consumption
Poor diet
Sedentary lifestyle
Obesity
Poor sleep

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14
Q

A patient who has a PMH of atherosclerosis is now presenting with chest pain. She also feels the pain in her abdomen and has mentioned her legs have been cramping. Braindump some differentials

A

Angina, MI, TIA, Stroke, PAD, Chronic mesenteric ischaemia

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15
Q

What is Leriche syndrome?

A

A term given for a group of symptoms caused by PAD of legs.

Occlusion in the distal aorta or proximal common illiac artery

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16
Q

What is the triad in Leriche syndrome?

A

thigh / buttock claudication, impotence and absence of femoral pulses.

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17
Q

How is Leriche syndrome managed?

A

Surgical revascularisation
Surgery - aortofemoral bypass or axillofemoral bypass with or without endartectomy (removing the plaque)

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18
Q

Describe the pathophysiology of Leriche syndrome

A

Severe atherosclerosis affecting the distal abdominal aorta, iliac arteries and femora-popliteal vessels. Can be bilateral depending on where the occlusion is.

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19
Q

What can PAD lead to?

A

Intermittent claudication.

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20
Q

What can intermittent claudication lead to?

A

Acute limb ischaemia or critical limb ischaemia.

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21
Q

Describe presentation of intermittent claudication

A

Crampy, achy, pain in calf, thigh or buttocks. Muscle fatigue when walking. Occurs at exertion and relieved at rest.

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22
Q

How can claudication be measured?

A

Claudication distance and Walking distance (maxima walking distance)

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23
Q

What is the claudication distance?

A

How long pt can walk until the pain starts

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24
Q

What is the walking distance (maximal walking)?

A

Once the pain has begun, this is how long the pt can continue to walk for

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25
Define acute limb ischaemia
Rapid onset of ischaemia often due to a thrombus blocking blood supply to a limb
26
Define critical limb ischaemia
End stage of PAD - not enough blood supply to limb to allow a normal function at rest. Pt at risk of losing limb
27
How can pt present with critical limb ischaemia?
Pain at rest, non-healing ulcers, gangrene. Pain worse at night when leg raised. Pt hangs leg off bed to help. Burning pain.
28
What are the 6Ps of critical limb ischaemia?
Pain, pallor, pulselessness, paralysis, parasthesia, perishingly cold.
29
What is a VTE?
Formation of a blood clot in the venous system with potential to embolism causing a PE.
30
What is in Virchow's triad?
Change in coagulability, stasis of blood, vessel wall injury
31
What are RF for VTE?
Immobility Recent trauma Long haul travel Pregnancy Hormone therapy containing oestrogen Polycythaemia SLE Thrombophillia
32
What prophylaxis against VTE is given/carried out in hospital before surgical procedure?
VTE risk assessed Prophylaxis given if risk is increased unless contraindicated. Prophylaxis usually with LWMH - enoxaparin, dalteparin. TED stockings given - unless contraindicated.
33
How does VTE present?
Unilateral calf or leg swelling Dilated superficial veins Calf tenderness Oedema Colour changes to leg
34
What is a Wells score?
Predicts risk of DVT or PE in patient presenting with symptoms
35
What investigations would you do for suspected VTE?
D dimer Wells score Doppler ultrasound CT pulmonary angiogram
36
Why is a D-dimer done for suspected VTE?
Helps exclude DVT but does not confirm it, as other conditions can cause a raised D dimer score
37
Why is a doppler ultrasound done for suspected VTE?
Assess blood flow in the leg. Repeat 6-8days later if DVT suspected but initial scan -ve.
38
Why is a CT pulmonary angiogram done in pt presenting with leg swelling, calf tenderness and colour changes to the leg?
Identify PE
39
How is VTE initially managed?
Apixaban, rivaroxaban
40
After a DVT, how are they managed?
Long term anticoags - doac, warfarin, LWMH
41
What are varicose veins?
Distended superficial veins \>3mm in diameter. Usually in the legs
42
Describe the pathophysiology of varicose veins
1. incompetent valves in perforating veins connecting deep and superficial veins. 2. backflow of blood from deep veins into superficial veins 3. superficial veins overloaded and become dilated and engorged
43
What are RF for varicose veins?
Increasing age, FHx, female, pregnancy, obesity, prolonged standing, DVT causing damage to valves
44
What are symptoms of varicose veins?
can be asymptomatic heavy dragging sensation in legs aching itching burning oedema muscle cramps restless legs
45
Name two conservative options for varicose veins
Weight loss Physical activity Elevate leg Compression stockings
46
What are surgical options available for varicose veins?
endothermal ablation sclerotherapy - inject irritant causing vein closure stripping- veins ligated and removed
47
What are complications associated to varicose veins?
Excessive bleeding post trauma Superficial trombophlebitis DVT Issues associated to venous insufficiency
48
What is chronic venous insufficiency?
Blood does not drain efficiently back to the heart, pools in the veins in the leg and causes venous hypertension. This can lead to changes in the skin
49
What are RF for chronic venous insufficiency?
increased age immobility obesity prolonged standing DVT causing damage to valves association with varicose veins
50
Where are skin changes in chronic venous insufficiency?
In gaiter area - below knee and above the ankle
51
What skin changes are seen in chronic venous insufficiency?
Haemosiderin staining Venous eczema Lipodermatosclerosis Atrophie blanche
52
What complications can arise from chronic venous insufficiency?
Cellulitis Poor wound healing Skin ulcers Pain
53
How is skin managed in chronic venous insufficiency?
Monitor skin health, regular emollients, topical steroids for flare of venous eczema or lipodermatosclerosis
54
How can venous drainage be improved in chronic venous insufficiency?
Weight loss Physical activity Elevate legs Compression stockings
55
How can complications of chronic venous insufficiency be managed?
Infection - abx flucloxacillin Analgesia Wound care and dressings
56
Causes of venous leg ulcers?
Venous hypertension, chronic venous insufficiency
57
Features of venous ulceration?
oedema, brown pigmentation, lipodermatosclerosis, eczema
58
Where do venous uclers commonly form?
Above the ankle
59
What is deep venous insufficiency related to ?
previous DVT
60
What is superficial venous insufficiency related too?
varicose veins
61
Management of venous ulcers?
cleaning, debridement and dressing, 4 layer compression banding Elevate the legs Use emollients to protect skin barrier if non healing - tissue viability.
62
Where do arterial ulcers commonly form?
Toes and heels
63
Cause of arterial ulcers?
insufficient blood supply to skin due to peripheral arterial disease
64
Features of arterial ulcers?
Cold with no palpable pulses, low ABPI index, possibly pitting oedema due to co-morbities
65
Cut offs for arterial disease in APBI?
\<0.5 severe arterial disease 0.5-0.8- arterial disease or mixed arterial venous disease
66
Management of arterial ulcers?
Urgent vascular review Conservative- smoking cessation, lose weight, exercise, CVS modification- anti-platelets, statins May need bypass or graft
67
Common sites for neuropathic ulcers?
Plantar surface of metatarsal head and plantar surface of hallux
68
Cause of neuropathic ulcer?
Pressure- lack of sensation (i.e loss of protective sensation) so injuries go unnoticed, immunocompromised and increased blood glucose leads to impaired wound healing
69
Management of diabetic foot ulcer
referral to diabetic foot ulcer clinic optimise diabetic control improve diet and exercise if approriate regular chiropody to ensure good foot hygiene and appropriate footwear may need surgical debridement skin swabs and Abx (flucloxacilin) if infection suspected amputation in severe necrotic/infected cases
70
What is an abdominal aortic aneurysm
Dilation of abdominal aorta greater than 3cm
71
RF for AAA?
Male Increased Age Smoking Hypertension Family history Existing CVS disease
72
Screening for AAA
All men in England at age 65 offered screening. Pts with aortic diameter over 3cm referred to vascular team
73
Investigations for AAA
US is initial diagnosis CT angiogram gives more detailed picture of aneurysm for repair
74
Management AAA
Risk of progression: Stop smoking Healthy diet and exercise Optimising mx of hypertension, diabetes, hyperlipidaemia Surveillance: Yearly for pts with aneurysm 3-4.4cm 3monthly for pts with 4.5-5.4cm Elective repair for patients: greater than 5.5cm Symptomatic aneurysm Growing more than 1cm a year
75
Classification of AAA
No aneurysm- less than 3 cm Small aneurysm- 3-4.4cm Medium aneurysm- 4.5-5.4cm Large aneurysm- above 5.5cm
76
Presentation of ruptured AAA
Severe abdo pain radiating to back or groin Haemodynamically unstable (hypotension and tachycardia) Pulsatile and expansile mass in abdo Collapse LOC
77
Driving rules for AAA?
Inform DVLA if aneurysm is above 6cm Stop driving is above 6.5cm Stricter rules if driving heavy vehicle
78
What is permissive hypotension in AAA management?
Allowing lower than normal blood pressure when fluid resuscitating as increased BP= increased blood loss
79
Location of diabetic foot ulcers?
Heel of foot, metatarsal heads
80
Investigations for diabetic foot ulcer?
ABPI, doppler to assess blood flow, blood glucose including HbA1c, skin swabs. XR if concerned of osteomyelitis.
81
Management of venous ulcers
compression bandaging, usually four layer (only treatment shown to be of real benefit) oral pentoxifylline, a peripheral vasodilator, improves healing rate
82
Polycyaethmia vera presentation?
Venous/arterial thromboembolism, raised haemoglobin, red cell count and haematocrit (red and white lines are also usually raised too)

Y3 surgery old (6 decks)

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