Vascular Surgery

Question 1

Definition of PAD

Answer 1

Narrowing of the arteries leading to reduced blood supply, often resulting in claudication

Question 2

Differences between neurogenic and vascular claudication

Answer 2

Vascular is worse uphill
Vascular is relieved by rest
Vascular has a positive bike test

Neurogenic is worse downhill (lordosis)
Neurogenic can be painful at rest
Neurogenic has a negative bike test
Neurogenic has a positive trolley sign
Weakness after walking

Question 3

What is critical limb ischemia?

Answer 3

End-stage PAD where normal function is impaired at rest

Question 4

What are the signs of critical limb ischemia?

Answer 4

Pain at rest (may be worse at night), non-healing ulcers and gangrene

Question 5

What is acute limb ischemia?

Answer 5

“MI of the leg” - rapid onset ischemia

Question 6

Signs of acute limb ischemia?

Answer 6

6Ps - pallor, pulselessness, pain, paraesthesia, perishing cold and paralysis

Question 7

What is Leriche syndrome?

Answer 7

Occlusion of the distal aorta/proximal common iliac artery leading to male impotence, absent femoral pulses and thigh/buttock claudication

Question 8

Investigations for PAD?

Answer 8

• ABPI
• Doppler US
• Angiography

Question 9

What is Bueger’s test?

Answer 9

Lie flat and legs held at 45 degrees at the hip joint; pallor indicates obstruction > arterial system. Then legs over the side of the bed; pink is healthy, blue shows deoxygenated blood and dark red shows vasodilation from metabolic products

Question 10

ABPI numbers and their meanings?

Answer 10

> 1.3 - calcification (diabetes)
0.9 - 1.3 - normal
0.6 - 0.9 - mild
0.3 - 0.6 - moderate to severe
<0.3 - severe to critical

Question 11

Management of intermittent claudication

Answer 11

• lifestyle
• exercise training
• medical: atorvastatin 80mg, clopidogrel 75mg, naftidrofuryl oxolate (5-HT2 ant –> vasodilator)
• surgery: endovascular, endarterectomy or bypass

Question 12

Management of critical limb ischemia

Answer 12

Surgery including amputation if needed

Question 13

Management of acute limb ischemia

Answer 13

Acutely - A to E with UFH and analgesia

Surgery including amputation or thrombectomy if needed

Question 14

Common features of an arterial ulcer

Answer 14

Occur distally
Small, deep and punched out
Less likely to bleed and paler
Well defined borders

Question 15

Management of arterial ulcers

Answer 15

Atorvastatin, clopidogrel and naftidrofuryl oxolate (5-HT2 ant –> vasodilator), as per PAD

Question 16

Common features of venous ulcers

Answer 16

Gaiter area
Larger, superficial and slopped edges
More likely to bleed
Less painful

Question 17

Management of venous ulcers

Answer 17

Wound care - TVN or district nurses
Compressions stockings
Abx and analgesia as needed (avoid NSAIDs)

Question 18

What is an aortic dissection?

Answer 18

A break or tear in the intima creates a false lumen in which blood can tract

Question 19

Two types of aortic dissection?

Answer 19

Type A and B, affecting the ascending aorta and descending aorta

Question 20

Three biggest risk factors of aortic dissection

Answer 20

HTN, surgery near the aorta and CTDs

Question 21

Investigations for an aortic dissection

Answer 21

BPs on each arm
ECG and CXR
CT angio

Question 22

Management of aortic dissection

Answer 22

Control BP and HR, usually with labetalol and consult vascular

Type As often need emergency surgery

Question 23

Complications of an aortic dissection

Answer 23

• CVA
• MI
• Cardiac tamponade
• Aortic regurgitation
• Rupture
• Death

Question 24

What is carotid stenosis?

Answer 24

Plaque formation of the carotid arteries leading to narrowing of the vessels

Question 25

Investigations for carotid stenosis?

Answer 25

US or CT angio

Question 26

Classification of carotid dissection

Answer 26

< 50% - mild
50 - 69% - moderate
>70% - severe

Question 27

Management of carotid stenosis

Answer 27

• lifestyle
• co-morbidities e.g. HTN
• anti-platelets e.g. clopidogrel
• anti-lipids e.g. atorvastatin
• endarterectomy (2% risk of stroke and risk of damage to facial, glossopharyngeal, hypoglossal and recurrent laryngeal nerves)
• angioplasty and stenting