Vascular Surgery

Question 1

abdominal aortic aneurysm screening & subsequent action

Answer 1

single abdominal ultrasound for males aged 65.

<3cm - normal - no further action
3-4.4cm - small aneurysm - rescan every 12 mos
4.5-5.4- medium - rescan every 3 mos
=> 5.5cm - large - 2w vasc surgery review for intervention.

also 2w vasc review if rapidly enlarging (>1cm/year) !!

Mx: elective endovascular repair (EVAR)
or open repair

Question 2

AAA RFs

Answer 2

smoking and hypertension mainly

also: syphilis and connective tissues diseases (Ehlers Danlos type 1, Marfan’s syndrome)

Question 3

Interpretation of ankle-brachial pressure index (ABPI)

Answer 3

> 1.2: calcified, stiff arteries-advanced age or PAD
1.0 - 1.2: normal
0.9 - 1.0: acceptable
< 0.9: likely PAD.
0.6-0.9 - claudication
0.3-0.6 - rest pain
<0.3 - impending

Values < 0.5- critical limb ischemia

(Compression bandaging is generally considered acceptable if the ABPI >= 0.8.)

Question 4

lower leg ulcer characteristics

Answer 4

venous:
- oedema, brown pigmentation, lipodermatosclerosis, eczema
- above ankle
- painless

Marjolin’s:
- SCC
- sites of chronic inflammation (burns)

Arterial
- toes & heals
- deep, punched out
- painful
- gangrene, cold, no palpable pulses
- low ABPI

Neuropathic
- Commonly over plantar surface of metatarsal head & hallux
- due to pressure - cushioned shoes

Pyoderma gangrenosum
- Associated with inflammatory bowel disease/RA
- sometimes stoma sides
- Erythematous nodules or pustules which ulcerate

Question 5

acute limb threatening ischemia 6 ps

Answer 5

pale
pulseless
painful
paralysed
paraesthetic
‘perishing with cold’

Question 6

acute limb threatening ischemia mx

Answer 6

Ix:
handheld arterial Doppler examination -> ankle-brachial pressure index (ABI)

Initial:
ABC approach
analgesia: IV opioids are often used
intravenous unfractionated heparin
vascular review

definitive:
intra-arterial thrombolysis
surgical embolectomy
angioplasty
bypass surgery
amputation: for patients with irreversible ischaemia

Question 7

Critical limb ischaemia dx

Answer 7

Features should include 1 or more of:
rest pain in foot for more than 2 weeks
ulceration
gangrene

Patients often report hanging their legs out of bed at night to ease the pain.

An ankle-brachial pressure index (ABPI) of < 0.5 is suggestive of critical limb ischaemia.

Question 8

peripheral arterial disease mx

Answer 8

quit smoking
manage comorbidities: HTN, DM, obesity
Atrovastatin 80mg
Clopidogrel (1st line antiplatelet for PAD)
Exercise training

Severe PAD or critical limb ischemia:
endovascular/ surgical revascularisation

critical limb ischaemia not suitable for above: Amputation

Question 9

Endovascular vs surgical revascularisation options & indications for PAD

Answer 9

• Endovascular revascularisation (percutaenous transluminal angioplasty +/- stent placement) -> for short segment stenosis (e.g. < 10 cm), aortic iliac disease and high-risk patients
• surgical revascularisation (bypass w autologous vein/ prosthetic or endarterectomy ) -> for long segment lesions (> 10 cm), multifocal lesions, lesions of the common femoral artery and purely infrapopliteal disease

Question 10

Ruptured AAA mx

Answer 10

surgical emergency - IMMEDIATE vasc review

haemodynamically unstable: clinical dx & straight to theatres (unless v frail - palliative )

haemodynamically stable: CT angiogram (if dx is in doubt) - also can assess suitability of endovascular repair

Question 11

Mx of thrombophlebitis

Answer 11

ultrasound scan to exclude concurrent DVT

anti-embolism Compression stockings (remember ABPI before!)

prophylactic doses of LMWH for up to 30 days or fondaparinux for 45 days.
–> If CI, 8-12 days of oral NSAIDS
(topical NSAID/heparinoids if really mild)

If near/ at sapheno-femoral junction - therapeutic anticoagulation for 6-12 wks

Question 12

Varicose veins mx

Answer 12

venous duplex ultrasound: this will demonstrate retrograde venous flow

Mx
- conservative: leg elevation, weight loss & exercise, graduated compression stockings

• refer to secondary care if: active/healed venous leg ulcer, troublesome symptoms, previous bleeding, chronic venous insufficiency skin changes, superficial thrombophlebitis

Possible tx:
- endothermal ablation: radiofrequency ablation or endovenous laser treatment
- foam sclerotherapy
- surgery: either ligation or stripping