Vascular surgery Flashcards
What is intermittent claudication?
Symptoms of ischaemia, occurs during exertion and is relived by rest, crampy/achy pain in calf/thigh/buttock (equivalent to stable angina)
What is critical limb ischaemia?
End stage of peripheral arterial disease, inadequate blood supply to limb results in pain at rest, non-healing ulcers and gangrene (equivalent to unstable angina)
What is acute limb ischaemia?
Rapid onset of ischaemia in a limb typically due to thrombus blocking the arterial supply of a distal limb (equivalent to MI)
What are the risk factors for peripheral vascular disease?
Older age, family history, male, smoking, alcohol consumption, poor diet, low exercise, poor sleep, obesity, stress
What are the 6 P’s of acute limb ischaemia?
Pain, pallor, pulselessness, paralysis, paraesthesia, perishingly cold
What ABPI indicates mild, moderate and severe peripheral vascular disease?
Normal = 0.9-1.3
Mild = 0.6-0.9
Moderate = 0.3-0.6
Severe = <0.3
What investigations are done in peripheral vascular disease?
1st line = duplex USS
CT/MRI angiography can be used to investigate following duplex USS
What medical management should everyone with peripheral arterial disease be taking?
Atorvastatin 80mg
Clopidogrel 75mg
How is critical limb ischaemia managed?
Urgent vascular referral, analgesia, surgery including stenting or bypass
How is acute limb ischaemia managed?
Urgent vascular referral, analgesia, IV heparin, surgical management
What are the risk factors for AAA?
Male, increased age, smoking, hypertension, family history, existing cardiovascular disease
Who is screened for AAA?
All men are offered screening USS at age 65 to detect asymptomatic AAA
What diameter of aorta requires referral and at what point does it become urgent?
> 3cm need referring
5.5cm urgent (within 2 weeks)
What investigation other than USS is done in AAA?
CT angiogram - gives more detailed picture of aneurysm and helps guide elective surgery to repair
For people with identified AAA how often are they rescanned?
Yearly in those 3-4.4cm
3 monthly in those 4.5-5.4
When is a AAA booked in for elective repair?
Symptomatic, diameter growing more than 1cm a year, diameter >5.5cm
What is the presentation of a ruptured AAA?
Severe abdo pain that may radiate to back or groin, hypotension and tachycardia, pulsatile and expansile mass in abdomen, loss of consciousness
What is the management of ruptured AAA?
Permissive hypotension, immediate surgical repair
What is aortic dissection?
Break or tear forms in the inner layer of the aorta allowing blood to flow between the layers, a false lumen is created
What is type A/type B aortic dissection?
A = ascending
B = descending
What are the risk factors for aortic dissection?
Hypertension, age, male, smoking, poor diet, connective tissue disorders
What is the presentation of aortic dissection?
Sudden onset severe ripping/tearing chest pain, may have large differences in BP between arms, may have abdo pain, hypotension
What investigations are done in aortic dissection?
ECG and CXR to exclude other causes
CT angiogram = initial investigation
MRI angiogram provides greater detail
How is aortic dissection managed?
Analgesia, BP and HR need to be well controlled to reduce stress on aortic walls (use beta blockers), surgery
How do diabetic ulcers present?
Who gets them, why they occur
Present in patients with diabetic neuropathy, lose sensation in feet and are more prone to injury, impaired wound healing due to damage to vessels (osteomyelitis is complication)
Who develops pressure ulcers?
Occur in patients with reduced mobility where prolonged pressure on particular areas lead to the skin breaking down
What scoring system is used to assess risk for pressure ulcers?
Waterlow score
What are the features of arterial ulcer?
Occur distally, occur in those with PAD, small and deep with well defined border, punched out appearance, pale, painful, worse at night or when elevating leg
What are the features of venous ulcers?
Most common between top of foot and bottom of calf, associated with venous eczema and lipodermatosclerosis, large superficial with irregular, gently sloping border, pain relieved by elevation
What investigations are done in those with leg ulcers?
ABPI (assess to arterial disease)
Charcoal swab of ulcer
Skin biopsy if skin cancer is suspected
What is the management of arterial ulcers?
Same as for peripheral arterial disease, may require surgical revascularisation
What is the management of venous ulcers?
Clean wound, debridement, dressing, compression therapy (once arterial disease ruled out)
What are the risk factors for chronic venous insufficiency?
Increasing age, family history, female, pregnancy, obesity, prolonged standing, DVT
What is the presentation of chronic venous insufficiency?
Varicose veins, heavy dragging sensation in legs, aching, itching, burning, oedema, cramps and restless legs
What is the management of chronic venous insufficiency?
Weight loss, physical activity, elevating legs, compression stockings, surgery
What is carotid artery stenosis?
Narrowing of the carotid arteries in the neck usually secondary to atherosclerosis
How is carotid artery stenosis classified?
Mild - less than 50% reduction
Moderate - 50-69% reduction
Severe - 70% or more
How is carotid artery stenosis diagnosed?
Usually diagnosed after TIA/stroke
Carotid USS is 1st line
CT/MRI angiogram may be used to assess stenosis in more detail
What is the management of cartoid artery stenosis?
Manage co-morbidities
Antiplatelet medication
Atorvastatin
Carotid endarterectomy
What is Buerger’s disease/thomboangiits obliterans?
Inflammatory condition that causes thrombus formation in the small and medium blood vessels in distal arterial system
Who is typically affected by Buerger’s disease/thomboangiits obliterans?
Males aged 25-35 who smoke (strong association with smoking)
What is the presentation of Buerger’s disease/thomboangiits obliterans?
Painful blue discolouration to fingertips, pain is often worse at night, may process to ulcers/gangrene
What is the management of Buerger’s disease/thomboangiits obliterans?
Angiogram - shows corkscrew collaterals
Completely stop smoking (NRT or cutting down does not improve the condition)
What murmur is heard in aortic dissection?
Aortic regurgitation
