Vascular Surgery Flashcards by Lubi Mupwaya

ABI values

> 1.4: Calcification –> Refer

1-1.4: Normal

0.9-1: Acceptable

0.8-0.9: Mild Arterial disease –> treat risk factors

0.5-0.8: Moderate Arterial disease –>
- Treat risk factors
- Refer if signs of gangrene or pain on rest.

< 0.5: Severe –> Refer

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Heparin ischaemia monitoring

Activated partial thromboplastin time (aPTT)

Maintain 1.5 to 2.5xs the baseline value (21 to 35 seconds)

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Warfarin ischaemia monitoring

INR

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Abdominal aortic aneurysm (AAA) symptoms

Triad:
1. abdominal and/or back pain
2. pulsatile abdominal mass
3. hypotension

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Abdominal aortic aneurysm (AAA) screening

family history 20%
>50 years US

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Abdominal aortic aneurysm (AAA) mortality rate

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Abdominal aortic aneurysm (AAA) surgical intervention

Males > 5.5cm
Females > 5cm
Rapid growth > 1cm yearly
Symptomatic (abdominal/back pain, tenderness, distal embolization)

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Abdominal aortic aneurysm (AAA) investigation

>50 years fast US
CT angiogram (before elective surgical repair)

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Abdominal aortic aneurysm (AAA) size screening

3-3.9cm = 2 yearly US

4-4.5cm = 1 yearly US

4.6-5cm = 6m US

> 5cm = 3m US

> 5.5cm (male) = surgical intervention

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Aortic dissection/aneurysm vs myocardial infarction

Check if patient stable
if stable:
Initial: ECG
Best: CT angio

If unstable: fast US

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Aortic dissection (AD) confirmation investigation

CT angio

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Pseudoaneurysm management

Ultrasound-guided thrombin injection

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Pseudoaneurysm complication

femoral artery catheterization 7.5%

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Acute limb ischemia most common cause

Thrombosis
- lower limbs 80%

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Acute limb ischemia symptoms

1, Paralysis
2. Paraesthesia
3. Pulselessness
4. Pain
5. pallor
6. Poikilothermia

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Acute limb ischemia investigation

Measure ABI
CT angiogram (gold standard) for surgical
intervention

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Acute limb ischemia requiring surgical treatment

Paralysis
Paraesthesia
Rest pain

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Acute limb ischemia LMWH vs UFH

Preceding surgery/renal impairment: UFH
Medical Mangement only: LMWH (enoxaparin)

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Acute limb ischemia treatment

embolectomy

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Acute limb ischemia reperfusion injury features

– Acute renal failure
– Hyperkalaemia.
– Myoglobinemia.
– Metabolic acidosis.
– CK elevation

Chronic limb ischemia diagnostic symptoms

-Shiny, hyperpigmented skin.
-Hair loss and ulceration on the legs
-Thickened nails.
-Muscle atrophy.
-Vascular bruits.
-Poor pulses are the hallmark of the chronic obstructive arterial disease

Chronic limb ischemia symptoms that require surgical intervention

– Rest Pain
– Ischemic ulceration
– Gangrene
– Claudication symptoms limiting day to life & work, no improvement
with risk factor modifications, exercises, medical management > 6 months

Peripheral arterial disease (PAD) manifestation of

atherosclerosis

Peripheral arterial disease (PAD) affects ____ of general population

10–15%

How many px with PAD are asymptomatic

approximately 50% - worse prognosis if symptomatic

Peripheral arterial disease (PAD) symptoms

- calf muscle intermittent claudication (IC) 10%

Peripheral arterial disease (PAD) complications

- AAA 10% - Popliteal aneurysm (prominent popliteal pulses) - diabetic foot ulcers

Peripheral arterial disease (PAD) investigation

- Initial: ABI - **US doppler** -CT angio if aneurysm suspected

Peripheral arterial disease (PAD) management

< 0.9: -Anti-cholesterol (even in absence of dyslipidaemia) - Antihypertensives: ACEI or ARBs - Statins - Supervised exercise program NOTE: -Antiplatelets: aspirin or clopidogrel ONLY is evident cardiovascular disease - avoid beta-blockers unless for cardio protection

Peripheral arterial disease (PAD) conservative management failed

Revascularization by: – Endovascular angioplasty or stenting – Open surgical reconstruction by bypass or endarterectomy

Thrombophlebitis complications

- DVT - PE

Thrombophlebitis management

- LMWH (spontaneous superficial) 4 weeks - NSAIDs (superficial)

Varicose veins investigation

Venous duplex ultrasound (gold standard)

Varicose veins referral indications

CEAP > 3 - thrombophlebitis - chronic venous insufficiency - Venous ulcer - Venous eczema - bleeding - severe discomfort

Chronic venous ulcers management

compression stockings

Compression sticking contraindications

- **ABI < 0.8** - cardiac, renal or liver failure - cellulitis - acute DVT

Internal carotid artery stenosis divided into

Asymptomatic Symptomatic

Asymptomatic internal carotid artery stenosis

< 80% - yearly follow up with CDUS >80% = refer

Symptomatic internal carotid artery stenosis

Stroke or TIA < 49%: medical therapy with antiplatelets + follow up >50%: surgery (1-2 weeks after event) + medical therapy

Carotid artery stenosis stroke prevention surgery

Carotid endarterectomy

Fibromuscular dysplasia renal artery stenosis management

Renal artery angioplasty

Atherosclerotic renal artery stenosis management

- unilateral: **ACE inhibitors and ARBs** to reach goal blood pressure - if goal blood pressure not reached: - thiazide diuretic (chlorthalidone or indapamide) - calcium channel blocker - mineralocorticoid receptor antagonist - beta blocker

Deep Vein Thrombosis (DVT) risk factors

– > 60 years – Obesity especially BMI > 40 – Smoking – Prolonged immobilisation due to surgery (total knee replacement) – Pregnancy – HRT or OCP – Malignant diseases – Congestive cardiac failure – Inflammatory bowel disease (Crohn’s and ulcerative colitis)

Deep Vein Thrombosis (DVT) investigation

Doppler venous ultrasound

Deep Vein Thrombosis (DVT) prophylaxis

- Enoxaparin 24-48 hours - Warfarin after 24-48 hours

Thromboembolism risk factors before surgery CA

- Cardiac failure (VTE) - acute bowel inflammation • Cardiac Failure increases the risk of blood clots before surgery because the heart pumps blood less effectively, leading to slow-moving blood that’s more likely to clot. • Acute Bowel Inflammation raises clotting risk because inflammation can cause the blood to become more prone to clotting, and surgery can exacerbate this condition.

Pulmonary Embolism (PE) symptoms

- Hx of long flight, pregnancy - acute shortness of breath - sinus tachycardia

Pulmonary Embolism (PE) investigation

CTPA (radiation risk in pregnancy) - V/Q (**normal chest X-ray**), pregancy

Inferior vena cava filter placement

1. Absolute contraindication to therapeutic anticoagulation. 2. Failure of anticoagulation when there is acute proximal venous thrombosis (failure to maintain INR)