Vascular Surgery Flashcards
What is the screening of AAA?
Single Abdo US at aged 65
What is the screening outcomes for AAA?
<3cm - Normal
3cm - 4.4cm - Rescan every 12 months
4.4 - 5.4cm - Rescan every 3 months
5.5cm - Refer within 2 weeks for intervention
What are high rupture risks for AAA?
- Symptomatic
- Rapidly enlarging: >1cm every year
- Needs referral within 2 weeks for vascular intervention
How is AAA treated?
- Treat with EVAR or open repair if unsuitable
- If evidence of rupture, immediate vascular review with emergency surgery needed
What causes venous leg ulcers?
- Mostly due to venous HTN due to chronic venous insufficiency
- Above the ankle and painless
- Managed with compression banding or surgery
What are arterial ulcers?
- Occur on the toes and heel
- Have a deep, punched out appearance
- Painful
- Low ABPI measurements
What are the 3 main presentations of PAD?
- Intermittent claudication
- Critical limb ischaemia
- Acute limb-threatening ischaemia
What are the features of limb-threatening ischaemia
Pain, pallor, pulseless, paraesthesia, paralysis, perishing cold
How to investigate limb-threatening ischaemia?
- Handheld arterial doppler FIRST
- ABPI
- Assess whether this is due to thrombus or embolus (AF)
How is limb-threatening ischaemia managed?
- Vascular review
- Analgesia + IV Heparin
- Angioplasty/Intra-arterial thrombolysis
What is critical limb ischaemia?
- Rest pain in foot for more than 2 weeks
- Ulceration
- Gangrene
- Hang legs out of bed at night to help with pain
- ABPI < 0.5
- Tx includes manage risk factors
What is intermittent claudication?
- Aching or burning in muscles after walking
- Relieved by stopping and not present at rest
- Check foot pulses, ABPI, US scan
How is peripheral arterial disease managed?
- Stop smoking
- Atorvastatin 80mg
- Clopidogrel
- Exercise training
Management options for PAD?
Endovascular revascularization: angioplasty used for short stenosis, high risk patients
Surgical revascularization: surgical bypass used for long lesions, multifocal lesions
What is superficial thrombophlebitis?
- Inflammation/thrombosis of one of the superficial veins: long saphenous vein
What is immediate management of suspected superficial thrombophlebitis?
US scan to exclude DVT
What are other management options for superficial thrombophlebitis?
- NSAIDs
- Compression stockings
What are varicose veins?
Dilated, superficial veins which occur secondary to incompetent venous valves - commonest in great saphenous and small saphenous vein
What are risk factors for varicose veins?
- Increasing age
- Female
- Pregnancy
- Obesity
How should varicose veins be investigated?
Venous duplex US which will show retrograde venous flow
How are varicose veins managed?
- Leg elevation, weight loss, compression stockings
- Refer if ulcers, troublesome symptoms
What is an arterial aneurysm?
Abnormal dilatation to more than 150% of the original diametes of the blood vessel due to weakness in the vessel wall
True vs false aneurysm
True - abnormal dilatation of the vessel
False - collection of blood around the vessel
What is the number needed to screen?
A number needed to screen is a reference to the number of patients who will need to be screened by the program me to prevent one excess death /morbidity
Causes of AAA
- Ehlers-Danlos/Marfans
- Atheromatous degeneration
What are disadvantages of using EVAR?
- Long term follow up needed
- Not suitable for every type of aneurysm
- High reintervention rate
What is trash foot?
Cholesterol embolism which occurs after vascular surgery where debris is shed and lodges in distal vessels causing local ischaemia
When does irreversible tissue ischaemic occur?
Within 6 hours
How does heparin work?
Activates anti-thrombin III which inactivates Xa preventing the clotting cascade
What type of pain will be in compartment syndrome?
Pain on dorsiflexion
Acute limb ischaemia with no history of claudication?
Think embolic cause -> AF rather than smoking
What are ABPI results?
1 - Normal
0.6 - 0.9 - Claudication
0.3 - 0.6 - Rest pain (critical limb)
<0.3 - impending concerns
What are causes of AAA?
- Marfans
- Atherosclerosis
- Ehlers-Danlos
- Abdo trauma
What is Virchow’s triad?
- Endothelial injury (trauma, surgery)
- Stasis of blood flow (AF, immobility)
- Hypercoagulability (pregnancy, malignancy)
What are some chronic venous changes which can occur?
- Varicose veins
- Varicose eczema
- Lipodermatosclerosis
What are the 2 classification systems for aortic dissection?
Stanford
De Bakey
Varicose vein + venous ulcer?
Refer to vascular
What is permisive hypotension?
Strategy used in the resus of bleeding trauma patients - advocates for cautious use of fluid as large increases in BP can lead to clot formation, tear the aorta or increase blood loss
What is the 2 classifications of varicose veins?
Primary - degeneration of valve leaflets
Secondary - valve destruction
What are risk factors for varicose veins?
- Female
- Pregnancy
- Pelvic/Abdominal mass
- FH
Early vs late signs of compartment syndrome
Early - pain out of proportion to injury, absent pulse, swelling
Late - paralysis, pale limb, cold limb
ABPI > 1 can indicate what?
Calcified, stiff arteries - commonly seen in diabetes
How do neuropathic ulcers form?
Commonly due to increased pressure e.g tight fitting shoes or unnoticed trauma and will be painless
Claudication in femoral vessels vs iliac vessels?
Femoral - Calf pain
Iliac - Buttock pain
What is a non pharmacological management option for PAD?
Exercise training
Patients with diabetes with PVD can get what?
Falsely high ABPI measurements due to abnormal hardening of the arteries
Dry gangrene vs wet gangrene?
Dry is a complication of critical limb ischaemic where the tissue necroses
Wet - infection of the dry
Embolic vs thrombotic cause of acute ischaemia?
Embolic will develop over minutes whereas thrombotic will develop over hours - days
What programme should be offered to all those with intermittent claudication?
Supervised exercise programme
What is a paradoxical embolus?
Where a VTE travels through inferior vena cava and then crosses septal defect to enter left heart circulation and cause an arterial embolus
Long saphenous system vs short saphenous system?
Long - side of long toe - medial malleolus
Short - side of short toe - lateral malleolus
