Vascular Surgery Flashcards
1
Q
What are the Vascular conditions?
A
Varicose Veins
Aortic dissection
Aortic Aneurysm
Carotid artery stenosis
Peripheral arterial disease
* Chronic Limb ischaemia
* Acute limb ischeamia
2
Q
What is Varicose Veins?
A
Bulging , enlarged veins & they look swollen and twisted under the skin
3
Q
What is the definition of Varicose veins?
A
When SQ dilated veins are > 3mm in diameter, frequently elongated and tortous
It mainly involve superficial
4
Q
What is the pathophysiology of Varicose veins?
A
when the valves fail to prevent backflow of venous blood unline deep veins
5
Q
What are veins?
A
Veins are pulseless
carry deoxygenated blood back to the heart
6
Q
Veins are made up of ?
A
Superficial veins (10% of the venous return)
Deep veins (contribute 90% of the venous return)
7
Q
What are perforators?
A
8
Q
How does veins carry blood without pulse? any backflow?
A
No backflow beacuse they contain valves
9
Q
what is the main function of valve?
A
To prevent from backflow
10
Q
RF of Varicose veins
A
Obesity
Long-time standing
history of DVT
11
Q
What is the clinical presentation?
A
**Unslightly visible veins and discolouration of the skin,
skin also becomes sclerotic, venous leg ulcers
( located in the malleous region of the feet )
12
Q
What is the investigation of Varicose Veins?
A
Duplex ultrasound
MR venography
13
Q
What is the management of Varicose veins ?
A
Firstly, rencourage Weight loss
Avoid prolonged standing
Elevates when possible
Then, refer to vascular specialist if there is symptomatic vv , pigmentation or eczema or any other skin changes.
if it is hard and painful veins
if ther is venous leg ulcer or a healed venous leg ulcer
14
Q
Next step management of VV medically?
A
Heparinoid cream/anti-inflammatory
15
Q
What is the management for VV with surgery?
A
Endothelial ablation-RFA
Foam scletherapy
Open surgery
16
Q
What is Aortic Dissection?
A
when the inner layer of the aorta tears and blood flows between the layers, creating a bulge and weakening the artery wall.
17
Q
What is the anatomy of aorta?
A
18
Q
What is the definition of Aortic Dissection?
A
the separation in the aortic wall intima which causes blood flow to the false channel composed of the inner and outer layers of the media
19
Q
What are the RF of aortic dissection?
A
Age,HTN, Marfan syndrome, pregnancy, connective tissue disorders, (Ehlers-Danlos syndromegiant cell arteritis, systemic lupus erythematous)
20
Q
Who are at risk of aortic dissection?
A
Men
Hypertension (70%)
aged btw 50-70
Afro-carribean pts
21
Q
What is the pathophysiology of Aortic Dissection?
A
When the high shear stress and pulsatile blood flow intimal tear and splits the media, creating a true and false lumen.
It also causes weakening of tunica media layer
Majority occur in the ascending aorta due to greater pressure( closer to the LV outflow)
Dissection may travel down to the common iliac bifurcation in seconds casuing maximal pain
22
Q
what are the classification of aortic disection?
A
Stanford and Debakey classification
23
Q
What is stanford clssification, explain?
A
Type A - involves ascending aorta & needs emergency surgical intervention
Type B - involves Descending aorta & needs medical treatment
24
Q
What is DeBakey Classification, explain?
A
Type 1 involves both ascending & descending
Type 2 only the ascending aorta
Type 3 only the descending aorta
25
What are the clinical presentation?
Severe and sudden chest pain described as 'sharp & tearing' >90%
26
What more of clinical presentation could be present on pts with aortic dissection?
Abdominal pain ( could also be aortic tear/mesenteric ischemia)
Hypotension - type A dissection
Hypertension - type B disection
Cardiac tamponade
27
How does sudden death signify aortic dissection ?
Sudden death signifies free rupture
28
What is the investigation of Aortic dissection?
29
What is the management of Aortic disection?
Type A open surgery - middle sternotomy
Type B Tevar - thoracic endovascular aortic repair
30
What is Aortic Aneurysm?
Bulge in the aorta
31
What is the pathophysiology of aortic aneurysm ?
32
What are the RF of aortic aeurysm ?
**SMOKING **
33
Clinical prestentation of AAA?
Asymtomatic
if aneurysm ruptures, lead to life- threatening and fatal
Pt aslo present with sudden abdo pain(excruciating) pain of the lower back or Left flank pain.
Pt can also present with chronic lower back pain as the AAA enlarges
34
What is the key during physical examination for AAA?
a palpable pulsatile mass, most commonly supraumbilical and in the midline.
35
What is the investigation of AAA?
CT angiography- useful for surgical planning
Ultrasound- utilised for screening and surveillance
36
What is the management for AAA?
It depends on the size of AAA and the status of the Pt
37
What is the surveillance of AAA?
<55mm
38
What is the management of AAA?
Unruptured AAA - open surgical repair or endovascular aneurysm repair
39
Management for Ruptured AAA?
Do immediate resusciattion and repair
Mortality is 80-90% die before reaching the hospital
management - ABCDE, IV acess but limit fluids, permissive hypotension, maintain mentation
Treatment option is to Repair through open or EVAR
40
What is the main complication in AAA?
Open surgery - cardiac ischaemia and infarct
EVAR - endoleak
41
What is the Open AAA repair?
Open Laparotomy and aorta clamped so need relatively good cardio-respiratory fitness
42
What is thh standard EVAR?
insert the cathetor through femoral
43
What is Carotid Artery Stenosis?
Narrowing of the carotid arteries primarily due to astherosclerosis.
44
Medical term fro stroke?
Cerebrovascular accident
45
What is CVA (Stroke)?
Focal cerebral ischaemia resulting in neurological functional impairment.
Ischaemic or haemorrhagic
46
What are the RF of CVA ?
**Atherosclerosis**- build-up of fatty material/plaque in the lumen of the arteries
* Diabetes
* Smoking
* Advancing age
* Hypertension
* Dyslipidaemia
* Obesity
**>50% ischemic strokes are due to fibrin or cholesterol emboli from an internal carotid artery (ICA) stenosis **
47
What are the symptoms of CVA in right hemisphere?
Contralateral weakness UL/LL
Contralateral numbness
Contralateral facial droop
Ipsilateral ocular symptoms
Contralateral neglect
Poor judgement of distance, size, speed and position
Speech disturbance less likely
48
What are the symptoms of the CVA in left hemisphere?
Contralateral weakness UL/LL
Contralateral numbness
Contralateral facial droop
Ipsilateral ocular symptoms
Contralateral neglect
Speech disturbance more likely (dysphasia and aphasia)
49
What is the Anterior circulation stroke?
Most common type (70%)
Middle cerebreal artery is the most common one which results in contralateral spastic paralysis/weakness and gaze palsy
50
What is the Posterior circulation stroke?
It includes the vertebral, posterior inferior cerebellar, basilar, and the posterior cerebral arteries
Cerebellar dysfunction, CN palsy, bilateral motor/sensory deficit
51
What is the imaging for carotid stenosis?
Duplex ultrasound - first step
-Direct visualisation of stenoses
- Assessment of stenosis from flow velocities
52
What if there is a significant stenosis seen in carotid stenosis?
either a second duplex to confirm CTA/MRA is neccessary
* CTA also allows assessment of synchronous lesions
* carotid anatomy for surgical planning
53
Within how many days should the surgery be done for the carotid stenosis?
surgery must be done within the 14 days & aim to treat within 2 days
54
Who should we operate on?
Pts with >50% to 99% stenosis, carry out carotid endarterectomy and this is reccommended within 3-6 months of symptoms
55
Why should the surgery for carotid must be carried out within 14 days?
| Majority of benefit is received if the surgery is done within 14 days
Stroke pts with significant recovery of brain function which also help prevent future strokes and it also improves outcomes for pts with internal carotid artery stenosis.
56
What is Carotid Endarterectomy (CEA) ?
It is a surgical procedure to remove the plaque that is buildup from insidethe carotid artery which also improve the blood flow to th ebrain and prevent stroke.
57
How is cardiac Enderactomy carried out?
* Done under LA or GA
* Standard to use shunt during GA.
* Risk of CN injuries
* 2-3% risk of stroke/death
58
What is Perpheral Arterial Disease? (PAD)
Also called as Peripheral vascular Disease, and it is mostly found in primary care- intermittent claudication is the most common initial symptom of LL PAD.
58
What are the 2 types of limb ischaemia ?
Acute limb ischaemia
Chronic limb ischaemia
59
What is the definition of PAD?
Narrowing or occlusion of the peripheral artery, affecting the blood supply to the LL.
60
What is acute limb iscahemia?
signs and symptoms present for less than 2 weeks
61
What is chronic limb ischaemia?
signs and symptoms present for more than 2 weeks
62
What is the pathophysiology of PAD?
the arteries narrow, that lead to decrease in blood flow and that causes pain.
pain is due to insufficient of oxygen reaching the muscles ( crampy pain), this is especially during physical activity.
63
what is the most common pathologic change associated with PAD?
Astheroclerosis
64
What are the RF of PAD?
Smoking
DM
advanced age
family history
hypertension
hypercholesterolemia
atherosclerosis in other sites (carotids, coronaries)
65
pathophysiology tree of PAD?
Normal arterial tree -Acute Limb Ischaemia
-
Asymptomatic PAD
-
Symptomatic PAD
-
Critical Limb iscahemia
-
Non- viable limb
66
What is the clinical presentation of **Chronic Limb ischaemia**?
Symptoms are progressive
asymptomatic
Intermittent claudication
Rest pain
Night pain - burning pain at night which is releived by hanging legs over side of bed or by sleeping in a chair.
67
What is Critical Limb Ischaemia?
absence/decreased pulses
Presence/Absence of ulcers
Non-healing wounds
gangerene (wet/dry)
Chronic ischaemic rest pain
68
How do critical limb ischaemia present?
Rest pain
- Distal extremities
- Usually have associated short distance claudication and loss of sensation
-Caused by fall in CO and in gravitational effect
69
What is the clinical presentation of Chronic Limb iscaheamia ?
Claudication may affect all the major muscle groups associated with walking
Buttock claudication- internal iliac arteries
Calf claudication- superficial femoral artery (travels through the adductor canal) most common site of atherosclerosis
Foot claudication-tibial artery disease (rare)
Pain involving the hamstrings is not characteristic of claudication
70
What do you look in the physical examination of chronic limb ischaemia?
During examination, check for Xanthalasma,anaemia, tar staning
AAA & masses in abdo
pulses in femoral, popliteal, DP, PT
Check on the limb/feet - deformaties
Check for Ulcers/Gangerene -
check for the site, size, edges, slough, base, exduate, surrounding tissue.
Moreover, check for Burger's sign
On elevation, check for pallor, venous guttering,
On dependence, check for hyperaremia
Also, check for the muscle power, tenderness and sensation.
71
What is the investigation of Chronic Limb Ischaemia?
Confirm the presence & severity of PAD
Identify the anatomical location of the disease
assess the sustainability for intervention
72
What are the further investigation you carry out for chronic limb ischaemia ?
Measure ankle-brachial pressure index (ABPI)
Doppler ultrasound/ Duplex scanning
Digital subtraction percutaneous angiography
Blood exams- FBC, U&Es, HBA1c, lipid profile
Electrocardiogram (ECG)
73
How to measure the ankle-brachial pressure index? (ABPI)
Less than 0.5 suggests severe arterial disease.
Greater than 0.5 to less than 0.8 suggests the presence of arterial disease or mixed arterial/venous disease.
Between 0.8 and 1.3 suggests no evidence of significant arterial disease.
Greater than 1.3 may suggest the presence of arterial calcification (DM)
A normal ABPI does not exclude the diagnosis
74
What is the management for chronic limb ischaemia ?
Intermittetent claudication
(We need to change the lifestyle claudication such as quit smoking, manage comorbid conditions such as HTN, high cholestrol and DM)
75
What is Rutherford Classification?
Staging system to describe lower extremity ischaemia.
76
List the classifications of Rutherfod classification?
stage 0 - asymptomatic
stage 1 - mild claudication
stage 2 - moderate claudication
stage 3 - severe claudication
stage 4- rest pain
stage 5 - ischaemic ulceration not
exceeding ulcer of the digits of the foot
stage 6 - severe ischemic ulcers or frank gangrene
77
What is Fontaine Classification?
Stage 1 - Asymptomatic
Stage 2 - Intermittent Claudication
Stage IIA- intermittetent claudication >200 metres
Stage IIB - intermittetent claudication <200 metres
Stage 3 - rest pain
Stage 4 - Ischemic ulcers or gangrene
78
What is the surgical procedure for chronic limb ischaemic ?
Invasive treatment options include
Angioplasty/stenting (for stenosis and short occlusions)
Surgical bypass or endarterectomy (long occlusions)
Procedures include femoral–popliteal bypass & aorto–bifemoral bypass grafts.
Autologous vein grafts (saphenous vein grafts) are superior to prosthetic grafts (eg Dacron® or PTFE).
79
What is the rationale of chronic limb ischaemia?
Risk of limb loss for patients with claudication (provided they do not have ischemic rest pain or tissue loss):
5-year risk of limb loss for patients with claudication is 5%
10-year risk of limb loss is 10%
Risk of limb loss for patients with ischemic rest pain:
Approximately 50% will have limb loss at 1 year without intervention
80
What is acute limb ischaemia ?
Any sudden decrease in limb perfusion causing a potential threat to limb viability
81
What are the symptoms of acute limb ischaemia ?
Patients presenting with symptoms for less than 2 weeks.
ranges from the patient with a few hours’ history of a painful cold white leg, to the patient with a sudden increase in ischaemic symptoms on a background of peripheral arterial disease
82
What is the pathophysiology of acute limb ischaemia?
Different causes leading to ALI:
arterial embolism (30%), arterial thrombosis due to plaque progression (40%), aneurysm (5%), trauma (5%)
83
What are the Risk factors of Acute limb ischaemia?
atrial fibrillation
recent myocardial infarction
valvular disease
and congestive heart failure are all common conditions that predispose to formation of cardio-emboli
84
What is the clinical presentation of acute limb ischaemia?
Classic features of ALI include the six P’s (developing over a period of less than 2 weeks)
*Not all need to be present:
Pain- constantly present and persistent.
Pulseless- ankle pulses are always absent.
Pallor (or cyanosis or mottling).
Paraesthesia or reduced sensation or numbness.
Perishing with cold.
Paralysis- poor prognostic sign; indicates irreversible ischaemia.
85
What is the more clinical presentation of acute limb ischaemia?
If ischaemia is due to a thrombus
Onset is more gradual.
The leg may not be white and symptoms may be less severe (due to collateral circulation, which is often well-developed in people with chronic peripheral vascular disease).
Presentation is usually with worsening claudication and rest pain.
Pulses in the other leg may also be absent
86
What are the investigation of acute limb ischaemia?
**Duplex ultrasound (DUS)**
Useful to assess anatomic location and degree of obstruction
**CT angiography/MRA**
First line modality for anatomical imaging (ESVS)
Long imaging session thus used in patients with non-immediately threatened limb
**Invasive angiogram (DSA)**
Invasive (w/potential complications)
Should not be used as 1st diagnostic tool
Should not replace but be complimentary to DUS in management
87
What are the investigation (blood) for cute limb ischaemia?
* Bloods
* coagulation tests
* ABG
* U &E
* CXR
* ECG
* Echocardiogram
88
What is the management for acute limb ischaemia?
Evaluate limb viability
* Prompt referral to centres that have 24- hour vascular team available (delay can jeopardize limb viability)
* Urgent anticoagulation w/ heparin (UFH 5,000 units IV)
* Analgesia for pain
* Oxygen & IV fluids
* DUS or CTA
for patients with stage I or IIa (determine nature & extent of obstruction)
89
What are the further management of acute limb ischaemia?
Definitive treatment (based on Rutherford classification):
Stage I or IIA
Formal imaging (CT, MR, angiogram) to determine nature & extent of obstruction& guide operative/endovascular management
Stage IIB (threatened limb)
Need urgent revascularization (either do operative intervention or thrombolysis)
Stage III (irreversible ischaemia)
Either palliation or amputation
90
What is the management of acute limb ischaemia?
Thrombolysis
Intra-arterial thrombolysis is an alternative treatment to surgery
In the UK thrombolysis use peaked in the late 1990s
Most centres now use surgery as a first line management in most patients, mainly due to concerns regarding efficacy and complication rates
Contraindications: bleeding tendency, pregnancy, CVA/TIA<2 months, intracerebral tumour, AVM, aneurysm, surgery < 2 wks, previous GI surgery
Complications of revascularization
Reperfusion injury
Compartment syndrome- managed by doing a fasciotomy
