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Phase 4 Question Knowledge > Vascular surgery > Flashcards

Vascular surgery Flashcards

1
Q

DVT

A

thrombus in deep veins of calf / hip

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2
Q

DVT RFs

A
  • immobility
  • recent surgery
  • long haul flight
  • pregnancy
  • cOCP, combined HRT
  • tamoxifen, olanzapine
  • malignancy
  • polycythaemia
  • SLE
  • thrombophilias
  • sickle cell
  • hyperviscosity syndrome
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3
Q

VTE prophylaxis

A
  • assess risk
  • LMWH - enoxaparin - CI if bleeding / anticoagulated
  • Anti-embolic compression stockings - CI in PAD
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4
Q

DVT Px

A
  • unilateral calf / leg swelling
  • pain
  • dilated superficial veins
  • tender
  • oedema
  • colour changes
  • ask about SOB, pleuritic CP
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5
Q

DVT Wells Score

A
  • Active cancer 1
  • Paralysis / immobilisation of lower limbs 1
  • Bedridden for 3+ days, or major surgery within 12wks 1
  • Localised tenderness 1
  • Entire leg swollen 1
  • Calf swelling >3cm than other side 1
  • Unilateral pitting oedema 1
  • Dilated superficial veins 1
  • Previous DVT 1
  • Alternative dx likely -2

If 1 or less points - DVT unlikely, 2 or more - DVT likely

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6
Q

If DVT likely (2 or more) on Wells

A

USS <4hrs
- positive -> DVT Mx
- negative -> D dimer - if positive, stop interim anticoagulants, rpt US 1wk (negative - DVT unlikely)

If US not available <4hrs, D-dimer, start interim DOAC / LMWH, USS <24hrs

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7
Q

IF DVT unlikely (1 or less) on Wells

A

D-dimer
- positive -> USS <4hrs, or start anticoagulation and scan <24hrs
- negative - DVT unlikely

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8
Q

DVT Mx

A
  • Apixaban / rivaroxaban - 1st line / active cancer
  • LMWH, followed by dabigatran / edoxaban / warfarin
  • renal impairment - LMWH, heparin / warfarin
  • APl syndrome - LMWH, warfarin
  • ORBIT score
  • ?Catheter-directed thrombolysis
  • IVC filter

Provoked VTE
- 3mo tx (3-6mo if active cancer)

Unprovoked VTE
- 6mo tx
- APl ABs, Ix for thrombophilias

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9
Q

Peripheral artery disease (PAD)

A
  • narrowing of artery - atherosclerosis / thrombus

Intermittent claudication
- cramping, relieved by rest

Critical limb ischaemia
- claudication at rest, eg nocturnal

Acute limb ischaemia
- sudden decrease in limb ischaemia

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10
Q

Atherosclerosis RFs

A
  • older, FHx, male
  • smoking, alcohol, poor diet, low exercise, obesity, poor sleep, stress
  • DM, HTN, CKD, RA, atypical antipsychotics
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11
Q

PAD Px

A

Intermittent claudication
- aching / burning in legs after walking
- relieved by rest
- not at rest

Critical limb ischaemia
- rest pain
- worse at night
- hang foot off bed to relieve pain
- ulcers, gangrene

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12
Q

PAD Ix

A
  • Pulses, Buerger’s
  • FBC…
  • ABPI - PAD 0.5-0.9, critical <0.5
  • Doppler US
  • MR / CT angiography
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13
Q

PAD Mx

A
  • exercise, stop smoking

Medical
- atorvastatin 80mg
- clopidogrel
- Tx comorbidities
- consider naftidrofuryl oxalate

Surgical
- angioplasty +/- stent
- surgical bypass
- endarterectomy
- amputation

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14
Q

Acute limb ischaemia

A

sudden decrease in arterial perfusion to limb

factors suggesting thrombus
- pre-existing claudication
- reduced pulses in other limb
- vascular disease, eg MI, stroke, TIA

Embolus
- sudden onset pain
- no hx claudication
- embolus source, eg AF, recent MI
- no PAD
- proximal aneurysm, eg abdo / popliteal

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15
Q

Acute limb ischaemia Px

A
  • pale
  • Pulseless
  • Painful
  • Paralysed
  • Paraesthesia
  • Perishingly cold
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16
Q

Acute limb ischaemia Ix

A
  • US doppler
  • CT angio
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17
Q

Acute limb ischaemia Mx

A
  • unfractionated heparin
  • IV opioids - analgesia

Vascular mx
- endovascular thrombolysis
- endovascular thrombectomy
- surgical embolectomy / thrombectomy
- angioplasty
- bypass surgery
- amputation

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18
Q

Varicose veins

A
  • dilated, tortuous, superficial veins, commonly found in legs
  • incompetent valves
  • often in great / small saphenous veins in legs
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19
Q

Varicose veins RFs

A
  • older
  • female
  • pregnancy
  • obesity
  • FHx
  • prolonged sitting / standing
  • Hx of DVT
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20
Q

Varicose veins Px

A
  • varicose veins
  • aching, throbbing
  • itching
  • swelling
  • heaviness

Cx
- skin changes - varicose eczema, haemosiderin, lipodermatosclerosis, atrophie blanche
- bleeding
- superficial thrombophlebitis
- venous ulceration
- DVT

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21
Q

Varicose veins Ix

A
  • tap test
  • cough test
  • Trendelenburg test
  • Perthes test
  • venous duplex US
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22
Q

Varicose veins Mx

A
  • elevate leg, wt loss, exercise
  • graduated compression stockings

Indications for secondary care referral
- severe sx, pain, discomfort
- previous bleed
- skin changes
- superficial thrombophlebitis
- active / healed venous leg ulcer

Secondary care tx
- endothermal ablation
- foam sclerotherapy
- surgery - ligation / stripping

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23
Q

Chronic venous insufficiency

A
  • blood doesn’t drain back to heart from legs efficiently

Patho
- incompetent valves
- damage with age, immobility, obesity, prolonged standing, DVT
- varicose veins
- venous HTN

24
Q

Chronic venous insufficiency Px

A
  • haemosiderin staining
  • venous eczema
  • lipodermatosclerosis
  • atrophie blanche
  • cellulitis
  • poor healing post-injury
  • skin ulcers
  • pain
25
Q

Chronic venous insufficiency Mx

A

Healthy skin
- emollients
- topical steroids for venous eczema
- potent steroids - lipodermatosclerosis

Improve venous drainage
- wt loss, keep active
- elevate legs
- compression stockings

Mx of Cx
- Abx for infection
- analgesia for pain
- wound care for ulcers

26
Q

Lymphoedema

A
  • oedema from impaired lymphatic drainage

Primary
- rare, genetic condition

Secondary
- lymph node removal, radio, cellulitis, trauma, DVT, obesity, sedentary

27
Q

Lymphoedema Px

A
  • uncomfortable swelling
  • restricted movt
  • limb aches, feels heavy
  • clear fluid leaks from skin
  • thickened skin
28
Q

Lymphoedema Ix

A
  • clinical dx
  • R/o DVT
  • CT / MRI for ?malignancy blocking lymphatics
  • Stemmer’s sign
  • calculate limb volume - measure circumference / water displacement / perometry
  • bioelectric impedance spectrometry
  • lymphoscintigraphy
29
Q

Lymphoedema Mx

A
  • clinical dx
  • R/o DVT
  • CT / MRI for ?malignancy blocking lymphatics
  • Stemmer’s sign
  • calculate limb volume - measure circumference / water displacement / perometry
  • bioelectric impedance spectrometry
  • lymphoscintigraphy

Lymphoedema Mx
- refer to lymphoedema service
- abx for cellulitis
- avoid cannulating / measuring BP in limb

Non-surgical
- massage
- compression bandages
- exercises
- wt loss, good skin care

Surgical
- lymphaticovenular anastomosis

30
Q

Lymphatic filariasis

A
  • infectious disease - parasitic worms spread by mosquitoes
  • live in lymphatics - cause severe lymphoedema
31
Q

AAA

A
  • dilatation of abdo aorta >3cm

True
- dilatation of all layers of arterial wall - degradation of elastic lamellae

False
- pseudoaneurysm
- blood leaks through arterial wall, but contained by adventitia / surrounding tissue

32
Q

AAA RFs

A

M, older, smoking, HTN, FHx, CVD

33
Q

AAA screening

A
  • offer to men >65yo
  • consider in women >70yo with RFs
34
Q

AAA classification

A
  • Normal <3cm - no further action
  • Small 3-4.4cm - rescan every 12mo
  • Medium 4.5-5.4cm - rescan every 3mo
  • Large >5.5cm - refer within 2wks to vascular
35
Q

AAA Px

A

Unruptured
- asym
- non-specific back pain
- pulsatile / expansile mass in abdo

Ruptured
- severe abdo pain, ?radiate to back/groin
- haemodynamically unstable
- pulsatile / expansile mass in abdo
- collapse, LOC
- if retroperitoneal, may maintain BP temporarily

36
Q

AAA Ix

A
  • USS
  • CT angio
37
Q

AAA Mx

A
  • stop smoking, mx HTN, DM, lipids

Elective repair
- EVAR - endovascular aneurysm repair
- open repair - laparotomy

Ruptured
- emergency surgery
- blood

38
Q

Thoracic aortic aneurysm

A

aneurysm of thoracic aorta

Causes
- genetics
- Marfan’s, EDS
- mycotic aneurysm
- aortic dissection
- weightlifting, cocaine, amphetamines

RFs
- HTN, older, smoking, bicuspid / unicuspid aortic valves, atherosclerosis, COPD, renal failure

39
Q

Thoracic aortic aneurysm Px

A
  • asym
  • aortic regurg
  • fever if infective
  • collapse, shock
  • cardiac tamponade
  • compression of local structures - hoarse voice, cough, SOB
  • pain - chest, neck, back
  • haemoptysis
40
Q

Thoracic aortic aneurysm Ix

A
  • CT angio
  • USS
41
Q

Thoracic aortic aneurysm Mx

A
  • Tx cause
  • stop smoking, control BP
  • surgical repair
42
Q

Aortic dissection

A
  • tear in wall of aorta - blood enters false lumen between intima + media
43
Q

Aortic dissection classification

A

Stanford system
- Type A - 2/3 cases, ascending aorta, before brachiocephalic artery
- Type B - descending aorta, after left subclavian artery

DeBakey system
- Type I - begins in ascending aorta, involves at least aortic arch, if not beyond
- Type II - isolated to ascending aorta
- Type IIIa - begins in descending aorta, involves only section above diaphragm
- Type IIIb - begins in descending aorta, involves aorta below diaphragm

44
Q

Aortic dissection RFs

A
  • Older, male, smoking, HTN, poor diet / exercise, raised cholesterol
  • weightlifting, cocaine
  • bicuspid aortic valve, coarctation of aorta, aortic valve replacement, CABG
  • EDS, Marfan’s
45
Q

Aortic dissection Px

A
  • sudden onset severe tearing chest pain
  • pain maximal at onset
  • anterior chest / back / abdo
  • may migrate
  • may be hypertensive
  • BP difference >20 between arms
  • pulse deficit - carotid, brachial, femoral, radial
  • diastolic murmur
  • collapse
  • hypotension eventually
  • Coronary arteries - angina - RCA involvement
  • Spinal arteries - paraplegia, weakness/paraesthesia
  • Distal aorta - limb ischaemia
46
Q

Aortic dissection Ix

A
  • ECG
  • CXR - widened mediastinum
  • CT angio
  • USS
47
Q

Aortic dissection Mx

A
  • analgesia
  • IV labetalol for BP

Vascular surgery review
- Type A - midline sternotomy, synthetic graft
- Type B - TEVAR - thoracic endovascular aortic repair, via femoral artery

48
Q

Superficial thrombophlebitis

A
  • inflammation with superficial vein thrombosis - usually long saphenous vein
  • may have secondary bacterial infection
  • 20% have DVT

Ix
- USS to r/o DVT

Mx
- LMWH
- NSAIDs
- topical heparinoids
- compression stockings

49
Q

Leriche syndrome

A
  • atheromatous disease of distal aorta / proximal common iliac artery

Px
- thigh / buttock claudication
- absent femoral pulses
- male impotence

Ix
- angiography

Mx
- endovascular angioplasty / stent

50
Q

Carotid artery stenosis

A
  • narrowing of carotid arteries - from atherosclerosis
  • risk of embolus, also coronary artery disease, MI

Classification
- mild <50% reduction
- moderate 50-69% reduction
- severe >70% reduction

51
Q

Carotid artery stenosis Px

A
  • asym
  • dx after TIA / stroke
  • carotid bruit on auscultation - systolic
52
Q

Carotid artery stenosis Ix

A
  • carotid ultrasound
  • CT / MRI angiogram
53
Q

Carotid artery stenosis Mx

A
  • healthy diet, exercise, stop smoking
  • Mx HTN, DM, lipids
  • aspirin, clopidogrel / ticagrelor

Surgical
- carotid endarterectomy (risk of nerve damage)
- angioplasty + stenting

54
Q

Buerger disease

A
  • inflammatory condition - thrombosis in small / medium vessels in distal arterial system - hands + feet
  • strong smoking association
55
Q

Buerger disease Px

A
  • painful blue discolouration to fingertips / toe tips
  • worse at night
  • may see Raynauds
  • ulcers, gangrene, amputation
56
Q

Buerger disease Ix

A
  • angiography - corkscrew collaterals

for Dx
- <50yo
- no RFs for atherosclerosis, other than smoking

57
Q

Buerger disease Mx

A
  • stop smoking completely
  • IV iloprost maybe

Phase 4 Question Knowledge (30 decks)

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