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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
Chronic venous insufficiency Mx
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
Lymphoedema
- oedema from impaired lymphatic drainage Primary - rare, genetic condition Secondary - lymph node removal, radio, cellulitis, trauma, DVT, obesity, sedentary
27
Lymphoedema Px
- uncomfortable swelling - restricted movt - limb aches, feels heavy - clear fluid leaks from skin - thickened skin
28
Lymphoedema Ix
- 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
Lymphoedema Mx
- 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
Lymphatic filariasis
- infectious disease - parasitic worms spread by mosquitoes - live in lymphatics - cause severe lymphoedema
31
AAA
- 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
AAA RFs
M, older, smoking, HTN, FHx, CVD
33
AAA screening
- offer to men >65yo - consider in women >70yo with RFs
34
AAA classification
- 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
AAA Px
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
AAA Ix
- USS - CT angio
37
AAA Mx
- stop smoking, mx HTN, DM, lipids Elective repair - EVAR - endovascular aneurysm repair - open repair - laparotomy Ruptured - emergency surgery - blood
38
Thoracic aortic aneurysm
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
Thoracic aortic aneurysm Px
- asym - aortic regurg - fever if infective - collapse, shock - cardiac tamponade - compression of local structures - hoarse voice, cough, SOB - pain - chest, neck, back - haemoptysis
40
Thoracic aortic aneurysm Ix
- CT angio - USS
41
Thoracic aortic aneurysm Mx
- Tx cause - stop smoking, control BP - surgical repair
42
Aortic dissection
- tear in wall of aorta - blood enters false lumen between intima + media
43
Aortic dissection classification
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
Aortic dissection RFs
- 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
Aortic dissection Px
- 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
Aortic dissection Ix
- ECG - CXR - widened mediastinum - CT angio - USS
47
Aortic dissection Mx
- 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
Superficial thrombophlebitis
- 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
Leriche syndrome
- 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
Carotid artery stenosis
- 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
Carotid artery stenosis Px
- asym - dx after TIA / stroke - carotid bruit on auscultation - systolic
52
Carotid artery stenosis Ix
- carotid ultrasound - CT / MRI angiogram
53
Carotid artery stenosis Mx
- healthy diet, exercise, stop smoking - Mx HTN, DM, lipids - aspirin, clopidogrel / ticagrelor Surgical - carotid endarterectomy (risk of nerve damage) - angioplasty + stenting
54
Buerger disease
- inflammatory condition - thrombosis in small / medium vessels in distal arterial system - hands + feet - strong smoking association
55
Buerger disease Px
- painful blue discolouration to fingertips / toe tips - worse at night - may see Raynauds - ulcers, gangrene, amputation
56
Buerger disease Ix
- angiography - corkscrew collaterals for Dx - <50yo - no RFs for atherosclerosis, other than smoking
57
Buerger disease Mx
- stop smoking completely - IV iloprost maybe

Phase 4 Question Knowledge (36 decks)

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