Vascular surgery Flashcards
DVT
thrombus in deep veins of calf / hip
DVT RFs
- immobility
- recent surgery
- long haul flight
- pregnancy
- cOCP, combined HRT
- tamoxifen, olanzapine
- malignancy
- polycythaemia
- SLE
- thrombophilias
- sickle cell
- hyperviscosity syndrome
VTE prophylaxis
- assess risk
- LMWH - enoxaparin - CI if bleeding / anticoagulated
- Anti-embolic compression stockings - CI in PAD
DVT Px
- unilateral calf / leg swelling
- pain
- dilated superficial veins
- tender
- oedema
- colour changes
- ask about SOB, pleuritic CP
DVT Wells Score
- 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
If DVT likely (2 or more) on Wells
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
IF DVT unlikely (1 or less) on Wells
D-dimer
- positive -> USS <4hrs, or start anticoagulation and scan <24hrs
- negative - DVT unlikely
DVT Mx
- 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
Peripheral artery disease (PAD)
- 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
Atherosclerosis RFs
- older, FHx, male
- smoking, alcohol, poor diet, low exercise, obesity, poor sleep, stress
- DM, HTN, CKD, RA, atypical antipsychotics
PAD Px
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
PAD Ix
- Pulses, Buerger’s
- FBC…
- ABPI - PAD 0.5-0.9, critical <0.5
- Doppler US
- MR / CT angiography
PAD Mx
- exercise, stop smoking
Medical
- atorvastatin 80mg
- clopidogrel
- Tx comorbidities
- consider naftidrofuryl oxalate
Surgical
- angioplasty +/- stent
- surgical bypass
- endarterectomy
- amputation
Acute limb ischaemia
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
Acute limb ischaemia Px
- pale
- Pulseless
- Painful
- Paralysed
- Paraesthesia
- Perishingly cold
Acute limb ischaemia Ix
- US doppler
- CT angio
Acute limb ischaemia Mx
- unfractionated heparin
- IV opioids - analgesia
Vascular mx
- endovascular thrombolysis
- endovascular thrombectomy
- surgical embolectomy / thrombectomy
- angioplasty
- bypass surgery
- amputation
Varicose veins
- dilated, tortuous, superficial veins, commonly found in legs
- incompetent valves
- often in great / small saphenous veins in legs
Varicose veins RFs
- older
- female
- pregnancy
- obesity
- FHx
- prolonged sitting / standing
- Hx of DVT
Varicose veins Px
- varicose veins
- aching, throbbing
- itching
- swelling
- heaviness
Cx
- skin changes - varicose eczema, haemosiderin, lipodermatosclerosis, atrophie blanche
- bleeding
- superficial thrombophlebitis
- venous ulceration
- DVT
Varicose veins Ix
- tap test
- cough test
- Trendelenburg test
- Perthes test
- venous duplex US
Varicose veins Mx
- 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
Chronic venous insufficiency
- 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
Chronic venous insufficiency Px
- haemosiderin staining
- venous eczema
- lipodermatosclerosis
- atrophie blanche
- cellulitis
- poor healing post-injury
- skin ulcers
- pain
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
Lymphoedema
- oedema from impaired lymphatic drainage
Primary
- rare, genetic condition
Secondary
- lymph node removal, radio, cellulitis, trauma, DVT, obesity, sedentary
Lymphoedema Px
- uncomfortable swelling
- restricted movt
- limb aches, feels heavy
- clear fluid leaks from skin
- thickened skin
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
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
Lymphatic filariasis
- infectious disease - parasitic worms spread by mosquitoes
- live in lymphatics - cause severe lymphoedema
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
AAA RFs
M, older, smoking, HTN, FHx, CVD
AAA screening
- offer to men >65yo
- consider in women >70yo with RFs
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
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
AAA Ix
- USS
- CT angio
AAA Mx
- stop smoking, mx HTN, DM, lipids
Elective repair
- EVAR - endovascular aneurysm repair
- open repair - laparotomy
Ruptured
- emergency surgery
- blood
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
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
Thoracic aortic aneurysm Ix
- CT angio
- USS
Thoracic aortic aneurysm Mx
- Tx cause
- stop smoking, control BP
- surgical repair
Aortic dissection
- tear in wall of aorta - blood enters false lumen between intima + media
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
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
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
Aortic dissection Ix
- ECG
- CXR - widened mediastinum
- CT angio
- USS
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
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
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
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
Carotid artery stenosis Px
- asym
- dx after TIA / stroke
- carotid bruit on auscultation - systolic
Carotid artery stenosis Ix
- carotid ultrasound
- CT / MRI angiogram
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
Buerger disease
- inflammatory condition - thrombosis in small / medium vessels in distal arterial system - hands + feet
- strong smoking association
Buerger disease Px
- painful blue discolouration to fingertips / toe tips
- worse at night
- may see Raynauds
- ulcers, gangrene, amputation
Buerger disease Ix
- angiography - corkscrew collaterals
for Dx
- <50yo
- no RFs for atherosclerosis, other than smoking
Buerger disease Mx
- stop smoking completely
- IV iloprost maybe
