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CARDIOVASCULAR MEDICINE > VASCULAR SURGERY > Flashcards

VASCULAR SURGERY Flashcards

1
Q

Does chronic limb ischaemia usually affect the upper or lower limbs?

A

Lower, but patients often have a history of other ischaemic problems such as angina

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2
Q

What are the risk factors for developing chronic lower limb ischaemia?

A 
Atherosclerosis
Diabetes mellitus
Hyperlipidaemia
Family history
Smoking
Buerger's disease
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3
Q

What is Buerger’s disease?

A

Recurring progressive inflammation and thrombosis of small and medium arteries and veins of the hands and feet. It is strongly associated with smoking.

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4
Q

What are the three stages of chronic limb ischaemia?

A

Intermittent claudication
Rest pain
Gangrene or ischaemic ulceration

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5
Q

What is intermittent claudication?

A

Cramp like pain in the legs (most often calf) exacerbated by exercise and relieved by rest. Pain develops distal to the obstruction.

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6
Q

What does pain at rest signify about chronic lower limb ischaemia?

A

That it has reached a critical stage where the viability of the leg is threatened. The artery is almost completely occluded at this point.

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7
Q

What are the two types of gangrene?

A

Wet

Dry

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8
Q

What is dry gangrene (as opposed to wet gangrene)?

A

Death of tissue. Tissue becomes black and there is a clear line of demarcation. No infection.

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9
Q

What is wet gangrene (as opposed to dry gangrene)?

A

Tissue is infected with pathogenic bacteria so infection will spread proximally and can cause systemic toxicity. The tissue will appear brown, moist and ulcerated.

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10
Q

What investigations would you do in someone who presented with intermittent claudication?

A

FBC - Aneamia, polycythemia
Lipidaemia
U&Es
BM - diabetes

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11
Q

How do you assess the vasculature of someone with intermittent claudication?

A

ABPI (ankle/brachial pressure measurement)
Doppler ultrasound
Arteriography

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12
Q

How would manage someone who was the in the first stage of chronic limb ischaemia (intermitent claudication)?

A 
Advise cessation of smoking
Encourage exercise
Prescribe 75mg Aspirin
Prescribe a statin
Control diabetes
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13
Q

How do you manage someone who presents with critical limb ischaemia (pain at rest/ulceration/gangrene)?

A

Heparinise, rehydrate and oxygenate them.

Send them for arteriography

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14
Q

A patient presents to you with critical limb ischaemia. You heparinise him, give him fluids and oxygen. The arteriogram shows a single short segment of blockage less than 5 cm long. How you manage this patient?

A

If less than 5cm balloon angioplasty can be used. Success rate of 85%.

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15
Q

A patient presents to you with critical limb ischaemia. You heparinise him, give him fluids and oxygen. The arteriogram shows a single segment of blockage more than 5 cm long. How you manage this patient?

A

A ballow angioplasty is not likely to be successful due to the length of the blockage. Use an expandable metal stent.

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16
Q

A patient presents to you with critical limb ischaemia. You heparinise him, give him fluids and oxygen. The arteriogram shows multisegment disease. How do you manage this patient?

A

Revascularisation through reconstructive surgery (bypass). Bypass surgery can either use a vein (in-situ or reversed) or a synthetic tube.

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17
Q

How is aortoiliac disease (blockage) causing critical limb ischaemia surgically treated?

A

Synthetic bifurcated graft from the aorta (proximal to blockage) to both femoral arteries (distal blockage)

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18
Q

How is aortoiliac disease (blockage) causing critical limb ischaemia surgically treated in someone who unfit for major abdominal surgery?

A

A graft can be passed from the axillary artery to the femoral artery under local anaesthetic.

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19
Q

What are the usual causes of acute limb ischaemia?

A 
Embolus or throbosis
Vascular injury (after trauma or intervention such as arteriography)
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20
Q

What are the six P’s of acute limb ischaemia?

A 
Pain
Perishing with cold
Pallor
Pulselessness
Paraesthesia
Paralysis
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21
Q

What does muscle rigidity imply in someone with acute limb ischaemia?

A

That the damage is irreversible

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22
Q

What are the main originating sites of an embolus that causes acute limb ischaemia?

A

Mural thrombus (in AF or site of previous MI)
Heart valves
Atrial myxoma
Atheromatous plaque

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23
Q

If there is no history of intermittent claudication in a patient with acute limb ischaemia, then what is the most likely cause?

A

Embolus

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24
Q

If there is a history of intermittent claudication in a patient with acute limb ischaemia, then what is the most likely cause?

A

Thrombus

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25
Q

How do you manage someone with acute limb ischaemia likely to be caused by an embolus (rather than chronic limb ischaemia and thrombus)?

A

Heparinise them

Embolectomy under local anaesthetic

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26
Q

What is used to extract an embolus in someone with acute limb ischaemia?

A

Fogarty balloon catheter

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27
Q

How do you manage someone with acute limb ischaemia likely to be caused by acute on chronic limb ischaemia (thrombus rather than embolus)?

A 
Arteriogram is needed
Thrombolytic therapy (streptokinase or similar) - cannot be used if viability of limb is threatened
Reconstructive surgery - bypass
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28
Q

In ischaemic limb patient in whom reconstructive surgery fails or is not possible, how do surgeons decide on the type of amputation?

A

Level of adequate blood supply

Suitability for prosthetic limb

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29
Q

What are the indications for limb amputation?

A 
Irreversible ischaemia
Refractory ulceration
Extensive rhabdomyolisis
Malignancy
Severe infection
Congenital deformity
Paralysed 'useless' limb
30
Q

What percentage of leg amputations are a consequence of vascular disease?

A

80%

31
Q

What are the common sites of amputation?

A 
Above knee
Through knee
Below knee
Transmetatarsal 
Ray amputation of digits
32
Q

What is a common complication of limb amputation?

A

Severe phantom limb pain

33
Q

How do you manage a patient following amputation?

A

Physiotherapy
Occupational therapy - prosthesis
Counselling (if needed)

34
Q

What is an aneurysm?

A

Abnormal dilatation of a vessel by more than 50%

35
Q

What are the common arterial sites that aneurysms occur?

A 
Abdominal aorta
Iliac
Thoracic aorta
Femoral
Popliteal
Cerebral
36
Q

What is the difference between a true and a false aneurysm?

A

A true aneurysm is one that involves all three layers of the wall of an artery (intima, media and adventitia)

A pseudoaneurysm, also known as a false aneurysm, is a hematoma that forms as the result of a leaking hole in an artery. Note that the hematoma forms outside the arterial wall, so it is contained by the surrounding tissues.

37
Q

What is the difference between a fusiform vs a saccular aneurysm?

A

Saccular aneurysms are spherical in shape and involve only a portion of the vessel wall; they vary in size from 5 to 20 cm (8 in) in diameter, and are often filled, either partially or fully, by a thrombus.

Fusiform aneurysms (“spindle-shaped” aneurysms) are variable in both their diameter and length; their diameters can extend up to 20 cm (8 in). They often involve large portions of the ascending and transverse aortic arch, the abdominal aorta, or less frequently the iliac arteries.

38
Q

What is the most common cause of aneurysm?

A

Atherosclerosis

39
Q

Other than atherosclerosis, what are the causes of aneurysm?

A

Congenital
Infection - mycotic or syphilitic
Trauma - eg intervention radiology

40
Q

What is the name given to an aneurysm in the circle of Willis?

A

Berry aneurysm

41
Q

What is the most common cause of Berry aneurysm?

A

Congenital

42
Q

How might someone with an abdominal aortic aneurysm present?

A

Asymptomatic - detected during routine examination
Abdominal pulsation
Recent onset severe back pain / flank pain
Hypotension
Circulatory collapse and severe abdominal pain - rupture
Signs of CHF, abdominal bruit, oedema - erosion into vena cava

43
Q

What is the mortality rate for a ruptured abdominal aortic aneurysm?

A

80%

44
Q

What are the risk factors for developing an abdominal aortic aneurysm?

A 
Age
Male (5:1)
Smoking
Hypertension
Faimly history
Connective tissue disorder (Ehlers Danlos)
45
Q

What is the risk of an AAA that is 3 cm in diameter rupturing in the next year?

A

0.4%

46
Q

What is the risk of an AAA that is 4 cm in diameter rupturing in the next year?

A

1%

47
Q

What is the risk of an AAA that is 4.5 cm in diameter rupturing in the next year?

A

2%

48
Q

What is the risk of an AAA that is 5 -5.9 cm in diameter rupturing in the next year?

A

9%

49
Q

What is the risk of an AAA that is 6 - 6.9 cm in diameter rupturing in the next year?

A

19%

50
Q

What is the risk of an AAA that is over 7 cm in diameter rupturing in the next year?

A

34%

51
Q

What diameter must an AAA reach for the benefits of elective surgery to outweigh the risks?

A

5.5 cm

52
Q

How is an AAA repaired electively?

A

Stent
Endovascular aortic aneurysm repair (EVAR) - stent delivered via the femoral artery
Fenestrated endovascular aortic aneurysm repair (FEVAR)

53
Q

What are the complications of surgical repair of an AAA?

A

Lower limb ischaemia due to thrombus or embolus
Colonic ischaemia
Spinal cord ischaemia
Graft infection
Aortoenteric fistula
False aneurysm at site of anastomosis (post surgery for ruptured aneurysm)

54
Q

What are varicose veins?

A

Tortuous, dilated, superficial veins with incompetent valves.

55
Q

What are the veins that usually become varicose veins?

A

Long and short saphenous veins of the leg

56
Q

What is the name of the congenital syndrome comprising of varicose veins, limb hypertrophy and a port wine stain?

A

Klippel-Trenaunay syndrome

57
Q

What proportion of the population of over 40 year olds are affected by varicose veins?

A

50%

58
Q

What are the risk factors for developing varicose veins?

A 
Family history
Female (5:1, although 2:1 after 6th decade)
Age over 50
Multiparity (having more than one child)
Prolonged standing
Obesity
Previous DVT
59
Q

What are the symptoms of varicose veins?

A 
Often asymptomatic
Cosmetic dissatisfaction
Aching
Itching
Heavy legs
Swelling
60
Q

What are the signs of varicose veins?

A 
Distended veins on standing
Telangiectasia (small red or purple clusters on the skin)
Eczema
Mild pitting oedema
Ulceration
61
Q

How might you further investigate someone who presents with varicose veins?

A

Clinical examination or Duplex scan to find level of incompetent vein
Venogram to check for thrombosis (only if there is history of thrombosis)

62
Q

How would manage someone with varicose veins?

A

Elevation
Support hosiery (stockings)
Laser/radiofrequency ablation
Open surgery - stripping, high tie (disconnection from femoral vein), ligation, avulsions

63
Q

What are the complications of surgically treating varicose veins?

A 
Recurrence
Nerve damage
Bruising
Infection
Bleeding
DVT
Pigmentation
64
Q

What is the most common point of incompetence in people with varicose veins?

A

The saphenofemoral junction

65
Q

What is lymphoedema?

A

Failure of the lymphatic transport system, resulting protein rich fluid accumulating in the subcutaneous tissue.

66
Q

What is the difference between primary and secondary lymphoedema?

A

Primary - Congenital abnormality,

Secondary - interruption or blockage of lymphatic channels

67
Q

What are the causes of secondary lymphoedema?

A

Surgical excision
Infection
Tumour infiltration
Radiotherapy

68
Q

What are the clinical features of lymphoedema?

A

Painless diffuse swelling in a distal to proximal distribution
Hyperkeratosis
Sausage shaped toes
Stemmers sign

69
Q

What is hyperkeratosis?

A

Thickening of the outer layer of skin

70
Q

What is Stemmer’s sign?

A

Inability to pick up a fold of skin at the base of the second toe

71
Q

How do you manage someone with lymphoedema?

A

First exclude other causes (eg heart failure)
Supportive treatment: skin care, elevation, support hosiery (stockings)
Manual lymphatic drainage (massage)
Surgery

72
Q

How can you tell the difference between an ischaemic and a neuropathic ulcer in a diabetic patient?

A 
Ischaemic:
Painful
No pulses
Ulceration on toes and pressure areas
Cold to touch
Associated with intermittent claudication
Neuropathic:
Sensory impairment
Pulses present
Plantar ulceration - deep and painless
Warm due to autonomic neuropathy
Associated with trophic skin lesions, Charcot's joints

CARDIOVASCULAR MEDICINE (15 decks)

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