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Periop > Vascular Surgery > Flashcards

Vascular Surgery Flashcards

1
Q

What is the range of ABPI you would expect in patients with intermittent claudication?

A

0.5-0.9

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2
Q

Lis the symptoms and signs found on examination of a patient with chronic lower limb arterial disease

A
  • brittle nails
  • thin dry skin
  • pallor, esp on elevation
  • sunset foot
  • superficial veins that fill sluggishly in horizontal position
  • muscle wasting
  • decreased temp
  • pulses weak or absent
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3
Q

What is ABPI?

A

Ankle Brachial Pressure Index - using an ankle cuff and a hand held Doppler to measure the blood pressure in the ankle; this is compared to the brachial pressure. The ratio is calculated as ankle pressure / brachial pressure

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4
Q

Why does sunset foot occur?

A

Due to reactive hyperaemia

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5
Q

Describe Buergers test in patient with chronic lower limb arterial disease

A

Elevation of the foot to assess vascular flow. In a normal leg, it would remain pink on elevation, however in chronic arterial disease, the leg may become pale. Once the leg is lowered again, it will go back to pink and then to red due to reactive hyperaemia (this is SUNSET FOOT)

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6
Q

Define Intermittent claudication

A

Pain in the calf/thigh/buttock only associated with exercise and resolves quickly (

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7
Q

What are the causes of intermittent claudication?

A

Nearly always atherosclerosis

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8
Q

What is the claudication distance

A

The distance at which a patient with intermittent claudication exercises before they get symptoms - this is a constant distance

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9
Q

What determines the pain pattern experienced in intermittent claudication

A

The artery affected
If sfa - calf claudication
If aortoiliac artery - thigh/buttock claudication

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10
Q

Step by step, go through the management options for intermittent claudication

A
  • best medical therapy
  • endovascular intervention considered if symptoms or signs last >6 months despite bmt
  • surgical intervention
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11
Q

What does best medical therapy for a patient with intermittent claudication involve, and what drugs may they be started on

A

Smoking cessation
Statin
Anti platelet therapy
Supervised exercise

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12
Q

What may be found on examination with a patient who has intermittent claudication

A

ABPI near normal at rest but reduced on exercise
Pulse may be diminished
Bruit may be heard at or below the stenosis
(Ankle and popliteal pulses absent if thrombosis occurs)

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13
Q

What is the progression like for patients with intermittent claudication

A

May remain stable for several years as collateral circulation develops
Atherosclerosis continues developing and may involve other segments without bmt
As the symptoms develop and worsen, may progress to critical limb ischaemia

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14
Q

Give two differential diagnoses for intermittent claudication

A

Venous claudication, neurogenic claudication

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15
Q

What is venous claudication

A

Claudication due to venous outflow obstruction, caused by iliofemoral venous occlusion secondary to DVT

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16
Q

What is neurogenic claudication

A

Lumbar nerve roots or cauda equina (spinal stenosis) compression

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17
Q

How is neurogenic claudication different to intermittent claudication?

A 
Involves whole leg
Often bilateral
Often immediate upon walking or standing, not gradual like intermittent claudication 
Tingling or numbness
Pulses normal
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18
Q

What are the symptoms of venous claudication

A 
Whole leg
Bursting in nature
Nearly always unilateral 
Elevating leg gives relief
Cyanosis
Often visible varicose veins
Venous skin changes 
Temp increased
Swelling always present 
Pulses present
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19
Q

What is critical limb ischaemia

A

Condition of chronic rest pain, ulcers or gangrene in one or both legs, attributable to extensive arterial disease (occlusive). Advanced stage of peripheral artery disease

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20
Q

What is critical limb ischaemia caused by

A

Multiple lesions affecting different arterial segments down the leg (unlike intermittent claudication, which is usually single level)

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21
Q

When do patients get pain with CLI and why?

A

At night (rest) as there is a decreased in perfusion to the peripheral leg due to loss of gravity when lying down. The patient hence dangles their foot off their bed to gain relief

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22
Q

Some patients who have CLI may sleep in a chair to gain relief from pain, what can this cause however

A

May result in dependent oedema, which is caused by increased interstitial pressure leading to reduced arterial perfusion

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23
Q

What are the three stages of chronic lower limb arterial disease

A
  • non critical : IC
  • subcritical : night/rest pain
  • critical : tissue loss (ulceration and gangrene)
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24
Q

List the different management options for a patient with lower limb ischaemia

A
  • BMT
  • endovascular management - balloon angioplasty +/- stent to enlarge lumen
  • for arterial occlusion - endarterectomy, bypass grafting
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25
Q

What is endarterectomy

A

Direct removal or atherosclerotic plaque (+patch angioplasty)

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26
Q

What is Buergers disease also know as

A

Thromboangitis obliterans

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27
Q

What is buergers disease

A

Smoking related inflammation of the veins, nerves and middle sized arteries, which thrombosis and lead to gangrene. Unknown cause

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28
Q

What is vital in buergers disease

A

Stopping smoking

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29
Q

What are the patients affected with buergers disease usually?

A

Young, male

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30
Q

What are the symptoms of buergers disease

A

Claudication in feet and rest pain in toes and fingers

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31
Q

When would amputation be considered with chronic limb ishcaemia

A

When arterial reconstruction is inappropriate or impossible

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32
Q

At what level should amputations be carried out

A

Lowest possible consistent with healing, it is important it try and preserve the knee joint

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33
Q

What is the difference in treatment of embolus vs thrombus

A

Embolus is treated with embolectomy and warfarin

Thrombus is treated with bypass and thrombolysis

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34
Q

What is administered in a patient with a thrombus

A

Heparin

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35
Q

In reperfusion injury, which substances are released by the reperfused tissue which can lead to acute respiratory distress syndrome, myocardial stunting and endotoxaemia

A

Free radicals, enzymes, neutrophils, H+, K+, co2, myoglobin

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36
Q

What are the sequelae of endothelial injury in compartment syndrome?

A

Increased cap permeability, leading to oedema on reperfusion, increased interstitial tissue pressure in tight fascial boundaries. This leads to muscle necrosis

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37
Q

How do we test for compartment syndrome

A

Swelling and pain on squeezing the calf muscle

Passive stretch test causes pain on moving toes or ankle

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38
Q

What are the symptoms of sensory neuropathy in diabetic feet

A

Decreased pain sensation and proprioception

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39
Q

What are the symptoms of motor neuropathy on patients with diabetic feet

A

Does increasingly dorsiflexed and flexors in leg tend to be affected more
Atrophy

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40
Q

What are the symptoms of autonomic neuropathy in patients with diabetic foot

A

Dry foot
Loss of sweating
Scaling and fissuring

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41
Q

How is compartment syndrome treated

A

Dermatofasciotomy

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42
Q

List the 6 ps

A 
Pallor 
Perishingly cold
Paraesthesia
Pain
Pulse lessens
Paralysis
43
Q

Describe the symptoms of acute limb ischaemia over time

A

At first intense arterial spasm - “marble white” pain
Spasm relaxes over the next few hours and fills with deox. Blood - mottling, which blanches on pressure
Progression to darker mottling which doesn’t blanch as blood coagulates in skin
Blistering and liquefaction

44
Q

What are the three types of varicose vein

A

Trunk, reticular, telangiectasia

45
Q

What do trunk varicose veins look like

A

Palpable, large, usually involve mainstream or major tributaries

46
Q

What are some of the risk factors for varicose veins

A

Familial tendency, obesity, pregnancy, constipation, prolonged standing

47
Q

What do reticular varicose veins look like

A

Impalpable, render overlying skin dark blue

48
Q

What does telangeictasia look like

A

Spider or thread veins which lie superficial to the dermis
They’re impalpable
Overlying skin purple or bright red

49
Q

How is chronic venous ulceration treated

A

Graduated compression four layer or three layer bandaging

The greatest compression is at the ankle Improves venous function

50
Q

What is a contraindication to treating chronic venous ulceration with graduated compression bandaging

A

Significant arterial disease (ABPI

51
Q

What may be found on examination of a patient with a chronic venous ulcer

A 
Usually above medial malleolus
Surrounding skin damaged 
Subcut fibrosis
Pigmentation 
Acute inflammation
52
Q

What are some of the complications of chronic venous ulcers

A

Haemorrhage

Thrombophlebitis

53
Q

What is Raynaud’s phenomenon

A

Condition where there is pallor due to vasospams, followed by cyanosis (deox. blood), then rub or due to reactive hyperaemia

54
Q

What may trigger an attack in Raynaud’s disease

A

Cold or emotional stimuli

55
Q

How is Raynaud’s disease treated

A

CCB

56
Q

What is the conservative management of chronic venous ulceration

A

Elastic hose support, weight loss, regular exercise

57
Q

What are the surgical options for a person with chronic venous ulceration

A

Stripping of space out vein

Ligation at sfj if lsv affected

58
Q

What are the endovascular treatment options for chronic venous ulceration/varicose veins

A

Radiofrequency ablation
Endovascular laser ablation (evla)
Ultrasound guided sclerotherapy

59
Q

Are abx indicated in patient with chronic venous ulceration

A

No, unless you can confirm presence of B haemolytic strep or S aureus

60
Q

Of the ulcer and surrounding area are red , what should you suspect in a patient with chronic venous ulceration?

A

Cellulitis, take swabs and clean with warm tap water

61
Q

What is the usual diameter of the abdominal aorta, and at what diameter of an AAA would you consider surgery for the patient

A

Usually 2 cm, would consider surgery at 5.5 cm

62
Q

What are the treatment options for AAA

A

EVAR

Open repair

63
Q

What are some of the typical features of a ruptured AAA

A

Sudden collapse
Abdo / low back pain
Low BP
Vomiting

64
Q

How would you manage a patient who presents with a ruptured AAA

A

Don’t give large vols of fluid

Transfer to theatre where aorta would be clamped and treated either with open repair or EVAR

65
Q

What bloods would you do in patient who presents with ruptures AAA

A 
FBC
U and E
X match 
6 units 
Platelets
Clotting factors
66
Q

How do you assess the size of a AAA

A

USS

67
Q

What is a more precise measure of AAA size than an USS

A

More accurate info from CT, but is not a method of surveillance

68
Q

How is AAA usually picked up

A

As an incidental finding on USS, but may be picked up in the national screening programme of males >65 yo

69
Q

Where can AAAs extend into

A

Common iliac, and even the internal iliac artery

70
Q

How are popliteal aneurysms best treated

A

Bypass

71
Q

What structure can popliteal aneurysms compress

A

Popliteal vein –> DVT

72
Q

What are the two types of aneurysm shape

A

Saccular

Fusiform

73
Q

At which position on the abdominal aorta are AAAs usually found

A

Infrarenal

74
Q

List some other areas that are less commonly affected by aneurysms expect for the abdominal aorta

A

Popliteal
Femoral
Subclavian arteries

75
Q

What is the aetiology of aneurysms

A

Usually atherosclerotic, but may be caused by infections such as syphillis and salmonella

76
Q

What is the difference between a true and false aneurysm

A

True - involves all 3 layers of the arterial wall, enclosing the aneurysm
False - wall of artery damaged and the surrounding haematoma can remain within the lumen leading to pulsatilla swelling whose wall comprises compact thrombus and surrounding connective tissue

77
Q

How can a AAA cause DVT

A

Compression of the femoral vein may result

78
Q

Define stroke

A

Episode of focal neurological dysfunction lasting over 24 hours of presumes vascular aetiology

79
Q

What are the symptoms of a cva

A

Loss of speech, unilateral visual loss or disturbance, motor and sensory loss

80
Q

How is cva managed

A

Aspirin
Duplex scan carotids
CT scan to exclude haemorrhage

81
Q

What is Amaurosis fugax ?

A

Transient, usually incomplete loss of vision in one eye owing to occlusion of branch of the retinal artery by emboli
“Veil” or “curtain” coming across eye

82
Q

What is carotid endarterectomy

A

Shunt put in to maintain blood flow to head while the occluding plaque is removed and the artery is repaired by primary closure or with patch graft (patch angioplasty)

83
Q

Except for carotid endarterectomy, what is another option for treating carotid atherosclerosis

A

Carotid stenting

84
Q

What are varicose veins

A

Veins seen with chronic venous insufficiency due to failure of venous drainage of leg due to valvular incompetence - leading to skin ulceration and discolouration

85
Q

What are some of the predisposing factors to varicose veins

A

Female
History of childbirth
Occupations involving long periods of standing

86
Q

Why is it important to ask about previous fractures in patients with varicose veins

A

The fracture may have caused a DVT preventing drainage through veins because of the occlusion

87
Q

How can you investigate varicose veins

A

Duplex ultrasound

Trendelenburg test

88
Q

What is the most commonly affected vein in patients who suffer from varicose veins

A

Lsv

89
Q

What are the symptoms of varicose veins

A

Uncomfortable and heavy leg when standing up for a long time due to poor venous drainage
Damage to skin such as lipodermatosclerosis? And pigmentation

90
Q

Which valve is usually incompetent to cause varicose veins

A

Sfj

91
Q

What are secondary varicose veins a product of

A

DVT

92
Q

What is the trendelenburg test when assessing a vascular patient

A

Raise leg to empty veins
Apply tourniquet on high thigh
If veins fill rapidly, the. There is valvular incompetence below the level of the tourniquet

93
Q

List some of the presentations of varicose veins

A 
Cosmetic
Tiredness
Heaviness
Ulceration
Itchiness
94
Q

In the trendeleburg test, what does veins filling more rapidly with the tourniquet on suggest

A

There is valvular incompetence below the level of the tourniquet I.e. In the deep veins

95
Q

In the trendelenburg test, if the tourniquet is removed and the veins then fill rapidly, what does this indicate

A

That superficial veins are incompetent

96
Q

List the hard signs of arterial injury (these patients require immediate surgery)

A
  • external arterial bleeding
  • rapidly expanding haematoma
  • palpable thrill, audible bruit
  • avoids acute limb ishcaemia
97
Q

What are the soft signs of arterial injury

A
  • history of bleeding at scene
  • trauma/injury near major artery
  • unilateral pulse diminished
  • small, non pulsation haematoma
  • neurogenic deficit
98
Q

How are patients with soft signs of arterial injury assessed

A

Serial examination, duplex scan, or arteriography, seek vascular surgeon opinion

99
Q

Which particular fracture sites are associated with a higher risk of vascular injury

A

Supracondylar humerus
High tibial
Knee dislocation
Shoulder dislocation

100
Q

What is the difference in pathophysiology between venous and arterial ulcers

A
  • venous ulcers are caused by venous hypertension, venous stasis, inadequate calf pump
  • arterial ulcers are caused by progressive atherosclerosis or embolus. Leads to ischaemia.
101
Q

What is the difference between arterial and venous ulcers in terms of where the ulcers are found on the legs

A

Arterial - often on the feet : toes etc.

Venous - just above medial malleolus, inner aspect

102
Q

What is the difference in appearance between arterial and venous ulcers

A
  • arterial : yellow/brown/grey/black. Usually doesn’t bleed

- venous : red base colour, irregularly shaped, discolouration: haemosidirin

103
Q

List some non-arterial or venous types of ulcer

A
  • neuropathic
  • arteritis
  • traumatic
  • neoplastic

Periop (3 decks)

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