Vascular Surgery Flashcards
What is the range of ABPI you would expect in patients with intermittent claudication?
0.5-0.9
Lis the symptoms and signs found on examination of a patient with chronic lower limb arterial disease
- 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
What is ABPI?
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
Why does sunset foot occur?
Due to reactive hyperaemia
Describe Buergers test in patient with chronic lower limb arterial disease
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)
Define Intermittent claudication
Pain in the calf/thigh/buttock only associated with exercise and resolves quickly (
What are the causes of intermittent claudication?
Nearly always atherosclerosis
What is the claudication distance
The distance at which a patient with intermittent claudication exercises before they get symptoms - this is a constant distance
What determines the pain pattern experienced in intermittent claudication
The artery affected
If sfa - calf claudication
If aortoiliac artery - thigh/buttock claudication
Step by step, go through the management options for intermittent claudication
- best medical therapy
- endovascular intervention considered if symptoms or signs last >6 months despite bmt
- surgical intervention
What does best medical therapy for a patient with intermittent claudication involve, and what drugs may they be started on
Smoking cessation
Statin
Anti platelet therapy
Supervised exercise
What may be found on examination with a patient who has intermittent claudication
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)
What is the progression like for patients with intermittent claudication
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
Give two differential diagnoses for intermittent claudication
Venous claudication, neurogenic claudication
What is venous claudication
Claudication due to venous outflow obstruction, caused by iliofemoral venous occlusion secondary to DVT
What is neurogenic claudication
Lumbar nerve roots or cauda equina (spinal stenosis) compression
How is neurogenic claudication different to intermittent claudication?
Involves whole leg Often bilateral Often immediate upon walking or standing, not gradual like intermittent claudication Tingling or numbness Pulses normal
What are the symptoms of venous claudication
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
What is critical limb ischaemia
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
What is critical limb ischaemia caused by
Multiple lesions affecting different arterial segments down the leg (unlike intermittent claudication, which is usually single level)
When do patients get pain with CLI and why?
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
Some patients who have CLI may sleep in a chair to gain relief from pain, what can this cause however
May result in dependent oedema, which is caused by increased interstitial pressure leading to reduced arterial perfusion
What are the three stages of chronic lower limb arterial disease
- non critical : IC
- subcritical : night/rest pain
- critical : tissue loss (ulceration and gangrene)
List the different management options for a patient with lower limb ischaemia
- BMT
- endovascular management - balloon angioplasty +/- stent to enlarge lumen
- for arterial occlusion - endarterectomy, bypass grafting
What is endarterectomy
Direct removal or atherosclerotic plaque (+patch angioplasty)
What is Buergers disease also know as
Thromboangitis obliterans
What is buergers disease
Smoking related inflammation of the veins, nerves and middle sized arteries, which thrombosis and lead to gangrene. Unknown cause
What is vital in buergers disease
Stopping smoking
What are the patients affected with buergers disease usually?
Young, male
What are the symptoms of buergers disease
Claudication in feet and rest pain in toes and fingers
When would amputation be considered with chronic limb ishcaemia
When arterial reconstruction is inappropriate or impossible
At what level should amputations be carried out
Lowest possible consistent with healing, it is important it try and preserve the knee joint
What is the difference in treatment of embolus vs thrombus
Embolus is treated with embolectomy and warfarin
Thrombus is treated with bypass and thrombolysis
What is administered in a patient with a thrombus
Heparin
In reperfusion injury, which substances are released by the reperfused tissue which can lead to acute respiratory distress syndrome, myocardial stunting and endotoxaemia
Free radicals, enzymes, neutrophils, H+, K+, co2, myoglobin
What are the sequelae of endothelial injury in compartment syndrome?
Increased cap permeability, leading to oedema on reperfusion, increased interstitial tissue pressure in tight fascial boundaries. This leads to muscle necrosis
How do we test for compartment syndrome
Swelling and pain on squeezing the calf muscle
Passive stretch test causes pain on moving toes or ankle
What are the symptoms of sensory neuropathy in diabetic feet
Decreased pain sensation and proprioception
What are the symptoms of motor neuropathy on patients with diabetic feet
Does increasingly dorsiflexed and flexors in leg tend to be affected more
Atrophy
What are the symptoms of autonomic neuropathy in patients with diabetic foot
Dry foot
Loss of sweating
Scaling and fissuring
How is compartment syndrome treated
Dermatofasciotomy
List the 6 ps
Pallor Perishingly cold Paraesthesia Pain Pulse lessens Paralysis
Describe the symptoms of acute limb ischaemia over time
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
What are the three types of varicose vein
Trunk, reticular, telangiectasia
What do trunk varicose veins look like
Palpable, large, usually involve mainstream or major tributaries
What are some of the risk factors for varicose veins
Familial tendency, obesity, pregnancy, constipation, prolonged standing
What do reticular varicose veins look like
Impalpable, render overlying skin dark blue
What does telangeictasia look like
Spider or thread veins which lie superficial to the dermis
They’re impalpable
Overlying skin purple or bright red
How is chronic venous ulceration treated
Graduated compression four layer or three layer bandaging
The greatest compression is at the ankle Improves venous function
What is a contraindication to treating chronic venous ulceration with graduated compression bandaging
Significant arterial disease (ABPI
What may be found on examination of a patient with a chronic venous ulcer
Usually above medial malleolus Surrounding skin damaged Subcut fibrosis Pigmentation Acute inflammation
What are some of the complications of chronic venous ulcers
Haemorrhage
Thrombophlebitis
What is Raynaud’s phenomenon
Condition where there is pallor due to vasospams, followed by cyanosis (deox. blood), then rub or due to reactive hyperaemia
What may trigger an attack in Raynaud’s disease
Cold or emotional stimuli
How is Raynaud’s disease treated
CCB
What is the conservative management of chronic venous ulceration
Elastic hose support, weight loss, regular exercise
What are the surgical options for a person with chronic venous ulceration
Stripping of space out vein
Ligation at sfj if lsv affected
What are the endovascular treatment options for chronic venous ulceration/varicose veins
Radiofrequency ablation
Endovascular laser ablation (evla)
Ultrasound guided sclerotherapy
Are abx indicated in patient with chronic venous ulceration
No, unless you can confirm presence of B haemolytic strep or S aureus
Of the ulcer and surrounding area are red , what should you suspect in a patient with chronic venous ulceration?
Cellulitis, take swabs and clean with warm tap water
What is the usual diameter of the abdominal aorta, and at what diameter of an AAA would you consider surgery for the patient
Usually 2 cm, would consider surgery at 5.5 cm
What are the treatment options for AAA
EVAR
Open repair
What are some of the typical features of a ruptured AAA
Sudden collapse
Abdo / low back pain
Low BP
Vomiting
How would you manage a patient who presents with a ruptured AAA
Don’t give large vols of fluid
Transfer to theatre where aorta would be clamped and treated either with open repair or EVAR
What bloods would you do in patient who presents with ruptures AAA
FBC U and E X match 6 units Platelets Clotting factors
How do you assess the size of a AAA
USS
What is a more precise measure of AAA size than an USS
More accurate info from CT, but is not a method of surveillance
How is AAA usually picked up
As an incidental finding on USS, but may be picked up in the national screening programme of males >65 yo
Where can AAAs extend into
Common iliac, and even the internal iliac artery
How are popliteal aneurysms best treated
Bypass
What structure can popliteal aneurysms compress
Popliteal vein –> DVT
What are the two types of aneurysm shape
Saccular
Fusiform
At which position on the abdominal aorta are AAAs usually found
Infrarenal
List some other areas that are less commonly affected by aneurysms expect for the abdominal aorta
Popliteal
Femoral
Subclavian arteries
What is the aetiology of aneurysms
Usually atherosclerotic, but may be caused by infections such as syphillis and salmonella
What is the difference between a true and false aneurysm
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
How can a AAA cause DVT
Compression of the femoral vein may result
Define stroke
Episode of focal neurological dysfunction lasting over 24 hours of presumes vascular aetiology
What are the symptoms of a cva
Loss of speech, unilateral visual loss or disturbance, motor and sensory loss
How is cva managed
Aspirin
Duplex scan carotids
CT scan to exclude haemorrhage
What is Amaurosis fugax ?
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
What is carotid endarterectomy
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)
Except for carotid endarterectomy, what is another option for treating carotid atherosclerosis
Carotid stenting
What are varicose veins
Veins seen with chronic venous insufficiency due to failure of venous drainage of leg due to valvular incompetence - leading to skin ulceration and discolouration
What are some of the predisposing factors to varicose veins
Female
History of childbirth
Occupations involving long periods of standing
Why is it important to ask about previous fractures in patients with varicose veins
The fracture may have caused a DVT preventing drainage through veins because of the occlusion
How can you investigate varicose veins
Duplex ultrasound
Trendelenburg test
What is the most commonly affected vein in patients who suffer from varicose veins
Lsv
What are the symptoms of varicose veins
Uncomfortable and heavy leg when standing up for a long time due to poor venous drainage
Damage to skin such as lipodermatosclerosis? And pigmentation
Which valve is usually incompetent to cause varicose veins
Sfj
What are secondary varicose veins a product of
DVT
What is the trendelenburg test when assessing a vascular patient
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
List some of the presentations of varicose veins
Cosmetic Tiredness Heaviness Ulceration Itchiness
In the trendeleburg test, what does veins filling more rapidly with the tourniquet on suggest
There is valvular incompetence below the level of the tourniquet I.e. In the deep veins
In the trendelenburg test, if the tourniquet is removed and the veins then fill rapidly, what does this indicate
That superficial veins are incompetent
List the hard signs of arterial injury (these patients require immediate surgery)
- external arterial bleeding
- rapidly expanding haematoma
- palpable thrill, audible bruit
- avoids acute limb ishcaemia
What are the soft signs of arterial injury
- history of bleeding at scene
- trauma/injury near major artery
- unilateral pulse diminished
- small, non pulsation haematoma
- neurogenic deficit
How are patients with soft signs of arterial injury assessed
Serial examination, duplex scan, or arteriography, seek vascular surgeon opinion
Which particular fracture sites are associated with a higher risk of vascular injury
Supracondylar humerus
High tibial
Knee dislocation
Shoulder dislocation
What is the difference in pathophysiology between venous and arterial ulcers
- venous ulcers are caused by venous hypertension, venous stasis, inadequate calf pump
- arterial ulcers are caused by progressive atherosclerosis or embolus. Leads to ischaemia.
What is the difference between arterial and venous ulcers in terms of where the ulcers are found on the legs
Arterial - often on the feet : toes etc.
Venous - just above medial malleolus, inner aspect
What is the difference in appearance between arterial and venous ulcers
- arterial : yellow/brown/grey/black. Usually doesn’t bleed
- venous : red base colour, irregularly shaped, discolouration: haemosidirin
List some non-arterial or venous types of ulcer
- neuropathic
- arteritis
- traumatic
- neoplastic
