Vascular Surgery

Question 1

What is the difference between Acute Limb Ischaemia and PAD and why classify?

Answer 1

• Acute Limb Ischaemia – acute ↓perfusion that threatens limb viability** presenting **≤2 weeks of symptom onset
• PAD – ↓perfusion in causing limb ischaemia for >2 weeks
• Critical limb ischaemia [3% PAD] = If limb viability is threatened; worse PROGNOSIS [mortality = 25%; amputation = 30% within 1 yr]
• Asymptomatic [50%] & Claudicants [40%]
  
  • 75% do not progress in 5 yrs [stable claudicants]
  • Still has 10-15% mortality [75% of CVS events]

Question 2

Management of PAD

Answer 2

• Lifestyle Modifications – CVS RF [1^o Prevention – diet, exercise, smoking cessation, weight reduction]; Supervised exercise program [12wks]
• Pharmacological – CVS RF [2^o Prevention – ACEI, Statin, Aspirin, DM control]; Cilostazol [PDE3 inhibitor]
• Revascularisation – Balloon Angioplasty +/- Stenting or Bypass Graft

Question 3

Indications for Surgical Management of PAD

Answer 3

1. Limb Salvage – in critical limb ischaemia
2. Prevention of Atheroembolisation
3. Refractory – after 6mo. conservative treatment; need ABI & claudication distance monitoring

• Deteriorating condition OR
• Plateau in condition + Intolerance of symptoms + Discuss risks & benefits

Question 4

What are the clinical features of acute limb ischaemia?

Answer 4

[6Ps – 3 arterial; 3 neural]

• Pulseless
• Pallor
• Perishing Coldness
• Pain
• Paralysis
• Paraesthesia

Question 5

How would you manage a patient with AAA?

Answer 5

• Management depends on presentation of the patient
• 3x presentations of AAA – (1) Asymptomatic [incidental]; (2) Symptomatic; (3) Ruptured
• Asymptomatic
• Elective Surgical Repair if indicated + Fit for surgery [mortality <5%]
  
  • Largest diameter >5.5cm measured using US
  • ↑Diameter by ≥1cm/yr
• Surveillance if not indicated
  
  • Diameter <5.5cm – surgery offers X survival benefit; risk>benefit
  • Statin therapy ↓risk of rupture & growth
• Symptomatic – E.g. Pain, Distal emboli, Pressure effect
• Elective Surgical Repair if indicated – Pain/Tender, AAA causing embolisation
• Ruptured – Presents with acute abd. pain radiating → back + shock +/- pulsatile epigastric mass

1. Resuscitate [2x large bore IV cannula + IV N/S + T&S + Transfuse FFP & Platelets]
2. Call seniors
3. Quickly understand Hx & PE
4. Bedside US + Pre-op Ix [FBC, RFT, Clotting Profile, ECG, CXR]
5. General measures [NGT + NPO, Supplemental O2, Foley’s, I/O chart, CVP/IA catheter, avoid intubate if possible – NBM releases tamponade effect]
6. Send to OT prep for surgery + obtain inform consent [inform of ↑mortality]

Question 6

What are the complications of Open AAA repair?

Answer 6

• As with all surgical classification these can be classified into →
• Intra-operative
  
  • Haemorrhage – ∵Surgery involving aorta
  • Distal Leg Thrombus/Embolisation – ∵Clamping of aorta
• Early Post-operative – Ischaemia/Hypoperfusion of 5 major systems
  
  • CNS → CVA [Hypotensive or Embolic] & Spinal cord ischaemia
  • CVS → AMI [contributes most to mortality]
  • Respi → Atelectasis, Lung base consolidation
  • GI → Sigmoid colon ischaemia
  • Renal → ARF
• Late Post-operative – False Sex GIF
  
  • False aneurysm
  • Sexual dysfunction [impotence]
  • Graft Infection [Prosthesis]
  • Fistula – Aorto-enteric since aorta was incised