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General Surgery > Vascular Surgery > Flashcards

Vascular Surgery Flashcards

1
Q

Describe the clinical presentation of acute limb ischaemia

A

The 6Ps

Pain
Pallor
Paraesthesia
Pulselessness
Paralysis
Poikilothermia (cold limb)
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2
Q

What is the etiology of acute limb ischaemia?

A

Cardiac embolism

Thrombosis

Trauma

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3
Q

What are the classic angiographic finding of an embolism

A

Sudden cutoff

Convex filling defect

Otherwise relatively normal vessels

No visible atherosclerosis

Often lodge at bifurcations

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4
Q

List some of the causes of a cardiac embolism

A

Atrial fibrillation

MI with mural thrombosis

Ventricular aneurysm

Mechanical valve

Endocarditis

Atrial myxoma

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5
Q

List some of the causes of a thrombosis

A

Atherosclerosis obstruction

Previous bypass/stent

Peripheral aneurysms - popliteal

Hypercoaguable states

Aortic Dissection

Cocaine/vasopressors

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6
Q

What are the angiography findings of atherosclerosis

A

Diffuse atherosclerosis

Tapered irregularly cutoff vessels

Well developed collaterals

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7
Q

List some risk factors for a hypercoaguable state

A

Malignancy

HIV

Anti-phospholipid syndrome

Heparin induces thrombocytopenia

Inherited thrombophilia

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8
Q

Provide a DDx of acute limb ischaemia

A

Shock

Venous threatened limb

Acute compression neurology

Guillain Barre

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9
Q

Describe the Rutherford classification of acute ischemia for a 2b threatened limb

A

Salvageable if immediately treated

Slow/absent capillary refill

Partial muscle paralysis

Partial/complete sensory loss

Inaudible arterial Doppler signals

Audible venous Doppler signals

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10
Q

Describe the Rutherford classification of acute ischemia for a non-viable limb

A

Primary amputation needed

Absent capillary refill - fixed skin staining due to ruptured capillaries

Complete tense muscle paralysis - flexor rigidity (stiff ankle)

Complete sensory loss

Inaudible arterial Doppler signal

Inaudible venous Doppler signal

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11
Q

What special investigations would you do in a patient with suspected acute limb ischaemia?

A

CT angiography

Digital subtraction angiography (DSA)

Ultrasound - Doppler flow

MR angiography

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12
Q

What is the management of acute limb ischaemia?

A

Heparin 5000 IU - prevention of further thrombosis

Oxygen

IV analgesia

Embolectomy/thrombolectomy

Bypass surgery

Amputation

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13
Q

What are the complications of revascularization?

A

Reperfusion injury

Oxygen free radicals damage cell membrane

Compartment syndrome

Systemic release of lactate, potassium and myoglobin

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14
Q

What are the risk factors for chronic arterial disease (critical limb ischaemia)

A

Smoking

DM

HPT

Hyperlipidaemia

Older age

Obesity

Males and post menapausal women

Family history

Chronic renal failure

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15
Q

What are the symptoms of chronic arterial disease?

A

Usually asymptomatic

Intermittent Claudication - ischaemic muscle pain induced by exercise and relieved by rest

Critical limb ischaemia:
Rest pain - severe burning pain in the forefoot or toes that’s worse at night and improves with walking or hanging the limb off the bed
Gangrene
Ischaemic ulcer

Impotence - aortic-iliac/bilateral iliac disease

Acute on chronic vascular occlusion

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16
Q

Provide a DDx for claudication

A

Osteoarthritis of the hip/knee

Neurospinal claudication

Chronic compartment syndrome

Venous claudication

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17
Q

Provide a DDx for rest pain

A

Diabetic neuropathy

Gout

Plantar fasciitis

Night cramps

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18
Q

What is critical limb ischaemia (CLI)?

A

It implies impending limb loss

When the blood supply to a limb is critically diminished

Often a multilevel disease

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19
Q

What are the symptoms/signs of critical limb ischaemia?

A

Rest pain

Non-healing ischaemic ulcer

Gangrene

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20
Q

When assessing a patient the femoral pulse and all pulses below it are absent. What is anatomical level of disease?

A

Aorta-iliac disease

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21
Q

When assessing a patient the highest pulse palpable is the popliteal pulse. What is anatomical level of disease?

A

Trifurcation disease

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22
Q

When assessing a patient the highest pulse palpable is the foot pulse. What is anatomical level of disease?

A

Distal disease

23
Q

When assessing a patient the highest pulse palpable is the femoral pulse. What is anatomical level of disease?

A

Femero-popliteal disease

24
Q

What special investigations would you do for a patient with chronic arterial disease?

A

Duplex Doppler

CT angiography

Digital Subtraction Angiography

MR angiography

25
Q

Discuss the management of claudication

A

Stop smoking

Manage risk factors - DM, HPT, hypercholesteraemia (ACE inhibitors is HPT)

Aspirin

Simvastatin

Supervised exercise program

Foot care in diabetes

Warn patients about symptoms of CLI and acute on chronic vascular occlusion

Refer for intervention is conservative treatment fails

26
Q

Discuss the management of critical limb ischaemia

A

Need revascularization for limb salvage:
Imaging - duplex Doppler, CT angiography, DSA
Revascularization - endovascular, surgery
Amputation of gangrenous toes

Risk factor management

27
Q

How do you manage a patient with critical limb ischaemia that is NOT a candidate for revascularization?

A

Amputate - Unbearable pain/progressive infection

Medical management - Stable pain

28
Q

List the options for revascularization

A

Endovascular:
Balloon dilatation
Stent

Surgery:
Bypass
Endarterectomy
Sympatectomy
Amputation
29
Q

How would you manage a patient with aorto-iliac disease?

A

Aortabifemoral bypass

OR

Fem-fem bypass

30
Q

Discuss the treatment of a septic diabetic foot

A

Diagnose and treat diabetic ketoacidosis

IV fluids - Ringers

Correct electrolytes

Give insulin

IV antibiotics - Entrapenem/Vancomycin

Drainage and debridement of sepsis

?Amputate

?Revascularize

31
Q

What are the indications for amputation

A

Non-viable limb

Critical limb ischaemia with no bypass option

Foot no longer salvageable

Immobile or contracture of limb

Patient preference

32
Q

What is the etiology of True aneurysms?

A

Atherosclerosis

HIV

33
Q

What is the etiology of False aneurysms?

A

Infective - TB, syphilis, staph aureus

Dissecting

Traumatic

Genetic - Marfan syndrome

Inflammatory - Giant cell arthritis

34
Q

Classify Abdominal Aortic Aneurysms by CT measurements

A

Normal: 2-3cm

Small AAA: 4-5cm

Moderate AAA: 5-6cm

Large AAA: 6-7cm (50% risk of rupture in 5 years)

Very large AAA: >7cm (100% risk of rupture in 5 years)

35
Q

What are the complications of an AAA

A

Rupture

Compression of surrounding structures

Embolization

36
Q

When is surgery indicated in an asymptomatic AAA

A

> 5.5cm

> 1cm increase in size in a year

Uncontrolled HPT

Patients request

37
Q

What are the indications for a stent placement in AAA

A

Neck is atleast 1cm below renal artery or normal aorta

<60% angulation of the neck

Must have adequate access

May not be too torturous or calcified

38
Q

What are the surgical options for AAA?

A

Aneurysmectomy

Stent placement

39
Q

What is the conservative management of an AAA

A

Smoking cessation

BP control

Simvastatin

6 monthly follow-up for US

40
Q

What are the symptoms of an AAA

A

Abdominal pain that radiates to the back

Tenderness over AAA

Rapid expansion

41
Q

What are the complications of endovascular (stent) repair?

A

Endoleaks

Migration

Neck dilatation

Limb occlusion

42
Q

List the 3 components of Virchows triad

A

Changes in blood flow - stasis

Changes in blood composition - hypercoaguability

Changes in vessel wall - endothelial damage

43
Q

What are the risk factors for DVT?

A

Immobility

Malignancy

Previous DVT

Pregnancy

Traveling

Post-surgery

Trauma

Inherited thrombophilia

44
Q

Describe the clinical picture of a patient with a DVT

A

Swelling

Limb Pain and tenderness

Warm

Oedema

Haman’s signs - pain in the calf on dorsiflexion of the ankle

Pulmonary embolism - SOB, chest pain

45
Q

Provide a DDx for a unilateral swollen leg

A

DVT

Cellulitis

Abscess

Necrotising fasciitis

Lymphedema

Malignancy

Trauma - fracture, haematoma

46
Q

How would you diagnose a DVT?

A

Clinically using Wells score

D-dimer

Duplex US

Ascending venogram

CT venogram

47
Q

How is Wells score used to aid the diagnosis of a DVT?

A

Low probability: score of less than or equal to zero

Moderate probability: score of 1-2

High probability: score of more than 3

48
Q

What are the complications of DVT?

A

PE

Post-thrombotic syndrome

Venous gangrene

Recurrence

Death

49
Q

Discuss the management of DVT

A

Thrombolytic therapy
>streptokinase

Anticoagulation therapy
>unfractioned heparin till INR >2 for 24hours
>warfarin

Venous thrombectomy - if worsening of treatment/gangrene

Interruption of vena cava - prevent PE

50
Q

What are the risk factors for varicose veins?

A

Female

Obesity

Pregnancy

Inactivity

Prolonged standing

51
Q

What are the signs and symptoms of complicated varicose veins?

A

Increased pain

Increased swelling

Hyperpigmentation

Stasis and dermatitis

Venous ulcer

Bleeding

Lipodermatosclerosis

52
Q

What are the indications for surgery for varicose veins?

A

Persisting or disabling pain

Recurrent thrombophlebitis

Skin erosion with bleeding

Chronic venous insufficiency

53
Q

What are the Hard signs of vascular injury?

A

Expanding haematoma

Pulseless limb

Bruits or arterial thrill

Cold pale limb

Extravasation/bleeding

Stroke

54
Q

What are the Soft signs of vascular injury?

A

History of bleeding

Differences in pulses

Neurological fallout

Normal haematoma

Proximity of injury

General Surgery (7 decks)

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