Vascular Surgery Flashcards
Describe the clinical presentation of acute limb ischaemia
The 6Ps
Pain Pallor Paraesthesia Pulselessness Paralysis Poikilothermia (cold limb)
What is the etiology of acute limb ischaemia?
Cardiac embolism
Thrombosis
Trauma
What are the classic angiographic finding of an embolism
Sudden cutoff
Convex filling defect
Otherwise relatively normal vessels
No visible atherosclerosis
Often lodge at bifurcations
List some of the causes of a cardiac embolism
Atrial fibrillation
MI with mural thrombosis
Ventricular aneurysm
Mechanical valve
Endocarditis
Atrial myxoma
List some of the causes of a thrombosis
Atherosclerosis obstruction
Previous bypass/stent
Peripheral aneurysms - popliteal
Hypercoaguable states
Aortic Dissection
Cocaine/vasopressors
What are the angiography findings of atherosclerosis
Diffuse atherosclerosis
Tapered irregularly cutoff vessels
Well developed collaterals
List some risk factors for a hypercoaguable state
Malignancy
HIV
Anti-phospholipid syndrome
Heparin induces thrombocytopenia
Inherited thrombophilia
Provide a DDx of acute limb ischaemia
Shock
Venous threatened limb
Acute compression neurology
Guillain Barre
Describe the Rutherford classification of acute ischemia for a 2b threatened limb
Salvageable if immediately treated
Slow/absent capillary refill
Partial muscle paralysis
Partial/complete sensory loss
Inaudible arterial Doppler signals
Audible venous Doppler signals
Describe the Rutherford classification of acute ischemia for a non-viable limb
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
What special investigations would you do in a patient with suspected acute limb ischaemia?
CT angiography
Digital subtraction angiography (DSA)
Ultrasound - Doppler flow
MR angiography
What is the management of acute limb ischaemia?
Heparin 5000 IU - prevention of further thrombosis
Oxygen
IV analgesia
Embolectomy/thrombolectomy
Bypass surgery
Amputation
What are the complications of revascularization?
Reperfusion injury
Oxygen free radicals damage cell membrane
Compartment syndrome
Systemic release of lactate, potassium and myoglobin
What are the risk factors for chronic arterial disease (critical limb ischaemia)
Smoking
DM
HPT
Hyperlipidaemia
Older age
Obesity
Males and post menapausal women
Family history
Chronic renal failure
What are the symptoms of chronic arterial disease?
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
Provide a DDx for claudication
Osteoarthritis of the hip/knee
Neurospinal claudication
Chronic compartment syndrome
Venous claudication
Provide a DDx for rest pain
Diabetic neuropathy
Gout
Plantar fasciitis
Night cramps
What is critical limb ischaemia (CLI)?
It implies impending limb loss
When the blood supply to a limb is critically diminished
Often a multilevel disease
What are the symptoms/signs of critical limb ischaemia?
Rest pain
Non-healing ischaemic ulcer
Gangrene
When assessing a patient the femoral pulse and all pulses below it are absent. What is anatomical level of disease?
Aorta-iliac disease
When assessing a patient the highest pulse palpable is the popliteal pulse. What is anatomical level of disease?
Trifurcation disease
When assessing a patient the highest pulse palpable is the foot pulse. What is anatomical level of disease?
Distal disease
When assessing a patient the highest pulse palpable is the femoral pulse. What is anatomical level of disease?
Femero-popliteal disease
What special investigations would you do for a patient with chronic arterial disease?
Duplex Doppler
CT angiography
Digital Subtraction Angiography
MR angiography
Discuss the management of claudication
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
Discuss the management of critical limb ischaemia
Need revascularization for limb salvage:
Imaging - duplex Doppler, CT angiography, DSA
Revascularization - endovascular, surgery
Amputation of gangrenous toes
Risk factor management
How do you manage a patient with critical limb ischaemia that is NOT a candidate for revascularization?
Amputate - Unbearable pain/progressive infection
Medical management - Stable pain
List the options for revascularization
Endovascular:
Balloon dilatation
Stent
Surgery: Bypass Endarterectomy Sympatectomy Amputation
How would you manage a patient with aorto-iliac disease?
Aortabifemoral bypass
OR
Fem-fem bypass
Discuss the treatment of a septic diabetic foot
Diagnose and treat diabetic ketoacidosis
IV fluids - Ringers
Correct electrolytes
Give insulin
IV antibiotics - Entrapenem/Vancomycin
Drainage and debridement of sepsis
?Amputate
?Revascularize
What are the indications for amputation
Non-viable limb
Critical limb ischaemia with no bypass option
Foot no longer salvageable
Immobile or contracture of limb
Patient preference
What is the etiology of True aneurysms?
Atherosclerosis
HIV
What is the etiology of False aneurysms?
Infective - TB, syphilis, staph aureus
Dissecting
Traumatic
Genetic - Marfan syndrome
Inflammatory - Giant cell arthritis
Classify Abdominal Aortic Aneurysms by CT measurements
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)
What are the complications of an AAA
Rupture
Compression of surrounding structures
Embolization
When is surgery indicated in an asymptomatic AAA
> 5.5cm
> 1cm increase in size in a year
Uncontrolled HPT
Patients request
What are the indications for a stent placement in AAA
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
What are the surgical options for AAA?
Aneurysmectomy
Stent placement
What is the conservative management of an AAA
Smoking cessation
BP control
Simvastatin
6 monthly follow-up for US
What are the symptoms of an AAA
Abdominal pain that radiates to the back
Tenderness over AAA
Rapid expansion
What are the complications of endovascular (stent) repair?
Endoleaks
Migration
Neck dilatation
Limb occlusion
List the 3 components of Virchows triad
Changes in blood flow - stasis
Changes in blood composition - hypercoaguability
Changes in vessel wall - endothelial damage
What are the risk factors for DVT?
Immobility
Malignancy
Previous DVT
Pregnancy
Traveling
Post-surgery
Trauma
Inherited thrombophilia
Describe the clinical picture of a patient with a DVT
Swelling
Limb Pain and tenderness
Warm
Oedema
Haman’s signs - pain in the calf on dorsiflexion of the ankle
Pulmonary embolism - SOB, chest pain
Provide a DDx for a unilateral swollen leg
DVT
Cellulitis
Abscess
Necrotising fasciitis
Lymphedema
Malignancy
Trauma - fracture, haematoma
How would you diagnose a DVT?
Clinically using Wells score
D-dimer
Duplex US
Ascending venogram
CT venogram
How is Wells score used to aid the diagnosis of a DVT?
Low probability: score of less than or equal to zero
Moderate probability: score of 1-2
High probability: score of more than 3
What are the complications of DVT?
PE
Post-thrombotic syndrome
Venous gangrene
Recurrence
Death
Discuss the management of DVT
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
What are the risk factors for varicose veins?
Female
Obesity
Pregnancy
Inactivity
Prolonged standing
What are the signs and symptoms of complicated varicose veins?
Increased pain
Increased swelling
Hyperpigmentation
Stasis and dermatitis
Venous ulcer
Bleeding
Lipodermatosclerosis
What are the indications for surgery for varicose veins?
Persisting or disabling pain
Recurrent thrombophlebitis
Skin erosion with bleeding
Chronic venous insufficiency
What are the Hard signs of vascular injury?
Expanding haematoma
Pulseless limb
Bruits or arterial thrill
Cold pale limb
Extravasation/bleeding
Stroke
What are the Soft signs of vascular injury?
History of bleeding
Differences in pulses
Neurological fallout
Normal haematoma
Proximity of injury
