Vascular Surgery

Question 1

what are common misdiagnosis for ruptured AAA?

Answer 1

renal colic 
diverticulitis 
GI bleed
MI 
mechanical/muscular back pain

Question 2

how does ruptured AAA present?

Answer 2

sudden, severe, crippling abdo and back pain
bilateral leg ischaemia
hypotension
tachycardia
cold clammy peripheries with poor CRT (generalised shock state)
elderly

Question 3

how do you differentiate between an expansile aortic mass or a mass above the aorta which is transmitting the pulse?

Answer 3

pulsatile/expansile aorta will move your hands apart

a mass above the aorta will move your hands upwards

Question 4

what should be suspected in an elderly man who presents with renal colic for the first time??

Answer 4

rupture AAA

Question 5

when should an aorto-enteric fistula be suspected?

Answer 5

in a patient with a GI bleed and previous aortic surgery

Question 6

what are the branches of the abdominal aorta ?

Answer 6

1) coeliac trunk 
(giving off splenic artery, hepatic artery and left gastric)
2) left and right renal arteries
3) superior mesenteric
4) inferior mesenteric

Question 7

how does the abdominal aorta end?

Answer 7

bifurcates into left and right common iliac (external and internal iliac arteries)

Question 8

coeliac trunk arises at which vertebral level?

Answer 8

L1

Question 9

which clamping method in AAA repair surgery puts most and least strain on the heart?

Answer 9

most strain = supra-coeliac clamping
less strain = supra renal clamping
least strain = infra renal clamping

Question 10

what is the pathophysiology of peripheral vascular disease?

Answer 10

senescence, shear stress or circulating toxins lead to endothelial dysfunction and damage. this leads to artherosclerotic plaque build up,
chronic ischaemia is caused by narrowed lumen and haemodynamic flow limitation
acute ischaemia is caused by plaque rupture and thrombus formation

Question 11

how is chronic limb ischaemia classified?

Answer 11

fontaine 1 asymptomatic
fontaine 2 claudication
fontaine 3 rest pain
fontaine 4 tissue

Question 12

how does claudication present?

Answer 12

aching muscles on effort
predictable
worse on hills, with speed
settles swiftly on rest

Question 13

how does rest pain present?

Answer 13

icy, burning, constant foot ache
worse on elevation or at night
need opiates

Question 14

what are examples of ischaemic tissue loss?

Answer 14

ulcers, gangrene, necrosis

Question 15

how is intermittent claudication (PAD) treated?

Answer 15

1. stop smoking
2. antiplatelet therapy - clopidogrel
3. good BP control
4. statin - atorovastarin 80mg
5. take regular exercise, loss weight

Question 16

how is PAD assessed in lower limb?

Answer 16

• check limb pulses
• check ABPI (ankle brachial pressure indec)
• 1st line investigation = duplex ultrasound scan
• perform magnetic resonance angiography (MRA) before any intervention

Question 17

how are ABPI measurements interpreted?

Answer 17

1 = normal
0.6 - 0.9 = claudication
0.3 - 0.6 = rest pain
< 0.3 tissue loss

Question 18

in which ways can PAD present?

Answer 18

intermittent claudication
critical ischaemia
acute-limb threatening ischaemia

Question 19

what are the features of a limb threatening ischaemia? 6Ps

Answer 19

Pale 
Pulseless
Painful 
Paralysed
Paraesthesia 
Perishingly cold

Question 20

how is critical limb ischaemia/severe PAD treated?

Answer 20

1. angioplasty
2. stenting
3. bypass surgery
4. amputation if none of the above are suitable

Question 21

which drugs are licensed for treatment in PAD?

Answer 21

naftidrofuryl oxalate - vasodilator

for patients with v poor QOL

Question 22

what is the most common risk assoc. with popliteal artery aneurysm?

Answer 22

thrombosis of the aneurysm

embolisation of mural thrombus

Question 23

what is the 5 year prognosis for patients with AAA who don’t receive surgery

Answer 23

20% are alive in 5 years

Question 24

what are the most common causes of mortality after emergency correcting of an AAA?

Answer 24

acute renal insufficiency

myocardial infarction

Question 25

what does involuntary muscle contractions in an ischaemic limb indicate?

Answer 25

restored flow cannot save the extremity

Question 26

what are the causes for early pallor in the case of an arterial embolus?

Answer 26

reflex vasoconstriction

hypo-perfusion of skin

Question 27

which visceral aneurysm is most common?

Answer 27

splenic

Question 28

what are features of a low rupture risk AAA?

Answer 28

<5.5 cm
asymptomatic
treat with US surveillance and optimise CV risk factors

Question 29

what are features of a high rupture risk AAA?

Answer 29

> 5.5 cm
or rapidly enlarging (>1cm/year)
symptomatic - intervene regardless of size

Question 30

how are AAA diameter measurements interpreted?

Answer 30

<2.5 = normal
<3.5 = ectasia  
<4.5 = small AAA
>5.5 = large AAA

Question 31

what are surgical interventions for a severe AAA?

Answer 31

1) elective endovascular repair (EVAR)- access via femoral artery, the aneurysm is fitted with a stent to reline it.aims to prevent blood from collecting. (2% mortality)
2) open repair - affected segment is replaced with plastic graft (tube or bifurcate). clamping puts immense strain on heart. (5% mortality)

Question 32

what is a complication of EVAR??

Answer 32

endo-leak

the stent fails to exclude blood from the aneurysm

Question 33

what is MoA of tranexamic acid and what is it used for?

Answer 33

used to prevent blood loss in massive haemorrhage

strong antifibrinolytic

Question 34

what are 5 common complication associated with massive blood transfusion?

Answer 34

1) dilutional coagulopathy - abnormalities in clotting = due to dilution of platelets and clotting factors.
2) haemolytic reaction (most common) -usually caused by administration of mismatched blood types
3) hypothermia -RBCs are stored at 4 degrees. hypothermia shifts the oxygen dissociation curve so less oxygen delivery. also increases risk of hypocalcaemia, arrhythmias, metabolic acidosis
4) hypocalcaemia - due to present of citrate in tranfused products
5) transfusion related acute lung injury (TRALI) - most common cause of morbidity/death. represents as acute resp distress within 6 hr of transfusion