Vascular Surgery Flashcards by Bethany Fryar

When is an aortic aneurysm indicated for surgery?

If it is…
symptomatic
>5.5cm
Or growing >1cm a year

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What surgery can be done for an aortic aneurysm?

EVAR (inserting a stent via the femoral arteries)

2. Open surgery to remove dilated segment and replace with a prosthetic graft

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What is a common risk with EVAR?

Endovascular leak due to an incomplete seal around the aneurysm

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How does recovery typically differ between AA patients who have had EVAR compared to open surgery?

EVAR has better 30 day mortality and a reduced hospital stay

But EVAR has a higher risk of rupture and reintervention

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What size does the abdominal aorta have to be to classify as an aortic aneurysm?

Greater than 3cm

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What are some risk factors for aortic aneurysm?

Hypertension
Smoking
Hyperlipidaemia
Male
Increasing age
Family history

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Who is AAA screening offered to?

All men in their 65th year

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How is a AAA diagnosed?

Abdominal USS
(then confirmed by CT with contrast when at the threshold of 5.5cm)

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What anti platelet drug is first line for patients to reduce their likelihood of peripheral arterial disease?

Clopidogrel 75mg

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A patient has an AAA measuring 4.2cm. How often should they be monitored by USS?

Annual USS

(3 to 4.4cm = annual USS
5 to 5.4cm = 3 monthly USS
>6cm = notify DVLA and suspension of driving until repaired)

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Do most AAAs rupture anteriorly or posteriorly?

80% rupture posteriorly

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How would a px with a ruptured AAA present?

Flank/ back pain
Hypotension (shock)
Pulsation abdominal mass

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What are the 6 P’s of acute limb ischaemia?

Pain
Pulselessness
Paralysis
Pallor
Perishingly cold
Paraesthesia

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What can be measured in the blood to determine the level of ischaemia?

Lactate

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Where do venom ulcers usually occur?

Gaiter region of the leg, medial malleolus area

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How do venous ulcers usually look like?

Shallow
Irregular borer
Granulating bass

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What are some risk factors for venous ulcers?

DVT
Pregnancy
Obesity
Varicose veins
Trauma

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What is the cause of a venous ulcer?

Venous insufficiency
Due to venous hypertension
Due to calf muscle pump failure

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How can venous ulcers be managed?

4 layer compression banding, changed 1-2x per week

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What must the ABPI be in order to manage a venous ulcer with compression banding?

0.7

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How do arterial ulcers typically appear?

Small, deep lesions with a well defined bored and necrotic base

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Where do arterial ulcers usually form?

On pressure points eg toes and heels

Or distal to a site of trauma

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Why do arterial ulcers form?

Due to a reduction in arterial flow, leading to reduced perfusion and poor healing of tissue

What are common conditions with peripheral neuropathy?

Diabetes Mellitus

Vitamin B12 deficiency

How do neuropathic ulcers usually appear?

Variable in size and depth | Usually with a “punched out” appearance

What are some features of venous insufficiency that may be noticed on examination?

``` Varicose veins Haemosiderin staining Lipodermatosclerosis Varicose eczema Atrophied blanche Oedema Venous ulcers ```

What’re some risk factors for varicose veins?

Pregnancy Obesity Prolonged standing Family history

What are some methods of treatment for varicose veins?

``` Vein ligation (surgically cut the veins) Thermal ablation (heating the vein with radio frequency under US guidance to close the vein off) Foam scleropathy (inject sclerosing agent into the vein to cause an inflammatory response so the vein closes off) ```

Which testicle is a varicocele more common in, and why?

Left Because the left testicular vein drains into the renal vein at an acute angle (Whereas the R testicular vein drains directly into the IVC)

Where are most arterial stenoses in patients with intermittent claudication?

Superficial femoral artery

What is the range of a typical ABPI for a px with intermittent claudication?

0.6 to 0.9

What are some risk factors for intermittent claudication?

``` Smoking Hyperlipidaemia Hypertension Family history Diabetes ```

What is intermittent claudication?

Aching in legs after walking a predictable distance Pain stops upon rest Is due to muscle ischaemia -> anaerobic respiration Usually in calf muscles, but can be more proximal

What investigations would you do for a px with intermittent claudication?

``` FBC (check for anaemia) Blood glucose (diabetes control) Lipids (hyperlipidaemia) Examine ABPI Duplex scan 1st line Then CT/ MRA with IV contrast ```

What is critical limb ischaemia?

Advanced stage of peripheral artery disease | Seen with pain at rest and possible tissue loss (arterial ulcers or gangrene)

What would the ABPI be of a patient with critical limb ischaemia?

<0.5

What is the first line antiplatelet for a patient with peripheral vascular disease?

Clopidogrel 75mg

What is the management for peripheral vascular disease?

``` Smoking cessation Exercise Reduce risk factors e.g. statin, antiplatelet, tx any diabetes, tx any anaemia Angioplasty and stent Bypass graft Amputation ```

How do venous ulcers typically appear?

Shallow Irregular border Granulating base

Where do venous ulcers usually form?

In the gaiter region of the leg

What examination findings can indicate venous insufficiency?

``` Oedema Haemosidderin skin staining Varicose eczema Lipodermatosclerosis Atrophied Blanche ```

What must the ABPI be greater than for safe application of compression banding on venous ulcers?

> 0.7

How can venous ulcers be managed?

4 layer compression banding

What is ABPI?

Ankle brachial pressure index Can assess extent of arterial disease in the lower limbs Ratio of blood pressure in the brachial artery and in the foot arteries (use the highest of the two pressure from PT and DP)

How do arterial ulcers typically appear?

Small, deep lesions with well defined borders and a necrotic base Usually form on pressure areas eg toes and heels

How do neuropathic ulcers typically appear?

Punched out appearance

What conditions involve peripheral neuropathy?

Diabetes Mellitus | B12 deficiency

What does an ABPI >1.2 indicate?

Abnormally hard, calcified vessel Usually in diabetes Can give false negative result

What are some risk factors for varicose veins?

Prolonged standing Obesity Pregnancy Family history

What are varicose veins?

Torturous, dilated veins associated with valvular incompetence and venous hypertension which leads to dilation of the superficial veins

How can varicose veins be treated?

- vein ligation (surgical stripping) - thermal ablation (heating the vein using radio frequency so it closes off) - foam scleropathy (inject sclerosis’s agent into the vein to cause an inflammatory response so it closes off)

What is a varicocele?

Abnormal dilation of testicular veins

Which testicle are varicoceles more common in, and why?

Left testicle Due to the acute angle that the left testicular vein enters the left Renal vein (whereas the right testicular vein drains directly into the IVC)

Which is the first line analgesic recommended for renal colic?

IM diclofenac

Buttock claudication suggests peripheral arterial disease of which artery?

Iliac

An ABPI of less than which value suggests critical limb ischaemia?

0.5

What imaging modalities are used to investigate peripheral arterial disease?

1st line: Doppler Then MR/CT angiography to assess the location and extent of stenoses