Vascular surgery Flashcards
Risk factors for PVD
Male, age 60-70, smoking, DM, HTN, high cholesterol, obesity, sedentary
Intermittent claudication
Chronic LL arterial insufficiency - pain on walking a reproducible distance, worse uphill, forced to stop then pain stops, recurs at same walking distance
Usually worse in one limb
Leriche syndrome - impotence (may be ass)
Peripheral pulses reduced/absent on affected side, trophic skin changes rare
Majority stay same/improve, some need surgery, some need amputation
Marker of CAD
Chronic ischaemic rest pain
Severe arterial obstruction, usually v severe and burning, worse at night, relieved by hanging foot off bed
May also have tissue loss
How does acute critical ischaemia present?
Pain - sudden onset
Pallor - white, then mottled due to stagnated deoxygenated blood, if doesn’t blanch on pressure is not viable
Pulseless - foot pulses absent, femoral/popliteal may also be gone
Perishing coldness
Paraesthesia - severe sign
Paralysis - of calf muscles, severe
What skin changes may be seen in PVD?
Trophic changes - esp gaiter area. Like atrophic red skin
Chronic venous disease - venous eczema, haemosiderin deposits (red cells extravasate into tissue due to raised pressure), lipodermatosclerosis, ‘champagne bottle leg’
Colour - blue toes (pre-gangrene), black toes (necrosis-dry gangrene, if infected wet gangrene), redness (implies oxygenated blood in caps)
Ulceration
What may cause leg swelling?
Local - sluggish venous return (immobile, pregnant), lymphatic obstruction tropical disease, chronic venous insufficiency (causing superficial venous reflux), congenital e.g. Milroy’s, acute obstruction of venous return
Regional - LVF, venous obstruction by pelvic mass, radiation destruction, IVCO
Systemic - CCF, low albumin, fluid overload
What is the relevance of u/l and b/l leg swelling?
B/l more likely central cause
U/l more likely surgical
Upper limb swelling
Axillary vein thrombosis - from excess use or cervical rib obstructing
May also be blue, heavy, prominent collateral veins
Usually goes away
Upper limb acute white/blue colour
Embolism/trauma to brachial a
May also have the 6 Ps
White fingers
Raynaud’s disease (white - blue - red from vasospasm), or secondary Raynaud’s phenomenon e.g. to SLE, Sjogren’s
Red painful fingers
Reflex sympathetic dystrophy after trauma
Vascular pain upper limb
Subclavian a narrowing (usually asymptomatic, may get muscle pain on exercise)
Or acute ischaemia from a cardiac thrombus
Upper limb neurovascular pain
Thoracic outlet syndrome - C8/T1
Severe LL ischaemia (chronic)
Usually w/o IC, usually older less active patients
Rest pain, trophic skin changes, ischaemic ulcers between toes/pressure areas, positive Buerger’s test
Most progress to necrosis - infection + wet gangrene - sepsis so do surgery before this
How does spinal stenosis present?
Pain relieved by sitting not standing, worse going downhill as more pressure on nerve roots
Pain goes down lateral leg in the TFL
What is Buerger’s test?
Raise leg, goes pale at <20 degrees is positive, then hang legs over bed again it becomes very red
What is critical limb ischaemia?
Arterial insufficiency so bad that it threatens limb viability. Persistently recurring rest pain needing analgesia for >2w, or ulceration/gangrene with ABPI <0.5. Limb pale, cold, pulseless, hair loss, skin change, thickening of nails
Interpretation of the ankle brachial pressure index
Ankle/brachial systolic pressure (ankle usually slightly above arm).
Normal: 0.9-1.2
>1.2: calcification in diabetics prevents cuff compression
0.8-0.9: mild disease
0.8-0.5: moderate, severe IC
<0.5: critical ischaemia, rest pain
<0.2: gangrene + ulceration
What are the commonest sites for peripheral arterial disease?
Superficial femoral a
Common iliac arteries
Patchy disease beyond the popliteal trifurcation
How would you manage a patient with chronic LL ischaemia?
Medical - lifestyle, statins for all, anti platelet (clopidogrel), optimise DM control
Surgical - when exercise hasn’t improved symptoms or in critical limb ischaemia. For single regions angioplasty + stenting, for diffuse disease bypass grafting, if incurable/sepsis amputation
What is acute LL ischaemia?
Sudden reduction in limb perfusion that threatens its viability
Common sites are aortic bifurcation (saddle embolus), CFA bifurcation + popliteal trifurcation
What is the cause of acute LL ischaemia?
Thrombosis - most common. Atheroma plaque ruptures, acute or acute-on-chornic. E.g. popliteal aneurysms
Embolism - thrombus from a proximal source occludes a more distal artery, ischaemia worse as fewer collaterals distally. Causes include mitral stenosis, AF, post-MI, AAA, prosthetic valve.
Less common - trauma e.g. compartment syndrome, hyper coagulable states
Describe the Rutherford classification for acute limb ischaemia
I - viable, no sensory/motor loss, Dopplers audible
IIA - marginally threatened prompt treatment, minimal sensory loss, no motor loss, arterial doppler inaudible
IIB - immediately threatened. more sensory loss, rest pain, mild-moderate motor deficit, inaudible arterial doppler
III - irreversible. Major tissue loss, profound sensory + motor deficits, both arterial + venous dopplers inaudible
Outline the management of acute limb ischaemia
High flow O2, heparin bolus + infusion
Rutherford I and IIa - prolonged course of heparin and r/v
IIb and beyond - surgical. E.g. embolectomy, thrombolysis, angioplasty, bypass. If irreversible urgent amputation or palliative (mottled, non-blanching, woody muscles)
