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DPD > Vascular surgery > Flashcards

Vascular surgery Flashcards

1
Q

What are the vascular risk factors?

A 
Smoking
Hypertension
Diabetes mellitus
High cholesterol
Family history
Renal failure
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2
Q

Give examples of disease in coronary and carotid territories.

A

MI, angina, coronary revascularisation.

Stroke, TIA, amaeurosis fugax, carotid intervention.

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3
Q

How is vascular disease prevented?

A

Antiplatelet medication.
Statins.
Risk factor modification.

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4
Q

What is claudication?

A

Pain that becomes worse with exercise- usually in calves, thigh or buttocks.
Measured in metres- how far can you walk without pain, does it go away with rest?
Peripheral vascular disease.
Intermittent, exercise driven.
Muscle doesn’t get enough oxygen.
Reproducible.
Impact on social function, QOL.
Need to differentiate from nerve root compression.

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5
Q

What is critical ischaemia?

A

Rest pain requiring analgesia >2 weeks, or tissue loss.
Limb involved is always ischaemic- constant pain- black, blue, ulcers, cold, etc.
Forefoot/toes.
Night.
Relieved by dependency.
Gangrene/ulceration.
Never enough blood with oxygen.

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6
Q

What is rest pain?

A

In pain at rest, peripheral vascular disease, sign of critical ischaemia.

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7
Q

What is the prognosis and what makes it worse for patients with intermittent claudication?

A 
80% chance of improving/stable.
20% chance of getting worse.
5%- intervention, 1%- major amputation.
15%- dead 5 years stroke/MI. 
-Diabetes mellitus.
-Smoking.
-Occlusive disease below the knee.
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8
Q

What is the prognosis for patients with critical limb ischaemia?

A

90%- intervention within 1 year.
25%- major amputation.
50%- dead within 5 years MI/stroke.

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9
Q

Which of the following describes ischaemic rest pain?

a) it is cramping in nature
b) it is typically felt in the calf at night
c) it indicates impending limb loss
d) it is relieved by leg elevation

A

It indicates impending limb loss.

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10
Q

What is ankle brachial pressure index?

A 
Compare BP in leg to arm.
Ankle SBP/Brachial SBP.
Normal 0.9-1.
Claudication 0.6-0.9.
Single level occlusion >0.5.
Multi-level occlusion <0.5.
Rest pain/gangrene 0.3.
Calcification can alter results- diabetes.
Incompressible arteries- spuriously high ankle pressures.
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11
Q

Which of the following is NOT true with respect to ABPI measurements?

a) ABPI <0.9 almost always indicates significant arterial disease
b) claudicants have on average ABPI of 0.6
c) in limbs with rest pain and gangrene the ABPI is typically 0.3
d) ABPI is the investigation of choice in diabetes.

A

ABPI is NOT the investigation of choice in diabetes.

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12
Q

How can you image arteries?

A

Duplex ultrasound.
Angiography.
Magnetic resonance angiography.

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13
Q

What are the advantages of duplex ultrasound?

A

Non-invasive.
Fast/cheap.
Few complications.

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14
Q

What are the disadvantages of duplex ultrasound?

A

Dependent on ultrasonographer’s ability.

Poor visualisation below the knee.

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15
Q

What are the advantages of angiography?

A

Gold standard for demonstrating anatomy.

Provides therapeutic opportunities, e.g. PTA.

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16
Q

What are the disadvantages of angiography?

A

Invasive: risk of haemorrhage, aneurysm, infection.

Contrast in nephrotoxic.

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17
Q

What are the different types of diabetic foot?

A

45% neuropathic.
10% ischaemic.
45% mixed.

18
Q

What are the 6Ps of acute limb ischaemia?

A 
Pain
Pallor
Perishing cold
Pulseless
Paraesthesia
Paralysis

Surgical emergency.

19
Q

What are the stages of acute limb ischaemia?

A

Viable: no neuropathy, audible doppler at ankle.
Threatened: sensory loss, tense calf, no doppler.
Dead: complete neurological deficit, fixed mottling.

20
Q

What are the causes of acute limb ischaemia?

A 
Thrombosis.
Embolism.
Graft thrombosis/post angioplasty.
Trauma.
Iatrogenic.
Thrombosed popliteal artery aneurysm.
21
Q

Embolic vs. thrombotic acute limb ischaemia.

A

Embolic: sudden, no Hx PVD, opposite limb normal, identifiable source (80% AF, 10% post MI, 10% aneurysm aortic/popliteal).
Plaque thrombosis: sudden/less acute, claudicant, abnormalities in other limb.

22
Q

What are the initial investigations for acute limb ischaemia?

A 
FBC, clotting, G&amp;S.
ECG.
CXR.
Cardiac enzymes.
ABPI.
Duplex US.
Angiogram.
23
Q

What is the treatment for acute limb ischaemia?

A 
Analgesia.
Heparin.
Catheter.
IV access &amp; fluids.
Consent.
Embolectomy ± fasciotomies/ thrombectomy.
Thrombolysis.
24
Q

What is the most likely aetiology of ‘trash foot’?

a) infective endocarditis
b) SFA occlusion
c) abdominal aortic aneurysm
d) popliteal aneurysm
e) all of the above

A

Abdominal aortic aneurysm.

25
Q

What is carotid artery disease?

A

Stroke: completed (deficit lasting >3 weeks), TIA (symptoms resolve completely <24hrs).
Amaurosis fugax = transient blindness in one eye.
Necrotic plaque in arteries ruptures, debris discharged; ulcer, platelet deposition, platelet emboli; trauma (carotid dissection).

26
Q

What is the epidemiology of stroke?

A 
700,000 new stroke patients yearly.
Mortality rate of 10-35%, 30% die within 1yr.
3rd leading cause of death.
Annual cost of stroke >50 billion.
27% haemorrhagic, 71% ischaemic.
27
Q

How is carotid artery disease diagnosed?

A

History (TIA, stroke), physical exam (carotid bruits).
Carotid duplex.
CT/MR brain, CTA aortic arch and carotids.
Angiography.

28
Q

How is carotid artery disease treated?

A

Symptomatic: >70% ICA stenosis (ESCT, SACET), carotid endarterectomy = CEA, 17% risk reduction at 2 years; 50-69% ICA stenosis (NASCET), CEA, 6% risk reduction at 5 years; 30-50% ICA stenosis (NASCET), BMT.
Asymptomatic: BMT, 50% risk reduction; aspirin, clopidogrel, dipyridamole; statin.

29
Q

What is DVT?

A

Deep vein thrombosis.
Detected by scanning- d-dimers.
Treated by anticoagulation, compression, adequate analgesia and adequate rehydration.

30
Q

What are varicose veins?

A 
Common- 10% of population.
Superficial veins.
Valve dysfunction.
Bulging veins.
Chronic venous insufficiency: leg swelling, skin colour and texture changes, venous ulcers.
31
Q

What is the treatment or varicose veins?

A

High frequency ultrasound/ laser ablates vein under ultrasound guidance and local anaesthetic.

32
Q

What is an aneurysm?

A

A permanent localised dilatation of an artery, at least >1.5 original vessel diameter.
Ectasia.

33
Q

What is a true aneurysm and what are the causes?

A

Dilatation of all layers of arterial wall.

Degenerative- atherosclerotic.
Connective tissue- Marfan's.
Post-dissection- thoracic/ type B.
Infection- syphilitic, salmonella.
Inflammatory- takayasus, PAN.
Congenital.
34
Q

What are false aneurysms?

A

Traumatic, connective tissue wall, post haematoma.

35
Q

What are the different types of aneurysms?

A

Saccular.
Fusiform.
Pseudoaneurysm.

36
Q

What are the clinical features of aortic aneurysms?

A 
Asymptomatic (75% incidental).
Symptomatic (25%):
- rupture = abdominal/flank/back pain.
- compression = sciatica, leg swelling, vomiting, hydronephrosis.
- fistulation = aorto-duodenal, aorto-caval fistula.
- distal embolisation.
Surgical emergency.
4:1 female:male.
37
Q

How are aortic aneurysms assessed?

A

Physical exam: palpation around (up+left) umbilicus.
USS.
CTA.

38
Q

What is the rupture risk of abdominal aortic aneurysms?

A

Low <1% with diameter <5.5cm.
Rises to 10%/year over 6cm, 25%/year over 7cm.
Rupture mortality: 80% community, 50% hospital.

39
Q

A 673y/o man comes to the clinic and describes pain in both calves after walking 50m.
He is a smoker and has had diabetes for many years.
Imaging reveals that he has severe arterial disease in his femoral arteries and vessels distal to them.
What is this symptom best described as?

A

Intermittent claudication.

40
Q

A 68y/o man comes to the clinic with a 3yr history of leg ulcers treated unsuccessfully by district nurses with dressings.
A scan shows normal arteries, but bilateral incompetence of both his great saphenous veins.
He is otherwise fit and well and mobilises easily.
What is the most appropriate next step in management?

A

Ablation.

DPD (32 decks)

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