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Surgery > Vascular Surgery > Flashcards

Vascular Surgery Flashcards

1
Q

what is Leriche’s Syndrome?

A

Aortoiliac Occlusive Disease

Atherosclerotic occlusion of abdominal aorta and iliacs

triad of:

Buttock claudication and wasting

Erectile dysfunction
Absent femoral pulses

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2
Q

what is Buerger’s Disease?

A

Thombroangiitis Obliterans

Young, male, heavy smoker
Acute inflammation and thrombosis of arteries and veins in the hands and feet → ulceration and gangrene

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3
Q

features of intermittent claudication?

A

Cramping pain after walking a fixed distance
Pain rapidly relieved by rest

Calf pain = superficial femoral disease (commonest)

Buttock pain = iliac disease (internal or common)

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4
Q

features of critical limb ischaemia?

A

Rest pain

Especially @ night
Usually felt in the foot
Pt. hangs foot out of bed

Due to ↓ CO and loss of gravity help

Ulceration/ Gangrene

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5
Q

modifiable risk factors of chronic limb ischaemia?

A

Smoking

BP

DM control

Hyperlipidaemia

↓ exercise

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6
Q

non modifiable risk factors of chronic limb ischaemia?

A

FH and PMH

Male
↑ age
Genetic

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7
Q

associated vascular disease of chronic limb ischaemia?

A

IHD: 90%

Carotid stenosis: 15%

AAA

Renovascular disease

DM microvascular disease

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8
Q

Signs of chronic Limb ischaemia?

A

Pulses: pulses and ↑ CRT (norm ≤2sec)
Ulcers: painful, punched-out, on pressure points

Nail dystrophy / Onycholysis
Skin: cold, white, atrophy, absent hair
Venous guttering
Muscle atrophy

decreased Buerger’s Angle

+ve Buerger’s Sign

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9
Q

What is Buerger’s Angle?

A

The vascular angle, which is also called Buerger’s angle, is the angle to which the leg has to be raised before it becomes pale, whilst lying down. In a limb with a normal circulation the toes and sole of the foot, stay pink, even when the limb is raised by 90 degrees.

90 and >: normal

20-30: ischaemia

<20: severe ischaemia

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10
Q

What is Buerger’s Sign?

A

+ve in critical limb ischaemia

Reactive hyperaemia due to accumulation of

deoxygenated blood in dilated capillaries

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11
Q

Fontaine clinical classification of chronic limb ischaemia?

A
  1. Asympto (subclinical)
  2. Intermittent claudication

a. >200m

b. <200m
3. Ischaemic rest pain

  1. Ulceration / gangrene
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12
Q

Rutherford classification of chronic limb ischaemia?

A
  1. Mild claudication
  2. Moderate claudication
  3. Severe claudication
  4. Ischaemic rest pain
  5. Minor tissue loss
  6. Major tissue loss
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13
Q

definition of chronic limb ischaemia?

A

Ankle artery pressure <50mmHg (toe <30mmHg)

And either:

  • Persistent rest pain requiring analgesia for ≥2wks
  • Ulceration or gangrene
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14
Q

Ix of chronic limb ischaemia?

A

Doppler Waveforms:

  • Normal: triphasic
  • Mild Stenosis: biphasic
  • Severe stenosis: monophasic

ABPI:

Normal ≥1

Asymptomatic: 0.8-0.9

Claudication: 0.6-0.8

Rest pain: 0.3-0.6

Ulceration and gangrene: <0.3

Walk Test:

walk on treadmill @ certain speed and incline to establish max claudication distance

ABPI measured before and after: 20% drop is significant

Bloods:

FBC, U+Es: anaemia, renovascular disease

Lipids + glucose

ESR: arteritits

G+S: possible procedure

Imaging:

assess site, extent and distal run-off

Colour duplex US

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15
Q

Doppler Waveforms Ix of chronic limb ischaemia may show?

A

Normal: triphasic

Mild Stenosis: biphasic

Severe stenosis: monophasic

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16
Q

ABPI Ix of chronic limb ischaemia may show?

A

>1.4: Calcification of vessels: DM, chronic renal failure

≥1: normal

  1. 8-0.9: asymptomatic
  2. 6-0.8: claudication
  3. 3-0.6: rest pain

<0.3: ulceration and gangrene

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17
Q

What is ABPI?

A

ratio of the blood pressure at the ankle to the blood pressure in the upper arm (brachium).

Compared to the arm, lower blood pressure in the leg suggests blocked arteries due to peripheral artery disease (PAD).

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18
Q

why may ABPI be falsely high?

A

Falsely high results may be obtained in DM / CRF due to calcification of vessels: mediasclerosis

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19
Q

Walk Test Ix of chronic limb ischaemia?

A

Walk on treadmill @ certain speed and incline to establish maximum claudication distance.

ABPI measured before and after: 20% ↓ is sig

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20
Q

Bloods Ix of chronic limb ischaemia?

A

FBC + U+E: anaemia, renovascular disease

Lipids + glucose

ESR: arteritis

G+S: possible procedure

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21
Q

conservative mx of chronic limb ischaemia?

A

Most pts w claudication can be managed conservatively

↑ exercise and employ exercise programs

Stop smoking

Wt. loss

Foot care

Prog: 1/3 improve, 1/3 stay the same, 1/3 deteriorate

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22
Q

medical mx of chronic limb ischaemia?

A

Risk factors: BP, lipids, DM

β-B don’t worsen intermittent claudication but usē w caution in Chronic Limb Ischamia

Antiplatelets: aspirin / clopidogrel

Analgesia: may need opiates

(Parenteral prostanoids ↓ pain in pts. unfit for surgery)

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23
Q

endovascular mx of chronic limb ischaemia?

A

Percutaneous Transluminal Angioplasty ± stenting
Good for short stenosis in big vessels: e.g. iliacs, SFA
Lower risk for pt.: performed under LA as day case
Improved inflow → ↓ pain but restoration of foot pulses is required for Rx of ulceration / gangrene.

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24
Q

indications for surgical reconstruction of chronic limb ischaemia?

A

V. short claudication distance (e.g. <100m)

Symptoms greatly affecting pts. QoL

Development of rest pain

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25
Q

6 Ps of acute limb ischaemia?

A

Pale

Pulseless

Perishingly cold

Painful

Paraesthesia

Paralysis

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26
Q

causes of acute limb ischaemia?

A

Thrombosis in situ (60%)

A previously stenosed vessel w plaque rupture

Usually incomplete ischaemia

Embolism (30%)

80% from LA in AF
Valve disease
Iatrogenic from angioplasty / surgery
Cholesterol in long bone #
Paradoxical (venous via PFO)
Typically lodge at femoral bifurcation

Often complete ischaemia

Graft / stent occlusion

Trauma

Aortic dissection

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27
Q

difference between thrombosis and embolus causing acute limb ischaemia?

A

thrombosis:

hrs-days onset, less severe due to collaterals, hx of claudication, absent contralateral pulses

embolus:

sudden onset, profound ischaemia, absent hx of claudication, contralateral pulses +ve

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28
Q

mx of thrombosis vs embolus causing acute limb ischaemia?

A

thrombosis:

thrombolysis, bypass sx

embolus:

embolectomy + warfarin

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29
Q

mx of acute limb ischaemia?

A

In an acutely ischaemic limb discuss immediately w a senior as time is crucial.

NBM
Rehydration: IV fluids
Analgesia: morphine + metoclopramide
Abx: e.g augmentin if signs of infection
Unfractionated heparin IVI: prevent extension

Complete occlusion?

Yes: urgent surgery: embolectomy or bypass

No: angiogram + observe for deterioration

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30
Q

severity of acute limb ischaemia?

A

Incomplete: limb not threatened

Complete: limb threatened

  • Loss of limb unless intervention w/i/ 6hrs

Irreversible: requires amputation

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31
Q

angiography in acute limb ischaemia?

A

Not performed if there is complete occlusion as it introduces delay: take straight to theatre.

If incomplete occlusion, pre-op angio will guide any distal bypass.

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32
Q

mx of embolus -> acute limb ischaemia?

A
  1. Embolectomy
  2. Thrombolysis

Consider if embolectomy unsuccessful

E.g. local injection of TPA

Post-embolectomy

Anticoagulate: heparin IVI → warfarin

ID embolic source: ECG, echo, US aorta, fem and pop

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33
Q

complications post-embolectomy of acute limb ischaemia?

A

Reperfusion injury

Local swelling → compartment syndrome

Acidosis and arrhythmia 2O to ↑K

ARDS

GI oedema → endotoxic shock

Chronic pain syndromes

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34
Q

how does embolectomy work?

A

Under LA or GA
Wire fed through embolus
Fogarty catheter fed over the top
Balloon inflated and catheter withdrawn, removing the embolism.
Send embolism for histo (exclude atrial myxoma)

Adequacy confirmed by on-table angiography

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35
Q

mx of thrombosis -> acute limb ischaemia?

A

Emergency reconstruction if complete occlusion

Angiography + angioplasty
Thrombolysis
Amputation

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36
Q

definition of stroke?

A

sudden neurological deficit of vascular origin

lasting >24h

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37
Q

definition of TIA?

A

sudden neurological deficit of vascular origin lasting <24h (usually lasts <1h) w complete recovery

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38
Q

pathogenesis of carotid artery disease?

A

Turbulent flow → ↓ shear stress @ carotid bifurcation promoting atherosclerosis and plaque formation.

Plaque rupture → complete occlusion or distal emboli

Cause 15-25% of CVA/TIA

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39
Q

presentation of carotid artery disease?

A

carotid bruit

CVA/ TIA

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40
Q

ix of carotid artery disease?

A

duplex carotid doppler

MR angiogram

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41
Q

mx of carotid artery disease?

A

aspirin/ clopidogrel

control risk factors

surgical: endarterectomy

( surgical procedure to remove the atheromatous plaquematerial, or blockage, in the lining of an artery constricted by the buildup of deposits)

or Stenting:

Less invasive: ↓ hospital stay, ↓ infection, ↓ CN injury

(stenting better for younger pts)

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42
Q

complications of endarterectomy?

A

Stroke or death: 3%

HTN: 60%

Haematoma
MI

Nerve injury
Hypoglossal: ipsilateral tongue deviation
Great auricular: numb ear lobe
Recurrent laryngeal: hoarse voice, bovine cough

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43
Q

definition of aneurysm?

A

Abnormal dilatation of a blood vessel > 50% of its normal diameter.

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44
Q

true vs false aneurysm?

A

true aneurysm:

Dilatation of a blood vessel involving all layers of the wall and is >50% of its normal diameter

Two different morphologies

  • Fusiform: e.g AAA
  • Saccular: e.g Berry aneurysm

False aneurysm:

Collection of blood around a vessel wall that communicates w the vessel lumen.

Usually iatrogenic: puncture, cannulation

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45
Q

what is a dissecting aneurysm?

A

Vessel dilatation caused by blood splaying apart the media to form a channel w/i the vessel wall.

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46
Q

complications of aneurysms?

A

Rupture
Thrombosis
Distal embolization
Pressure: DVT, oesophagus, nutcracker syndrome

Fistula (IVC, intestine)

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47
Q

causes of aneurysms?

A

Congenital:

ADPKD → Berry aneurysms

Marfan’s, Ehlers-Danlos

Acquired:

Atherosclerosis
Trauma: e.g. penetrating trauma
Iflammatory: Takayasu’s aortitis, HSP

Infection

Mycotic: SBE

Tertiary syphilis (esp. thoracic)

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48
Q

features of popliteal aneurysm?

A

Very easily palpable popliteal pulse

50% bilateral

Rupture is relatively rare

Thrombosis and distal embolism is main complication

→ acute limb ischaemia

50% of pts w popliteal aneurysm also have AAA

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49
Q

mx of popliteal aneurysm?

A

Acute: embolectomy or fem-distal bypass

Stable: elective grafting + tie off vessel

50
Q

pathology of abdominal aortic aneurysm?

A

Dilatation of the abdominal aorta ≥3cm

90% infrarenal

30% involve the iliac arteries

51
Q

presentation of abdominal aortic anuerysm?

A

Usually asympto: discovered incidentally

May → back pain or umbilical pain radiating to groin

Acute limb ischaemia

Blue toe syndrome: distal embolisation

Acute rupture

52
Q

examination findings of abdominal aortic aneurysm?

A

expansile mass just above the umbilicus

bruits may be heard

tenderness + shock suggests rupture

53
Q

ix of abdominal aortic aneurysm?

A

AXR: calcification may be seen

Abdo US: screening and monitoring

Abdo and Pelvic CT

Angiography

54
Q

mx of AAA

low rupture risk: diameter < 5.5 cm

asymptomatic

A

abdominal US surveillance:

<4.4 cm: US scans yearly

4.4 - 5.5 cm: US scans every 3 months

optimise cardiovascular risk factors (e.g. stop smoking)

55
Q

mx of AAA

high rupture risk: > 5.5cm

symptomatic or rapidly enlarging (>1cm/ year)

A

elective endovascular repair (EVAR) or open repair if unsuitable.

In EVAR a stent is placed into the abdominal aorta via the femoral artery to prevent blood from collecting in the aneurysm.

56
Q

indications for surgical treatment of AAA?

A

operate when risk of rupture > risk of surgery

symptomatic (back pain - imminent rupture)

diameter > 5.5cm

rapidly expanding > 1cm/ yr

causing complications: e.g. emboli

57
Q

increased rupture rate of AAA if?

A

increased diameter

raised BP

smoker

female

strong FH

58
Q

presentation of ruptured AAA?

A

Sudden onset severe abdominal pain
Intermittent or continuous
Radiates to back or flanks (don’t dismiss as colic)

Collapse → shock

Expansile abdominal mass

59
Q

mx of ruptured AAA?

A

surgical emergency

High flow O2

2 large bore cannulae in each antecubital fossa:

give fluids if shocked but keep SBP < 100mmHg

give O- blood if desperate

Bloods: FBC, U+E, clotting, amylase, Xmatch

instigate major haemorrhage protocol

call vascular surgeon, anaesthetist and warn theatre

analgesia

abx prophylaxis: cef n met

urinary catheter + CVP line

if stable + dx uncertain: US/ CT feasible

take to theatre: clamp neck, insert dacron graft

60
Q

definition of thoracic aortic dissection?

A

Blood splays apart the laminar planes of the media to form a channel w/i the aortic wall.

61
Q

presentation of aortic dissection?

A

sudden onset, tearing chest pain

  • radiates to the back
  • tachycardia and HTN (primary + sympathetic)

Distal propagation → sequential occlusion of branches

  • Left hemiplegia
  • Unequal arm pulses and BP
  • Paraplegia (anterior spinal A.)
  • Anuria

Proximal propagation
- Aortic regurgitation

  • Tamponade

Rupture into pericardial, pleural or peritoneal cavities

  • Commonest cause of death
62
Q

Pathophysiology of aortic dissection?

A

Atherosclerosis and HTN cause 90%

Minority caused by connective tissue disorder

  • Marfan’s, Ehlers Danlos
  • Vitamin C deficiency
63
Q

Stanford classification of aortic dissection?

A

Type A: Proximal

70%

Involves ascending aorta ± descending

Higher mortality due to probable cardiac involvement

Usually require surgery

Type B: Distal

30%

Involves descending aorta only: distal to L Subclavian artery

Usually best managed conservatively

64
Q

ix of aortic dissection?

A

Bloods:

xmatch, FBC, U+E, clotting, amylase

ECG: to exclude MI

20% show ischaemia due to involvement of the coronary ostia

Imaging:

CXR

TOE: can be used if pt is haemodynamically unstable

CT/MRI: not suitable if haemodynamically unstable

65
Q

Mx of Aortic Dissection?

A

Resus

Analgesia

Lower BP:

  • Labetalol or esmolol (short half life)
  • keep SBP 100-110 mmHg

Type A: open repair

Type B: conservative initially, surgery if persistent pain or complications

consider TEVAR if uncomplicated

66
Q

definition of gangrene?

A

death of tissue from poor vascular supply

67
Q

wet vs dry gangrene?

A

wet: tissue death + infection

Dry: tissue death only

68
Q

presentation of gangrene?

A

black tissues + slough

may be suppuration +/- sepsis

69
Q

organism causing gas gangrene?

A

clostridium perfringens

70
Q

Presentation of gas gangrene?

A

toxaemia

haemolytic jaundice

oedema

crepitus from surgical emphysema

bubbly brown pus

71
Q

mx of gas gangrene?

A

debridement (may need amputation)

benzylpenicillin + metronidazole

hyperbaric O2

72
Q

Risk factors of gas gangrene?

A

DM, trauma, malignancy

73
Q

what is Fournier’s Gangrene?

A

type of necrotizing fasciitis or gangreneaffecting the external genitalia and/or perineum.

more likely to occur in diabetics, alcoholics, or those who are immunocompromised.

74
Q

what is meleney’s gangrene?

A

post op ulceration -> progressive gangrene

more common in immunosuppressed individuals

75
Q

mx of gangrene?

A

take cultures

debridement (including amputation)

benzylpenicillin +/- clindamycin

76
Q

definition of varicose veins?

A

tortuous, dilated veins of the superficial venous system

77
Q

pathophysiology of varicose veins?

A

one way flow from superficial -> deep veins maintained by valves

valve failure -> increased pressure in superficial veins -> varicosity

78
Q

where are the 3 main sites where valve incompetence occurs?

A

Saphenofemoral junction: 3 cm below and 3 cm lateral to pubic tubercle

Saphenopopliteal junction: popliteal fossa

perforators: draining great saphenous vein
- 3 medial calf perforators (Cockett’s)
- 1 medial thigh perforator (Hunter’s)

79
Q

primary causes of varicose veins?

A

idiopathic (congenitally weak valves)

  • prolonged standing
  • pregnancy
  • obesity
  • OCP
  • FH

congenital valve absence (v rare)

80
Q

secondary causes of varicose veins?

A

valve destruction -> reflux: DVT, thrombophlebitis

Obstruction: DVT, foetus, pelvic mass

constipation

AVM

Overactive pumps e.g. cyclists

Klippel-Trenaunay:

Port wine stains, varicose veins, limb hypertrophy

81
Q

Port wine stains, varicose veins, limb hypertrophy?

A

Klippel-Trenaunay Syndrome

82
Q

symptoms of varicose veins?

A

cosmetic defect

pain, cramping, heaviness

tingling

bleeding - may be severe

swelling

83
Q

signs of varicose veins?

A

skin changes:

venous stars

haemosiderin deposition

venous eczema

lipodermatosclerosis

atrophie blanche

ulcers: medial malleolus/ gaiter area

oedema

thrombophlebitis

84
Q

ix of varicose veins?

A

Duplex ultrasonagraphy:

anatomy, presence of incompetence, caused by obstruction or reflex

Surgery: FBC, U+E, clotting, G+S, CXR, ECG

85
Q

conservative mx of varicose veins?

A

treat any contributing factors:

lose weight, relieve constipation

education:

avoid prolonged standing, regular walks

Class II graduated compression stockings

  • 18-24 mmHg
  • symptomatic relief and slows progression

Skin care

  • maintain hydration w emmollients
  • treat ulcers rapidly
86
Q

indications for minimally invasive tx of varicose veins?

ie. injection sclerotherapy/ endovenous laser or radiofrequency ablation

A

small below knee varicosities not involving great saphenous vein or small saphenous vein

87
Q

minimally invasive tx of varicose veins?

A

done under LA or GA

injection sclerotherapy: 1% Na tetradecyl sulphate

endovenous laser or radiofrequency ablation

post op: compression bandage for 24h and compression stockings for 1 mo

88
Q

indications for surgical mx of varicose veins?

A

Saphenofemoral junction incompetence

major perforator incompetence

symptomatic: ulceration, skin changes, pain

89
Q

complications of surgical tx of varicose veins?

A

haematoma (esp groin)

wound sepsis

damage to cutaneous n (e.g. long saphenous)

superficial thrombophlebitis

DVT

recurrence

90
Q

post op instructions for varicose veins?

A

bandage tightly

elevate for 24h

discharge w compression stockings + instructed to walk daily

91
Q

definition of leg ulcer?

A

interruption in the continuity of an epithelial surface

92
Q

causes of leg ulcers?

A

venous: commonest
arterial: large or small vessel disease
neuropathic: alcohol, DM
traumatic: e.g pressure

systemic disease: e.g. pyoderma gangrenosum

neoplastic: SCC

93
Q

features of venous ulcers?

A

painless, sloping, shallow ulcers

usually on medial malleolus: “gaiter area”

assoc w haemosiderin deposition and lipodermatosclerosis

94
Q

risk factors of venous ulcers?

A

venous insufficiency, varicosities, DVT, obesity

95
Q

where are venous ulcers usually found?

A

medial malleolus

96
Q

features of arterial ulcers?

A

hx of vasculopathy and risk factors

painful, deep, punched out lesions

occur @ pressure points

  • heel
  • tips of and between toes
  • metatarsal heads esp 5th

other signs of chronic leg ischaemia

97
Q

features of neuropathic ulcer?

A

painless w insensate surrounding skin

warm foot w good pulses

98
Q

complications of leg ulcers?

A

osteomyelitis

development of scc in the ulcer (Marjolin’s ulcer)

99
Q

ix of leg ulcer?

A

wound swab

ABPI: leg ischaemia? (must differentiate between venous and arterial ulcers as diff mx!)

duplex ultrasonagraphy

biopsy: ?malignancy

100
Q

mx of Venous ulcers?

A

refer to leg ulcer community clinic

graduated compression stockings (if ABPI > 0.8)

analgesia

bed rest + elevate leg

optimise risk factors: smoking, nutrition

Pentoxyfylline PO: increases microcirculatory blood flow and improves healing rates

101
Q

differential of unilateral leg swelling?

A

Venous insufficiency

DVT
Infection or inflammation

Lymphoedema

102
Q

differential of bilateral leg swelling?

A

↑ Venous Pressure

RHF
Venous insufficiency

Drugs: e.g. nifedipine

↓ Oncotic Pressure

Nephrotic syndrome

Hepatic failure
Protein losing enteropathy

Lymphoedema

Myxoedema

Hyper- / hypo-thyroidism

103
Q

what is lymphoedema?

A

Collection of interstitial fluid due to blockage or absence of lymphatics

104
Q

mx of lymphoedema?

A

Conservative

Skin care
Compression stocking
Physio
Treat or prevent comorbid infections

Surgical: debulking operation

105
Q

1st line ix of peripheral arterial disease?

A

Duplex ultrasound

followed by MRA, where clinically appropriate and if needed, offers the most accurate, safe and cost-effective imaging strategy for people with PAD

106
Q

Brown pigmentation (haemosiderin), lipodermatosclerosis (champagne bottle legs), and eczema?

A

signs of chronic venous insufficiency, which can lead to venous ulcers

107
Q

pyoderma gangrenosum assoc w?

A

inflammatory bowel disease/RA

108
Q

screening for AAA?

A

In the UK, all men aged 65 years are offered aneurysm screening with a single abdominal ultrasound.

109
Q

1st line mx of peripheral arterial disease?

A

Exercise training

+

quit smoking.

Comorbidities should be treated, including

hypertension

diabetes mellitus

obesity

110
Q

1st line medical mx of peripheral arterial disease

A

Clopidogrel

Atorvastatin

111
Q

primary causes of lymphoedema?

A

congenital absence of lymphatics

may/ may not be familial

Congenital: evident from birth

Lymphoedema praecox: after birth but < 35 yrs

Lymphoedema Tarda: > 35 yrs

112
Q

familial AD subtype of congenital lymphoedema?

Disruption of the normal drainage of lymph leads to fluid accumulation and hypertrophy of soft tissues.

A

Milroy’s Syndrome

113
Q

Secondary causes of lymphoedema?

A

FIIT

Fibrosis: eg. post radiotherapy

Infiltration:

Ca- prostate, lymphoma

Filariasis: wuchereria bancrofti

Infection: TB

Trauma: block dissection of lymphatics

114
Q

Raynauds?

A

Digits become: white →blue →red

Treatment is with calcium antagonists

115
Q

cervical rib signs?

A

Compression of the subclavian artery may produce absent radial pulse on clinical examination and in particular may result in a positive Adsons test (lateral flexion of the neck away from symptomatic side and traction of the symptomatic arm- leads to obliteration of radial pulse)

thoracic outlet syndrome

tx if evidence of neurovascular compromise

116
Q

CXR of aortic dissection?

A

Widening of aorta

117
Q

diagnosis of aortic dissection?

A

CT scan

118
Q

what is subclavian steal syndrome?

A

Due to proximal stenotic lesion of the subclavian artery

Results in retrograte flow through vertebral or internal thoracic arteries

-> decrease in cerebral blood flow may occur and produce syncopal symptoms

119
Q

ix of subclavian steal syndrome?

A

duplex US or angiogram

120
Q

What is Takayasu’s arteritis?

A

Large vessel granulomatous vasculitis

Results in intimal narrowing

commonly young asian females

Patients present with features of mild systemic illness, followed by pulseless phase with symptoms of vascular insufficiency

Treatment is with systemic steroids

121
Q

late signs of severe limb ischaemia?

A

parasthesiae and paralysis

Surgery (17 decks)

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