Vascular Surgery Flashcards
what is Leriche’s Syndrome?
Aortoiliac Occlusive Disease
Atherosclerotic occlusion of abdominal aorta and iliacs
triad of:
Buttock claudication and wasting
Erectile dysfunction
Absent femoral pulses
what is Buerger’s Disease?
Thombroangiitis Obliterans
Young, male, heavy smoker
Acute inflammation and thrombosis of arteries and veins in the hands and feet → ulceration and gangrene
features of intermittent claudication?
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)
features of critical limb ischaemia?
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
modifiable risk factors of chronic limb ischaemia?
Smoking
BP
DM control
Hyperlipidaemia
↓ exercise
non modifiable risk factors of chronic limb ischaemia?
FH and PMH
Male
↑ age
Genetic
associated vascular disease of chronic limb ischaemia?
IHD: 90%
Carotid stenosis: 15%
AAA
Renovascular disease
DM microvascular disease
Signs of chronic Limb ischaemia?
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
What is Buerger’s Angle?
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
What is Buerger’s Sign?
+ve in critical limb ischaemia
Reactive hyperaemia due to accumulation of
deoxygenated blood in dilated capillaries
Fontaine clinical classification of chronic limb ischaemia?
- Asympto (subclinical)
- Intermittent claudication
a. >200m
b. <200m
3. Ischaemic rest pain
- Ulceration / gangrene
Rutherford classification of chronic limb ischaemia?
- Mild claudication
- Moderate claudication
- Severe claudication
- Ischaemic rest pain
- Minor tissue loss
- Major tissue loss
definition of chronic limb ischaemia?
Ankle artery pressure <50mmHg (toe <30mmHg)
And either:
- Persistent rest pain requiring analgesia for ≥2wks
- Ulceration or gangrene
Ix of chronic limb ischaemia?
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
Doppler Waveforms Ix of chronic limb ischaemia may show?
Normal: triphasic
Mild Stenosis: biphasic
Severe stenosis: monophasic
ABPI Ix of chronic limb ischaemia may show?
>1.4: Calcification of vessels: DM, chronic renal failure
≥1: normal
- 8-0.9: asymptomatic
- 6-0.8: claudication
- 3-0.6: rest pain
<0.3: ulceration and gangrene
What is ABPI?
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).
why may ABPI be falsely high?
Falsely high results may be obtained in DM / CRF due to calcification of vessels: mediasclerosis
Walk Test Ix of chronic limb ischaemia?
Walk on treadmill @ certain speed and incline to establish maximum claudication distance.
ABPI measured before and after: 20% ↓ is sig
Bloods Ix of chronic limb ischaemia?
FBC + U+E: anaemia, renovascular disease
Lipids + glucose
ESR: arteritis
G+S: possible procedure
conservative mx of chronic limb ischaemia?
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
medical mx of chronic limb ischaemia?
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)
endovascular mx of chronic limb ischaemia?
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.
indications for surgical reconstruction of chronic limb ischaemia?
V. short claudication distance (e.g. <100m)
Symptoms greatly affecting pts. QoL
Development of rest pain
6 Ps of acute limb ischaemia?
Pale
Pulseless
Perishingly cold
Painful
Paraesthesia
Paralysis
causes of acute limb ischaemia?
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
difference between thrombosis and embolus causing acute limb ischaemia?
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
mx of thrombosis vs embolus causing acute limb ischaemia?
thrombosis:
thrombolysis, bypass sx
embolus:
embolectomy + warfarin
mx of acute limb ischaemia?
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
severity of acute limb ischaemia?
Incomplete: limb not threatened
Complete: limb threatened
- Loss of limb unless intervention w/i/ 6hrs
Irreversible: requires amputation
angiography in acute limb ischaemia?
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.
mx of embolus -> acute limb ischaemia?
- Embolectomy
- 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
complications post-embolectomy of acute limb ischaemia?
Reperfusion injury
Local swelling → compartment syndrome
Acidosis and arrhythmia 2O to ↑K
ARDS
GI oedema → endotoxic shock
Chronic pain syndromes
how does embolectomy work?
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
mx of thrombosis -> acute limb ischaemia?
Emergency reconstruction if complete occlusion
Angiography + angioplasty
Thrombolysis
Amputation
definition of stroke?
sudden neurological deficit of vascular origin
lasting >24h
definition of TIA?
sudden neurological deficit of vascular origin lasting <24h (usually lasts <1h) w complete recovery
pathogenesis of carotid artery disease?
Turbulent flow → ↓ shear stress @ carotid bifurcation promoting atherosclerosis and plaque formation.
Plaque rupture → complete occlusion or distal emboli
Cause 15-25% of CVA/TIA
presentation of carotid artery disease?
carotid bruit
CVA/ TIA
ix of carotid artery disease?
duplex carotid doppler
MR angiogram
mx of carotid artery disease?
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)
complications of endarterectomy?
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
definition of aneurysm?
Abnormal dilatation of a blood vessel > 50% of its normal diameter.
true vs false aneurysm?
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
what is a dissecting aneurysm?
Vessel dilatation caused by blood splaying apart the media to form a channel w/i the vessel wall.
complications of aneurysms?
Rupture
Thrombosis
Distal embolization
Pressure: DVT, oesophagus, nutcracker syndrome
Fistula (IVC, intestine)
causes of aneurysms?
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)
features of popliteal aneurysm?
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
mx of popliteal aneurysm?
Acute: embolectomy or fem-distal bypass
Stable: elective grafting + tie off vessel
pathology of abdominal aortic aneurysm?
Dilatation of the abdominal aorta ≥3cm
90% infrarenal
30% involve the iliac arteries
presentation of abdominal aortic anuerysm?
Usually asympto: discovered incidentally
May → back pain or umbilical pain radiating to groin
Acute limb ischaemia
Blue toe syndrome: distal embolisation
Acute rupture
examination findings of abdominal aortic aneurysm?
expansile mass just above the umbilicus
bruits may be heard
tenderness + shock suggests rupture
ix of abdominal aortic aneurysm?
AXR: calcification may be seen
Abdo US: screening and monitoring
Abdo and Pelvic CT
Angiography
mx of AAA
low rupture risk: diameter < 5.5 cm
asymptomatic
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)
mx of AAA
high rupture risk: > 5.5cm
symptomatic or rapidly enlarging (>1cm/ year)
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.
indications for surgical treatment of AAA?
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
increased rupture rate of AAA if?
increased diameter
raised BP
smoker
female
strong FH
presentation of ruptured AAA?
Sudden onset severe abdominal pain
Intermittent or continuous
Radiates to back or flanks (don’t dismiss as colic)
Collapse → shock
Expansile abdominal mass
mx of ruptured AAA?
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
definition of thoracic aortic dissection?
Blood splays apart the laminar planes of the media to form a channel w/i the aortic wall.
presentation of aortic dissection?
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
Pathophysiology of aortic dissection?
Atherosclerosis and HTN cause 90%
Minority caused by connective tissue disorder
- Marfan’s, Ehlers Danlos
- Vitamin C deficiency
Stanford classification of aortic dissection?
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
ix of aortic dissection?
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
Mx of Aortic Dissection?
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
definition of gangrene?
death of tissue from poor vascular supply
wet vs dry gangrene?
wet: tissue death + infection
Dry: tissue death only
presentation of gangrene?
black tissues + slough
may be suppuration +/- sepsis
organism causing gas gangrene?
clostridium perfringens
Presentation of gas gangrene?
toxaemia
haemolytic jaundice
oedema
crepitus from surgical emphysema
bubbly brown pus
mx of gas gangrene?
debridement (may need amputation)
benzylpenicillin + metronidazole
hyperbaric O2
Risk factors of gas gangrene?
DM, trauma, malignancy
what is Fournier’s Gangrene?
type of necrotizing fasciitis or gangreneaffecting the external genitalia and/or perineum.
more likely to occur in diabetics, alcoholics, or those who are immunocompromised.
what is meleney’s gangrene?
post op ulceration -> progressive gangrene
more common in immunosuppressed individuals
mx of gangrene?
take cultures
debridement (including amputation)
benzylpenicillin +/- clindamycin
definition of varicose veins?
tortuous, dilated veins of the superficial venous system
pathophysiology of varicose veins?
one way flow from superficial -> deep veins maintained by valves
valve failure -> increased pressure in superficial veins -> varicosity
where are the 3 main sites where valve incompetence occurs?
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)
primary causes of varicose veins?
idiopathic (congenitally weak valves)
- prolonged standing
- pregnancy
- obesity
- OCP
- FH
congenital valve absence (v rare)
secondary causes of varicose veins?
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
Port wine stains, varicose veins, limb hypertrophy?
Klippel-Trenaunay Syndrome
symptoms of varicose veins?
cosmetic defect
pain, cramping, heaviness
tingling
bleeding - may be severe
swelling
signs of varicose veins?
skin changes:
venous stars
haemosiderin deposition
venous eczema
lipodermatosclerosis
atrophie blanche
ulcers: medial malleolus/ gaiter area
oedema
thrombophlebitis
ix of varicose veins?
Duplex ultrasonagraphy:
anatomy, presence of incompetence, caused by obstruction or reflex
Surgery: FBC, U+E, clotting, G+S, CXR, ECG
conservative mx of varicose veins?
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
indications for minimally invasive tx of varicose veins?
ie. injection sclerotherapy/ endovenous laser or radiofrequency ablation
small below knee varicosities not involving great saphenous vein or small saphenous vein
minimally invasive tx of varicose veins?
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
indications for surgical mx of varicose veins?
Saphenofemoral junction incompetence
major perforator incompetence
symptomatic: ulceration, skin changes, pain
complications of surgical tx of varicose veins?
haematoma (esp groin)
wound sepsis
damage to cutaneous n (e.g. long saphenous)
superficial thrombophlebitis
DVT
recurrence
post op instructions for varicose veins?
bandage tightly
elevate for 24h
discharge w compression stockings + instructed to walk daily
definition of leg ulcer?
interruption in the continuity of an epithelial surface
causes of leg ulcers?
venous: commonest
arterial: large or small vessel disease
neuropathic: alcohol, DM
traumatic: e.g pressure
systemic disease: e.g. pyoderma gangrenosum
neoplastic: SCC
features of venous ulcers?
painless, sloping, shallow ulcers
usually on medial malleolus: “gaiter area”
assoc w haemosiderin deposition and lipodermatosclerosis
risk factors of venous ulcers?
venous insufficiency, varicosities, DVT, obesity
where are venous ulcers usually found?
medial malleolus
features of arterial ulcers?
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
features of neuropathic ulcer?
painless w insensate surrounding skin
warm foot w good pulses
complications of leg ulcers?
osteomyelitis
development of scc in the ulcer (Marjolin’s ulcer)
ix of leg ulcer?
wound swab
ABPI: leg ischaemia? (must differentiate between venous and arterial ulcers as diff mx!)
duplex ultrasonagraphy
biopsy: ?malignancy
mx of Venous ulcers?
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
differential of unilateral leg swelling?
Venous insufficiency
DVT
Infection or inflammation
Lymphoedema
differential of bilateral leg swelling?
↑ Venous Pressure
RHF
Venous insufficiency
Drugs: e.g. nifedipine
↓ Oncotic Pressure
Nephrotic syndrome
Hepatic failure
Protein losing enteropathy
Lymphoedema
Myxoedema
Hyper- / hypo-thyroidism
what is lymphoedema?
Collection of interstitial fluid due to blockage or absence of lymphatics
mx of lymphoedema?
Conservative
Skin care
Compression stocking
Physio
Treat or prevent comorbid infections
Surgical: debulking operation
1st line ix of peripheral arterial disease?
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
Brown pigmentation (haemosiderin), lipodermatosclerosis (champagne bottle legs), and eczema?
signs of chronic venous insufficiency, which can lead to venous ulcers
pyoderma gangrenosum assoc w?
inflammatory bowel disease/RA
screening for AAA?
In the UK, all men aged 65 years are offered aneurysm screening with a single abdominal ultrasound.
1st line mx of peripheral arterial disease?
Exercise training
+
quit smoking.
Comorbidities should be treated, including
hypertension
diabetes mellitus
obesity
1st line medical mx of peripheral arterial disease
Clopidogrel
Atorvastatin
primary causes of lymphoedema?
congenital absence of lymphatics
may/ may not be familial
Congenital: evident from birth
Lymphoedema praecox: after birth but < 35 yrs
Lymphoedema Tarda: > 35 yrs
familial AD subtype of congenital lymphoedema?
Disruption of the normal drainage of lymph leads to fluid accumulation and hypertrophy of soft tissues.
Milroy’s Syndrome
Secondary causes of lymphoedema?
FIIT
Fibrosis: eg. post radiotherapy
Infiltration:
Ca- prostate, lymphoma
Filariasis: wuchereria bancrofti
Infection: TB
Trauma: block dissection of lymphatics
Raynauds?
Digits become: white →blue →red
Treatment is with calcium antagonists
cervical rib signs?
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
CXR of aortic dissection?
Widening of aorta
diagnosis of aortic dissection?
CT scan
what is subclavian steal syndrome?
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
ix of subclavian steal syndrome?
duplex US or angiogram
What is Takayasu’s arteritis?
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
late signs of severe limb ischaemia?
parasthesiae and paralysis
