Vascular surgery Flashcards
What is Budd-Chiari syndrome and what 2 conditions can it present as
Hepatic vein obstruction causing ischaemia and hepatocyte damage, presenting with liver failure or insidious cirrhosis
3 sx and a finding on bloods for Budd-Chiari
Abdominal pain
Ascites
Hepatomegaly
Raised ALT
Causes of Budd-Chiari
Primary - hypercoagulable = pregnancy, malignancy, pill, polycythaemia rubra Vera, thrombophilia
Secondary - obstructive = liver, renal, adrenal tumour causing hepatic vein thrombus
Investigate Budd-Chiari
USS
Hepatic vein Doppler
CT/MRI
Manage Budd-Chiari
Transjugular Intrahepatic Portosystemic Shunt (TIPS) or surgical shunt
Angioplasty
Anticoagulation lifelong unless varices
Consider transplant if fulminant hepatic necrosis or cirrhosis
5 causes of aneurysms in arteries
Atheroma
Trauma
Infection - mycotic aneurysm in endocarditis
Connective tissue disorders - Marfan’s, EDS
Inflammatory - Takayasu’s aortitis
What are true and false aneurysms?
True = abnormal dilatations of arteries, involving all layers of wall False/pseudoaneuryms = collections of blood ie after trauma, around vessel wall communicating with the lumen
What are the 2 types of artery aneurysms
Fusiform = both sides eg AAA = more common
Sac like = one side eg berry aneurysm
4 Common sites of artery aneurysms
Aorta (infrarenal)
Iliac
Femoral
Popliteal
5 complications of artery aneurysms
Rupture Thrombosis Embolism Fistulae Pressure on other structures
Sx of ruptured AAA - triad, plus 4
Triad: 1) back pain, 2) expansile pulsatile mass, 3) hypotension/shock (haemodynamically unstable)
Intermittent or continuous abdo pain radiating to back, iliac fossa or groin
Vomiting
Syncope
Retroperitoneal haemorrhage - Cullen’s and Grey-Turner’s signs
Preventing AAA - 2
Manage BP
Quit smoking, weight loss, exercise
Statins and aspirin
Regular USS for men if >65y
Emergency treatment of AAA - 7
- ECG
- Bloods for amylase, Hb and cross match 10-40u
- Catheterise
- 2 large bore cannulas
- O neg blood but keep systolic bp<100
- Prophylactic abx - cefuroxime and metronidazole IV
- Surgery - clamp aorta above leak and insert graft
Definition of arterial and aortic aneurysms
> 150% dilatation of original diameter
AAA = >3cm across
Cause of AAA
Degeneration of elastic lamellar and smooth muscle loss
Genetic component
Sx unruptured AAA
Often asymptomatic, can be discovered on abdo exam incidentally
May have abdo/back pain
Monitoring (2 levels) and elective surgery (3 conditions) on AAA
If <5.5cm, monitor by regular exam and US/CT: - 3-4 = /year - 4.5-5.5 = /3m Elective surgery if 1. >5.5 cm or 2. expanding at >1cm/y 3. or symptomatic
Risk factors for AAA rupture
Smoker
Raised BP
Female
Strong family history
Complication of elective surgical repair for AAA
Spinal or mesenteric ischaemia from dislodged thrombus debris
Surgery options for AAA, its pros and cons
If older, endovacular stent via femoral artery CT angiogram
+ = shorter hospital stay and fewer transfusions, less invasive, lower short term mortality
- = failure to totally exclude blood flow = endoleak; aneurysm may progress; higher risk of need for re-intervention
Younger patients = open surgery = clamp aorta and iliac arteries, remove and replace with prosthetic graft
What is thoracic aortic dissection and what can it cause at different places?
Blood splits aortic media with sudden tearing chest pain +- radiating to back, sequentially occluding branches of aorta
- hemiplegia - carotid artery
- unequal arm pulses and BP
- acute limb ischaemia
- paraplegia - anterior spinal artery
- anuria - renal arteries
- aortic incompetence and inferior MI - more proximal movement
2 types of thoracic aortic dissection and relevance to treatment
Type A = ascending aorta involved - consider for surgery
Type B = ascending aorta not involved - may be managed medically unless leaking, ruptured or compromising vital organs
Manage thoracic aortic dissection
Crossmatch 10u blood
ECG and CXR - expanded mediastinum is rare
CT/MRI or TransOesophageal Echocardiography (TOE)
Hypotensive to keep systolic BP at 100-110 = labetalol IVI
Early and late signs of limb ischaemia
Early - pain, pallor, pulseless
Late - paraesthesia, perishingly cold, paralysis
5 risk factors for limb ischaemia
Smoking Hypertension Diabetes MI AF
Investigate acute limb ischaemia and when
CT angiogram for anatomical delineation and urgent vascular review
Within 6h or irreversible tissue damage
3 causes of acute limb ischaemia
- Thrombosis in situ (60%) - atheroma ruptures and thrombus forms on plaque’s cap - acute or acute on chronic
- Embolisation - proximal thrombus travels distally, from AF, post-MI, AAA, prosthetic heart valve
- Trauma - compartment syndrome
Investigations for acute limb ischaemia - 3
Serum lactate
Doppler USS
CT angiography and arteriography for pre op locating
Manage acute limb ischaemia - 5
- Oxygen and IV access
- Heparin - IVi
- Surgery
- embolus = embolectomy with fogarty catheter, local intraarterial thrombolysis (tissue plasminogen activator) or bypass
- thrombus = angioplasty, local intraarterial thrombolysis or bypass
- amputate if mottled, non-blanching or woody muscles - Look for emboli source with USS of aorta, popliteal and femoral arteries, annd echo
- Manage risk factors and give antiplatelet (clopidogrel or low dose aspirin)
Complications of limb ischaemia
Reperfusin injury due to sudden increase in capillary permeability - can cause compartment syndrome and substance release = hyperkalaemia, acidosis and rhabdomyolysis
4 levels of acute ischaemia and prognosis
1 = viable, no sensory or motor deficit - only level with arterial and venous Dopplers 2a = marginal, salvageable with prompt treatment, minor sensory loss, no motor deficit - venous Doppler only 2b = immediately threatened but salvageable if immediately revascularised, sensory loss and pain at rest, mild motor deficit - venous Doppler only 3 = irreversible major tissue loss with permanent nerve damage, profound sensory and motor deficit - no dopplers
What is chronic limb ischaemia
Peripheral artery disease causing symptomatic reduction in blood supply to limbs, due to atherosclerosis
Staging of chronic limb ischaemia
Fontaine classification:
- Asymptomatic
- Intermittent claudication
- Ischaemic rest pain
- Ulceration/gangrene
Differentials for chronic limb ischaemia
Spinal stenosis - lateral radiating pain, better sitting than standing
Acute ischaemia - <14d
3 key features of critical limb ischaemia, plus other features
- ABPI <0.5
- Rest pain >2w requiring opioids, better when hanging legs off side of bed
- Ischaemic lesions/gangrene
Pale and cold, weak/absent pulses, hair loss, atrophic skin, thickened nails
What is the condition of peripheral arterial disease affecting buttock and thigh?
Leriche syndrome - peripheral arterial disease at aortic bifurcation causes buttock/thigh pain and erectile dysfunction
Investigating chronic limb ischaemia and findings - 7
- ABPI:
>0.9 = normal
0.8-9 = mild
0.5-8 = moderate
<0.5 = severe
[>1.2 = calcification - falsely high) - Doppler USS for severity and location
- CT angiography
- CV risk assessment - BP, BM, lipids, ECG
- Rule out other features - arteritis (ESR/CRP), anaemia/infection (fbc), renal disease (U&Es)
- Thrombophilia screen and homocysteine levels if <50y and no risk factors
- Buerger’s - angle <20 and cap refil >15s = severe ischaemia
Manage chronic limb ischaemia - 2 areas
CVS risk factors - smoking, exercise, weight
- statins, antiplatelets, diabetes control
Surgical - percutaneous transluminal angioplasty (stent) and bypass graft if diffuse
- amputate if unsuitable/gangrene
Complications of chronic limb ischaemia - 4
Infected gangrene causing sepsis
Acute on chronic ischaemia
Amputation
Mobility and quality of life reduced
Progression of chronic limb ischaemia
Mostly stable
10-20% worse
5-10% critical
1-2% amputated
What are young heavy smokers at risk of regarding ischaemia?
Buerger’s disease - thromboangiitis obliterans
Drug to stop before angiography for limb ischaemia and why
Metformin - avoid metabolic acidosis
Post op complication of amputation and manage
Phantom limb pain - gabapentin, can start before surgery
What is carotid artery disease caused by
Atherosclerotic plaque causes either stenosis/occlusion or rupture/atheroembolism
Causes ischaemic stroke or TIA
What makes an atherosclerotic plaque?
Fatty streak - lipid core - fibrous plaque
How much of diameter is lost in mild atherosclerosis?
50%
Symptoms of carotid artery disease
Generally asymptomatic as collaterals from contralateral ICA and vertebral arteries via circle of Willis
Carotid bruits
Stroke/TIA when rupture/occlude
Differentials for carotid artery disease and relevant info of each - 3
- Carotid dissection - if connective tissue disease, trauma, esp <50yo
- Thrombotic occlusion - only differentiated on imaging
- Fibromuscular dysplasia = hypertrophy of vessel wall, focal neuro deficit, <50yo females
Investigations of carotid artery disease
CT head
Bloods, ECG, CXR
Duplex USS/CT angiography to exclude other causes and find degree of stenosis
Management of carotid artery disease
- initial treatment
- general management
- long term medication
If <1.5h, IV alteplase (r-tPA) then 300mg aspirin for 14d
Screen swallowing, give o2 and keep BM 4-11mmol
Long term:
- antiplatelet clopidogrel or aspirin and dipyridamole
- statin
- Hypertension and diabetes management
- quit smoking, exercise
Surgery for asymptomatic carotid artery disease, and ADR
Surgical revascularisation in <2w = carotid endarterectomy to remove atheroma and damaged intima, use temporal bypass during procedure
ADR = Stroke, damage to CN9, 10, 12, MI, bleeding, infection
Classifications of acute mesenteric ischaemia and examples of cause - 4
Embolus eg from AF/murmur/valve replacement or AAA
Thrombus eg from atherosclerosis
Non-occlusive eg from hypovolaemic/cardiogenic shock
Venous eg from coagulopathy (look for DVT/PE, antiphospholipid syndrome), malignancy, inflammatory disorders
3 risk factors for acute mesenteric ischaemic
Hypertension
Hyperlipidaemia
Smoking
Sx of acute mesenteric ischaemia - 2
Generalised abdo pain out of proportion with clinical findings, diffuse and constant
N&V
Bloods for acute mesenteric ischaemia
Lactate for acidosis
Clotting
LFT - liver ischaemia from disruption to coeliac trunk
Amylase
5 causes of raised amylase
Pancreatitis Acute mesenteric ischaemia DKA Ectopic pregnancy Bowel perforation
2 imaging for acute mesenteric ischaemia and finding
CT with IV contrast for oedema, causing loss of wall enhancement and pneumatosis
AXR/CXR/CT abdo if suspect perforation
Management of acute mesenteric ischaemia - 4
Resuscitation with IV access and fluids - fluid balance chart and catheterise
Broad spectrum abx
ITU if acidotic/organ failure
Surgery - excise necrotic/nonviable bowel, or revascularise with angioplasty or open embolectomy
ADR of acute mesenteric ischaemia
Short bowel syndrome from excision
Necrosis or perforation
50-80% mortality
Which 3 vessels is chronic mesenteric ischaemia in?
Coeliac trunk
SMA
IMA
What age group in chronic mesenteric ischaemia in?
> 60yo females
Symptoms and PMH of chronic mesenteric ischaemia - 5
Transient pain - when demand is increased in eating (10m-4h after) or hypovolaemia
Weight loss from anorexia and malabsorption
Loose bowels
N&V
Vascular comorbidities - stroke, MI, peripheral vascular disease
Exam findings for chronic mesenteric ischaemia - 3
Cachexia
Generalised abdo tenderness
Abdo bruits
Complications of chronic mesenteric ischaemia - 3
Infarct of bowel
Malabsorption
Concurrent CVD
Investigations of chronic mesenteric ischaemia - 2
CT angiography
CV profile
Treatment for chronic mesenteric ischaemia
Weight loss, exercise, quit smoking
Statin
Antiplatelets
Surgery if severe, progressive or debilitating symptoms - endovascular angioplasty and stent, or open endarterectomy or bypass
What are varicose veins and where are they normally?
Dilated torturous segments associated with valvular incompetence
Saphenofemoral and saphenopopliteal junctions
Causes of varicose veins and risk factors
Normally primary
Secondary = DVT, pelvic mass (fibroid, pregnancy) or AVM
RF: standing, obesity, pregnancy, family history
Differentials of varicose veins - 3
Cellulitis
Ischaemic ulcer
DVT
Symptoms of varicose veins
Pain, ache Swelling, particularly at the end of the day and after standing Itching Skin changes, ulcer, thrombophlebitis Bleeding
Signs on inspection of venous insufficiency - 8
Examine from anterior thigh to medial calf (long saphenous vein) and back of calf (short saphenous vein): Oedema Varicose eczema Thrombophlebitis - tenderness Hard = thrombosis Ulcers usually above medial malleolus Haemosiderin deposits Lipodermatosclerosis (upside down bottle) Atrophic blanche
Mass in groin with vascular insufficiency, investigation and treatment?
Saphena varix = dilatation of saphenous vein at saphenofemoral junction in groin
Sx - cough impulse and blue tinge
Duplex USS and high saphenous ligation
Investigate varicose veins and 5 specific tests
Duplex USS - valve incompetence at great/short saphenous veins
Cough impulse and percussion test at SFJ
Auscultation for bruits over varicosities (AVM)
Trendelenburg’s test
Tourniquet test
Perthes disease
What is Trendelenberg’s test for varicose veins
For SFJ valve competence
Lie down and raise leg (empties vein)
Put 2 fingers on SFJ (5cm below and medial to femoral pulse)
Stand up, keeping fingers in place
If varicosities are controlled, will not rapidly fill. Release fingers to confirm that they then fill
Varicosities are not controlled = incompetence at a lower level
Tourniquet test?
Tourniquet tied around thigh at level of SFJ. If not controlled, move tourniquet move down leg (above then below knee) until incompetence identified
Perthes’ test?
Determines if deep femoral veins are competent - tourniquet put around mid thigh while standing and patient walks for 5 mins. If saphenous veins collapse below tourniquet, deep veins are patent and communicating veins are competent
If no change, both saphenous and communicating veins are incompetent
If veins increase in prominence and pain, deep veins are occluded
Manage varicose veins - 6
Education - avoid prolonged standing, lose weight, regular walks Compression stockings 4 layer compression bandaging for ulcers Injection/foam sclerotherapy Laser coagulation Surgery - ligation/strip
Complications of varicose veins and surgery
Get worse with time if not treated Haemorrhage Thrombophlebitis from ablation and foam DVT Nerve damage - saphenous and sural
Where is the long saphenous vein system?
Medial thigh including saphenous opening, and posterior arch and medial perforators in calf
Where is the short saphenous vein system?
Posterior thigh including saphenopopliteal junction, communication with long saphenous vein, and inconstant perforators in calf
Features of venous ulcers on exam
Medial malleolus (gaiter region)
Irregular border with granulating base
Painful, especially at the end of the day
Dry, itchy, distended veins, varicose veins, oedema, varicose eczema
Atrophie blanche, haemosiderin, lipodermatosclerosis
Features of arterial ulcers on exam
Small, deep, well defined with necrotic base
At sites of trauma and pressure areas
Cold, necrotic toes, hair loss, reduced or absent pulses
Sensation maintained
Features of neuropathic ulcers on exam
Painless ulcers on pressure points, eg repetitive stress and injury
Burning/tingling
Punched out, variable sizes
Warm feet and good pulses
Often with vascular disease
History of peripheral neuropathy or atrophic neuropathy
Pathophysiology of venous ulcers
Retrograde flow in superficial venous system causing dilatation and pooling
Reduces oxygen to skin and causes ulcer, along long and short saphenous veins
Pathophysiology of arterial ulcers
Reduced arterial blood flow reducing perfusion and impairing healing
Associated conditions with arterial ulcers
Intermittent claudication, peripheral artery disease
Investigations for ulcers
ABPI low in arterial ulcers - show concurrent arterial disease in neuropathic ulcers
CT angiography +- MRA for arterial
Duplex shows insufficiency at junctions inn venous ulcers - show concurrent venous disease in neuropathic ulcers
Swab if infected, X-ray if suspect osteomyelitis (neuropathic more)
BM and B12 in neuropathic ulcers
Manage venous ulcers - 5
Leg elevation and calf exercise
Emollient for dry skin
Antibiotics
4 layer compression bandages as long as ABPI >0.8
Radiofrequency ablation of varicose veins can improve healing
Manage arterial ulcers
Conservative - improve CVD risk factors
Statin, antiplatelets, BP and BM management
Angioplasty or bypass graft +- skin reconstruction
Manage neuropathic ulcers
Exercise and diet, maintain HbA1c <7%
Abx if infection +- surgical debridement
Chiropodist and foot wear
What is a complication of neuropathy in foot?
Charcot’s foot - neuroarthropathy, deformity from repeated trauma
Causes swelling, distortion, pain, reduced function
- rocker bottom foot
When does an ulcer become chronic?
> 4w from injury
Complication of ulcer?
Marjolin’s ulcer
What is slough in an ulcer?
Mix of fibrin, cell breakdown products, serous exudates, leukocytes and bacteria
Can be part of normal healing process
Causes of ulcers
Venous disease Arterial disease Neuropathic - diabetes Lymphoedema Vasculitis Malignancy Infection - TB, syphilis Trauma Pyoderma gangrenosum Drugs
3 types of gangrene
Wet = with infection and tissue death Dry = no infection Gas = clostridium perfringens myositis
Manage gangrene
Cultures - group A b-haemolytic strep = necrotising fasciitis or myositis
Surgical help if atypical cellulitis
Radical debridement +- amputation, + 5d benzylpenicilin
What is gas gangrene? Sx and management
Clostridium perfringens myositis, risk factors = diabetes, trauma, malignancy
Early toxaemia, delirium and haemolytic jaundice
Oedema, surgical emphysema, bubbly brown pus
Remove all dead tissue, give benzylpenicillin, hyperbaric O2, clindamycin and metronidazole
VTE prophylaxis for surgery
Dalteparin 5000u evening before surgery if admitted, or evening of surgery if arrived on day as long as 4h has passed since epidural
Antiembolic stockings
Intermittent pneumatic compression boots in theatre
No dalteparin or AES if neck surgery
