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Final Year > Vascular Surgery > Flashcards

Vascular Surgery Flashcards

1
Q

An artery over ? % of its original diameter has an aneurysm?

A

50% (1.5X its original size)

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2
Q

What is a true aneurysm?

A

An abnormal dilatation that involves all layers of the arterial wall

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3
Q

What is a false/pseudo aneurysm?

A

A collection of blood in the outer layer only (the adventitia) which communicates with the lumen (e.g. after trauma) through a hole in the vessel wall.
There is a breach in the vessel wall such that blood leaks through the wall but is contained by the adventitia or surrounding perivascular soft tissue. A direct communication of blood flow exists between the vessel lumen and the aneurysm lumen through the hole in the vessel wall.
It is not lines with endothelium

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4
Q

Is the risk of rupture higher with a true or false aneurysm?

A

Risk is higher with false aneurysms

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5
Q

What are the 6 layers of artery walls (from internal to external)

A
  1. Endothelium
  2. Tunica intima
  3. Internal elastic membrane
  4. Tunica media
  5. External elastic membrane
  6. Tunica externa (adventitia)
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6
Q

Causes of arterial aneurysms

A 
Atheroma
Trauma
Infection (endocarditis, syphilis)
Connective tissue disorders (Marfans, Ehlers-Danlos)
Inflammatory (Takayasu's aortitis)
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7
Q

Common sites of arterial aneurysms

A

Aorta
Iliac
Femoral
Popliteal

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8
Q

Complications of arterial aneurysms

A 
Rupture
Thrombosis
Embolism
Fistulae
Pressure on adjacent structures
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9
Q

Who gets invited for AAA screening in the UK?

A

Men >65 years old

Haven’t already been treated for AAA

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10
Q

What conditions are AAAs commonly misdiagnosed as

A 
Renal colic
Diverticulitis
GI bleed
MI
MSK back pain
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11
Q

How do you tell the difference between a pulsatile/expansile mass and a transmitted pulsation on palpation

A

Pulsatile/expansile - fingers move outwards - swelling is coming from the artery itself
Transmitted pulsation - fingers move upwards - it is being transmitted through other tissue

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12
Q

If you’re looking for AAA and feel a transmitted pulsation how can you move this away from the aorta?

A

Put the patient in the knee-elbow position - swelling should move away and pulsation disappear

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13
Q

Which vessel that is routinely ligated during AAA repair can be a source of endoleak after EVAR

A

Inferior mesenteric artery

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14
Q

What is EVAR

A

Endovascular aneurysm repair

Involves inserting an endovascular stent via the femoral artery

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15
Q

What are the 3 types of clamping used in AAA repair

A

Supra-coeliac: highest stress on the heart, ischaemia to all organs below the coeliac artery
Supra-renal: high stress on the heart, ischaemia to all organs below the superior mesenteric artery
Infra-renal: relatively less stress on the heart, ischaemia to all organs below the kidneys

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16
Q

Describe the major haemorrhage pathway

A

Ring 4444 and locate O negative blood if patient is bleeding/collapses or ongoing bleeding (150ml/min + shock)
Give tranexamic acid within 1hr
Assemble team including lab and consultant
Take bloods: XM, FBC, PT, APTT, fibrinogen, U+E, Ca, ABG
Order and give massive haemorrhage pack 1
Reassess
Order and give massive haemorrhage pack 2
Reassess

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17
Q

What does massive haemorrhage pack 1 include

A

4 units of red cells

4 units of FFP

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18
Q

What does massive haemorrhage pack 2 include

A

4 units of red cells
4 units of FFP
1 dose of platelets

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19
Q

What do you give to patients with a major haemorrhage who are taking warfarin

A

Vitamin K and prothrombin complex concentrate

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20
Q

Which antibodies does group and save check for

A

ABO and rhesus

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21
Q

Which antibodies does cross matching check for

A

All of them

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22
Q

Risk factors for peripheral vascular disease

A 
Age
Male
FH
Smoking
HTN
High cholesterol
Diabetes
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23
Q

Describe mild chronic PVD

A

Collateralised peripheral arterial occlusive disease

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24
Q

Describe mild acute PVD

A

Small vessel thrombosis, transient claudication

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25
Q

Describe critical acute PVD

A

Embolic, dissection, large vessel thrombosis

6 P’s

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26
Q

Describe critical chronic PVD

A

Decompensated peripheral arterial occlusive disease, rest pain, ulceration

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27
Q

What are the 6 P’s of critical limb ischaemia

A 
Pain
Pallor
Pulselessness
Paraesthesia
Paralysis
Perishingly cold
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28
Q

What is the name of the classification system for PAD

A

Fontaine classification

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29
Q

Describe Fontaine stage I PAD

A

Asymptomatic for the most part but careful hx may reveal paraesthesias, O/E may have cold extremities, bruits, absent pulses

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30
Q

Describe Fontaine stage II PAD

A

Intermittent claudication
Patients usually have a set distance that they start to experience pain at
Stage IIa is after >200m of pain free walking
Stage IIb is after <200m of pain free walking

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31
Q

Describe intermittent claudication

A

Aching muscles on effort, predictable, worse on hills/with load/at speed. Settles quickly with rest

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32
Q

Describe Fontaine stage III PAD

A

Rest pain - icy, burning, constant aching in foot, worse on elevation or at night, needs opiates. Worse during the night because legs usually raised lose the effect of gravity which will have helped pain during the day

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33
Q

Describe Fontaine stage IV PAD

A

Tissue loss, ischaemic ulcers or gangrene (which may be dry or humid)

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34
Q

Describe the treatment of peripheral vascular disease

A

Smoking cessation, exercise, lifestyle, weight loss
BP control
DM control
Cholesterol control
Start them on antiplatelet therapy (Clopidogrel or Aspirin 75mg OD) to reduce risk of progression and CV risk
Supervised exercise programmes - to increase collateral blood flow (2hrs/wk for 3 months)
Surgical intervention

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35
Q

Describe the surgical options for PVD

A

PTA - Percutaneous transluminal angioplasty: if disease is limited to a single arterial segment then you inflate a balloon in it, stent can be used to maintain it
Surgical reconstruction: bypass grafts (femoral-popliteal, femoral-femoral crossover, aorto-bifemoral), can use autologous veins or prosthetic grafts
Amputation

36
Q

Overview of Fontaine classification stages

A

I - asymptomatic
2 - intermittent claudication
3 - ischaemic rest pain
4 - critical ischaemia (ulceration/gangrene)

37
Q

Criteria to be a candidate for carotid endarterectomy

A

Symptomatic in the last 6 months

>70% stenosis of the internal carotid artery

38
Q

Signs/symptoms of ruptured AAA

A

Intermittent or continuous abdominal pain (radiates to back/iliac fossae/groin), collapse, expansile abdominal mass, shock

39
Q

Cause of AAA

A

Degeneration of the elastic layers of the abdominal aorta and smooth muscle loss (tunica media)
Has a genetic component

40
Q

When to operate on AAA

A

If symptomatic (regardless of size)
If >5.5cm
If expanding at >1cm/yr

41
Q

Emergency treatment of ruptured AAA

A

Call vascular surgeon and experienced anaesthetist
Warn theatre
Do an ECG, take blood for amylase, Hb, XM (may need 10-40 units)
Catheterise bladder
IV access 2 large bore cannulas
Use O negative blood to treat shock initially but keep systolic BP <100 to avoid rupturing a contained leak
Take them straight to theatre
Give prophylactic IV abx (Co-amoxiclav)
Surgery to clamp above the leak and insert graft

42
Q

What shapes can aneurysms be

A

Fusiform (bulges on both sides)

Saccular (bulges on one side)

43
Q

Are AAA’s more commonly suprarenal or infrarenal

A

Infrarenal

44
Q

Size limits of aorta in cm

A

Normal <2.5
Ectasia <3.5
Small AAA <4.5
Large AAA <5.5

45
Q

Key facts about popliteal aneurysms

A 
Often bilateral
Associated with AAA
Can be familial
Get limb ischaemia rather than rupture
Surgical repair if >2.5cm or symptomatic (stent if unfit)
46
Q

Aortic dissection is a tear between which layers of the aorta?

A

The tunica intima and tunica media

47
Q

Once an aortic dissection has happened what are the two possible outcomes

A

A) It propagates and keeps filling

B) It forms an exit tear back into the aorta

48
Q

Causes/risk factors for dissection

A

HTN
Connective tissue disorders (Marfans, Ehlers-Danlos)
Trauma

49
Q

Describe the Stanford system of types of thoracic aortic dissection

A

Type A - ascending aorta involved (before the left subclavian artery comes off)
Type B - ascending aorta not involved (after the left subclavian artery comes off)

50
Q

Which type of thoracic aortic dissection is most common

A

Type A - involving the ascending aorta

51
Q

Which type of thoracic aortic dissection almost always needs surgery

A

Type A

52
Q

Signs/symptoms of thoracic aortic dissection

A

Sudden onset severe central chest pain radiating to the back, tearing sensation in the back, pain going down arms, sweating, nausea, SOB, weakness, collapse
Unequal arm pulses/BP

53
Q

Diagnostic investigations of thoracic aortic dissection

A

Transoesophageal echo
CT
MR angiogram

54
Q

Management of thoracic aortic dissection

A 
Cross match 10 units 
ECG + CXR (expanded mediastinum)
Involve ITU
Keep BP 100-110 (beta blockers or calcium channel blockers)
Urgent cardiothoracic surgeon advice
55
Q

What are the different types of shock

A

Hypovolaemic
Distributive
Cardiogenic
Obstructive

56
Q

Causes of hypovolaemic shock

A

Haemorrhage
Burns
D+V
Dehydration

57
Q

Causes of distributive shock

A 
Vasodilation and malperfusion;
Sepsis
Trauma
Anaphylaxis
Pancreatitis
Burns
Neurogenic
58
Q

Causes of cardiogenic shock

A

MI
Arrhythmia
Acute valvular pathology

59
Q

Causes of obstructive shock

A

PE
Cardiac tamponade
Tension pneumothorax

60
Q

What is shock characterised by

A

Organ malperfusion and cellular hypoxia

61
Q

Signs of organ hypoperfusion

A

Skin pallor
Oliguria
Cognitive changes
Metabolic acidosis

62
Q

What is transfusion associated lung injury

A

Rapid onset hypoxic respiratory distress following blood transfusion
Acute dyspnoea and tachypnoea
May be associated fever, cyanosis and hypotension
Bilateral pulmonary oedema without signs of congestive heart failure or volume overload

63
Q

What is the definition of a massive transfusion

A

Receiving more than 10 units of blood in 24hrs or more than 4 in 1 hour

64
Q

Is PT a measure of the intrinsic or extrinsic pathway

A

Extrinsic

65
Q

Is APTT a measure of the intrinsic or extrinsic pathway

A

Intrinsic

66
Q

Does Warfarin affect the intrinsic or extrinsic pathway

A

Extrinsic (PT)

67
Q

Complications in patients who spend prolonged time in a critical care unit

A 
Muscle weakness/wasting
Nutritional deficiencies
Sleep disorders
Ineffective swallow and microaspirations
Recurrent chest infections
68
Q

Calf claudication suggests PVD is affecting which artery?

A

Femoral disease

69
Q

Buttock claudication suggests PVD is affecting which artery?

A

Iliac disease

70
Q

Cardinal features of critical ischaemia (not the 6Ps)

A

Foot pain at rest - e.g. burning pain at night, relieved by hanging legs over the side of the bed
Ulceration
Gangrene

71
Q

What is Leriche’s syndrome

A

Aorto-iliac occlusive disease - a type of PAD
Atherosclerotic arterial disease of the aorta as it bifurcates into the iliac arteries
Triad: weak/absent femoral pulse, buttock/thigh claudication, erectile dysfunction

72
Q

What is Buerger’s disease

A

Thromboangiitis obliterans - a disease of the small and medium arteries and veins that restricts blood flow to the hands and feet
Clots form causing paraesthesia, ulcers and gangrene in fingers and toes
Almost exclusive to young heavy smokers

73
Q

ABPI measurements; normal, PAD, critical limb ischaemia

A 
Normal = 1-1.2
PAD = 0.5-0.9
CLI = <0.5 or ankle systolic pressure <50mmHg
74
Q

In acute limb ischaemia how long is the window to revascularise and save the limb

A

4-6hrs

75
Q

Causes of acute limb ischaemia

A

Thrombosis in situ
Emboli
Graft/angioplasty occlusion
Trauma

76
Q

What causes varicose veins

A

The valves that usually prevent blood flowing from the deep to superficial venous system become incompetent leading to venous hypertension and dilation of the superficial veins
Can also be secondary to obstruction (DVT, fetus, pelvic tumour), AV malformations

77
Q

Risk factors for varicose veins

A 
Prolonged standing
Obesity
Pregnancy
FH
Contraceptive pill
Overactive muscle pumps e.g. cyclists
78
Q

Criteria for specialist referral of patients with varicose veins

A

Bleeding, pain, ulceration, superficial thrombophlebitis, severe impact on quality of life (not just cosmetic)

79
Q

Treatment options for varicose veins

A

Endovascular - radiofrequency ablation, endovenous laser ablation, injection sclerotherapy
Surgical ligation

80
Q

What is saphena varix

A

Dilation where saphenous vein meets femoral vein

Can be mistaken for inguinal hernia because it transmits a cough impulse

81
Q

Difference between dry and wet gangrene

A

Dry is necrosis in the absence of infection - there will be a clear demarcated line between living and dead tissue
Wet is when there is tissue death and infection associated with discharge

82
Q

What is gas gangrene

A

A subset of necrotising myositis - rapid onset of myonecrosis, muscle swelling, gas production, sepsis and severe pain.
Cause by spore forming Clostridial species
Risk factors = DM, trauma, malignancy

83
Q

What is necrotising fasciitis

A

A rapidly progressive infection of the deep fascia causing necrosis of subcutaneous tissue. Intense pain over the affected skin and underlying muscle
Group A beta-haemolytic strep is a big cause but it’s often polymicrobial

84
Q

Causes of ulcers

A 
Venous disease/mixed venous arterial disease/arterial disease
Neuropathy (DM)
Lymphoedema
Vasculitis
Malignancy
Infection (TB, Syphilis)
Trauma (pressure sores)
Pyoderma gangrenosum
Meds (Nicorandil, Hydroxyurea)
85
Q

When examining an ulcer what are some key features to mention

A

Site - e.g. Gaiter area is the area above the medial malleolus and is typical for venous ulcers, ulcers over areas typical for pressure sores
Temperature - if area around it is cold this suggests ischaemia, if warm then more likely a local cause
Surface area - draw a map so you can monitor it
Shape
Edge - shelved/sloping is healing, punched out is ischaemic or syphilis, rolled/everted is malignant, undermined is TB
Base - note any muscle/bone/tendon destruction, slough, granulation tissue
Depth
Discharge
Associated lymphadenopathy - suggests infection or malignancy
Sensation - decreased implies neuropathy
Whether it is extending or healing - inflamed margins suggest extension whereas granulation tissue/scar formation/epithelialization suggest healing

86
Q

How long does an ulcer need to present for to be defined as chronic

A

> 4 weeks

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