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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
Describe critical acute PVD
Embolic, dissection, large vessel thrombosis | 6 P's
26
Describe critical chronic PVD
Decompensated peripheral arterial occlusive disease, rest pain, ulceration
27
What are the 6 P's of critical limb ischaemia
``` Pain Pallor Pulselessness Paraesthesia Paralysis Perishingly cold ```
28
What is the name of the classification system for PAD
Fontaine classification
29
Describe Fontaine stage I PAD
Asymptomatic for the most part but careful hx may reveal paraesthesias, O/E may have cold extremities, bruits, absent pulses
30
Describe Fontaine stage II PAD
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
31
Describe intermittent claudication
Aching muscles on effort, predictable, worse on hills/with load/at speed. Settles quickly with rest
32
Describe Fontaine stage III PAD
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
33
Describe Fontaine stage IV PAD
Tissue loss, ischaemic ulcers or gangrene (which may be dry or humid)
34
Describe the treatment of peripheral vascular disease
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
35
Describe the surgical options for PVD
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
Overview of Fontaine classification stages
I - asymptomatic 2 - intermittent claudication 3 - ischaemic rest pain 4 - critical ischaemia (ulceration/gangrene)
37
Criteria to be a candidate for carotid endarterectomy
Symptomatic in the last 6 months | >70% stenosis of the internal carotid artery
38
Signs/symptoms of ruptured AAA
Intermittent or continuous abdominal pain (radiates to back/iliac fossae/groin), collapse, expansile abdominal mass, shock
39
Cause of AAA
Degeneration of the elastic layers of the abdominal aorta and smooth muscle loss (tunica media) Has a genetic component
40
When to operate on AAA
If symptomatic (regardless of size) If >5.5cm If expanding at >1cm/yr
41
Emergency treatment of ruptured AAA
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
What shapes can aneurysms be
Fusiform (bulges on both sides) | Saccular (bulges on one side)
43
Are AAA's more commonly suprarenal or infrarenal
Infrarenal
44
Size limits of aorta in cm
Normal <2.5 Ectasia <3.5 Small AAA <4.5 Large AAA <5.5
45
Key facts about popliteal aneurysms
``` 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
Aortic dissection is a tear between which layers of the aorta?
The tunica intima and tunica media
47
Once an aortic dissection has happened what are the two possible outcomes
A) It propagates and keeps filling | B) It forms an exit tear back into the aorta
48
Causes/risk factors for dissection
HTN Connective tissue disorders (Marfans, Ehlers-Danlos) Trauma
49
Describe the Stanford system of types of thoracic aortic dissection
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
Which type of thoracic aortic dissection is most common
Type A - involving the ascending aorta
51
Which type of thoracic aortic dissection almost always needs surgery
Type A
52
Signs/symptoms of thoracic aortic dissection
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
Diagnostic investigations of thoracic aortic dissection
Transoesophageal echo CT MR angiogram
54
Management of thoracic aortic dissection
``` 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
What are the different types of shock
Hypovolaemic Distributive Cardiogenic Obstructive
56
Causes of hypovolaemic shock
Haemorrhage Burns D+V Dehydration
57
Causes of distributive shock
``` Vasodilation and malperfusion; Sepsis Trauma Anaphylaxis Pancreatitis Burns Neurogenic ```
58
Causes of cardiogenic shock
MI Arrhythmia Acute valvular pathology
59
Causes of obstructive shock
PE Cardiac tamponade Tension pneumothorax
60
What is shock characterised by
Organ malperfusion and cellular hypoxia
61
Signs of organ hypoperfusion
Skin pallor Oliguria Cognitive changes Metabolic acidosis
62
What is transfusion associated lung injury
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
What is the definition of a massive transfusion
Receiving more than 10 units of blood in 24hrs or more than 4 in 1 hour
64
Is PT a measure of the intrinsic or extrinsic pathway
Extrinsic
65
Is APTT a measure of the intrinsic or extrinsic pathway
Intrinsic
66
Does Warfarin affect the intrinsic or extrinsic pathway
Extrinsic (PT)
67
Complications in patients who spend prolonged time in a critical care unit
``` Muscle weakness/wasting Nutritional deficiencies Sleep disorders Ineffective swallow and microaspirations Recurrent chest infections ```
68
Calf claudication suggests PVD is affecting which artery?
Femoral disease
69
Buttock claudication suggests PVD is affecting which artery?
Iliac disease
70
Cardinal features of critical ischaemia (not the 6Ps)
Foot pain at rest - e.g. burning pain at night, relieved by hanging legs over the side of the bed Ulceration Gangrene
71
What is Leriche's syndrome
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
What is Buerger's disease
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
ABPI measurements; normal, PAD, critical limb ischaemia
``` Normal = 1-1.2 PAD = 0.5-0.9 CLI = <0.5 or ankle systolic pressure <50mmHg ```
74
In acute limb ischaemia how long is the window to revascularise and save the limb
4-6hrs
75
Causes of acute limb ischaemia
Thrombosis in situ Emboli Graft/angioplasty occlusion Trauma
76
What causes varicose veins
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
Risk factors for varicose veins
``` Prolonged standing Obesity Pregnancy FH Contraceptive pill Overactive muscle pumps e.g. cyclists ```
78
Criteria for specialist referral of patients with varicose veins
Bleeding, pain, ulceration, superficial thrombophlebitis, severe impact on quality of life (not just cosmetic)
79
Treatment options for varicose veins
Endovascular - radiofrequency ablation, endovenous laser ablation, injection sclerotherapy Surgical ligation
80
What is saphena varix
Dilation where saphenous vein meets femoral vein | Can be mistaken for inguinal hernia because it transmits a cough impulse
81
Difference between dry and wet gangrene
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
What is gas gangrene
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
What is necrotising fasciitis
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
Causes of ulcers
``` 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
When examining an ulcer what are some key features to mention
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
How long does an ulcer need to present for to be defined as chronic
>4 weeks

Final Year (4 decks)

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