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Phase 4 > Vascular Surgery > Flashcards

Vascular Surgery Flashcards

1
Q

How much blood should be cross matched when carrying out AAA repair?

A

4-6 units cross matched

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2
Q

What are the risk factors associated with AAA?

A 
Hypertension 
Smoking 
Atherosclerosis 
>55 years 
Male 
Family history 
Connective tissue disorders
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3
Q

When is screening offered for AAA?

A

One of US at age 65.
If >3.4cm - 4.4cm = yearly ultrasound
if >4.4 - 5.4cm = 3 monthly
if >5.5cm = surgery

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4
Q

What is the criteria for surgery for AAA?

A

> 5.5cm

advanced more >1cm in a year

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5
Q

What are the symptoms of a rupture AAA?

A

Severe sudden epigastric pain, radiating to:

  • loins
  • back

Episode of blackout

Hypotension

**any male >50 should with loin or back pain should be suspected for ruptured AAA

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6
Q

What surgeries are there for AAA?

A

Open surgery

Endovascular aneurysm repair (EVAR)

  • advantageous because done laparoscopically
  • disadvantage - high early re-intervention needed. life long follow up.
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7
Q

What complications can occur with EVAR?

A

Endoleak ~24%

Type 1: leak at attachment site

Type 2: Retrograde flow into aneurysm

Type 3: Graft defect leading to leak

Type 4: porus graft

Type 5: enlargement of aneurysm with no known cause

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8
Q

What classification system is used for thoracic-abdominal aneurysms?

A

Crawford classification

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9
Q

Broadly what type of aneurysms are there?

A

True
- all layers of vessel wall are affected

Pseudoaneurysm:

  • haematoma forms containing blood leaking from a damaged vessel
  • caused by trauma
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10
Q

What important investigation should be done following a stroke, which may lead to surgery?

A

Carotid colour duplex scan

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11
Q

Following a stroke, a stenosed carotid artery is seen, what surgery should be conducted and when?

A

Within 2 weeks a carotid endarterectomy should be conducted.

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12
Q

What classification system is used for chronic lower limb ischemia?

A 
Fontaine Classification: 
I - asymptomatic 
II - Intermittent claudication 
III - Rest pain 
IV - Ulcers/ Gangrene

Type III & IV are considered severe

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13
Q

What are some differentials for claudication pain?

A

Spinal stenosis

O/A
- at hip joint

Sciatica

Popliteal artery entrapment syndrome

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14
Q

What numbers of the ABPI correlate with symptoms?

A 
0 -.4 = ulceration/ tissue loss 
.2-.4 = severe rest pain 
.4-.9 = claudication 
1- 1.1 = normal 
>1.1 = calcification
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15
Q

Which disease can lead to a high ABPI > 1.1?

A

Diabetes

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16
Q

What are some symptoms which suggest severe limb ischemia?

A

Rest Pain
ABPI <0.5
Opiate management / not relieved by simple analgesia
Ulceration

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17
Q

What is the management of PVD?

A

40% with claudication will have coronary/ cerebral vascular disease. thus the main goal of treatment is to prevent further complications.

All put on:
- clopidogrel or aspirin
+
- Statin - regardless of lipid status

+
- lifestyle changes

Endovascular treatment:
- angioplasty + stent

Surgical:
- by-pass

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18
Q

What investigations should be done in a patient with claudication?

A

Typically it is diagnosed via physical exam.

ABPI
- doppler

Duplex ultrasound

Exercise ABPI

ECG

CT angiogram

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19
Q

What is a key features of severe limb ischemia?

A

Muscle tenderness.

just touching the muscle causes severe pain

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20
Q

What is the immediate management following a ruptured AAA?

A 
ABCDE
Immediate senior surgical assistance 
Cross match  - 10 units 
FFP 
Platelets

IV access
High flow O2
Modest amount of morphine

*do not chase normal blood pressure at risk of destabilizing clot

Straight to theatre

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21
Q

Where does the superficial veins of the leg drain into the deep veins?

A

Saphenous- femoral junction

Mid- thing perforators

Short-saphenous - popliteal junction

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22
Q

What is the typical classification system of varicose veins?

A

CEAP

C - clinical features C1 = telangiectasia veins, C6 = active ulcer

E - aEtiology

A - Anatomical

P - Pathophysiology
- reflux, obstruction

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23
Q

What are the symptoms of varicose veins and how are they investigated?

A 
Pain 
aching 
heaviness 
swelling 
oedema

Eczema
Phlebitis
lipodermatosclerosis

*Colour duplex

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24
Q

What are the treatment options for varicose veins?

A

Medical:

  • keeping legs raised
  • compressional bandages

Surgical:

  • Stripping veins
  • Ablation - radiofrequency
  • Sclerotherapy
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25
Q

What is the definition of claudication?

A

Pain experienced in distal muscle groups

Relieved by rest

Reproducible
- no good or bad days, always the same

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26
Q

During an exercise ABPI in someone with PVD, what would you expect the number to do?

A

Go down due to post stenosis dilation

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27
Q

What is the first line medical management for PVD?

A

Clopidogrel/ Aspirin
+
Statin

Lifestyle changes

Exercise regime
- to improve collaterals

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28
Q

What is the criteria for critical limb ischemia?

A

> 2 weeks rest pain
Need for opioid analgesia

<50mmHg ankle systolic pressure / ABPI <0.5
or
Non healing wound or gangrene

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29
Q

What is the management for critical limb ischemia?

A

Analgesia
Endovascular intervention
Surgical intervention
Palliation

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30
Q

Following treatment for Acute limb ischemia, what other surgical procedure may need to be done to prevent further complication?

A

fasciectomy

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31
Q

High light some clinical signs seen for a non-viable limb:

A

Fixed staining of tissue
Lack of blanching upon pressure of the limb
Anaesthesia of the limb
Rigor mortis

32
Q

What are the risk factors for varicose veins?

A

Family history

Standing for long periods of time

Pregnancy

Obesity

33
Q

What has a cough impulse and may be mistaken for a femoral hernia?

A

Salpena Varix

  • varicose vein of the great saphenous vein at the femerol-saphenous junction
34
Q

What is the diagnostic choice for varicose veins?

A

Duplex scan - 2secs retrograde flow after compression of limb/ tissue distal

35
Q

What is the management of varicose veins?

A

Compressive stalking
- only if surgical intervention is not indicated

Surgical:

  • vein ligation
  • vein stripping
  • Foam sclerotherapy
  • Thermal ablation
36
Q

What are the indication for surgery of varicose veins?

A

symptomatic

Skin changes

Ulceration

Superficial vein thrombosis

37
Q

What investigations should be done when there is acute limb ischemia?

A

Bloods:

  • Lactate - establish degree of hypoperfusion
  • group and save
  • coagulation studies

ECG
- assess for AF

Imaging: D

  • doppler
  • CT Angiogram ** gold standard
38
Q

What is the management of acute limb ischemia?

A

ABCDE assessment:

- Provide O2 
- Stabilise BP 

• Analgesia 
-  opioid based 

* IV fluids 
* NIL by mouth
  • all patients are given LMWH
  • monitor APTT every 4-6 hours

This is actually dependent on the severity and cause of the occlusion.
All start on, typically for Rutherford
1-2a Rutherford Classification:

• Heparin IV infusion

For more severe types:
>2b Rutherford Classification:

* Embolectomy 
* Local intra-arterial Thrombolysis 
* Angioplasty 
* By - pass

Irreversible Damage/ Rutherford >3

Here there will be mottled skin which is non blanching

• Amputation
39
Q

What are the complications of acute limb ischemia?

A

Mortality rate of 20%

• Reperfusion injury = compartment syndrome 

• Release of substances from necrotic muscle 
- K+ 
- H+  Myoglobulins - AKI
40
Q

What classification system is used for claudication?

A

Fontaine Classification

I - Asymptomatic

II - Intermittent claudication

III - Rest pain

IV - ulceration/ Gangrene

41
Q

What is the 5 year mortality in those with chronic limb ischemia?

A

50%

42
Q

What are the differentials for acute limb ischemia?

A

Critical limb ischemia

DVT

Trauma

Spinal stenosis

Slipped disc

43
Q

What is the long term management following acute limb ischemia?

A

Reduce risk factors

  • hypertension management (beta blockers may not be indicated due to lower BP)
  • Diabetes management

Aspirin
+
Atorvastatin

Exercise programs + OT

*rehabilitation if amputation

44
Q

What is a type of varicose vein that develops at the sapho-femoral venous junction? and what is it often mistaken for?

A

Saphena varix

45
Q

What are the risk factors for varicose veins?

A

Prolonged standing

pregnancy

Obesity

Family history

46
Q

When should varicose veins be treated?

A

Symptomatic
Skin changes
Ulceration
Venous embolism

47
Q

What is a syndrome that affects the aortic bifurcation leading to buttock pain?

A

Leriche syndrome
- where there is obstruction a the bifurcation causing:

  • Buttock pain
  • Erectile dysfunction
  • Absent femoral pulses
48
Q

What is the definition of critical limb ischemia?

A

Ischemic rest pain for greater than 2 weeks duration

Presence of ischemic lesions
- gangrene

ABPI <0.5

49
Q

What tests out with vessel analysis (CT angiograms, duplex) should be conducted into critical limb ischemia?

A

Metabolic profile

  • Blood pressure
  • Lipids
  • Glucose
  • ECG
50
Q

What is the criteria for intermittent claudication?

A

Pain in the muscle

Pain on activity

Pain relieved by rest

51
Q

When should surgical intervention be considered in critical limb ischemia and what type of surgery is usually performed?

A

When medical management is failing
When Exercise program has been completed

  • Angioplasty
  • By- pass graft
52
Q

What percentage of below knee amputation die within 2 years?

A

30%

53
Q

What are the complications of critical limb ischemia?

A

Sepsis
- gangrene

Acute on chronic ischemia

Reduced mobility and quality of life

54
Q

What are the signs associated with critical limb ischemia?

A 
Pale 
Cold 
Absent/ minimal pulses 
Nail changes 
Lack of hair 
Evidence of gangrene 
Loss of muscle 
Poor capillary refill
55
Q

What investigations should be done into venous insufficiency?

A

Doppler US Scan to assess venous Reflux *gold standard

ABPI

MR Venogram - if pelvic

Ultrasound

Bloods:

  • FBC
  • LFTs
  • U&Es
  • rule out other causes of oedema
56
Q

Prior to use of compression bandages in venous ulcers what important investigation should be done?

A

ABPI
+/-
Investigation into the arterial circulation. If the arterial circulation is compromised then bandaging should be avoided.

57
Q

What is a complication of a DVT other than P.E?

A

Post thrombotic syndrome

  • Heaviness
  • cramps
  • Pruritus
  • Ulcertation

Villalta Score

58
Q

What are the treatment options into venous ulceration?

A

Lifestyle changes, increased exercise
- use of muscle pump

Elevation of the leg

Multicomponent compression bandages

Dressing
- colloid dressing

Surgical:
- removal of varicose veins. Improves healing rates

59
Q

How would a venous ulcer be described?

A 
Shallow irregular ulcer 
Granulation tissue 
located: 
- medially 
- gaiter area
60
Q

In a young person with venous ulceration what should be considered?

A

Coagulopathies

61
Q

What is the management for Arterial ulceration?

A

Lifestyle changes

Medical

  • aspirin
  • Statin
  • glucose control

Surgical:

  • angioplasty
  • by-pass
  • Skin graft
62
Q

How does aortic dissection present?

A

Severe central pain
Radiates to the back
Hypertension + tachycardia

Uneven limb pulses

63
Q

What the two types of aortic dissection and how are they treated?

A

Type A:
- ascending aorta

*treated with surgical repair

Type B:
- Descending aorta

*treated conservatively

64
Q

What are the symptoms of Venous ulcers?

A

Aching
Bursting like pain
Pruritus
Cellulitis

65
Q

What two tests can be performed during an examination to test the competence of the valves when assessing for venous insufficiency?

A

Trendelenburg test

Cough impulse

*both these test the pressure on the valves

66
Q

What are some complications of a AAA?

A

Rupture
Aorta duodenal Fistula formation
Embolim - causing distal embolism
Pain

67
Q

What are the differentials for atherosclerosis of the carotid causing TIA?

A

Carotid dissection

Fibromuscular dysplasia

  • hyperproliferation of the muscle
  • usually young females
  • affects kidneys as well

Vasculitis
- Giant arteritis

68
Q

Following the Doppler Ultrasound duplex done at the time of the stroke - what further investigation is done?

A

CT Angiography

69
Q

What patients should be referred for assessment of carotid endarterectomy?

A

Any patients with symptoms or TIA with stenosis of:
50-99%
- typically >70% will have immediate surgery

70
Q

What are the main complications of endarterectomy?

A

Stroke

Nerve damage:

  • Vagus
  • Hypoglossal
  • Glossopharyngeal
71
Q

How many layers are used in compressional bandages?

A

4 layers

Changed weekly

72
Q

What is the ulcer that develops with varicose veins which is a type of squamous carcinoma?

A

Marjolin’s ulcer

73
Q

How much do you need to elevate the leg by in Buerger’s test before symptoms?

A

30 degrees

74
Q

What is the calculation for the ABPI?

A

Ankle pressure / Brachial pressure

75
Q

Following Arterial duplex scan, what additional imaging should be done?

A

Digital Subtraction Angiogram

- remove the bone and soft tissue images

76
Q

What are the differentials for chronic limb ischemia?

A

OA

Spinal Stenosis

Sciatic

Diabetic neuropathy

77
Q

When is by-pass graft preferred to angioplasty?

A

Large extensive disease

Phase 4 (49 decks)

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