Vascular Surgery Flashcards
How much blood should be cross matched when carrying out AAA repair?
4-6 units cross matched
What are the risk factors associated with AAA?
Hypertension Smoking Atherosclerosis >55 years Male Family history Connective tissue disorders
When is screening offered for AAA?
One of US at age 65.
If >3.4cm - 4.4cm = yearly ultrasound
if >4.4 - 5.4cm = 3 monthly
if >5.5cm = surgery
What is the criteria for surgery for AAA?
> 5.5cm
advanced more >1cm in a year
What are the symptoms of a rupture AAA?
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
What surgeries are there for AAA?
Open surgery
Endovascular aneurysm repair (EVAR)
- advantageous because done laparoscopically
- disadvantage - high early re-intervention needed. life long follow up.
What complications can occur with EVAR?
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
What classification system is used for thoracic-abdominal aneurysms?
Crawford classification
Broadly what type of aneurysms are there?
True
- all layers of vessel wall are affected
Pseudoaneurysm:
- haematoma forms containing blood leaking from a damaged vessel
- caused by trauma
What important investigation should be done following a stroke, which may lead to surgery?
Carotid colour duplex scan
Following a stroke, a stenosed carotid artery is seen, what surgery should be conducted and when?
Within 2 weeks a carotid endarterectomy should be conducted.
What classification system is used for chronic lower limb ischemia?
Fontaine Classification: I - asymptomatic II - Intermittent claudication III - Rest pain IV - Ulcers/ Gangrene
Type III & IV are considered severe
What are some differentials for claudication pain?
Spinal stenosis
O/A
- at hip joint
Sciatica
Popliteal artery entrapment syndrome
What numbers of the ABPI correlate with symptoms?
0 -.4 = ulceration/ tissue loss .2-.4 = severe rest pain .4-.9 = claudication 1- 1.1 = normal >1.1 = calcification
Which disease can lead to a high ABPI > 1.1?
Diabetes
What are some symptoms which suggest severe limb ischemia?
Rest Pain
ABPI <0.5
Opiate management / not relieved by simple analgesia
Ulceration
What is the management of PVD?
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
What investigations should be done in a patient with claudication?
Typically it is diagnosed via physical exam.
ABPI
- doppler
Duplex ultrasound
Exercise ABPI
ECG
CT angiogram
What is a key features of severe limb ischemia?
Muscle tenderness.
just touching the muscle causes severe pain
What is the immediate management following a ruptured AAA?
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
Where does the superficial veins of the leg drain into the deep veins?
Saphenous- femoral junction
Mid- thing perforators
Short-saphenous - popliteal junction
What is the typical classification system of varicose veins?
CEAP
C - clinical features C1 = telangiectasia veins, C6 = active ulcer
E - aEtiology
A - Anatomical
P - Pathophysiology
- reflux, obstruction
What are the symptoms of varicose veins and how are they investigated?
Pain aching heaviness swelling oedema
Eczema
Phlebitis
lipodermatosclerosis
*Colour duplex
What are the treatment options for varicose veins?
Medical:
- keeping legs raised
- compressional bandages
Surgical:
- Stripping veins
- Ablation - radiofrequency
- Sclerotherapy
What is the definition of claudication?
Pain experienced in distal muscle groups
Relieved by rest
Reproducible
- no good or bad days, always the same
During an exercise ABPI in someone with PVD, what would you expect the number to do?
Go down due to post stenosis dilation
What is the first line medical management for PVD?
Clopidogrel/ Aspirin
+
Statin
Lifestyle changes
Exercise regime
- to improve collaterals
What is the criteria for critical limb ischemia?
> 2 weeks rest pain
Need for opioid analgesia
<50mmHg ankle systolic pressure / ABPI <0.5
or
Non healing wound or gangrene
What is the management for critical limb ischemia?
Analgesia
Endovascular intervention
Surgical intervention
Palliation
Following treatment for Acute limb ischemia, what other surgical procedure may need to be done to prevent further complication?
fasciectomy
High light some clinical signs seen for a non-viable limb:
Fixed staining of tissue
Lack of blanching upon pressure of the limb
Anaesthesia of the limb
Rigor mortis
What are the risk factors for varicose veins?
Family history
Standing for long periods of time
Pregnancy
Obesity
What has a cough impulse and may be mistaken for a femoral hernia?
Salpena Varix
- varicose vein of the great saphenous vein at the femerol-saphenous junction
What is the diagnostic choice for varicose veins?
Duplex scan - 2secs retrograde flow after compression of limb/ tissue distal
What is the management of varicose veins?
Compressive stalking
- only if surgical intervention is not indicated
Surgical:
- vein ligation
- vein stripping
- Foam sclerotherapy
- Thermal ablation
What are the indication for surgery of varicose veins?
symptomatic
Skin changes
Ulceration
Superficial vein thrombosis
What investigations should be done when there is acute limb ischemia?
Bloods:
- Lactate - establish degree of hypoperfusion
- group and save
- coagulation studies
ECG
- assess for AF
Imaging: D
- doppler
- CT Angiogram ** gold standard
What is the management of acute limb ischemia?
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
What are the complications of acute limb ischemia?
Mortality rate of 20%
• Reperfusion injury = compartment syndrome • Release of substances from necrotic muscle - K+ - H+ Myoglobulins - AKI
What classification system is used for claudication?
Fontaine Classification
I - Asymptomatic
II - Intermittent claudication
III - Rest pain
IV - ulceration/ Gangrene
What is the 5 year mortality in those with chronic limb ischemia?
50%
What are the differentials for acute limb ischemia?
Critical limb ischemia
DVT
Trauma
Spinal stenosis
Slipped disc
What is the long term management following acute limb ischemia?
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
What is a type of varicose vein that develops at the sapho-femoral venous junction? and what is it often mistaken for?
Saphena varix
What are the risk factors for varicose veins?
Prolonged standing
pregnancy
Obesity
Family history
When should varicose veins be treated?
Symptomatic
Skin changes
Ulceration
Venous embolism
What is a syndrome that affects the aortic bifurcation leading to buttock pain?
Leriche syndrome
- where there is obstruction a the bifurcation causing:
- Buttock pain
- Erectile dysfunction
- Absent femoral pulses
What is the definition of critical limb ischemia?
Ischemic rest pain for greater than 2 weeks duration
Presence of ischemic lesions
- gangrene
ABPI <0.5
What tests out with vessel analysis (CT angiograms, duplex) should be conducted into critical limb ischemia?
Metabolic profile
- Blood pressure
- Lipids
- Glucose
- ECG
What is the criteria for intermittent claudication?
Pain in the muscle
Pain on activity
Pain relieved by rest
When should surgical intervention be considered in critical limb ischemia and what type of surgery is usually performed?
When medical management is failing
When Exercise program has been completed
- Angioplasty
- By- pass graft
What percentage of below knee amputation die within 2 years?
30%
What are the complications of critical limb ischemia?
Sepsis
- gangrene
Acute on chronic ischemia
Reduced mobility and quality of life
What are the signs associated with critical limb ischemia?
Pale Cold Absent/ minimal pulses Nail changes Lack of hair Evidence of gangrene Loss of muscle Poor capillary refill
What investigations should be done into venous insufficiency?
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
Prior to use of compression bandages in venous ulcers what important investigation should be done?
ABPI
+/-
Investigation into the arterial circulation. If the arterial circulation is compromised then bandaging should be avoided.
What is a complication of a DVT other than P.E?
Post thrombotic syndrome
- Heaviness
- cramps
- Pruritus
- Ulcertation
Villalta Score
What are the treatment options into venous ulceration?
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
How would a venous ulcer be described?
Shallow irregular ulcer Granulation tissue located: - medially - gaiter area
In a young person with venous ulceration what should be considered?
Coagulopathies
What is the management for Arterial ulceration?
Lifestyle changes
Medical
- aspirin
- Statin
- glucose control
Surgical:
- angioplasty
- by-pass
- Skin graft
How does aortic dissection present?
Severe central pain
Radiates to the back
Hypertension + tachycardia
Uneven limb pulses
What the two types of aortic dissection and how are they treated?
Type A:
- ascending aorta
*treated with surgical repair
Type B:
- Descending aorta
*treated conservatively
What are the symptoms of Venous ulcers?
Aching
Bursting like pain
Pruritus
Cellulitis
What two tests can be performed during an examination to test the competence of the valves when assessing for venous insufficiency?
Trendelenburg test
Cough impulse
*both these test the pressure on the valves
What are some complications of a AAA?
Rupture
Aorta duodenal Fistula formation
Embolim - causing distal embolism
Pain
What are the differentials for atherosclerosis of the carotid causing TIA?
Carotid dissection
Fibromuscular dysplasia
- hyperproliferation of the muscle
- usually young females
- affects kidneys as well
Vasculitis
- Giant arteritis
Following the Doppler Ultrasound duplex done at the time of the stroke - what further investigation is done?
CT Angiography
What patients should be referred for assessment of carotid endarterectomy?
Any patients with symptoms or TIA with stenosis of:
50-99%
- typically >70% will have immediate surgery
What are the main complications of endarterectomy?
Stroke
Nerve damage:
- Vagus
- Hypoglossal
- Glossopharyngeal
How many layers are used in compressional bandages?
4 layers
Changed weekly
What is the ulcer that develops with varicose veins which is a type of squamous carcinoma?
Marjolin’s ulcer
How much do you need to elevate the leg by in Buerger’s test before symptoms?
30 degrees
What is the calculation for the ABPI?
Ankle pressure / Brachial pressure
Following Arterial duplex scan, what additional imaging should be done?
Digital Subtraction Angiogram
- remove the bone and soft tissue images
What are the differentials for chronic limb ischemia?
OA
Spinal Stenosis
Sciatic
Diabetic neuropathy
When is by-pass graft preferred to angioplasty?
Large extensive disease
