Vascular surgery Flashcards
Who gets vascular disease?
Smokers Diabetics Smoking Hypertension Diabetes mellitus High cholesterol Family history Renal failure Coronary/ carotid diseases
How do you help RFs?
Antiplatelets Statins RF modifications
What is intermittent claudication?
Cramping calf, thigh or buttock pain precipitated by exercise Pain is normally where the lesion is (calf, thigh, buttock) due to not meeting metabolic pain Relieved by rest Reproducible – claudication distance
What is intermittent claudication similar to?
Similar to Nerve Root Compression, must differentiate
How does intermittent claudication affect people?
80% chance of improving/stable 20% chance of getting worse 5% - intervention, 1% -major amputation 15% - dead 5 years stroke/MI Impact on social function, QOL Prognosis worse if: DM, Smoking, Occlusive Disease below the knee
What is critical limb pain?
CLI= Rest pain requiring analgesia > 2 weeks, or tissue loss
What does rest pain cause?
In the Forefoot/toes Night Relieved by dependency Gangrene/ulceration
How are interventions done in critical limb ischaemia?
90% -intervention within 1 year 25% -major amputation 50% - dead within 5 years MI/Stroke
How does claudication result in limb ischaemia?
Which of the following describes ischaemic rest pain?
A. It is cramping in nature
B. It is typically felt in the calf at night
C. It indicates impending limb loss
D. It is relieved by leg elevation
C. It indicates impending limb loss
What is ABPI?
ANKLE BRACHIAL PRESSURE INDEX
What is normal ABPI?
0.9-1.0
What are the normals levels of ABPI?
- Claudication 0.6 to 0.9
- Single level occlusion > 0.5
- Multi level occlusion < 0.5
- Rest pain/gangrene 0.3
Calcification can alter results – DIABETES
Incompressible arteries – spuriously high ankle pressures
What imaging might you use?
- Duplex US
- Angiography (Gold Standard)
What are the pros and cons of duplex US?
Advantages
- Noninvasive
- Fast/cheap
- Few complications
Disadvantages
- Dependent on ultrasonographers ability
- Poor visualization below the knee
What are the pros and cons of using angiography?
Advantages
- Gold standard for demonstrating anatomy
- Provides therapeutic opportunities: eg.PTA
Disadvantages
• Invasive: risk of hemorrhage,
aneurysm,infection
• Contrast is nephrotoxic
What type of pain does diabetic foot tend to be?
45% Neuropathic
10% Ischaemic
45% Mixed
What is ABCDE in treatment of intermittent claudication?
- Aspirin/ Antiplatelets
- Blood Pressure control
- Cholesterol control (statins)
- Diabetic control
- Exercise
How do you treat critical limb ischaemia?
- Angiography
- Intrainguinal procedures
- Endovascular management
- Reversed or in situ vein
- Dacron / PTFE
Where do you go in intrainguinal procedures?
Femoral
- Above knee Popliteal
- Below Knee popliteal
- Anterior Tibial
- Posterior Tibial
- Peroneal
Popliteal - Pedal
What are the 6 Ps of acute limb ischaemia?
- Pain
- Pallor
- Perishing Cold
- Pulseless
- Paraesthesia
- Paralysis
What is the intervention for acute limb ischaemia?
Surgical intervention
What makes an ischaemic limb viable, threatened or dead?
- Viable - No neurology, audible doppler at ankle
- Threatened - Sensory loss, tense calf, no doppler
- Dead - Complete neurological deficit, fixed mottling
What are the causes of acute limb ischaemia?
2 Important:
- Thrombus
- Embolus
What are embolic events like?
- Sudden
- No Hx PVD
- Opposite limb normal
- Identifiable source:–80% AF, 10% post MI, 10% aneurysm (aortic/popliteal)
What are thrombolic events like?
- Sudden/less acute
- Claudicant
- Abnormalities in other limb
What initial events would you use?
- FBC, Clotting, G+S
- ECG
- CXR
- Cardiac enzymes
- ABPI
- Duplex
- Angiogram
What is the initial treatment of acute limb ischaemia?
- Analgesia
- Heparin
- Catheter
- IV access + fluids
- Consent
What surgical/radiological intervention for acute limb ischaemia?
Embolectomy (with a fogarty catheter) +/- fasciotomies
Thrombectomy
Thrombolysis
What is an aneurysm?
Dilatation of artery in question of more than 50% increas of normal diameter of that vessel
What are true and false aneurysms?
True- All layers involved
False- not all layers involved
Shapes of aneurysms
Fusiform
Saccular
What is the classification of aneurysms?
Location
(Relationship to renal A’s, clinically infrarenal)
Aetiology
(Atherosclerotic, inflammatory, syphilitic, TB, surgical sieve)
What is the epidemiology of aneurysms?
Men over 65
M:F 8:1
Incidence rising (ageing and imaging)
AAA common cause of sudden death
Most AAAs asymptomatic until they rupture, 75% die before getting to hospital
RFs?
Smoking - OR = 5 ADAM
HTN
Diameter
Atherosclerosis
Who ruptures more?
Females 3:1 (rupture at smaller diameters)
How do you find AAA?
Incidental findings
screening
Clinical presentation of AAA?
Skinny patient- mass with expansilitiy
Ache- abdo, back, flanks and tenderness over point
Rupture risk increased with pain
Acute- embolus of mural thrombus (sudden acute ischaemia, insidious IC/ ulceration/ rest pain)
Can have fistulas (aorta/ enteric, aorta/ caval)
Imaging for AAA?
- DUPLEX US
- CT
- ANGIOGRAPHY
What do you need to think about for the patient pre operatively?
Age over 80 doubled mortality
Resp assessment (often smokers)
Renal Assessment
Cardiac risk
Asymptomatic CAS
What are the surgical interventions for AAA?
- Open repair
- Endovascular procedure
What are the complications of a stent?
- Stent migration
- Endoleak
Type 1 between stendt graft and AAA wall
Type 2 Retrograde flow from aortic branches
Type 3 Graft failure
Type 4 Graft wall porosity
Type 5 Endotension
Which of the following is not true with respect to ABPI measurements?
A. ABPI< 0.9 almost always indicates significant arterial disease
B. Claudicants have on average ABPI of 0.6
C. In limbs with rest pain and gangrene the ABPI is typically 0.3
D. ABPI is the investigation of choice in diabetics
D. ABPI is the investigation of choice in diabetics
What is the most likely AAA rupture?
Infrarenal
How to treat chronic incompetent veins causing venous ulcers?
Laser ablation of incompetent veins then 4 layer compression bandages
