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DPD 2020 > Vascular surgery > Flashcards

Vascular surgery Flashcards

1
Q

What are the vascular risk factors?

A

Smoking
Family history

Hypertension
Renal failure

Diabetes mellitus
High cholesterol

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2
Q

Give examples of disease in coronary and carotid territories.

A

Coronary: MI, angina, coronary revascularisation.

Carotid: Stroke, TIA, amaurosis fugax, carotid intervention.

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3
Q

How is vascular disease prevented?

A

Antiplatelet medication.
Statins.
Risk factor modification.

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4
Q

What is claudication?

A

Pain that becomes worse with exercise- usually in calves, thigh or buttocks.

Measured in metres- how far can you walk without pain - claudication distance

Reproducible- claudication distance is fixed- always the same

Peripheral vascular disease- ischaemia- muscle doesn’t get enough oxygen.

Impact on social function, QOL.
Need to differentiate from nerve root compression.

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5
Q

What is critical ischaemia?

A

Rest pain requiring analgesia >2 weeks, or tissue loss.
Limb involved is always ischaemic- constant pain- black, blue, ulcers, cold, etc.
Forefoot/toes.
Night.
Relieved by dependency.
Gangrene/ulceration.
Never enough blood with oxygen.

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6
Q

What is rest pain?

A

In pain at rest, peripheral vascular disease, sign of critical ischaemia.

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7
Q

What is the prognosis and what makes it worse for patients with intermittent claudication?

A 
80% chance of improving/stable.
20% chance of getting worse.
5%- intervention, 1%- major amputation.
15%- dead 5 years stroke/MI. 
-Diabetes mellitus.
-Smoking.
-Occlusive disease below the knee.
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8
Q

What is the prognosis for patients with critical limb ischaemia?

A

90%- intervention within 1 year.
25%- major amputation.
50%- dead within 5 years MI/stroke.

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9
Q

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

A

It indicates impending limb loss.

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10
Q

What is ankle brachial pressure index?

A 
Compare BP in leg to arm.
Ankle SBP/Brachial SBP.
Normal 0.9-1.
Claudication 0.6-0.9.
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.

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11
Q

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 diabetes.

A

ABPI is NOT the investigation of choice in diabetes.

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12
Q

How can you image arteries?

A

Duplex ultrasound.
Angiography.
Magnetic resonance angiography.

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13
Q

What are the advantages of duplex ultrasound?

A

Non-invasive.
Fast/cheap.
Few complications.

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14
Q

What are the disadvantages of duplex ultrasound?

A

Dependent on ultrasonographer’s ability.

Poor visualisation below the knee.

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15
Q

What are the advantages of angiography?

A

Gold standard for demonstrating anatomy.

Provides therapeutic opportunities, e.g. PTA.

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16
Q

What are the disadvantages of angiography?

A

Invasive: risk of haemorrhage, aneurysm, infection.

Contrast in nephrotoxic.

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17
Q

What are the different types of diabetic foot?

A

45% neuropathic.
10% ischaemic.
45% mixed.

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18
Q

What are the 6Ps of acute limb ischaemia?

A 
Pain
Pallor
Perishing cold
Pulseless
[Signs of critical disease]
Paraesthesia
Paralysis

Surgical emergency.

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19
Q

What are all the causes of acute limb ischaemia?

A

Thrombosis.
Embolism.

Trauma.
Iatrogenic.
Thrombosed popliteal artery aneurysm.
Graft thrombosis/post angioplasty.

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20
Q

What are all the possible treatments for acute limb ischaemia?

A 
Analgesia.
Heparin.
Catheter.
IV access &amp; fluids.
Consent.
Embolectomy ± fasciotomies/ thrombectomy.
Thrombolysis.
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21
Q

What is the most likely aetiology of ‘trash foot’?

a) infective endocarditis
b) SFA occlusion
c) abdominal aortic aneurysm
d) popliteal aneurysm
e) all of the above

A

Abdominal aortic aneurysm.

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22
Q

What is carotid artery disease?

[*Not in lecture]

A

Stroke: completed (deficit lasting >3 weeks), TIA (symptoms resolve completely <24hrs).
Amaurosis fugax = transient blindness in one eye.
Necrotic plaque in arteries ruptures, debris discharged; ulcer, platelet deposition, platelet emboli; trauma (carotid dissection).

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23
Q

What is the epidemiology of stroke?

[*Not in lecture]

A 
700,000 new stroke patients yearly.
Mortality rate of 10-35%, 30% die within 1yr.
3rd leading cause of death.
Annual cost of stroke >50 billion.
27% haemorrhagic, 71% ischaemic.
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24
Q

How is carotid artery disease diagnosed?

[*Not in lecture]

A

History (TIA, stroke), physical exam (carotid bruits).
Carotid duplex/ doppler US.
CT/MR brain, CTA aortic arch and carotids.
Angiography.

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25
Q

How is carotid artery disease treated?

[*Not in lecture]

A

Symptomatic: >70% ICA stenosis (ESCT, SACET), carotid endarterectomy = CEA, 17% risk reduction at 2 years; 50-69% ICA stenosis (NASCET), CEA, 6% risk reduction at 5 years; 30-50% ICA stenosis (NASCET), BMT.

Asymptomatic: BMT, 50% risk reduction; aspirin, clopidogrel, dipyridamole; statin.

26
Q

What is DVT?

[*Not in lecture]

A

Deep vein thrombosis.
Detected by scanning- d-dimers.
Treated by anticoagulation, compression, adequate analgesia and adequate rehydration.

27
Q

What are varicose veins?

[*Not in lecture]

A 
Common- 10% of population.
Superficial veins.
Valve dysfunction.
Bulging veins.
Chronic venous insufficiency: leg swelling, skin colour and texture changes, venous ulcers.
28
Q

What is the treatment or varicose veins?

[*Not in lecture]

A

High frequency ultrasound/ laser ablates vein under ultrasound guidance and local anaesthetic.

29
Q

What is an aneurysm?

A

A permanent localised dilatation of an artery, at least >1.5 original vessel diameter.
Ectasia.

30
Q

What is a true aneurysm and what are the causes?

A

Dilatation of all layers of arterial wall.

Degenerative- atherosclerotic.
Connective tissue- Marfan's.
Post-dissection- thoracic/ type B.
Infection- syphilitic, salmonella.
Inflammatory- takayasus, PAN.
Congenital.
31
Q

What are false aneurysms?

A

Doesn’t involve all arterial layers

Traumatic, connective tissue wall, post haematoma.

32
Q

What are the different types of aneurysms?

A

Saccular- protrusion on one side
Fusiform- all around ballooning of artery

Pseudoaneurysm.

33
Q

What are the clinical features of aortic aneurysms?

What are the symptoms?

A

Most are asymptomatic (75% incidental)- until rupture

Symptomatic (25%):
- rupture

= generalised abdominal/flank/back pain.

or rarely-

  • compression = sciatica, leg swelling, vomiting, hydronephrosis.
  • fistulation = aorto-duodenal, aorto-caval fistula.
  • distal embolisation.

Surgical emergency.

34
Q

How are aortic aneurysms investigated?

A

> Physical exam: palpation around (up+left) umbilicus.

> USS- duplex [cannot see rupture though, hard in obese patients, limit in how far you can see]

> CT AORTA with contrast - Gold standard- can plan EVAR

> Can also do angiography- but can underestimate diameter- mural thrombus mimic aortic wall

35
Q

What is the rupture risk of abdominal aortic aneurysms?

A

Low <1% with diameter <5.5cm.
Rises to 10%/year over 6cm, 25%/year over 7cm.

Do elective repair if over 5.5cm

36
Q

A 67 y/o man comes to the clinic and describes pain in both calves after walking 50m.
He is a smoker and has had diabetes for many years.
Imaging reveals that he has severe arterial disease in his femoral arteries and vessels distal to them.
What is this symptom best described as?

A

Intermittent claudication.

37
Q

A 68y/o man comes to the clinic with a 3yr history of leg ulcers treated unsuccessfully by district nurses with dressings.
A scan shows normal arteries, but bilateral incompetence of both his great saphenous veins.
He is otherwise fit and well and mobilises easily.
What is the most appropriate next step in management?

A

Ablation.

38
Q

What is a bypass?

Which veins can be used for which infra inguinal [lower limb] bypasses?

A

Provide alternative routes for blood to flow around blockage using grafts [either veins from another part of body or synthetic material

Align valves in right way/remove valves

Sites
Femoral 
- Above knee popliteal
- Below knee popliteal
- Anterior tibial
- Posterior tibial

Popliteal
- Pedale

39
Q

Which grafts are better for a bypass- vein or synthetic?

A

Vein grafts- less risk of infection/more patency

Synthetic- made of Dacron/PTFE not as good

40
Q

When should you treat acute limb ischemia by?

A

6hrs of presentation

Unless dead limb- then don’t treat, just amputate

41
Q

Should you revascularize a dead foot?

A

No

All breakdown products go back into blood stream

42
Q

What are the features of a viable, threatened and dead limb?

A

Viable
audible tibial/ankle pulse on doppler

Threatened
No sound of doppler
Sensory loss
Tense calf

Dead
Discolouration- fixed mottling
Tissue loss
Neurological deficit

43
Q

What are the main causes of acute limb ischemia?

What are the features of acute limb ischemia presentation due to each cause?

A

Thrombotic

  • Atherosclerotic disease- in situ thrombosis- due to plaque injuring endothelium
  • Less acute
  • History of PVD- claudication
  • Abnormalities in other limb too

Embolic

  • Sudden
  • No Hx of PVD
  • Opposite leg is fine
44
Q

What are the causes/origin sources of embolic acute limb ischemia?

A

AF- eighty percent
Post MI- ten percent
Aneurysm - aortic/popliteal- ten percent

45
Q

Initial investigations for acute limb ischemia?

A
  • FBC
  • Group and Save, Cross match
  • ECG- for AF
  • CXR- cardiac?
  • Cardiac enzymes- silent MI
  • ABPI
  • Duplex USS, angiogram - if time
46
Q

Initial management for acute limb ischemia?

A 
Analgesia [if pain- foot not numb]
Heparin
Catheter
IV access and fluid
Consent for surgery
47
Q

How to define an abdominal aortic aneurysm?

A

> 3cm

or 1.5 x normal diameter [1.2-2 cm] [women have smaller aorta than men]

48
Q

How is the location of AAA defined?

A
  • Juxta renal
  • Infra renal

Defined by relationship to renal vessels

49
Q

Are most AAAs juxta renal or infra renal?

A

Infra renal

50
Q

Causes of AAA

A

Atherosclerotic
Inflammatory

Used to be mainly tuberculous/syphilic in past

51
Q

Epidemiology of AAA

A

Male > female - 8:1

Older age

Increasing prevalence : aging population, better detection

5% of men over 65 years have a AAA

Third most common cause of sudden death in UK

52
Q

Risk factors for AAA

A

Age
Smoking
HTN
Atherosclerosis

53
Q

How does smoking affect AAA?

A

Increased growth rate

More proximal AAA

54
Q

What increases risk of AAA rupture?

A

Female -3:1
Diameter >5.5cm

Mean arterial blood pressure- HTN
Smoking

Reduced FEV1

55
Q

Are AAA regularly screened for?

A

Yes
Cost effective
Reduces mortality

56
Q

Complications of AAA

A

Embolisation of mural thrombus- due to bad blood flow through aneurysm

  • Sudden- acute ischemia + pain
  • Insidious- trash foot- intermittent claudication, rest pain, ulcers

Fistula- aortoenteric- to duodenum- upper GI haemorhharge
- aortocaval- aorta + inferior vena cava

57
Q

How do you assess a AAA patient pre operatively- what factors do you consider?

A

Resp assessment
Renal assessment
Cardiac assessment- modify risk factors- smoking
Age over eighty year- operative mortality doubles
Check for asymptomatic cancer

Weigh up risks vs benefits
Especially if elective- due to screening programme- not rupture

58
Q

Complications of EVAR?

A

Stent migration
Endo leak- 5 types- blood accumulation
Higher mortality years after operation

59
Q

A 66 year old man attends A and E

Acute tearing abdominal pain

Cold and clammy

BP: 90/60
HR: 110
Tender abdomen
Pulsatile abdominal mass

Diagnosis?

A

AAA

60
Q

Mrs X- painful bilateral ulcers around ankles for one year.

Non smoker
Mobilises well
Foot pulses present
ABPI 0.98

Venous scan- patent deep venous system- working normally
but
bilateral incompetent great saphenous veins

a] Compression Hosiery
b] Four layer compression bandaging
c] Stripping of incompetent great saphenous veins, followed by compression bandaging
d] Laser ablation of incompetent great saphenous veins + compression bandaging
e] Oral broad spectrum abx + Four layer compression bandaging

A

Laser ablation of incompetent great saphenous veins + compression bandaging

DPD 2020 (48 decks)

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