Vascular surgery Flashcards
Define atherosclerosis
Chronic inflammation and activation of the immune system in the artery wall
Deposition of lipids in the wall –> fibrotic plaque formation
In atherosclerosis, what are the effects of plaque formation?
Stenosis –> reduced blood flow
Rupture –> thrombus which blocks a distal vessel –> ischaemia
What are risk factors of atherosclerosis?
Older age FHx Male Smoking and alcohol Poor diet Low exercise Obesity DM
Define peripheral arterial disease
Atherosclerosis causing stenosis of the arteries supplying the limbs and periphery
Define critical limb ischaemia
End stage of PAD where there is inadequate supply of blood to the limb to allow it function normally at rest
Define intermittent claudication
Symptoms of having ischaemia in a limb during exertion that is relieved by rest
What is Leriche’s syndrome
Clinical triad of
Thigh/buttock claudication
Absent femoral pulses
Male impotence
What is the Ankle-Brachial Pressure Index?
The ratio of systolic BP in the ankle vs the arm
What are the results of the ABPI?
>1.2 = calcified, stiffened arteries >0.9 = normal 0.6-0.9 = mild disease 0.3-0.6 = moderate/severe disease <0.3 = severe/critical ischaemia
What are the 6 P’s of critical limb ischaemia?
Pain Pallor Pulseless Paralysis Parathesia Perishingly cold
How can intermittent claudication be managed?
General lifestyle changes
Optomise medical treatments for co-morbidities (HTN, diabetes)
Medical treatment:
Atorvastatin
Clopidogrel
Naftidrofuryl oxalate (peripheral vasodilator)
Surgical:
Angioplasty and stenting
Bypass surgery
How should critical limb ischaemia be managed?
Urgent referral to vascular team
Analgesia
Urgent revascularisation (angioplasty and stenting or bypass surgery)
What are the features of critical limb ischaemia, and how many are required in order for a diagnosis to be made?
Rest pain in foot for >2 weeks
Ulceration
Gangrene
(1 or more)
How may a person with AAA present?
Asymptomatically - through screening Symptoms of PAD Non-specific abdominal pain Palpable expansile pulsation in the abdomen Incidental finding on AXR Diagnosed by US/angiography (MRI/CT)
What is the screening progress for AAA?
AUS for men at 65
AAA 3-4.4cm - AUS every 2 years
AAA 4.5-5.4cm - AUS every 3 months
AAA >5.5cm - surgery for repair
How should a patient with an AAA of less than 5.5cm be managed?
Treat reversible risk factors
Monitor size
Treat PAD
What surgical options are available in the management of AAA?
EVAR
Laparoscopic repair
Open repair
What are the ideal properties which make a patient more amenable to EVAR intervention for an AAA?
Long neck
Straight iliac vessels
Healthy groin vessels
How may a person with a ruptured AAA present?
Severe abdo pain (radiate to back)
Haemodynamically unstable
Collapse
Define a true aneurysm
Aneurysm affecting all three layers of the artery wall (intima, media and adventitia)
Define a false aneurysm
Single layer of fibrous tissue forms the aneurysm wall
What is an aortic dissection?
A break in the lumen of the aorta causes blood to flow between the layers of the wall of the aorta creating a false lumen
What risk factors for associated with an aortic dissection?
HTN
Ehlers-Danlos syndrome
Marfan’s syndrome
+ smoking, lack of exercise, increasing age etc
How may a patient with an aortic dissection present?
Sudden onset tearing chest pain Radiates to back HTN --> hypotension Paraplegia, angina etc Aortic regurgitation
What are the two types of aortic dissections?
Type A: Ascending aorta
Type B: Origin of left subclavian artery
How should a type A aortic dissection be managed?
IV beta-blockers
Emergency surgical repair
How should a type B aortic dissection with no end organ effects be managed?
Medically - analgesia, IV beta blockers and monitoring
How might an aortic dissection appear on CXR?
Wide mediastinum
What is carotid artery stenosis?
Stenosis of the carotid artery secondary to atherosclerosis
How can carotid artery stenosis be diagnosed?
Carotid ultrasound
Angiography (CT/MRI)
How can a person present with carotid artery stenosis?
Asymptomatic Syncope TIAs Amaurosis fulgax Carotid bruit Cognitive impairment
What is amaurosis fulgax
Painless, temporary loss of sight in one/both eyes (like a curtain)
How can carotid artery stenosis be managed?
Treat modifiable risk factors
Carotid endarterectomy if stenos >70%
Angioplasty and stenting
Describe the development of varicose veins
Deep veins and superficial veins are connected by perforators which have valves
The valves in the perforators become incompetent so blood can flow from the deep veins to the superficial veins
Superficial veins become overloaded with blood –> dilate and engorge - a varicose vein
The superficial veins become leaky due to the higher pressures, what is the result of this?
Haemosiderin deposited into shins –> brown discolouration –> legs become dry and inflamed –`> varicose eczema
How can varicose veins present?
Cosmetically unappealing dilated superficial leg veins
Heavy/dragging sensation in legs
Muscle cramps
What are the complications associated with varicose veins?
Ulcers
Infection
Thrombophlebitis
DVT
How can varicose veins be managed?
Mobilise, elevate legs, compression bandages
Surgery:
Endothermal ablation
Sclerotherapy
Stripping of veins
What is lipodermatosclerosis
in varicose veins, the skin and soft tissue becomes fibrotic so the lower legs become tight and narrowed
What is the pathophysiology of arterial ulcers?
Poor blood supply to the skin due to PAD
What is the typical appearance of arterial ulcers?
smaller, punched out sloughy base pallor absent pulses painful pain worse when elevated, relieved when hanging
What is the pathophysiology of venous ulcers?
Pooling of blood and waste products in the skin secondary to venous deficiency (varicose veins, DVT, phlebitis)
What is the typical presentation of venous ulcers?
Gaitor region Oedematous flushed skin Hyperpigmentation in skin Varicose eczema More likely to bleed Tend to be larger than arterial ulcers Pain relieved by elevation, worse when hanging
How should ulcers be managed?
Treat underlying cause
Good wound care
Debridement, cleaning, dressing
Antibiotics if infected
Tissue viability nurse and district nurses
Plastic surgery input if severe ?skin grafts
What is a Marjolin’s ulcer?
Squamous cell carcinoma in a chronic ulcer
What is lymphoedema?
Chronic, oedematous condition secondary to disruption or inadequate lymph drainage of an area
What is primary lymphoedema?
Idiopathic condition which usually presents in the first 3 decades of life
More common in girls
Result of a congenital lymphatic abnormality
What is secondary lymphoedema?
Lymphoedema caused due to infection, malignancy, radiotherapy, surgery
What are signs of lymphoedema?
Swollen limb
Thick, scaly skin
Lymphadenopathy - ?malignancy
If a person has lymphoedema, what infection are they prone to?
Cellulitis
How can lymphoedema be managed?
Massage - manually drain the lymphatic system
Compression bandages
Surgery - rare with generally poor outcomes
