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Vascular Surgery Flashcards

1
Q

What are the features on inspection of chronic venous insufficiency?

A

HAS LEGS

Haemosiderosis
Atrophie blanche
Swelling 
Lipodermatosclerosis
Eczema 
Gaiter ulcers
Venous stars
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2
Q

Where is the gaiter zone?

A

Area extending from just above the ankle to below the knee - both medially and laterally

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3
Q

What position should the patient be in when performing a venous exam?

A

Standing

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4
Q

Where would you see varicosities of the following veins:
Great saphenous
Short saphenous
Calf perforators

A

GS - Medial and above the knee
SS - Posterior and below knee
CP - Few varicosities with prominent skin changes

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5
Q

Which structures meet at the saphenofemoral junction?

A

Great saphenous vein
Common femoral vein
Superficial inguinal veins

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6
Q

Where is the saphenofemoral junction typically found?

A

Lateral to the pubic tubercle

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7
Q

What should be palpated in the venous exam?

A 
Pitting oedema
Varicosities
Saphenous varix (w. cough impulse)
Tap test
Pulses
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8
Q

Describe a positive Tap Test

A

When tapping the long saphenous vein at the level of the medial knee, there is a palpable impulse over the saphenofemoral junction.

This test indicates valve incompetence along this vein

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9
Q

What are the causes of varicosities?

A 
95% idiopathic
DVT/thrombophlebitis
Obstruction
AVM
Syndromes
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10
Q

What symptoms might be reported with varicose veins?

A 
Pain
Cramping
Heaviness
Tingling
Bleeding
Swelling
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11
Q

How would you investigate varicose veins?

A

Duplex USS

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12
Q

What is the management approach to varicose veins?

A 
Conservative
Weight loss + exercise
Avoid prolonged standing
Compression stockings
Emollients

Surgery (when SFJ incompetence or ulcers/pain)
Ligation and stripping

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13
Q

What are the complications of varicose vein surgeries?

A

Early
Haematoma
Sepsis
Nerve damage

Late
Thrombophlebitis
DVT
Recurrence

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14
Q

What are ligation and stripping?

A

Ligation - the surgical tying off of veins through small incisions to prevent poooling of blood
Stripping - removal of this vein through incisions in the groin or popliteal fossa

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15
Q

What is Perthe’s test and how do you perform it?

A

Tests for deep venous occlusion by high tourniquet around the patient’s leg and getting them to walk for 5 minutes.
Deep obstruction will cause pain and swelling

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16
Q

What is the commonest cause of post-phlebitic limb?

A

Post DVT - specifically reflux

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17
Q

Arterial exam of the lower limb starts where?

A

Toes

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18
Q

Arterial exam of the lower limb - inspection

A

Colour - pallor/cyanosis

Trophic change - atrophy, shiny dry skin, nail dystrophy and loss of hair

Ulcers - between toes, base of 1/5th metatarsals, heel

Gangrene

Scars - medial thigh and leg, sternotomy/laparotomy

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19
Q

Arterial exam of the lower limb - palpation

A

Temperature

Pulses (bilaterally) - Aorta -> femoral -> popliteal -> dorsalis pedis -> posterior tib

Cap refill

Auscultate for bruits

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20
Q

How do you perform Buerger’s angle and test?

A

Angle - Lift leg to 45deg and observe for pallor - anything <20 deg indicates severe ischaemia

Test - Then swing legs over bedside and look for reactive hyperaemia (+ve)

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21
Q

Arterial exam of the upper limb - inspection

A

Hands - tobacco staining, colour, trophic change, ulcers, gangrene, scars

Face and neck - Corneal arcus/xanthalesma, high arched palate (Marfans), carotid scar

Chest - mid line sternotomy

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22
Q

Arterial upper limb exam - palpation

A

Temp

Pulses - radial, ulnar, brachial, carotid

RR delay

RF delay (stenosis, coarctation, dissection)

Auscultate for bruits

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23
Q

What are the risk factors for chronic limb ischaemia?

A 
Modable
Smoking
BP
DM
Hyperlipidaemia
Low exercise

Non modable
Age
Male
FH
Genetics
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24
Q

What other vascular diseases are associated with chronic limb ischaemia?

A 
IHD - 90%
Carotid stenosis - 15%
AAA
Renovascular disease
DM microvasular disease
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25
What is the typical presentation of chronic limb ischaemia?
Intermittent claudication relieved by rest calf pain indicates superficial femoral disease and is most common Buttoc pain indicates iliac vessel disease and is more rare
26
What is the definition of critical limb ischaemia?
An ankle pressure <50mmHg or ABPI <0.3 AND EITHER Pain at rest requiring analgesia for over 2 weeks Ulceration or gangrene
27
What is the triad of Aortoiliac occlusive disease - and what is it's eponymous name?
Leriche syndrome presents with: Buttoc claudication Erectile dysfunction Absent femoral pulses
28
What is Buerger's disease and in whom is it commonly seen?
Thromboangiitis obliterans - acute inflammation and thrombosis of arteries and veins in the peripehries leading to ulceration and gangrene Commonly seen in young male smokers
29
What are the signs of chronic limb ischaemia?
``` Loss of pulses Oedema Ulceration Nail dystrophy Shiny skin Hair loss Reduced buergers angle (>90 is normal) Positive Buergers sign ```
30
Outline the results of an ABPI
``` Normal - >1 Asymptomatic - 0.8-0.9 Claudications - 0.6-0.8 Rest pain - 0.3-0.6 Critical (ulcers and gangrene) - <0.3 ```
31
How might you investigate CLI?
``` ABPI Doppler USS Walk test Bloods ECG ```
32
How might you conservatively manage CLI?
Exercise Stop smoking Weight loss Foot care
33
How might you medically manage CLI?
Manage RFs (BP, lipids, DM Antiplatelets Analgesia
34
How might you surgically manage CLI?
Percutaneous transluminal angioplasty +- stenting Endarterectomy Bypass
35
What time frames define acute and chronic limb ischaemia?
Acute: <14 days Acute on chronic: Worsening symptoms and signs for <14 days Chronic : Stable ischaemia for >14 days
36
What are the causes of acute limb ischaemia?
Thombosis in situ (plaque rupture) - 60% Embolism (30%)- typically from the left atrium in AF and lodge in the femoral bifurcation Graft occlusion Trauma Dissection
37
How might you distinguish between thrombosis and embolism in ALI?
Onset - embolism much more sudden Severity - Embolism much more severe AF - seen in embolism Hx - Claudication seen in thrombosis Contralateral pulses - seen in embolism
38
What is the general management of ALI?
NBM IV fluids M&M Coamox if signs of infection Unfractionated heparin to prevent extension Angiogram only if incomplete occlusion, otherwise surgery
39
What is the management of embolic ALI?
Embolectomy Thrombolysis Amputation if irreversible Post op Heparin -> Warfarin Identify source Monitor for reperfusion injury and chronic pain syndrome
40
What is the management of thrombotic ALI?
Emergency reconstruction Angiograpy + angioplasty Thrombolysis Amputation
41
What are the possible complications following carotid endarterectomy?
``` Stroke Death HTN - in 60% Haematoma MI Nerve injury: Hypoglossal -> tongue dev Rec laryngeal -> hoarse voice ```
42
What is the difference between a true and false aneurysm?
True aneurysms involve dilatation of all the vessel walls and is >50% the diameter of the vessel. False aneurysms are a collection of blood around a vessel wall that communicates with the vessel lumen
43
What are the causes of aneurysms?
Congenital ADPKD -> Berry Marfans Ehlers Danlos ``` Acquired Atherosclerosis Trauma Inflammatory e.g. Takayasu Infection e.g. 3ary syphillis ```
44
What are the possible complications of an aneursm?
``` Rupture Thrombosis Distal embolisation DVT due to compression Fistula ```
45
What is the assocaition between popliteal aneurysms and AAA?
AAAs more common, but 50% of people with popliteal aneurysms also have AAAs
46
What is the main complication of a popliteal aneurysm?
Thrombosis and distal emolisation leading to ALI They rarely rupture
47
How would you assess an aneurysm?
Pulsatile Expansile Bruits Distal Pulses
48
What is the definition of a AAA, and where do 90% of them occur?
Dilatation >=3cm | Infrarenally (just above the umbilicus)
49
What is the gold standard investigation for AAAs?
CT/MRI
50
What is the screening programme for AAAs?
Men over 65 are screened If small AAA detected (3-4.4cm) then annual screening If medium AAA detected (4.5-5.4cm) then 3 monthly screening If large AAA detected (>5.5cm) then urgent 2 week referral
51
When should an AAA be operated on?
Back pain >5.5cm Growing at >1cm/year Complications e.g. emboli
52
What are the two types of repair for AAAs?
Ope and EVAR - EVAR has reduced periop mortality but no difference at 5 years.
53
What is the management of a ruptured AAA?
``` HF O2 Two lare bore cannulae with fluid but keep systolic below 100 Xmatch 10 units Instigate major haemorrhage protocol Call vasc, anaesthetics and theatre Analgesia Abx prophylaxis Urinary catheter ```
54
What are the two most common causes of thoracic aortic dissection?
Atherosclerosis and HTN combined cause 90%
55
How might a dissection present?
Sudden tearing chest pain radiating to the back Tachycardia and HTN Distal propagation may cause hemiplegia and unequal arm pulses and BP Proximal propagation may cause aortic regurge and tamponade Rupture into pericardial, pleural or peritoneal cavities is the comonest cause of death
56
What are the Stanford types of aortic dissection?
A=Proximal -70% Ascending +- descending aorta B=distal- 30% Distal to left subclavian artery
57
How would you investigate an aortic dissection?
ECG - exclude MI TTE/TOE if haemodynamically unstable CTMRI if stable
58
What is the management of an aortic dissection?
Analgesia Lower BP - labetolol (short T1/2) Type A - open repair early Type B - conservative, consider EVAR if necessary
59
What are the different types of gangrene and what do they indicate?
Wet - infarction and infection Dry - infarction only Pregangrene
60
What is gas gangrene and how does it present?
Clostridium pergringens myositis ``` Toxaemia Haemolytic jaundice Oedema Creps from surgical emphysema Brown pus ```
61
Why might a patient have an amputation?
4 Ds Death (tissue) Danger - sepsis, malignancy Damage - trauma, burns, frostbite Damned nuisance - pain, neuro damage
62
What complications might occur following an amputation?
``` Mortality Haemorrhage Infection (cell, gang, osteo) Contractures Phantom limb pain Stump misshape inhibiting prosthesis ```
63
What features might you see and feel indicating diabetic foot?
Bilateral signs of chronic arterial disease Digital amputations Charcot joints Ulceration Stocking sensory loss Loss of pulses, thouch calcification may preserve them and also give a falsely high ABPI
64
Which type of ulcer is more common in diabetes, neuropathic or ischaemic?
Neuropathic (45-60%) Ischaemic (10%) Neuroischaemic (25-30%)
65
What must be done before a diabetic undergoes angiography?
Consider renal impairment when using contrast | Stop metformin to prevent lactic acidosis
66
What questions should you ask about Raynauds?
What is the main problem? When do symptoms occur? Is it precipitated by the weather? Describe the colour changes?
67
What is the typical colour progression seen in Raynauds?
White to blue to crimson
68
Name some secondary causes of Raynauds
``` Polycythaemia Atherosclerosis Beta blockers Thoracic outlet syndrome SLE/RA/SS ```
69
What is the management of Raynauds?
Wear gloves and avoid the cold Stop smoking CCBs esp nifedipine are effective IV prostacyclin
70
What are the signs of Thoracic outlet obstruction?
``` Oedema Cyanosis Pallor Raynauds Fingertip necrosis Claw hand Sensory loss Radicular pain ``` Symptoms exacerbated/only when arm is abducted and externaly rotated
71
What are the causes of thoracic outlet obstruction?
Cervical rib | Clavicle#
72
Outline a peripheral ulcer exam
3s BEDS 3s - Site, size, shape Base - Granulation, slough, floor (bone, tendon etc) ``` Edge - Sloping indicates healing (usually venous) Punched out is ischaemic or neuropathic Underminded in TB Rolled in BCC Everted in SCC ``` Dischage - serous, purulent, sanguinous Surroundings - Cellulitis, excoriations, LNs Feel around the ulcer and then for distal pulses
73
What are the commonest causes of ulcers?
``` Venous - 75% Arterial - 2% Mixed arteriovenous - 15% Neuropathic Pressure Malignant ```
74
Where are venous ulcers typicaly found?
Medial malleolus
75
Describe the base of a venous ulcer
Shallow with pink granulation
76
Describe the edge of a venous ulcer
Sloping
77
Describe the discharge of a venous ulcer
Seropurulent
78
Describe the surroundings of f a venous ulcer
Signs of chronic ischaemia (HASLEGS) | Varicose veins
79
What might you feel on palpation of a venous ulcer?
Painless Warm surroundings Sensate
80
What causes venous ulceration?
``` Valvular disease Varicose veins Post phlebitic Muscle pump failure Stroke NM disease ```
81
How would you investigate a venous ulcer?
ABPI Duplex USS Biopsy if persistent Look for malignant change
82
How would you manage a venous ulcer?
RF management, analgesia, bed rest and leg elevation Compression banding if ABPI>0.8 Can also use Pentoxyfylline to increase blood flow
83
Where would you typiaclly find an arterial ulcer?
Between the toes Base of 1st and 5th metatarsals Heel
84
Describe the base of an arterial ulcer
Deep +- slough but no granulation tissue
85
Describe the surroundings of an arterial ulcer
Pale with trophic changes
86
What might you find on palpation of an arterial ulcer?
Pain Cold surrounding Sensate Reduced distal pulses
87
What might cause arterial ulceration?
Large vessel - atherosclerosis, Buerger's disease Small vessel - DM, PAN, RA
88
How would you treat an arterial ulcer?
``` Analgesia as v painful Modify risk factors Low dose aspirin IV prostaglandins Avoid B blockers ```
89
Where would you typically fnid neuropathic ulcers?
Same as arterial - pressure areas
90
What shape are neuropathic ulcers typically?
Correspond to the shape of the rpessure point
91
Describe the base and edge of a neuropathic ulcer
Deep and punched out
92
Describe the surroundings of a neuropathic ulcer
Normal skin with Charcot joints
93
What might you feel on palpation of a neuropathic ulcer?
Normal temp Normal pulses Absent local sensation Absent ankle jerk
94
What might cause a neuropathic ulcer
``` DM EtOH B12 CKD Isoniazid, vincristine, amiodarone Vasculitides ```
95
What are the differentials of bilateral leg swelling?
Raised venous pressure: RHF Venous insufficiency Drugs e.g. nifedipine Reduced oncotic pressure: Nephrotic syndrome Hepatic failure Protein losing enteropathy Lymphoedmea Thyroid dysfunction
96
What are the differentials of a unilateral leg swelling?
DVT Venous insufficiency Lymphoedema Infection
97
What examination findings might indicate lymphoedema
``` Gross uni/bilateral swelling Thick skin Lichenification Yellow nails Pitting-> non pitting oedema Raised JVP and hepatomegaly if RFH ```
98
What is lymphoedema?
Collection of interstitial fluid due to blockage or absence of lymphatics?
99
What are the causes of lymphoedema?
Primary ``` Secondary: FIIT Fibrosis - post radiotherapy Infilatration - cancer Infection - TB Trauma ```
100
What is the management of lymphoedema?
``` Conservative: Skin care Comp stockings Prevent cellulitis Raise leg amap ``` Surgical: Debulking BYpass

Scott's Notes (21 decks)

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