Vascular Surgery Flashcards
What are the features on inspection of chronic venous insufficiency?
HAS LEGS
Haemosiderosis Atrophie blanche Swelling Lipodermatosclerosis Eczema Gaiter ulcers Venous stars
Where is the gaiter zone?
Area extending from just above the ankle to below the knee - both medially and laterally
What position should the patient be in when performing a venous exam?
Standing
Where would you see varicosities of the following veins:
Great saphenous
Short saphenous
Calf perforators
GS - Medial and above the knee
SS - Posterior and below knee
CP - Few varicosities with prominent skin changes
Which structures meet at the saphenofemoral junction?
Great saphenous vein
Common femoral vein
Superficial inguinal veins
Where is the saphenofemoral junction typically found?
Lateral to the pubic tubercle
What should be palpated in the venous exam?
Pitting oedema Varicosities Saphenous varix (w. cough impulse) Tap test Pulses
Describe a positive Tap Test
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
What are the causes of varicosities?
95% idiopathic DVT/thrombophlebitis Obstruction AVM Syndromes
What symptoms might be reported with varicose veins?
Pain Cramping Heaviness Tingling Bleeding Swelling
How would you investigate varicose veins?
Duplex USS
What is the management approach to varicose veins?
Conservative Weight loss + exercise Avoid prolonged standing Compression stockings Emollients
Surgery (when SFJ incompetence or ulcers/pain)
Ligation and stripping
What are the complications of varicose vein surgeries?
Early
Haematoma
Sepsis
Nerve damage
Late
Thrombophlebitis
DVT
Recurrence
What are ligation and stripping?
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
What is Perthe’s test and how do you perform it?
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
What is the commonest cause of post-phlebitic limb?
Post DVT - specifically reflux
Arterial exam of the lower limb starts where?
Toes
Arterial exam of the lower limb - inspection
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
Arterial exam of the lower limb - palpation
Temperature
Pulses (bilaterally) - Aorta -> femoral -> popliteal -> dorsalis pedis -> posterior tib
Cap refill
Auscultate for bruits
How do you perform Buerger’s angle and test?
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)
Arterial exam of the upper limb - inspection
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
Arterial upper limb exam - palpation
Temp
Pulses - radial, ulnar, brachial, carotid
RR delay
RF delay (stenosis, coarctation, dissection)
Auscultate for bruits
What are the risk factors for chronic limb ischaemia?
Modable Smoking BP DM Hyperlipidaemia Low exercise
Non modable Age Male FH Genetics
What other vascular diseases are associated with chronic limb ischaemia?
IHD - 90% Carotid stenosis - 15% AAA Renovascular disease DM microvasular disease
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
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
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
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
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
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
How might you investigate CLI?
ABPI Doppler USS Walk test Bloods ECG
How might you conservatively manage CLI?
Exercise
Stop smoking
Weight loss
Foot care
How might you medically manage CLI?
Manage RFs (BP, lipids, DM
Antiplatelets
Analgesia
How might you surgically manage CLI?
Percutaneous transluminal angioplasty +- stenting
Endarterectomy
Bypass
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
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
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
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
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
What is the management of thrombotic ALI?
Emergency reconstruction
Angiograpy + angioplasty
Thrombolysis
Amputation
What are the possible complications following carotid endarterectomy?
Stroke Death HTN - in 60% Haematoma MI Nerve injury: Hypoglossal -> tongue dev Rec laryngeal -> hoarse voice
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
What are the causes of aneurysms?
Congenital
ADPKD -> Berry
Marfans
Ehlers Danlos
Acquired Atherosclerosis Trauma Inflammatory e.g. Takayasu Infection e.g. 3ary syphillis
What are the possible complications of an aneursm?
Rupture Thrombosis Distal embolisation DVT due to compression Fistula
What is the assocaition between popliteal aneurysms and AAA?
AAAs more common, but 50% of people with popliteal aneurysms also have AAAs
What is the main complication of a popliteal aneurysm?
Thrombosis and distal emolisation leading to ALI
They rarely rupture
How would you assess an aneurysm?
Pulsatile
Expansile
Bruits
Distal Pulses
What is the definition of a AAA, and where do 90% of them occur?
Dilatation >=3cm
Infrarenally (just above the umbilicus)
What is the gold standard investigation for AAAs?
CT/MRI
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
When should an AAA be operated on?
Back pain
>5.5cm
Growing at >1cm/year
Complications e.g. emboli
What are the two types of repair for AAAs?
Ope and EVAR - EVAR has reduced periop mortality but no difference at 5 years.
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
What are the two most common causes of thoracic aortic dissection?
Atherosclerosis and HTN combined cause 90%
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
What are the Stanford types of aortic dissection?
A=Proximal -70%
Ascending +- descending aorta
B=distal- 30%
Distal to left subclavian artery
How would you investigate an aortic dissection?
ECG - exclude MI
TTE/TOE if haemodynamically unstable
CTMRI if stable
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
What are the different types of gangrene and what do they indicate?
Wet - infarction and infection
Dry - infarction only
Pregangrene
What is gas gangrene and how does it present?
Clostridium pergringens myositis
Toxaemia Haemolytic jaundice Oedema Creps from surgical emphysema Brown pus
Why might a patient have an amputation?
4 Ds
Death (tissue)
Danger - sepsis, malignancy
Damage - trauma, burns, frostbite
Damned nuisance - pain, neuro damage
What complications might occur following an amputation?
Mortality Haemorrhage Infection (cell, gang, osteo) Contractures Phantom limb pain Stump misshape inhibiting prosthesis
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
Which type of ulcer is more common in diabetes, neuropathic or ischaemic?
Neuropathic (45-60%)
Ischaemic (10%)
Neuroischaemic (25-30%)
What must be done before a diabetic undergoes angiography?
Consider renal impairment when using contrast
Stop metformin to prevent lactic acidosis
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?
What is the typical colour progression seen in Raynauds?
White to blue to crimson
Name some secondary causes of Raynauds
Polycythaemia Atherosclerosis Beta blockers Thoracic outlet syndrome SLE/RA/SS
What is the management of Raynauds?
Wear gloves and avoid the cold
Stop smoking
CCBs esp nifedipine are effective
IV prostacyclin
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
What are the causes of thoracic outlet obstruction?
Cervical rib
Clavicle#
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
What are the commonest causes of ulcers?
Venous - 75% Arterial - 2% Mixed arteriovenous - 15% Neuropathic Pressure Malignant
Where are venous ulcers typicaly found?
Medial malleolus
Describe the base of a venous ulcer
Shallow with pink granulation
Describe the edge of a venous ulcer
Sloping
Describe the discharge of a venous ulcer
Seropurulent
Describe the surroundings of f a venous ulcer
Signs of chronic ischaemia (HASLEGS)
Varicose veins
What might you feel on palpation of a venous ulcer?
Painless
Warm surroundings
Sensate
What causes venous ulceration?
Valvular disease Varicose veins Post phlebitic Muscle pump failure Stroke NM disease
How would you investigate a venous ulcer?
ABPI
Duplex USS
Biopsy if persistent
Look for malignant change
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
Where would you typiaclly find an arterial ulcer?
Between the toes
Base of 1st and 5th metatarsals
Heel
Describe the base of an arterial ulcer
Deep +- slough but no granulation tissue
Describe the surroundings of an arterial ulcer
Pale with trophic changes
What might you find on palpation of an arterial ulcer?
Pain
Cold surrounding
Sensate
Reduced distal pulses
What might cause arterial ulceration?
Large vessel - atherosclerosis, Buerger’s disease
Small vessel - DM, PAN, RA
How would you treat an arterial ulcer?
Analgesia as v painful Modify risk factors Low dose aspirin IV prostaglandins Avoid B blockers
Where would you typically fnid neuropathic ulcers?
Same as arterial - pressure areas
What shape are neuropathic ulcers typically?
Correspond to the shape of the rpessure point
Describe the base and edge of a neuropathic ulcer
Deep and punched out
Describe the surroundings of a neuropathic ulcer
Normal skin with Charcot joints
What might you feel on palpation of a neuropathic ulcer?
Normal temp
Normal pulses
Absent local sensation
Absent ankle jerk
What might cause a neuropathic ulcer
DM EtOH B12 CKD Isoniazid, vincristine, amiodarone Vasculitides
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
What are the differentials of a unilateral leg swelling?
DVT
Venous insufficiency
Lymphoedema
Infection
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
What is lymphoedema?
Collection of interstitial fluid due to blockage or absence of lymphatics?
What are the causes of lymphoedema?
Primary
Secondary: FIIT Fibrosis - post radiotherapy Infilatration - cancer Infection - TB Trauma
What is the management of lymphoedema?
Conservative: Skin care Comp stockings Prevent cellulitis Raise leg amap
Surgical:
Debulking
BYpass
