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Scott's Notes > Vascular Surgery > Flashcards

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
Q

What is the typical presentation of chronic limb ischaemia?

A

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

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26
Q

What is the definition of critical limb ischaemia?

A

An ankle pressure <50mmHg or ABPI <0.3 AND EITHER
Pain at rest requiring analgesia for over 2 weeks
Ulceration or gangrene

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27
Q

What is the triad of Aortoiliac occlusive disease - and what is it’s eponymous name?

A

Leriche syndrome presents with:
Buttoc claudication
Erectile dysfunction
Absent femoral pulses

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28
Q

What is Buerger’s disease and in whom is it commonly seen?

A

Thromboangiitis obliterans - acute inflammation and thrombosis of arteries and veins in the peripehries leading to ulceration and gangrene

Commonly seen in young male smokers

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29
Q

What are the signs of chronic limb ischaemia?

A 
Loss of pulses
Oedema
Ulceration
Nail dystrophy
Shiny skin
Hair loss
Reduced buergers angle (>90 is normal)
Positive Buergers sign
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30
Q

Outline the results of an ABPI

A 
Normal - >1
Asymptomatic - 0.8-0.9
Claudications - 0.6-0.8
Rest pain - 0.3-0.6
Critical (ulcers and gangrene) - <0.3
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31
Q

How might you investigate CLI?

A 
ABPI
Doppler USS
Walk test
Bloods
ECG
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32
Q

How might you conservatively manage CLI?

A

Exercise
Stop smoking
Weight loss
Foot care

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33
Q

How might you medically manage CLI?

A

Manage RFs (BP, lipids, DM
Antiplatelets
Analgesia

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34
Q

How might you surgically manage CLI?

A

Percutaneous transluminal angioplasty +- stenting
Endarterectomy
Bypass

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35
Q

What time frames define acute and chronic limb ischaemia?

A

Acute: <14 days
Acute on chronic: Worsening symptoms and signs for <14 days
Chronic : Stable ischaemia for >14 days

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36
Q

What are the causes of acute limb ischaemia?

A

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

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37
Q

How might you distinguish between thrombosis and embolism in ALI?

A

Onset - embolism much more sudden

Severity - Embolism much more severe

AF - seen in embolism

Hx - Claudication seen in thrombosis

Contralateral pulses - seen in embolism

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38
Q

What is the general management of ALI?

A

NBM
IV fluids
M&M
Coamox if signs of infection
Unfractionated heparin to prevent extension
Angiogram only if incomplete occlusion, otherwise surgery

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39
Q

What is the management of embolic ALI?

A

Embolectomy
Thrombolysis
Amputation if irreversible

Post op
Heparin -> Warfarin
Identify source
Monitor for reperfusion injury and chronic pain syndrome

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40
Q

What is the management of thrombotic ALI?

A

Emergency reconstruction
Angiograpy + angioplasty
Thrombolysis
Amputation

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41
Q

What are the possible complications following carotid endarterectomy?

A 
Stroke
Death
HTN - in 60%
Haematoma
MI
Nerve injury:
Hypoglossal -> tongue dev
Rec laryngeal -> hoarse voice
42
Q

What is the difference between a true and false aneurysm?

A

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
Q

What are the causes of aneurysms?

A

Congenital
ADPKD -> Berry
Marfans
Ehlers Danlos

Acquired
Atherosclerosis
Trauma
Inflammatory e.g. Takayasu
Infection e.g. 3ary syphillis
44
Q

What are the possible complications of an aneursm?

A 
Rupture
Thrombosis
Distal embolisation
DVT due to compression
Fistula
45
Q

What is the assocaition between popliteal aneurysms and AAA?

A

AAAs more common, but 50% of people with popliteal aneurysms also have AAAs

46
Q

What is the main complication of a popliteal aneurysm?

A

Thrombosis and distal emolisation leading to ALI

They rarely rupture

47
Q

How would you assess an aneurysm?

A

Pulsatile
Expansile
Bruits
Distal Pulses

48
Q

What is the definition of a AAA, and where do 90% of them occur?

A

Dilatation >=3cm

Infrarenally (just above the umbilicus)

49
Q

What is the gold standard investigation for AAAs?

A

CT/MRI

50
Q

What is the screening programme for AAAs?

A

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
Q

When should an AAA be operated on?

A

Back pain
>5.5cm
Growing at >1cm/year
Complications e.g. emboli

52
Q

What are the two types of repair for AAAs?

A

Ope and EVAR - EVAR has reduced periop mortality but no difference at 5 years.

53
Q

What is the management of a ruptured AAA?

A 
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
Q

What are the two most common causes of thoracic aortic dissection?

A

Atherosclerosis and HTN combined cause 90%

55
Q

How might a dissection present?

A

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
Q

What are the Stanford types of aortic dissection?

A

A=Proximal -70%
Ascending +- descending aorta

B=distal- 30%
Distal to left subclavian artery

57
Q

How would you investigate an aortic dissection?

A

ECG - exclude MI
TTE/TOE if haemodynamically unstable
CTMRI if stable

58
Q

What is the management of an aortic dissection?

A

Analgesia
Lower BP - labetolol (short T1/2)
Type A - open repair early
Type B - conservative, consider EVAR if necessary

59
Q

What are the different types of gangrene and what do they indicate?

A

Wet - infarction and infection
Dry - infarction only
Pregangrene

60
Q

What is gas gangrene and how does it present?

A

Clostridium pergringens myositis

Toxaemia
Haemolytic jaundice
Oedema
Creps from surgical emphysema
Brown pus
61
Q

Why might a patient have an amputation?

A

4 Ds

Death (tissue)
Danger - sepsis, malignancy
Damage - trauma, burns, frostbite
Damned nuisance - pain, neuro damage

62
Q

What complications might occur following an amputation?

A 
Mortality
Haemorrhage
Infection
(cell, gang, osteo)
Contractures
Phantom limb pain
Stump misshape inhibiting prosthesis
63
Q

What features might you see and feel indicating diabetic foot?

A

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
Q

Which type of ulcer is more common in diabetes, neuropathic or ischaemic?

A

Neuropathic (45-60%)
Ischaemic (10%)
Neuroischaemic (25-30%)

65
Q

What must be done before a diabetic undergoes angiography?

A

Consider renal impairment when using contrast

Stop metformin to prevent lactic acidosis

66
Q

What questions should you ask about Raynauds?

A

What is the main problem?
When do symptoms occur?
Is it precipitated by the weather?
Describe the colour changes?

67
Q

What is the typical colour progression seen in Raynauds?

A

White to blue to crimson

68
Q

Name some secondary causes of Raynauds

A 
Polycythaemia
Atherosclerosis
Beta blockers
Thoracic outlet syndrome
SLE/RA/SS
69
Q

What is the management of Raynauds?

A

Wear gloves and avoid the cold
Stop smoking

CCBs esp nifedipine are effective
IV prostacyclin

70
Q

What are the signs of Thoracic outlet obstruction?

A 
Oedema
Cyanosis
Pallor
Raynauds
Fingertip necrosis
Claw hand
Sensory loss
Radicular pain

Symptoms exacerbated/only when arm is abducted and externaly rotated

71
Q

What are the causes of thoracic outlet obstruction?

A

Cervical rib

Clavicle#

72
Q

Outline a peripheral ulcer exam

A

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
Q

What are the commonest causes of ulcers?

A 
Venous - 75%
Arterial - 2%
Mixed arteriovenous - 15%
Neuropathic
Pressure
Malignant
74
Q

Where are venous ulcers typicaly found?

A

Medial malleolus

75
Q

Describe the base of a venous ulcer

A

Shallow with pink granulation

76
Q

Describe the edge of a venous ulcer

A

Sloping

77
Q

Describe the discharge of a venous ulcer

A

Seropurulent

78
Q

Describe the surroundings of f a venous ulcer

A

Signs of chronic ischaemia (HASLEGS)

Varicose veins

79
Q

What might you feel on palpation of a venous ulcer?

A

Painless
Warm surroundings
Sensate

80
Q

What causes venous ulceration?

A 
Valvular disease
Varicose veins
Post phlebitic
Muscle pump failure
Stroke
NM disease
81
Q

How would you investigate a venous ulcer?

A

ABPI
Duplex USS
Biopsy if persistent
Look for malignant change

82
Q

How would you manage a venous ulcer?

A

RF management, analgesia, bed rest and leg elevation
Compression banding if ABPI>0.8

Can also use Pentoxyfylline to increase blood flow

83
Q

Where would you typiaclly find an arterial ulcer?

A

Between the toes
Base of 1st and 5th metatarsals
Heel

84
Q

Describe the base of an arterial ulcer

A

Deep +- slough but no granulation tissue

85
Q

Describe the surroundings of an arterial ulcer

A

Pale with trophic changes

86
Q

What might you find on palpation of an arterial ulcer?

A

Pain
Cold surrounding
Sensate
Reduced distal pulses

87
Q

What might cause arterial ulceration?

A

Large vessel - atherosclerosis, Buerger’s disease

Small vessel - DM, PAN, RA

88
Q

How would you treat an arterial ulcer?

A 
Analgesia as v painful
Modify risk factors
Low dose aspirin
IV prostaglandins
Avoid B blockers
89
Q

Where would you typically fnid neuropathic ulcers?

A

Same as arterial - pressure areas

90
Q

What shape are neuropathic ulcers typically?

A

Correspond to the shape of the rpessure point

91
Q

Describe the base and edge of a neuropathic ulcer

A

Deep and punched out

92
Q

Describe the surroundings of a neuropathic ulcer

A

Normal skin with Charcot joints

93
Q

What might you feel on palpation of a neuropathic ulcer?

A

Normal temp
Normal pulses
Absent local sensation
Absent ankle jerk

94
Q

What might cause a neuropathic ulcer

A 
DM
EtOH
B12
CKD
Isoniazid, vincristine, amiodarone
Vasculitides
95
Q

What are the differentials of bilateral leg swelling?

A

Raised venous pressure:
RHF
Venous insufficiency
Drugs e.g. nifedipine

Reduced oncotic pressure:
Nephrotic syndrome
Hepatic failure
Protein losing enteropathy

Lymphoedmea

Thyroid dysfunction

96
Q

What are the differentials of a unilateral leg swelling?

A

DVT
Venous insufficiency
Lymphoedema
Infection

97
Q

What examination findings might indicate lymphoedema

A 
Gross uni/bilateral swelling
Thick skin
Lichenification
Yellow nails
Pitting-> non pitting oedema
Raised JVP and hepatomegaly if RFH
98
Q

What is lymphoedema?

A

Collection of interstitial fluid due to blockage or absence of lymphatics?

99
Q

What are the causes of lymphoedema?

A

Primary

Secondary: FIIT
Fibrosis - post radiotherapy
Infilatration - cancer
Infection - TB
Trauma
100
Q

What is the management of lymphoedema?

A 
Conservative:
Skin care
Comp stockings
Prevent cellulitis
Raise leg amap

Surgical:
Debulking
BYpass

Scott's Notes (21 decks)

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