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Surgery > Vascular Surgery > Flashcards

Vascular Surgery Flashcards

1
Q

What are the 6 Ps of acute limb ischaemia?

A 
Pain
Pallor
Pulselessness
Perishingly Cold
Parasthesia
Paralysis

Most patients present initially with pulselessness, pain and pallor

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2
Q

What is the investigation of choice for acute limb ischaemia

A

Doppler US followed by CT angiography

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3
Q

What is the initial management for acute limb ischaemia

A

IV heparin therapeutic dose.

Monitor APPT

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4
Q

What is the management of choice for acute limb ischaemia? (embolic and thrombotic disease management)

A

Embolic - embolectomy via a fogarty catheter, local intra-arterial thrombolysis, bypass surgery

Thrombotic disease - local intra-arterial thrombolysis, angioplasty, bypass surgery

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5
Q

What is the management for irreversible limb ischaemia?

A

Urgent amputation

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6
Q

What are the long term conservative and medical management for acute limb ischaemia?

A

Reduce CVS risk - regular exercise, smoking cessation, weight loss

Medical - low-dose aspirin or clopidogrel. OR warfarin or DOAC.

PT/OT

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7
Q

What are the complications of surgery for acute limb ischaemia?

A

Reperfusion injury

Compartment syndrome

Release of substances from damaged muscle cells such as potassium, hydrogen, myoglobin.

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8
Q

What are the main risk factors for chronic limb ischaemia?

A 
Smoking
DM
HTN
Hyperlipidaemia
Increasing age
Family history
Obesity and physical inactivity
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9
Q

Clinical features of chronic limb ischaemia (stages 1-4)

A

1 - asymptomatic
2 - intermittent claudication
3 - Ischaemic rest pain
4 - ulceration or gangrene, or both

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10
Q

What is Buerger’s test

A

Lie patient supine and raise legs until they go pale, then lower them until colour returns.
Angle at which limb goes pale is Buerger’s angle.
Angle <20 degrees indicates severe ischaemia

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11
Q

What is Leriche syndrome?

A

Peripheral arterial disease affecting aortic bifurcation. Presents with buttock or thigh pain and associated erectile dysfunction

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12
Q

3 ways in which critical limb ischaemia can be defined

A

1 - Ischaemic rest pain for >2 weeks duration - requiring opiate analgesia
2 - Presence of ischaemic lesions or gangrene
3 - ABPI <0.5

Other signs - limb hair loss, skin changes, thickened nails. Burning pain at night relieved by hanging legs over side of bed.

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13
Q

What investigation is used to confirm diagnosis of chronic limb ischaemia? How is severity quantified using this investigation?

A

Ankle-brachial pressure index (ABPI)

Normal >0.9
Mild 0.8-0.9
Moderate 0.5-0.8
Severe <0.5

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14
Q

What can an ABPI value >1.2 indicate?

A

Calcification and hardening of arteries.

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15
Q

What investigation is used for critical limb ischaemia?

A

Doppler US

CT angiography or MR angiography

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16
Q

What are the conservative and medical managements for chronic limb ischaemia?

A

Lifestyle - smoking cessation, regular exercise, weight reduction
Statin therapy - atorvastatin 80mg
Anti-platelet - clopidogrel 75mg
Optimise DM control

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17
Q

Surgical management options of chronic limb ischaemia?

A

Surgery if risk factor modification has been discussed and supervised exercise has failed to improve symptoms.

Critical limb ischaemia - urgent referral for surgery

Angioplasty with or without stenting
Bypass grafting
Amputation

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18
Q

What are the complications of chronic limb ischaemia?

A

Sepsis - secondary to infected gangrene
Acute-on-chronic ischaemia
Amputation
Reduced mobility and quality of life

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19
Q

What are features of intermittent claudication? Name 4

A

Aching or burning in leg muscles following walking
Patients can typically walk for predictable distance before symptoms start
Relieved within minutes of stopping
Not present at rest

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20
Q

4 investigations for intermittent claudication

A

Check femoral, popliteal, posterior tibias and dorsalis pedis pulses
Check ABPI
Duplex US is first line investigation
MRA

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21
Q

What are the 4 causes of acute mesenteric ischaemia?

A

Acute mesenteric arterial thrombosis
Acute mesenteric arterial embolism
Non-occlusive mesenteric ischaemia (hypovolaemic and cardiogenic shock)
Mesenteric venous thrombosis

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22
Q

Symptoms and signs of acute mesenteric ischaemia

A 
Generalised abdominal pain, out of proportion to clinical findings
Diffuse and constant pain
Nausea and vomiting
O/E - abdomen often unremarkable
Difficult to localise pain

Late stage bowel ischaemia and necrosis can present as bowel perforation.

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23
Q

Investigations for acute mesenteric ischaemia

A

ABG
Bloods - FBC, U&Es, clotting, amylase, LFTs, G&S

Imaging - CT with IV contrast

CT shows oedematous bowel, loss of bowel wall enhancement and then pneumatosis.

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24
Q

What are the initial and definitive management for acute mesenteric ischaemia?

A 
Initial:
IV fluids
Catheter - fluid balance chart started
Broad-spec abx
ITU input

Definitive:
Excision of necrotic or non-viable bowel - end up with loop or end stoma (high chance of short gut syndrome)
Revascularisation of bowel (preferably done through angioplasty)

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25
Q

Complications of acute mesenteric ischaemia

A

Bowel necrosis and perforation

Short gut syndrome post-operatively.

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26
Q

Symptoms of chronic mesenteric ischaemia

A 
Postprandial pain (10 mins-4 hours after eating)
Weight loss (due to decreased food intake and malabsorption)
Concurrent vascular co-morbidities (previous MI, stroke or PVD)
27
Q

Management of chronic mesenteric ischaemia

A

Modify risk factors - smoking especially
Commence anti-platelet and statin therapy to minimise disease progression.

Surgery - in severe disease, progressive disease or presence of debilitating symptoms. 
Endovascular procedures (mesenteric angioplasty with stenting)
Open procedures (endarterectomy or bypass procedure)
28
Q

Risk factors for peripheral artery aneurysms

A

Smoking
HTN
Hyperlipidaemia
Family history

29
Q

Investigations for peripheral artery aneurysms

A

CT angiography
MR angiography (reduced risk of kidney damage and radiation)
US duplex scans for follow up

30
Q

Where is the most common location of peripheral artery aneurysms?

A

Popliteal artery - 70-80%

31
Q

Management of popliteal artery aneurysm

A

Asymptomatic but >2.5cm, symptomatic, thrombotic cases should be treated

Endovascular repair - stenting
Open repair - ligate aneurysm or resect aneurysm with bypass graft.

32
Q

Causes of femoral artery aneurysm

Management of femoral artery aneurysm

A

Percutaneous vascular interventions
Patient self-injecting

Open surgical repair

33
Q

Risk factors for splenic artery aneurysm

A 
Female
Multiple pregnancies
Portal hypertension
Pancreatitis
Pancreatic pseudocyst formation
34
Q

Symptoms of splenic artery aneurysm

Management of splenic artery aneurysm

A

Epigastric or LUQ pain

Endovascular repair

35
Q

What is definition of aneurysm?

A

Persistent, abnormal dilatation of an artery above 1.5 times normal diameter

36
Q

What are the signs and symptoms of carotid artery disease?

A

Transient ischaemic attack (TIA) - lasts less than 24 hours before full resolution.
Stroke - lasts for more than 24 hours without full resolution.

Carotid bruit may be auscultated in neck

Likely to be asymptomatic if unilateral due to collateral supply from contralateral internal carotid artery and vertebral arteries via circle of Willis.

37
Q

Investigations for carotid artery disease?

A

Urgent non-contrast CT head scan
Bloods - FBC, U&Es, clotting, lipid profile, glucose
ECG to check for AF

Screen with duplex USS once diagnosis has been made.

38
Q

Acute Management of carotid artery disease

A

Suspected stroke:
High flow oxygen
Blood glucose optimised
Swallowing screen assessment
Ischaemic - IV alteplase within 4.5 hours onset and 300mg aspirin
Haemorrhagic - correct coagulopathy, referral for neurosurgery

39
Q

Long term management of carotid artery disease

A

Anti-platelet therapy - aspirin 300mg for two weeks then clopidogrel 75mg OD
Statin therapy - high-dose atorvastatin
Aggressive management of hypertension or DM
Smoking cessation
Regular exercise and active lifestyle with weight loss
Refer for SALT

40
Q

Complications of carotid artery disease? Essentially complications of stroke?

A

Dysphagia, seizures, ongoing spasticity, bladder or bowel incontinence, depression, anxiety, cognitive decline.

41
Q

Definition of AAA

A

Dilatation of abdominal aorta >3cm

42
Q

Risk factors and causes of AAA

A

Atherosclerosis, trauma, infection, connective tissue disease (Marfan’s, Ehler’s Danlos) or inflammatory disease (Takayasu’s aortitis).

Risk factors - smoking, HTN, hyperlipidaemia, FH, male, age

43
Q

Clinical features of AAA

A 
Asymptomatic
Abdo pain
Back or loin pain
Distal embolisation producing limb ischaemia
Aortoenteric fistula

O/E - pulsatile mass felt in abdomen

44
Q

What is the screening process for AAA?

A

Abdominal US for all men in 65th year.

45
Q

Investigations for AAA

A

Initially by Abdominal USS

Once AAA confirmed, follow-up CT scan with contrast when at threshold diameter of 5.5cm

46
Q

Medical management of AAA

Surgical management of AAA

A

Less than 5.5cm monitored by duplex USS
3 - 4.4cm - yearly ultrasound
4.5 - 5.4cm - 3-monthly ultrasound

Smoking cessation
Improve BP control
Commence statin and aspirin therapy
Weight loss and increased exercise

Surgery considered for AAA >5.5cm, expanding at >1cm/year or symptomatic patient who is otherwise fit.

In unfit patient, AAA left until 6cm or more prior to repair due to significant risk of mortality from elective repair.

Open repair or end-vascular repair and graft/stent

47
Q

What is the most important complication of endovascular repair?

A

Endovascular Leaking

48
Q

What are signs and symptoms of ruptured AAA?

A 
Abdo pain 
Back pain
Syncope
Vomiting
Pulsatile abdominal mass and tenderness

Classic triad - flank or back pain, hypotension, pulsatile abdominal mass

49
Q

Management of ruptured AAA

A

Initial - oxygen, bloods, IV access, crossmatch minimum 6 units
Aim to keep BP <100mg to prevent dislodging of any clot.

Unstable - open surgical repair
Stable - CT angiogram and if suitable, end-vascular repair.

50
Q

What is aortic dissection?

A

Tear in intimal layer of aortic wall causing blood flow between and splitting apart the tunica intima and media

51
Q

Classification of aortic dissections

A

DeBakey classification
Type 1 - originates in ascending aorta, propagates to at least aortic arch and possibly beyond it distally.
Type 2 - originates in and is confined to ascending aorta
Type 3 - originates in descending aorta, rarely extends proximally but will extend distally.

Stanford classification
Type A - ascending aorta (2/3 cases)
Type B - descending aorta, distal to left subclavian origin (1/3 cases)

52
Q

Features of aortic dissection

A

chest pain: typically severe, radiates through to the back and ‘tearing’ in nature

aortic regurgitation

hypertension

other features may result from the involvement of specific arteries. For example coronary arteries → angina, spinal arteries → paraplegia, distal aorta → limb ischaemia

the majority of patients have no or non-specific ECG changes. In a minority of patients, ST-segment elevation may be seen in the inferior leads

53
Q

Investigations of aortic dissection

A 
Bloods - FBC, U&amp;Es, LFTs, troponin, coagulation
Cross-match - at least 4 units
ABG
ECG
CT angiogram
Transoesophageal ECHO
54
Q

Management of aortic dissection

A

Initial - oxygen, IV access, fluid resuscitation
Anti-HTN therapy, surveillance imaging due to risk of developing further dissection or other complications.

Type A dissections (worst prognosis) - Remove ascending aorta and replace with synthetic graft, including any branches such as brachiocephalic, left common carotid and left subclavian artery

Type B dissections -
Uncomplicated are managed medically - B-blockers or CCBs.
Surgery in presence of rupture, renal, visceral or limb ischaemia, refectory pain, uncontrolled HTN

55
Q

Complications of Aortic dissection

A 
Aortic rupture
Aortic regurgitation
Myocardial ischaemia
Cardiac tamponade
Stroke or paraplegia
56
Q

Risk factors for varicose veins

A 
prolonged standing
Obesity
Pregnancy
Family history
COCP
57
Q

Features of varicose veins

A

Cosmetic issues
Pain, aching, swelling, itching
Skin changes, ulceration, thrombophlebitis, bleeding
Varicose eczema, oedema, haemosiderin skin staining, lipodermatosclerosis, atrophie blanche.

Saphena varix - dilatation of saphenous vein at saphenofemoral junction in groin. Has cough impulse. Mistaken for femoral hernia.

58
Q

Investigations for varicose veins

A

Duplex US assessing valve incompetence

59
Q

Management of varicose veins

A

Patient education - avoid prolonged standing, weight loss and increase exercise.
Compression stockings if interventional treatment not appropriate.
Venous ulceration - 4 layer bandaging unless evidence of arterial insufficiency.

Surgical treatment criteria:
Symptomatic, lower limb skin changes, superficial vein thrombosis, venous leg ulcer.

Treatment options:
Vein ligation, stripping and avulsion
Foam sclerotherapy - closes off the vein
Thermal ablation (laser catheters or radio frequency)

60
Q

Criteria for specialist referral for varicose veins

A

Bleeding, pain, ulceration, superficial thrombophlebitis, severe impact on quality of life

61
Q

Features of venous ulcers
Risk factors
Investigations
Management

A

Shallow irregular borders
Granulating base
Medial malleolus location
Aching, itching, bursting sensation

Risk factors - age, venous incompetence, pregnancy, obesity, physical inactivity, severe leg injury or trauma

Investigations - Duplex US, ABPI, swab cultures if suspected infection.

Management - leg elevation, increased exercise. Lifestyle changes, weight reduction, improved nutrition etc.
Compression bandaging (if ABPI >0.6)
If have concurrent varicose veins, treat with endovenous techniques or open surgery.
62
Q

Arterial ulcers:
Features
Risk factors
Investigations

A 
Small deep lesions
Well defined borders
Necrotic base
At pressure areas
Intermittent claudication, critical limb ischaemia, cold limbs, thickened nails, necrotic toes, hair loss.

Risk factors - PAD, smoking, DM, HTN, hyperlipidaemia, increasing age, FH, obesity, physical inactivity.

Investigations:
ABPI, duplex US, CT angiography, MRA

Management:
Conservative - lifestyle
Medical - statin, aspirin, BP control, glucose
Surgical - angioplasty or bypass grafting

63
Q 
Neuropathic ulcers:
Features
Risk factors
Investigations
Management
A

Loss of sensation
Painless ulcers on pressure points
History of peripheral neuropathy or PAD
Burning/tingling in legs, single nerve involvement, amotrophic neuropathy
Punched out appearance. Glove and stocking distribution with warm feet and good pulses.

Risk factors:
DM and B12 deficiency

Investigations:
Blood glucose, serum B12
Swab
X-ray for osteomyelitis

Management:
Diabetic foot clinics
Diabetic control
Diet and exercise
Regular chiropody

Surgery (9 decks)

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