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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
Complications of acute mesenteric ischaemia
Bowel necrosis and perforation | Short gut syndrome post-operatively.
26
Symptoms of chronic mesenteric ischaemia
``` 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
Management of chronic mesenteric ischaemia
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
Risk factors for peripheral artery aneurysms
Smoking HTN Hyperlipidaemia Family history
29
Investigations for peripheral artery aneurysms
CT angiography MR angiography (reduced risk of kidney damage and radiation) US duplex scans for follow up
30
Where is the most common location of peripheral artery aneurysms?
Popliteal artery - 70-80%
31
Management of popliteal artery aneurysm
Asymptomatic but >2.5cm, symptomatic, thrombotic cases should be treated Endovascular repair - stenting Open repair - ligate aneurysm or resect aneurysm with bypass graft.
32
Causes of femoral artery aneurysm | Management of femoral artery aneurysm
Percutaneous vascular interventions Patient self-injecting Open surgical repair
33
Risk factors for splenic artery aneurysm
``` Female Multiple pregnancies Portal hypertension Pancreatitis Pancreatic pseudocyst formation ```
34
Symptoms of splenic artery aneurysm Management of splenic artery aneurysm
Epigastric or LUQ pain Endovascular repair
35
What is definition of aneurysm?
Persistent, abnormal dilatation of an artery above 1.5 times normal diameter
36
What are the signs and symptoms of carotid artery disease?
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
Investigations for carotid artery disease?
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
Acute Management of carotid artery disease
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
Long term management of carotid artery disease
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
Complications of carotid artery disease? Essentially complications of stroke?
Dysphagia, seizures, ongoing spasticity, bladder or bowel incontinence, depression, anxiety, cognitive decline.
41
Definition of AAA
Dilatation of abdominal aorta >3cm
42
Risk factors and causes of AAA
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
Clinical features of AAA
``` Asymptomatic Abdo pain Back or loin pain Distal embolisation producing limb ischaemia Aortoenteric fistula ``` O/E - pulsatile mass felt in abdomen
44
What is the screening process for AAA?
Abdominal US for all men in 65th year.
45
Investigations for AAA
Initially by Abdominal USS | Once AAA confirmed, follow-up CT scan with contrast when at threshold diameter of 5.5cm
46
Medical management of AAA | Surgical management of AAA
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
What is the most important complication of endovascular repair?
Endovascular Leaking
48
What are signs and symptoms of ruptured AAA?
``` Abdo pain Back pain Syncope Vomiting Pulsatile abdominal mass and tenderness ``` Classic triad - flank or back pain, hypotension, pulsatile abdominal mass
49
Management of ruptured AAA
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
What is aortic dissection?
Tear in intimal layer of aortic wall causing blood flow between and splitting apart the tunica intima and media
51
Classification of aortic dissections
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
Features of aortic dissection
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
Investigations of aortic dissection
``` Bloods - FBC, U&Es, LFTs, troponin, coagulation Cross-match - at least 4 units ABG ECG CT angiogram Transoesophageal ECHO ```
54
Management of aortic dissection
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
Complications of Aortic dissection
``` Aortic rupture Aortic regurgitation Myocardial ischaemia Cardiac tamponade Stroke or paraplegia ```
56
Risk factors for varicose veins
``` prolonged standing Obesity Pregnancy Family history COCP ```
57
Features of varicose veins
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
Investigations for varicose veins
Duplex US assessing valve incompetence
59
Management of varicose veins
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
Criteria for specialist referral for varicose veins
Bleeding, pain, ulceration, superficial thrombophlebitis, severe impact on quality of life
61
Features of venous ulcers Risk factors Investigations Management
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
Arterial ulcers: Features Risk factors Investigations
``` 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
``` Neuropathic ulcers: Features Risk factors Investigations Management ```
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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