Vascular Surgery

Question 1

Risk factors for Abdominal Aortic Aneurysm (AAA):

Answer 1

• Male, older age, family history
• Hyperlipidaemia, hypertension
• Smoking
• Inflammatory (Takayasu’s aortitis, Behcet’s) or connective tissue (Marfans, Ehlers Danlos)

Question 2

ABPI of 1.3 or more means what ulcer and what is the pathophysiology? Would you use leg compression?

Answer 2

Blood vessel hardening from PVS.
Most likely venous ulcer.
You can use leg compression.

Question 3

ABPI of less than 0.5 means what ulcer and what is the pathophysiology? Would you use leg compression?

Answer 3

Severe arterial damage.
Arterial ulcer.
Do not use leg compression.

Question 4

What are the characteristics of an arterial ulcer? and what can you find around the affected area?

Answer 4

Painful ulcer, usually around the toes or heels.
Might have areas of gangrene around.
Cold to touch. No palpable pulses.
Low ABPI.

Question 5

What are the characteristics of a venous ulcer? and what can you find around the affected area?

Answer 5

Painless ulcer, usually above the ankles.
Shallow and superficial.
Irregular shape

Question 6

What skin changes can you see with venous insufficiency?

Answer 6

Oedema, skin pigmentation (haemosiderin), lipodermatosclerosis, eczema or thrombophlebitis

Question 7

What is the typical description of an arterial ulcer?

Answer 7

Punched out appearance.
Smooth (regular) wound edges.
Usually lateral malleolus.
Lower extremities cool to touch. 
Pale shiny thin skin.
Minimal hair growth.
Minimal drainage from wound.

Question 8

Risk factors for venous ulcers?

Answer 8

DVT.
Incompetent valves.
Varicose veins.

Question 9

How do you define varicose veins?

Answer 9

Tortuous dilated segments of vein due to valvular incompetence.

Question 10

What is the pathophysiology of varicose veins? Hint: valve

Answer 10

Incompetent valves which allows blood from the deep venous system to the superficial venous system at the sapheno-femoral junction and sapheno-popliteal junction.

Question 11

Risk factors for varicose veins?

Answer 11

Pregnancy
Standing for long
Obesity
Family history

Question 12

Complications of varicose veins?

Answer 12

Unsightly, pain, itching, aching, swelling.

Skin changes, ulceration, thrombophlebitis or bleeding.

Question 13

What is the gold standard investigation for varicose veins?

Answer 13

Duplex ultrasound.

Question 14

What are the invasive (3) and non-invasive management options for varicose veins?

Answer 14

Invasive: thermal ablation, foam sclerotherapy, vein ligation/stripping/avulsion.

Non: Compression stocking w patient education.

Question 15

Causes of acute limb ischaemia?

Answer 15

Occlusion of the arterial supply due to:

embolization
thrombus in-situ
trauma (compartment syndrome)

Question 16

What are the classic symptoms of acute limb ischaemia?

Answer 16

Common: Pain, pulselessness, pallor

Paraesthesia, paralysis, perishing cold.

Question 17

Signs of Critical Limb Ischaemia

Answer 17

• 6Ps
• Gangrene/necrosis
• Unpalpable pulses
• Pallor on elevation
• Delayed cap refill time
• Ulceration
• ABPI < 0.5

Question 18

What could absent radial pulses mean?

Answer 18

• Acute limb ischaemia
• Chronic peripheral vascular disease (atheroma or vasculitis)
• Graft site for pv CABG

Question 19

What is a Marjolin Ulcer?

Answer 19

Aggressive ulcerating form of squamous cell carcinoma.

• Occurs at sites of chronic inflammation i.e. burns , osteomyelitis
• Usually lower limb.

Question 20

Management for neuropathic ulcers:

• Cons (1)
• Surg (1)

Answer 20

Cushioned shoes to reduce callous formation

Amputation

Question 21

What is a painful ulcer related to inflammatory bowl disease or rheumatoid arthritis?

Answer 21

Pyoderma gangrenosum.

Question 22

Tearing chest pain radiating to the back
Tachycardia and hypotension
New aortic regurgitation murmur
Signs of end organ ischaemia (6P, reduced urine)

Answer 22

Aortic dissection

Question 23

What investigations would you order for ‘‘tearing chest pain radiating to the back”

Answer 23

Bedsides: General obs, ECG

Bloods: FBC, U&Es, LFTs, troponin, coag studies, cross match 4u, ABG (lactate for ischaemia)

Imaging: CT angiogram (diagnose, classify and assist w surgery) and Transoesophageal ECHO

Question 24

DaBakey & Stanford classification for Aortic Dissection
I, II, IIIa & IIIb
Type A & Type B

Answer 24

1: ascending aorta + aortic arch
2: ascending aorta
3a: distal to subclavian at descending until diaphragm
3b: extends beyond diaphragm until abdominal

A: 1 2 + a bit of descending
B: 3

Question 25

Acute management of Aortic Dissection?

Answer 25

High flow oxygen
IV assess via two large bore cannula - Fluids and crossmatch blood. Keep blood pressure below 110mmHg and enough for cerebral perfusion.

Question 26

Management for Type A and Type B (asymptomatic)

Answer 26

A: surgical management due to bad prognosis
- removal of ascending aorta and replacement with graft.

B: if asymptomatic, manage medically.

• BP management via IV Labetalol (BB) or CCB if BB not tolerated.
• rapidly lower the systolic pressure, pulse pressure, and pulse rate to minimise stress of the dissection and limited further propagation.

Question 27

Complications of Aortic Dissection?

Answer 27

• MI secondary to coronary artery dissection
• Aortic aneurysm
• Aortic regurgitation
• Aortic rupture
• Cardiac tamponade
• Stroke or paraplegia (spinal artery)