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Vascular surgery Flashcards

1
Q

What is an aneurysm?

A

Permanent and irreversible localised dilatation of a blood vessel to more than 50% its expected diameter

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2
Q

What is an ectasia?

A

Permanent and irreversible localised dilatation of less than 150% the normal expected diameter

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3
Q

What is arteriomegaly?

A

Diffuse arterial enlargement without discrete aneurysm formation

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4
Q

Why are aneurysms most common in the intra-renal abdominal aorta?

A 
Bifurcation stresses
58% lower elastin content
Elastin not synthesised in adult life
Proteolytic activity
MMPs
Microfibrillar integrity
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5
Q

What is the aetiology of aortic aneurysms?

A 
Degenerative
Familial
Vasculitis
Connective tissue abnormalities (Marfan's syndrome, Ehlers-danlos syndrome)
Infected mycotic
Trauma
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6
Q

What are the risk factors for aorta aneurysms?

A 
Smoking
Hypertension
Hyperlipidaemia
Family history
Male
Increasing age
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7
Q

What are the ways an aortic aneurysm can present?

A 
Asymptomatic
Rupture
Compression
Embolism
Thrombosis
Fistulation
Infection
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8
Q

What are the symptoms of an abdominal aortic aneurysm?

A 
Abdominal pain
Back or loin pain
Distal embolism producing limb ischaemia
Aortoenteric fistula
Pulsatile mass in abdomen
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9
Q

What are the differential diagnoses of an aortic aneurysm?

A 
Renal colic
Diverticulitis
IBD
GI haemorrhage
Appendicitis
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10
Q

How can an AAA be managed?

A

Medical by monitoring and reducing RF

Surgically by open repair or endovascular repair

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11
Q

When is an open repair indicated for an AAA?

A

Unusual anatomy
Cost
Large / symptomatic juxta-renal aneurysm

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12
Q

What are the complications of an open repair for an AAA?

A

Graft infection
Aorta-enteric fistula
Autonomic dysfunction
Incisional hernia

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13
Q

What factors affect the risk of an AAA rupture?

A

Size and shape
Expansion rate
Gender

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14
Q

How does a ruptured AAA present?

A 
Abdominal pain
Back pain
Syncope
Vomiting
Haemodynamically compromised
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15
Q

What are the complications of an AAA?

A

Ruptured AAA
Retroperitoneal leak
Embolisation
Aortoduodenal fistula

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16
Q

What is an aortic dissection?

A

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

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17
Q

What is a group B aortic dissection?

A

Affect ascending aorta only and include DeBakey type III (originate distal to subclavian artery in descending aorta)

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18
Q

What are the risk factors of an aortic dissection?

A 
Hypertension
Atherosclerotic disease
Male
Connective tissue disorders
Bicuspid aortic valve
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19
Q

What are the clinical features of an aortic dissection?

A

Tearing chest pain that radiates to back
Tachycardia and hypotension
New aortic regurgitation murmur
End-organ hypo perfusion (oliguria, confusion, paraplegia, lower limb ischaemia)

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20
Q

What are the differentials of an aortic dissection?

A

MI
PE
Pericarditis
MSK back pain

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21
Q

How is a type B aortic dissection managed?

A

Medically if uncomplicated by controlling hypertension with beta blockers or CCB
Surgery if complicated (rupture; renal, visceral or limb ischaemia, refractory pain or uncontrollable hypertension)

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22
Q

What are the complications of a type B aortic dissection?

A 
Aortic rupture
Aortic regurgitation
Myocardial ischaemia
Cardiac tamponade
Stroke or paraplegia
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23
Q

What is atherosclerosis?

A

A degenerative disease affecting all arteries characterised by lipid deposition and fibrosis that causes them to harden

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24
Q

What arteries are most commonly affected by atherosclerosis?

A

Large elastic arteries - aorta, iliac, carotid

Medium sized - coronary, femoral, popliteal

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25
Q

What are the progression steps of atherosclerosis from the initial lesion to a complicated lesion?

A 
Initial lesion
Fatty streak
Intermediate lesion
Atheroma
Fibroatheroma
Complicated lesion
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26
Q

What are the clinical features of atherosclerosis?

A

Depend on arteries affected
Coronary artery causes angina and MI
Cerebrovascular artery causes strokes and TIA
Peripheral vascular disease causes claudication and limb ischaemia

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27
Q

How is atherosclerosis prevented?

A 
Primary prevention - smoking cessation, control BP, weight reduction, exercise, dietary modification
Secondary prevention (COBRA-A) - clopidogrel, omacar, bisoprolol, ramipril, aspirin, atorvastatin
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28
Q

How is atherosclerosis treated?

A

Angioplasty
Stenting
Surgical bypass

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29
Q

What are varicose veins?

A

Vein that is tortuous dilated and associated with valvular incompetence
Present in course of long / short saphenous veins

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30
Q

What are the risk factors for varicose veins?

A 
Prolonged standing
Obesity
Pregnancy
Family history
Increasing age
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31
Q

What is the CEAP system?

A 
Puts patients into categories to decide who gets treatment for varicose veins
Clinical manifestations
Etiology
Anatomic distribution
Pathophysiology
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32
Q

What are the clinical features of varicose veins?

A

Asymptomatic and cosmetic issues
Aching legs, heaviness, cramps, restlessness, itching
Features of venous insufficiency - oedema, varicose eczema, thrombophlebitis, ulcers, haemosiderin skin staining

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33
Q

What can a duplex USS for varicose veins assess?

A

Visualise vein and see how dilated it is
Assess for reflux
Assess valve incompetency and any perforators

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34
Q

What are the differentials of varicose veins?

A

Telangiectasias

Reticular veins

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35
Q

How can varicose veins be treated?

A

Conservative - avoid prolonged standing, weight loss, increase exercise, graduated compression stockings, 4-layer bandaging of any venous ulcerations
Surgical treatment

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36
Q

When is surgical treatment indicated for varicose veins?

A

Symptomatic primary or recurrent varicose veins
Lower-limb skin changes e.g. pigmentation or eczema
Superficial vein thrombosis
Venous leg ulcer

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37
Q

What surgical methods can be used to treat varicose veins?

A

Vein ligation, stripping and avulsion
Foam sclerotherapy
Thermal ablation

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38
Q

What is thermal ablation?

A

Heat vein from inside via radio frequency or laser catheters causing irreversible damage to vein which closes off
Done under USS or local anaesthetic

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39
Q

What are the complications of vein ligation, stripping and avulsion?

A

Infection
Nerve damage
Bleeding
DVT

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40
Q

What is foam sclerotherapy?

A

Inject sclerosis agent into varicosed veins which causes inflammatory response that closes vein

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41
Q

What are the complications of varicose veins?

A 
Skin changes
Venous ulceration
Thrombophlebitis
Bleeding
Oedema
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42
Q

What is the aetiology of leg ulcers?

A

Venous origin
Arterial insufficiency
Diabetic-related neuropathy
Infection, trauma, vasculitis, malignancy
Prolonged or excessive pressure over bony prominence

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43
Q

What are the risk factors for a venous ulcer?

A 
Increasing age
Pre-existing venous incompetence (varicose veins) or history of DVT
Pregnancy
Obesity or physical inactivity
Severe leg injury or trauma
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44
Q

What are the clinical features of a venous ulcer?

A

Shallow, irregular borders and granulating base
Painful
Symptoms of chronic venous disease - aching, itching or burning sensation
Varicose veins
Ankle / leg oedema
Features of venous insufficiency - varicose veins, thrombophlebitis, haemosiderin skin staining
Normal pulses

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45
Q

How does ABPI differ between venous and arterial ulcers?

A

Normal in venous ulcers

Low in arterial ulcers

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46
Q

What is the management of a venous ulcer?

A

Leg elevation and increase exercise
Weight reduction, improved nutrition
4 layer compression bandaging

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47
Q

What are the risk factors for an arterial ulcer?

A 
Smoking
diabetes mellitus
Hypertension
Hypercholesterolaemia
Increasing age
Family history
Obesity and physical inactivity
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48
Q

What are the clinical features of an arterial ulcer?

A

Small deep lesion with well defined borders and necrotic base
Preceding history of intermittent claudication or critical limb ischaemia
Painful
Cold limbs, thickened nails, necrotic toes and hair loss
Reduced / absent pulses
Normal sensation

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49
Q

How is an arterial ulcer managed?

A

Smoking cessation, weight loss, improved exercise
CVS risk factor modification - statins, anti platelet, control BP and glucose
Surgical - angioplasty or bypass grafting

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50
Q

What are the risk factors for a neuropathic ulcer?

A

Diabetes
Vitamin B12 deficiency
Foot deformity
Concurrent peripheral vascular disease

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51
Q

What are the clinical features of a neuropathic ulcer?

A

Vary in size and depth with punched out appearance
Common on pressure points of foot
Peripheral neuropathy
Warm feet with good pulses

52
Q

How are neuropathic ulcers treated?

A

Optimise diabetic control

Good footwear

53
Q

What is the function of compression stockings?

A

Contain calf muscles and reduce diameter of vein which improves flow through segment and brings valves together to function and be competent

54
Q

What causes deep venous disease?

A

Primary - underlying defect to vein wall or valvular component
Secondary to post-thrombotic disease, post-phlebitic disease, venous outflow obstruction and trauma

55
Q

What are the risk factors of deep venous disease?

A 
Increasing age
Female
Pregnancy
Previous DVT or phlebitis
Obesity
Smoking
56
Q

What are the symptoms of deep venous disease?

A 
Swollen lower limbs which becoming aching, pruritic and painful
Venous claudication
Varicose eczema
Thrombophlebitis
Haemosiderin skin staining
Lipodermatosclerosis
57
Q

How is deep venous disease managed?

A

Compression stockings

Analgesia

58
Q

What are the complications of deep venous disease?

A 
Swelling
Recurrent cellulitis
Chronic pain
Ulceration
DVT
Secondary lymphoedema
Varicose veins
59
Q

What are the 3 features of virchow’s triad?

A

Blood stasis - recent immobility
Hypercoagulability - smoking, sepsis, malignancy
Endothelial injury - atheroma formation, inflammatory response or direct trauma

60
Q

Give examples of thrombophilia disorders

A 
Factor V leiden
Anti-thrombin III deficiency
Protein C/S deficiency
Anti-phospholipid antibodies
Thrombocytosis
Polycythaemia
61
Q

Describe axillary vein thrombosis

A

Repetitive compression injury between clavicle and 1st rib
Presents with swelling and warmth, often in young patients
Treat with anticoagulation, catheter directed thrombosis or removal of 1st rib

62
Q

What are the clinical features of a DVT?

A 
Unilateral pain and swelling
Calf tenderness
Blue discolouration
Low grade pyrexia
Pitting oedema
63
Q

What can cause a falsely elevated D-dimer?

A

Recent surgery or trauma
Infection
Liver disease
Pregnancy

64
Q

How is a DVT treated?

A 
Mobilise
Anticoagulate with LMWH then warfarin or DOAC
Thrombolysis with alteplase 
Venous stunting and angioplasty
Stockings
65
Q

How long is anticoagulation given for after a DVT?

A

3 months if provoked DVT (prior surgery or trauma) or heterozygous for factor V leiden
6 months if unprovoked or idiopathic, 1st episode of recurrent, persistent risk factor (malignancy, COCP) or protein C/S deficiency
Indefinitely if inherited thrombophilia, antiphospholipid antibodies or more than 2 DVT / PE

66
Q

What is phelgmasia?

A

Occurs following ilii-femoral DVT where major obstruction of venous return impedes capillary blood flow causing reduction in arterial inflow
Presents with swollen, blue discolouration of limb and ischaemia

67
Q

What are the clinical features of a PE:?

A 
Collapse
SOB
Pleuritic chest pain
Haemoptysis
Tachycardia, tachypnoea, pyrexia, raised JVP, pleural rub
68
Q

What investigations are done for a PE?

A

Wells score
CXR, ECG, blood gas
CTPA

69
Q

How is a PE treated?

A

Anticoagulate
Anti-embolic stockings
Thrombolysis
IVC filter if absolute contraindication to anticoagulant therapy

70
Q

What is lymphedema?

A

Chronic progressive swelling of tissue with protein-rich fluid into interstitial space as a consequence of developmental or acquired disruption of the lymphatic system

71
Q

What is the aetiology of lymphedema?

A 
Primary 
Nematode infection (filariasis)
malignancy
Cancer treatment
Trauma
Lymph node dissection, radiotherapy or neoplastic infiltration
72
Q

What is the pathophysiology of lymphoedmea?

A

Dysfunction of lymphatic channels or nodes causing lymph accumulation in superficial interstitial space
Lymphatic stasis causing fat hypertrophy with associated thickening of SC tissue and immunological dysfunction
Elevated concentrations of interstitial protein cause inflammation and fibrosis

73
Q

What are the clinical features of lymphedema?

A

Painful unilateral limb swelling
Pitting oedema in early disease
Non-pitting in advanced disease

74
Q

What are the differentials of lymphedema?

A 
Chronic venous insufficiency
DVT
Obesity
CCF
Hypoalbuminaemia
Malignancy
75
Q

How is lymphoedema managed?

A 
Good skin care
Compression bandaging
Elevate legs, exercise, weight loss
Liposuction
Diethylcarbamazine or ivermectin
76
Q

What is the aetiology of carotid artery / occlusive disease?

A

Spontaneous
Iatrogenic
Traumatic

77
Q

What are the risk factors for carotid artery disease?

A 
Age above 65
Smoking
Hypertension
Hyperlipidaemia
Obesity
Diabetes mellitus
History of CVD
FHx of CVD
78
Q

What are the clinical features of carotid artery disease?

A 
Amaurosis fugax (transient monocular blindness)
TIA
Stroke
Stroke in evolution 
Headache
Neck pain
Horner's syndrome
Syncope
Cranial nerve lesions
79
Q

What are the differentials of carotid artery disease?

A 
Carotid dissection
Thrombotic occlusion of carotid artery
Fibromuscular dysplasia
Vasculitis
Hypoglycaemia, Todd's paresis, subdural haematoma, MS, post-octal state
80
Q

How is carotid artery disease treated?

A 
Medical
 - anti platelet - aspirin and clopidogrel
 - statins
 - smoking cessation, exercise, weight loss
 - control hypertension &DM
Surgical
 - carotid endartectomy
 - angioplasty / stenting
81
Q

What is the acute management of a suspected stroke?

A

Oxygen
IV alteplase and aspirin if ischaemic stroke
Correct coagulopathy and consider clot evacuation if haemorrhagic stroke
Thrombectomy if acute ischaemic

82
Q

What are the advantages and disadvantages of an angioplasty / stunting for carotid artery disease?

A

Advantages: no incision, less painful, quicker recovery, avoid cranial nerve injury
Disadvantages: more likely to have embolic event, dissection, disability

83
Q

Why is local anaesthetic preferred for a carotid endarterectomy?

A 
Allows for best cerebral monitoring
Preservation of cerebral autoregulation
Shunt is rarely needed
No delay between cases
Less cardiovascular complications
84
Q

What are the complications of a carotid andarterectomy?

A 
Stroke
Cerebral ischaemia due to reperfusion
BP changes
MI
Haematoma
Nerve injury - cutaneous nerve suppling angle of jaw, hypoglossal nerve, vagus, glossopharyngeal, superior thyroid
Haemorrhage
Wound infection
Hyperperfusion
85
Q

What are the types of carotid body tumour?

A

Chemodectoma
Glomus tumour
Paraganglionoma - neural crest tissue, neuropeptide hormones

86
Q

What are the signs and symptoms of a carotid body tumour?

A

Pulsatile neck mass
Headache
Tinnitus
Vocal cord paralysis

87
Q

How is a carotid body tumour treated?

A

Surgical excision

88
Q

What is the aetiology of a carotid aneurysm?

A 
TB, syphilis
Atherosclerosis
Trauma
Post carotid endarterectomy
Marfans
Fibromuscular dysplasia
Cystic medial necrosis
89
Q

What are the clinical features of a carotid aneurysm?

A 
Lump
Pain
Dysphagia
Cranial nerve lesion
TIA
90
Q

How is a carotid aneurysm treated?

A

Aspirin

Ligation, resection and repair

91
Q

What can cause pitting oedema?

A

Fluid retention
Protein deficiency - nephrotic syndrome, liver cirrhosis, malnutrition, protein-losing enteropathy
Hydrostatic - chronic venous insufficiency, pregnancy, DVT
Increased capillary permeability - inflammation, burns, allergic reactions, trauma

92
Q

What can cause non-pitting oedema?

A

Lymphoedema

Myxoedema

93
Q

What are the causes of acute unilateral leg swelling / pain?

A 
DVT
Cellulitis
Superficial thrombophlebitis
Popliteal (Bakers cyst)
Inflammatory pathology of knee
94
Q

What are the causes of acute bilateral leg swelling / pain?

A

Side effect of medications e.g. dihydropyridine CCB
Acute HF
Acute nephrotic syndrome
Bilateral DVT

95
Q

What are the causes of chronic unilateral leg swelling / pain?

A

Chronic venous disease
Lymphoedema
Complex regional pain syndrome

96
Q

What are the causes of chronic bilateral leg swelling / pain?

A 
Chronic venous disease
HF
Pulmonary hypertension
Renal disease
Liver disease
Pelvic neoplasm
Constrictive pericarditis
Malnutrition
97
Q

What are the 2 types of permanent vascular access for harm-dialysis?

A

Arteriovenous fistula

AV graft

98
Q

What are the requirements to use an AV fistula for harm-dialysis?

A

Accessible with patient in a comfortable sitting position
Volvar surface in forearm or anterior / lateral surface in upper arm
Able to be reliably cannulated repeatedly
Within 5-6mm of skin surface
Straight segment 8-10cm long to cannulate
Adequate blood flow to support dialysis prescription

99
Q

What are the types of AV fistula?

A 
Radial-cephalic
Forearm-basilic
Brachial-cephalic
Brachial-basilic
Lower extremity
100
Q

What are the complications of an AV fistula?

A

Local - bleeding, venous hypertension, aneurysm / pseudoaneurysm, infection, neuropathy, primary failure
Ischaemia and systemic problems - dialysis access steal syndrome, coronary steal, HF, pulmonary hypertension
Swelling of shoulder, chest wall or breast, malignancy

101
Q

What important branches come off the abdominal aorta?

A

Coeliac and superior and inferior mesenteric
Renal arteries
Iliac arteries

102
Q

What can cause occlusive disease of the abdominal aorta?

A

Acute - embolism, dissection

Chronic - atherosclerosis, fibromuscular dysplasia, external compression by tumour

103
Q

What are the common sites for occlusion of the abdominal aorta?

A

Splanchnic arteries - superior mesenteric, coeliac, renal

Bifurcation of aorta

104
Q

What are the clinical features of an acute occlusion of the abdominal aorta?

A

Severe diffuse abdo pain
Renal artery occlusion causes sudden onset flank pain and haematuria
Lower aorta and common iliac: both legs painful and cold, no pulse
Superior mesenteric artery: severe abdo pain, nausea and vomiting, distended abdomen, reduced BS, blood in stool

105
Q

What are the clinical features of a chronic occlusion of abdominal aorta?

A

Lower aorta and common iliac arteries: intermittent claudication, cold and pale, erectile dysfunction
Renal artery: kidney failure, hypertension
Superior mesenteric: umbilical pain 30-60min after eating, weight loss, nausea, vomiting, constipation, diarrhoea
Hepatic artery: abdominal pain, fevers, chills, nausea, vomiting, jaundice

106
Q

How is acute occlusion of abdominal aorta treated?

A

Percutaneous transluminal angioplasty and stenting
Bypass graft and bowel resection
Thrombolysis

107
Q

How is chronic occlusion of abdominal aorta treated?

A

Surgery or angioplasty

Risk factor modification and anti platelets

108
Q

What are the risks of endovascular surgery for occlusive abdominal aorta disease?

A

Renal failure due to excessive contrast
Bleeding
Groin infection
Seroma

109
Q

What are the risks of open surgery for occlusive abdominal aorta disease?

A 
Myocardial ischaemia
Renal failure
Bleeding at anastomotic site
Ureteric injury
Infection
110
Q

What are the risk factors of PVD?

A 
Smoking
DM
Hypertension
Hyperlipidaemia
Increasing age
Family history
Obesity and physical inactivity
111
Q

What is the aetiology of PVD?

A

Atherosclerosis
Aortic coarctation
Arterial fibrodysplasia
Arterial tumour, dissection, embolism, thrombosis, vasospasm and tumour

112
Q

What are the clinical features of PVD?

A

Often asymptomatic
Intermittent claudication
Decreased pulse

113
Q

How is PVD managed?

A 
Antiplatelet therapy
Anaglesia
Risk factor modification
Endovascular revascularisation and intra-arterial thrombolysis
Surgical revascularisation
Amputation
114
Q

What is acute limb ischaemia?

A

Sudden decrease in limb perfusion that threatens viability of limb

115
Q

What is the aetiology of acute limb ischaemia?

A

Embolisation - commonly due to AF
Thrombosis in situ
Trauma

116
Q

What are the clinical symptoms of acute limb ischaemia? (6P’s)

A 
Pain
Pallor
Pulselessness
Paraesthesia
Paralysis
Perishingly cold
117
Q

What are the differentials of acute limb ischaemia?

A

Chronic limb ischaemia
DVT
Spinal cord or peripheral nerve compression

118
Q

What is the management of acute limb ischaemia?

A

Oxygen, heparin
Surgical:
- if embolic: embolectomy, local intraarterial thrombosis or bypass surgery
- if thrombotic: local intra-arterial thrombosis, angioplasty, bypass surgery
If irreversible: amputation
Long term: reduce CVS mortality risk, exercise, weight loss, smoking, anti platelets (aspirin, clopidogrel, warfarin, DOAC)

119
Q

What is chronic critical limb ischaemia

A

Severe peripheral arterial disease that results in symptomatic reduced blood supply to limbs

120
Q

What are the clinical features of chronic limb ischaemia?

A

Intermittent claudication
Ischaemic rest pain
Ulceration or gangrene
Nocturnal rest pain

121
Q

What are the differentials of chronic limb ischaemia?

A 
Spinal stenosis
Acute limb ischaemia
PVD
Buerger's diease
External compression
Arteritis
122
Q

How is chronic limb ischaemia managed?

A

Medical: smoking cessation, weight reduction, regular walks, aspirin or clopidogrel, statins
Surgical: angioplasty, bypass grafting, amputation

123
Q

What are the complications of chronic limb ischaemia?

A

Sepsis
Acute on chronic ischaemia
Amputation
Reduced mobility and quality of life

124
Q

What are the indications for limb amputation?

A 
Severe pain, sepsis and extensive tissue loss
Peripheral arterial disease
Infection
Frostbite
Poor wound healing
Trauma
Extensive burns
Crush injury
Congenital malformation
125
Q

What are the types of lower limb amputation?

A 
Above knee (trans-femoral)
Below knee (trans-tibial)
Partial foot
Ankle disarticulation 
Through knee
Hip disarticulation
Hemipelvectomy
Transmetatarsal
126
Q

What are the complications of lower limb amputations?

A

Intraoperative: bleeding, anaesthetic risk (dental damage, anaphylaxis, malignant hyperthermia)
Early: pain, bleeding, infection, scarring, blood clots, stroke, MI, kidney failure
Phantom limb pain

KT (6 decks)

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