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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
What are the progression steps of atherosclerosis from the initial lesion to a complicated lesion?
``` Initial lesion Fatty streak Intermediate lesion Atheroma Fibroatheroma Complicated lesion ```
26
What are the clinical features of atherosclerosis?
Depend on arteries affected Coronary artery causes angina and MI Cerebrovascular artery causes strokes and TIA Peripheral vascular disease causes claudication and limb ischaemia
27
How is atherosclerosis prevented?
``` Primary prevention - smoking cessation, control BP, weight reduction, exercise, dietary modification Secondary prevention (COBRA-A) - clopidogrel, omacar, bisoprolol, ramipril, aspirin, atorvastatin ```
28
How is atherosclerosis treated?
Angioplasty Stenting Surgical bypass
29
What are varicose veins?
Vein that is tortuous dilated and associated with valvular incompetence Present in course of long / short saphenous veins
30
What are the risk factors for varicose veins?
``` Prolonged standing Obesity Pregnancy Family history Increasing age ```
31
What is the CEAP system?
``` Puts patients into categories to decide who gets treatment for varicose veins Clinical manifestations Etiology Anatomic distribution Pathophysiology ```
32
What are the clinical features of varicose veins?
Asymptomatic and cosmetic issues Aching legs, heaviness, cramps, restlessness, itching Features of venous insufficiency - oedema, varicose eczema, thrombophlebitis, ulcers, haemosiderin skin staining
33
What can a duplex USS for varicose veins assess?
Visualise vein and see how dilated it is Assess for reflux Assess valve incompetency and any perforators
34
What are the differentials of varicose veins?
Telangiectasias | Reticular veins
35
How can varicose veins be treated?
Conservative - avoid prolonged standing, weight loss, increase exercise, graduated compression stockings, 4-layer bandaging of any venous ulcerations Surgical treatment
36
When is surgical treatment indicated for varicose veins?
Symptomatic primary or recurrent varicose veins Lower-limb skin changes e.g. pigmentation or eczema Superficial vein thrombosis Venous leg ulcer
37
What surgical methods can be used to treat varicose veins?
Vein ligation, stripping and avulsion Foam sclerotherapy Thermal ablation
38
What is thermal ablation?
Heat vein from inside via radio frequency or laser catheters causing irreversible damage to vein which closes off Done under USS or local anaesthetic
39
What are the complications of vein ligation, stripping and avulsion?
Infection Nerve damage Bleeding DVT
40
What is foam sclerotherapy?
Inject sclerosis agent into varicosed veins which causes inflammatory response that closes vein
41
What are the complications of varicose veins?
``` Skin changes Venous ulceration Thrombophlebitis Bleeding Oedema ```
42
What is the aetiology of leg ulcers?
Venous origin Arterial insufficiency Diabetic-related neuropathy Infection, trauma, vasculitis, malignancy Prolonged or excessive pressure over bony prominence
43
What are the risk factors for a venous ulcer?
``` Increasing age Pre-existing venous incompetence (varicose veins) or history of DVT Pregnancy Obesity or physical inactivity Severe leg injury or trauma ```
44
What are the clinical features of a venous ulcer?
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
45
How does ABPI differ between venous and arterial ulcers?
Normal in venous ulcers | Low in arterial ulcers
46
What is the management of a venous ulcer?
Leg elevation and increase exercise Weight reduction, improved nutrition 4 layer compression bandaging
47
What are the risk factors for an arterial ulcer?
``` Smoking diabetes mellitus Hypertension Hypercholesterolaemia Increasing age Family history Obesity and physical inactivity ```
48
What are the clinical features of an arterial ulcer?
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
49
How is an arterial ulcer managed?
Smoking cessation, weight loss, improved exercise CVS risk factor modification - statins, anti platelet, control BP and glucose Surgical - angioplasty or bypass grafting
50
What are the risk factors for a neuropathic ulcer?
Diabetes Vitamin B12 deficiency Foot deformity Concurrent peripheral vascular disease
51
What are the clinical features of a neuropathic ulcer?
Vary in size and depth with punched out appearance Common on pressure points of foot Peripheral neuropathy Warm feet with good pulses
52
How are neuropathic ulcers treated?
Optimise diabetic control | Good footwear
53
What is the function of compression stockings?
Contain calf muscles and reduce diameter of vein which improves flow through segment and brings valves together to function and be competent
54
What causes deep venous disease?
Primary - underlying defect to vein wall or valvular component Secondary to post-thrombotic disease, post-phlebitic disease, venous outflow obstruction and trauma
55
What are the risk factors of deep venous disease?
``` Increasing age Female Pregnancy Previous DVT or phlebitis Obesity Smoking ```
56
What are the symptoms of deep venous disease?
``` Swollen lower limbs which becoming aching, pruritic and painful Venous claudication Varicose eczema Thrombophlebitis Haemosiderin skin staining Lipodermatosclerosis ```
57
How is deep venous disease managed?
Compression stockings | Analgesia
58
What are the complications of deep venous disease?
``` Swelling Recurrent cellulitis Chronic pain Ulceration DVT Secondary lymphoedema Varicose veins ```
59
What are the 3 features of virchow's triad?
Blood stasis - recent immobility Hypercoagulability - smoking, sepsis, malignancy Endothelial injury - atheroma formation, inflammatory response or direct trauma
60
Give examples of thrombophilia disorders
``` Factor V leiden Anti-thrombin III deficiency Protein C/S deficiency Anti-phospholipid antibodies Thrombocytosis Polycythaemia ```
61
Describe axillary vein thrombosis
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
What are the clinical features of a DVT?
``` Unilateral pain and swelling Calf tenderness Blue discolouration Low grade pyrexia Pitting oedema ```
63
What can cause a falsely elevated D-dimer?
Recent surgery or trauma Infection Liver disease Pregnancy
64
How is a DVT treated?
``` Mobilise Anticoagulate with LMWH then warfarin or DOAC Thrombolysis with alteplase Venous stunting and angioplasty Stockings ```
65
How long is anticoagulation given for after a DVT?
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
What is phelgmasia?
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
What are the clinical features of a PE:?
``` Collapse SOB Pleuritic chest pain Haemoptysis Tachycardia, tachypnoea, pyrexia, raised JVP, pleural rub ```
68
What investigations are done for a PE?
Wells score CXR, ECG, blood gas CTPA
69
How is a PE treated?
Anticoagulate Anti-embolic stockings Thrombolysis IVC filter if absolute contraindication to anticoagulant therapy
70
What is lymphedema?
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
What is the aetiology of lymphedema?
``` Primary Nematode infection (filariasis) malignancy Cancer treatment Trauma Lymph node dissection, radiotherapy or neoplastic infiltration ```
72
What is the pathophysiology of lymphoedmea?
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
What are the clinical features of lymphedema?
Painful unilateral limb swelling Pitting oedema in early disease Non-pitting in advanced disease
74
What are the differentials of lymphedema?
``` Chronic venous insufficiency DVT Obesity CCF Hypoalbuminaemia Malignancy ```
75
How is lymphoedema managed?
``` Good skin care Compression bandaging Elevate legs, exercise, weight loss Liposuction Diethylcarbamazine or ivermectin ```
76
What is the aetiology of carotid artery / occlusive disease?
Spontaneous Iatrogenic Traumatic
77
What are the risk factors for carotid artery disease?
``` Age above 65 Smoking Hypertension Hyperlipidaemia Obesity Diabetes mellitus History of CVD FHx of CVD ```
78
What are the clinical features of carotid artery disease?
``` Amaurosis fugax (transient monocular blindness) TIA Stroke Stroke in evolution Headache Neck pain Horner's syndrome Syncope Cranial nerve lesions ```
79
What are the differentials of carotid artery disease?
``` Carotid dissection Thrombotic occlusion of carotid artery Fibromuscular dysplasia Vasculitis Hypoglycaemia, Todd's paresis, subdural haematoma, MS, post-octal state ```
80
How is carotid artery disease treated?
``` Medical - anti platelet - aspirin and clopidogrel - statins - smoking cessation, exercise, weight loss - control hypertension &DM Surgical - carotid endartectomy - angioplasty / stenting ```
81
What is the acute management of a suspected stroke?
Oxygen IV alteplase and aspirin if ischaemic stroke Correct coagulopathy and consider clot evacuation if haemorrhagic stroke Thrombectomy if acute ischaemic
82
What are the advantages and disadvantages of an angioplasty / stunting for carotid artery disease?
Advantages: no incision, less painful, quicker recovery, avoid cranial nerve injury Disadvantages: more likely to have embolic event, dissection, disability
83
Why is local anaesthetic preferred for a carotid endarterectomy?
``` Allows for best cerebral monitoring Preservation of cerebral autoregulation Shunt is rarely needed No delay between cases Less cardiovascular complications ```
84
What are the complications of a carotid andarterectomy?
``` 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
What are the types of carotid body tumour?
Chemodectoma Glomus tumour Paraganglionoma - neural crest tissue, neuropeptide hormones
86
What are the signs and symptoms of a carotid body tumour?
Pulsatile neck mass Headache Tinnitus Vocal cord paralysis
87
How is a carotid body tumour treated?
Surgical excision
88
What is the aetiology of a carotid aneurysm?
``` TB, syphilis Atherosclerosis Trauma Post carotid endarterectomy Marfans Fibromuscular dysplasia Cystic medial necrosis ```
89
What are the clinical features of a carotid aneurysm?
``` Lump Pain Dysphagia Cranial nerve lesion TIA ```
90
How is a carotid aneurysm treated?
Aspirin | Ligation, resection and repair
91
What can cause pitting oedema?
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
What can cause non-pitting oedema?
Lymphoedema | Myxoedema
93
What are the causes of acute unilateral leg swelling / pain?
``` DVT Cellulitis Superficial thrombophlebitis Popliteal (Bakers cyst) Inflammatory pathology of knee ```
94
What are the causes of acute bilateral leg swelling / pain?
Side effect of medications e.g. dihydropyridine CCB Acute HF Acute nephrotic syndrome Bilateral DVT
95
What are the causes of chronic unilateral leg swelling / pain?
Chronic venous disease Lymphoedema Complex regional pain syndrome
96
What are the causes of chronic bilateral leg swelling / pain?
``` Chronic venous disease HF Pulmonary hypertension Renal disease Liver disease Pelvic neoplasm Constrictive pericarditis Malnutrition ```
97
What are the 2 types of permanent vascular access for harm-dialysis?
Arteriovenous fistula | AV graft
98
What are the requirements to use an AV fistula for harm-dialysis?
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
What are the types of AV fistula?
``` Radial-cephalic Forearm-basilic Brachial-cephalic Brachial-basilic Lower extremity ```
100
What are the complications of an AV fistula?
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
What important branches come off the abdominal aorta?
Coeliac and superior and inferior mesenteric Renal arteries Iliac arteries
102
What can cause occlusive disease of the abdominal aorta?
Acute - embolism, dissection | Chronic - atherosclerosis, fibromuscular dysplasia, external compression by tumour
103
What are the common sites for occlusion of the abdominal aorta?
Splanchnic arteries - superior mesenteric, coeliac, renal | Bifurcation of aorta
104
What are the clinical features of an acute occlusion of the abdominal aorta?
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
What are the clinical features of a chronic occlusion of abdominal aorta?
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
How is acute occlusion of abdominal aorta treated?
Percutaneous transluminal angioplasty and stenting Bypass graft and bowel resection Thrombolysis
107
How is chronic occlusion of abdominal aorta treated?
Surgery or angioplasty | Risk factor modification and anti platelets
108
What are the risks of endovascular surgery for occlusive abdominal aorta disease?
Renal failure due to excessive contrast Bleeding Groin infection Seroma
109
What are the risks of open surgery for occlusive abdominal aorta disease?
``` Myocardial ischaemia Renal failure Bleeding at anastomotic site Ureteric injury Infection ```
110
What are the risk factors of PVD?
``` Smoking DM Hypertension Hyperlipidaemia Increasing age Family history Obesity and physical inactivity ```
111
What is the aetiology of PVD?
Atherosclerosis Aortic coarctation Arterial fibrodysplasia Arterial tumour, dissection, embolism, thrombosis, vasospasm and tumour
112
What are the clinical features of PVD?
Often asymptomatic Intermittent claudication Decreased pulse
113
How is PVD managed?
``` Antiplatelet therapy Anaglesia Risk factor modification Endovascular revascularisation and intra-arterial thrombolysis Surgical revascularisation Amputation ```
114
What is acute limb ischaemia?
Sudden decrease in limb perfusion that threatens viability of limb
115
What is the aetiology of acute limb ischaemia?
Embolisation - commonly due to AF Thrombosis in situ Trauma
116
What are the clinical symptoms of acute limb ischaemia? (6P's)
``` Pain Pallor Pulselessness Paraesthesia Paralysis Perishingly cold ```
117
What are the differentials of acute limb ischaemia?
Chronic limb ischaemia DVT Spinal cord or peripheral nerve compression
118
What is the management of acute limb ischaemia?
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
What is chronic critical limb ischaemia
Severe peripheral arterial disease that results in symptomatic reduced blood supply to limbs
120
What are the clinical features of chronic limb ischaemia?
Intermittent claudication Ischaemic rest pain Ulceration or gangrene Nocturnal rest pain
121
What are the differentials of chronic limb ischaemia?
``` Spinal stenosis Acute limb ischaemia PVD Buerger's diease External compression Arteritis ```
122
How is chronic limb ischaemia managed?
Medical: smoking cessation, weight reduction, regular walks, aspirin or clopidogrel, statins Surgical: angioplasty, bypass grafting, amputation
123
What are the complications of chronic limb ischaemia?
Sepsis Acute on chronic ischaemia Amputation Reduced mobility and quality of life
124
What are the indications for limb amputation?
``` Severe pain, sepsis and extensive tissue loss Peripheral arterial disease Infection Frostbite Poor wound healing Trauma Extensive burns Crush injury Congenital malformation ```
125
What are the types of lower limb amputation?
``` Above knee (trans-femoral) Below knee (trans-tibial) Partial foot Ankle disarticulation Through knee Hip disarticulation Hemipelvectomy Transmetatarsal ```
126
What are the complications of lower limb amputations?
Intraoperative: bleeding, anaesthetic risk (dental damage, anaphylaxis, malignant hyperthermia) Early: pain, bleeding, infection, scarring, blood clots, stroke, MI, kidney failure Phantom limb pain

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