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taz year 3 surgery > Vascular Surgery > Flashcards

Vascular Surgery Flashcards

1
Q

Define Abdominal Aortic Aneurysm

A

Abnormal dilation of Abdominal Aorta by more than 50% (ie dilation greater than 3cm)

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2
Q

Give 4 causes of AAA

A

Atherosclerosis
Trauma
Infection
CT Disease

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3
Q

Describe four clinical features of AAA

A 
Abdominal Pain
Back/Loin Pain
Distal Embolisation (blue toe)
Pulsatile Abdominal Mass
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4
Q

How would you investigate AAA

A

Ultrasound

CT with Contrast

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5
Q

What is the AAA screening tool

A

Abdominal USS for all men in their 65th year

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6
Q

Describe the medical management of AAA

A

Monitoring with Ultrasounds
Reduce Risk Factors
If greater than 6.5cm - notify DVLA and unable to drive

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7
Q

When is surgery for AAA considered?

A

AAA>5.5cm
Expanding more at a rate of more than 1cm a year
Symptomatic AAA (if otherwise fit)

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8
Q

Describe the two surgical options for AAA

A

Open Repair - Midline laparotomy, clamping proximally and iliac arteries distally, segment removed and replaced with graft

Endovascular Repair - Introducing graft via femoral arteries

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9
Q

Give three complications of AAA

A

Embolisation
Aortoduodenal Fistula
Rupture

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10
Q

What is the AAA rupture triad?

A

Pulsatile Abdo Mass
Hypotension
Back/Flank Pain

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11
Q

How would you manage an AAA rupture

A

IV Fluids and circulatory support (try to keep systolic under 100mmHg to prevent dislodging clots)

If unstable - Immediate open surgical repair
If stable - CT Angiogram Pre-Op

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12
Q

What is an Aortic Dissection?

A

Tear in the intimal layer of aortic wall, causing blood to flow between Tunica Intima and Tunica Media

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13
Q

Describe the two different types of Aortic Dissection progression

A

Anterograde - Towards Iliac Arteries

Retrograde - Towards Aortic Valve

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14
Q

Describe the Stanford Classification of Aortic Dissection

A

Group A - Ascending Aorta

Group B - Descending Aorta

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15
Q

Describe the DeBakey Classification of Aortic Dissection

A

I - Ascending Aorta to arch (atleast)
II - Confined to Ascending Aorta
III - Originates distal to subclavian in descending
IIIa - Extends distally to diaphragm
IIIb - Extends beyond diaphragm (encompassing AA)

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16
Q

What are the clinical features of an Aortic Dissection?

A

Tearing chest pain radiating to the back
Tachycardia
Hypotension
Aortic Regurg

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17
Q

How would you image Aortic Dissections?

A

CT Angiogram

TOE

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18
Q

How would you manage Aortic Dissections?

A

Both types require O2 and IV Fluids (only enough to maintain cerebral perfusion)

Type A - Immediate transfer to cardiothoracic centre and graft
Type B - Medical management with IV Beta Blovkers, surgery if ischaemia/rupture or uncontrolled

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19
Q

Thoracic Aneurysms are less common than Abdominal Aneurysms but have a high mortality. How do they present?

A

Often incidental finding
Ascending Aorta - Anterior Chest Pain
Aortic Arch - Neck Pain
Descending Aorta - Pain between scapulae

May get secondary compression symptoms

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20
Q

How would you image a suspected Thoracic Aneurysm?

A

CT chest with contrast

TOE

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21
Q

What is Acute Limb Ischaemia?

A

Sudden decrease in limb perfusion that threatens limb viability (doesn’t have to be a complete occlusion)

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22
Q

Give 3 underlying causes of Acute Limb Ischaemia

A

Embolisation
Thrombosis In-situ
Trauma

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23
Q

Using the 6P’s, describe the clinical features of Acute Limb Ischaemia

A 
Pain
Pallor
Pulselessness
Paraesthesia
Paralysis
Perishingly Cold
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24
Q

How are Acute Limb Ischaemias classified?

A

Using the Rutherford Classification

Parameters include Prognosis, Sensory Loss, Motor Deficit, Arterial Doppler, Venous Doppler

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25
Give four investigations for Acute Limb Ischaemia
Routine bloods (inc serum lactate and thrombophilia screen) ECG Doppler USS CT Angiography
26
What is the initial management of Acute Limb Ischaemia?
High Flow O2 IV Access Heparin bolus then heparin infusion
27
What is the conservative management of Acute Limb Ischaemia?
Prolonged course of Heparin and monitoring of APTT
28
Describe the surgical management of Acute Limb Ischaemia
Embolic Cause - Embolectomy, Bypass Thrombotic Cause - Angioplasty, Bypass Amputation
29
What is Chronic Limb Ischaemia?
Peripheral arterial disease resulting in symptomatic reduced blood supply Typically caused by atherosclerosis and affects lower limbs
30
What are the four clinical stages of Chronic Limb Ischaemia?
I - Asymptomatic II - Intermittent Claudication III - Ischaemic Rest Pain IV - Ulceration/Gangrene
31
Describe the Buerger's Test
Lay the patient supine, and raise the affected leg until pale, and hen lower to normal Buerger's Angle of less than 30 degrees indicates severe limb ischaemia
32
What is Leriche Syndrome?
A form of Peripheral Arterial Disease specifically affecting the aortic bifurcation Presents with buttock/thigh pain and associated erectile dysfunction
33
What is Critical Limb Ischaemia?
- rest pain going on for 2 weeks despite analgesia or presence of ischaemia lesions or gangrene
34
How does Critical Limb Ischaemia present?
``` Ischaemic Rest Pain for longer than two weeks Presence of Ischaemic Lesions/Gangrene ABPI<0.5 Limb Hair Loss Thickened Nails ```
35
Describe the medical treatment of Chronic Limb Ischaemia
80mg OD Atorvastatin 75mg Clopidogrel Optimising diabetes control
36
Describe the surgical options to treat Chronic Limb Ischaemia
Angioplasty (with or without stenting) Bypass Grafting (in diffuse disease or in younger patients) Amputations
37
What is Acute Mesenteric Ischaemia?
Sudden decrease in blood supply to the bowel (resulting in ischaemia, and if not treated - gangrene and death)
38
Describe the aetiology of Acute Mesenteric Ischaemia
Thrombus In Situ (AMAT) Embolism (AMAE) Non Occlusive Cause (NOMI) Venous Occlusion and Congestion (MVT)
39
How does AMI present?
Generalised abdominal pain out of proportion to clinical findings Associated nausea and vomiting Remember if late stage - may present as perforation
40
After an initial CXR to rule out bowel perforation, what imaging could you use for AMI?
CT with IV contrast Oedematous and then bowel wall enhancement
41
What lab investigations could you do for a suspected AMI?
ABG (Assesses levels of acidosis) | Bloods - FBC, U&Es, Clotting
42
After initial treatment with IV fluids/Abx, describe the two possible definitive managements of AMI
Excision of necrotic/non viable bowel (loop or end stoma - risk of short gut syndrome) Revascularisation of bowel (via removal of embolus)
43
What is Chronic Mesenteric Ischaemia?
Reduced blood supply to the bowel which gradually deteriorates over time as a result of atherosclerosis in Coeliac trunk/SMA/IMA Due to collateral supply, two branches have to be occluded to be symptomatic
44
Describe three clinical features of Chronic Mesenteric Ischaemia
Post Prandial Pain (10mins - 4hrs after eating) Weight Loss Concurrent Vascular Comorbidities
45
What is the gold stanard investigation for suspected Chronic Mesenteric Ischaemia?
CT Angiography
46
How is Chronic Mesenteric Ischaemia managed?
Modify risk factors | Surgery - Mesenteric Angioplasty/Stenting/Bypass
47
Where is the most common site for Peripheral Aneurysms?
Popliteal Artery
48
Describe three possible presentations of Peripheral Popliteal Aneurysms
Acute Limb Ischaemia (if embolus) Intermittent Claudiation Compression Symptoms
49
How would you investigate a suspected Popliteal Aneurysm?
Ultrasound Scan first to rule out Baker's Cyst/Lymphadenopathy CT Angiography
50
Femoral Aneurysms are typically Pseudoaneurysms, give two causes
Patient Self Injecting | Percutaneous Vascular Injections
51
Describe two possible clinical features of Femoral Aneurysms
May just be a painless groin swelling | Varying degrees of intermittent claudication
52
What is the most common Visceral Aneurysm?
Splenic Aneurysm
53
Name two other types of Visceral Aneurysm
Hepatic | Renal
54
What is the mainstay of treatment of Visceral Aneurysms?
Endovascular Repair
55
What are Varicose Veins?
Tortuous dilated segments of veins associated with vascular incompetence
56
Describe the pathophysiology of Varicose Veins
Incompetent valves permit blood flow from deep to superficial veins resulting in venous hypertension and dilation
57
98% of Varicose Veins are Idiopathic. State some secondary causes
DVT Pelvic Masses AV Malformation
58
Give 3 risk factors for Varicose Veins
Prolonged Standing Obesity Pregnancy
59
Name two veins commonly implicated in Varicose Veins
Great Saphenous Vein | Short Saphenous Vein
60
Describe three clinical presentations of Varicose Veins
Aching Itching Venous Insuffiency
61
How are Varicose Veins investigated?
Duplex Ultrasound
62
What are the NICE criteria for surgical management of Varicose Veins
Symptomatic Lower Limb Skin Changes (Eczema/Pigmentation) Superficial Vein Thrombosis Venous Leg Ulcer
63
Describe the three surgical managements of Varicose Veins
- Ligation and stripping - Foam Sclerotherapy (sclerosing agent creates inflammatory response which closes off vein) Thermal Ablation (Causes irreversible damage which closes off vein)
64
Define Venous Insufficiency
Deep Venous Insufficiency is the failure of the venous system, characterised by valvular reflux/venous hypertension/obstruction Similar pathophysiology to Variose Veins except in the deep veins
65
State the two types of Venous Insufficiency
Primary - Underlying defect to vein wall/valvular component | Secondary - Trauma/Venous Outflow Obstruction
66
Describe four clinical features of Venous Insufficiency
Chronically swollen limbs which can suddenly become aching/pruritic/painful Varicose Eczema Haemosiderin Staining Lipodermatosclerosis (Inverted Champagne Bottles)
67
How does Venous Claudication present?
Bursting pain and tightness on walking | Resolved by leg elevation
68
State two investigations for Venous Insufficiency
Doppler USS | ABPI
69
Describe four management principles of Venous Insufficiency
Foot Stockings Analgesia Venous Ulcer - Four layer bandage Deep Venous Stenting
70
What is Thoracic Outlet Syndrome?
Clinical features that arise from compression of NVB within the thoracic outlet Can be divided into neurological, venous and arterial
71
Give 3 causes of Thoracic Outlet Syndrome
Rib Anomalies Muscular Anomalies Repetitive Stress
72
Give a presenting feature of each arterial, venous and nervous TOS
Arterial - Claudication Venous - DVT Nervous - Brachial Plexus Palsy
73
What is Subclavian Steal Syndrome?
Syncope or Neurological Deficit when blood supply to the affected arm is increased through exercise, secondary to stenosing lesion/occlusion in Subclavian Artery
74
Describe the pathophysiology in Subclavian Steal Syndrome
To compensate for the reduced blood supply to the limb, blood is drawn from the collateral circulation, reducing flow in the vertebral arteries and hence reducing cerebral perfusion
75
Subclavian Steal Syndrome can be investigated with Doppler USS, however a CT Scan is used for risk scoring. Explain the level of risk in terms of direction of blood flow
Pre-Subclavian Steal - Reduced anterograde flow in Vertebral Arteries Intermittent Alternating - antero in diastolic, Retrograde flow in systolic Advanced - Permanent retrograde
76
Describe the management of Subclavian Steal Syndrome
Antiplatelets & Statins | Endovascular/Bypass Repair
77
Why does Atherosclerosis commonly occur at the bifurcation of Carotid?
Turbulent Flow (Virchow's Triad)
78
What is Carotid Endarterectomy?
Risk reduction surgery to remove plaque if narrowing is greater than 50%
79
Give 3 risk factors for Carotid Artery Dissection
Men<50 Marfans Trauma (lateral rotation and hyperextension, crushing it between skull and C2)
80
Give 4 presenting symptoms of Carotid Artery Dissection
Ipsilateral Headache/Neck Pain Horners III/IV/VI Palsy Stroke/TIA
81
How would you manage a Carotid Artery Dissection?
Anticoagulate and aim to recanalise the clot | If this fails then consider stent
82
Give 5 risk factors for peripheral artery disease
- smoking - diabetes - hypertension - hyperlipidaemia - increased age - FHx - obesity - inactivity
83
Describe the clinical features of peripheral artery disease
- cramping like pain in calf, thigh or buttocks after walking a fixed distance, releived after standing still/ resting for a minute - hairloss - skin changes - thickened nails - weak pulses, pale, cold feet - pain at night, relieved by dangling foot out of the bed - beurgers angle <20 degrees= severe ischaemia - ulceration and gangrene (stage 4)
84
How should suspected peripheral artery disease be investigated?
- Bloods: fbc (anaemia will precipitate symptoms), lipids, hba1c, u&e (many need contrast so need renal function check) - Ankle brachial pulse pressure index (<0.9 or >1.3 pathological) - duplex USS of lower limb arteries - CT w/ contrast (angio) if arterial tree not well visualised on USS or disease is very proximal
85
How is intermittent claudication managed?
- CVS risk factor modification - supervised exercise programme - antiplatelet therapy with aspirin or clopidogrel - angioplasty if supervised exercise programme as not helped - prescribe naftidrofuryl oxalate if they dont want referal for surgery - bypass if claudication distance is short and angioplasty fails
86
What are the 2 surgical options fo varicose veins
Open surgery: long saphenous stripping, saphenfemoral disconnection, multiple avulsions Endovascular laser ablation: of long or short saphenous veins, under local, combined with foam scleropathy to improve cosmetic appearance
87
Describe the pathophysiology of venous ulcers
- chronic venous hypertension (due to varicose veins, DVT, CVI) - get odema in lower limb - results in impaired tissue perfusion as oxygen and metabolites have to diffuse greater distances to get to tissue cells - become ischaemic when walking - then reperfusion injury when rest - more inflammation- more odema- more tissue fibrosis - ulceration is last after the other skin changes
88
How should venous ulcers be managed?
- 4 layer compression bandaging if arterial circulation is ok - leg elevation - improve mobility - reduce obesity and improve nutrition - varicose vein surgery if thats the cause - skin grafting in selected pts - monitor for infection
89
How should a DVT be managed?
- wells score- USS or/ and D dimer - Treatment dose LMWH - warfarin or apixaban for at least 3 months - CVS RF modification - if cant get USS within 4 hrs, give IV anticoag for 24 hrs in interim - if unprovoked do CXR, FBC, serum calcium, LFTs, urinalysis, examine for cancer +/- CT CAP and mammogram
90
How may carotid artery disease present?
asymptomatic but bruit picked up - TIA (transient cerebral or monocular visual loss) - CVA (usually hemisensory/ motor deficit affecting face arm and leg or loss of higher cortical function (dysphagia, neglect))
91
How is carotid artery disease investigated?
- carotid artery duplex USS - CT or MRI angio where the artery isnt easy to asses on USS (calcification or thick neck) or if distal/ proximal disease suspected
92
How is carotid disease managed?
- CVS risk factor modification - antiplatelets (aspirin or clopidogrel) - carotid endarterectomy (if symptomatic severe stenosis as reduces stroke risk, used if pt fit for surgery)

taz year 3 surgery (10 decks)

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