Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Year 3 - Surgery > Vascular Surgery > Flashcards

Vascular Surgery Flashcards

1
Q

What is an AAA?

A
  • Permanent pathological localised dilatation >50% (>1.5 times) of its original diameters
  • Or >3cm
  • Aneurysms may be fusiform (eg most aaas) or sac-like (eg Berry aneurysms
  • More than 90% of aneurysms originate below the renal arterie
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

How does a triple AAA present?

A
  • Assymptomatic -> till tupture
  • Incidental discovery
  • Intermittent or continuous abdominal pain (radiates to back, iliac fossae, or groins; don’t dismiss this as renal colic)
  • Expansive, pulsatile abdominal mass
  • Malaise
  • Collapse
  • Shock and hypotension possible
  • Weight loss: inflammatory aneurysm
  • Mild abdo sx + tenderness -> retroperitoneal rupture
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What are some of the differentials of AAA and how would you investigate these?

A
  • MI - ECG
  • Acute pancreatitis - serum amylase
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

How is AAA diagnosed?

A
  • 1st: Abdominal USS
  • Others: Bloods: ESR, CRP, FBC,
  • Imaging:CTA/ CT, MRA/MRI
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

When should you decide to repair a AAA?

A
  • Symptomatic
  • Rapidly expanding/ expansion of >1cm per year
  • Ruptures
  • Diameter >5.5cm
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

When is USS surveillance used instead of treatment for AAA?

A
  • Assymptomatic
  • AAA <5.5cm in diameter
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

For small AAA (<5.5cm) USS is used, how often?

A
  • Yearly - 3.5-3.9cm
  • 3 months - 4-5.5cm
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

How are small AAA (<5.5cm managed)

A
  • Manage RFs: smoking, hypertension, high cholesterol
  • Pharmacologically: doxycycline + statin - awaiting clinical trial results
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is involved in the peri-operative assessment of AAA?

A
  • CT/ MRI
  • Pre op assessment:
    • Haematology
    • Biochemical
    • CXR
    • ECG (IHD)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

How is AAA managed surgically? What are the two options

A
  1. Conventional Open Repair
  2. Endovascular Repair - Stenting
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What does conventional open repair of a AAA involve?

A
  • Midline/ transverse incision
  • Peritoneal contents examined
  • Aneurysm repair after proximal and distal arterial control
  • Use prosthetic graft (Dacron/ PFTE) inserted by classic inlay
  • Ask whether iliacs are involved?
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What does endovascular repair of AAA involve?

A
  • Insertion of a stent graft, via femoral artery using X ray
  • Aim: exclude aneurysm sac from circulation
  • 1.5cm typically below renal arteries to allow for implantation and good seal
  • Avoids: laparotomy, infra peritoneal manipulation, aortic occlusion time
  • Clinical results: improved survival
  • Long life surveillance is required after
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Who are AAA screenings given to and how?

A
  • USS
  • Men over 65 years
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

The most common location of AAA?

A

Below the kidneys

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is the emergency management of a AAA?

A
  • Summon a vascular surgeon + warn theatre.
  • ECG, Bloods: amylase, Hb, crossmatch
  • Catheterize
  • IV access with 2 large-bore cannulae
  • Give blood for shock: O Rh−ve blood (if not cross matched)
  • Take the patient straight to theatre
  • Give prophylactic antibiotics, eg co-amoxiclav 625mg iv.
  • Open repair: surgery involves clamping the aorta above the leak, and inserting a Dacron® graft (eg ‘tube graft’ or, if significant iliac aneurysm also, a ‘trouser graft’ with each ‘leg’ attached to an iliac artery).
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

The mortality rate for AAA surgey is 5-7%. What are the causes of death?

A
  • Cardiac complications
  • Haemorrhage
  • Respiratory failure
  • PE/ thromboembolism of distal arterial tree
  • Impotence / graph injection
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What is Peripheral Vascular Disease?

A
  • Occurs due to atherosclerosis causing stenosis of arteries
  • Multifactorial process involving modifiable and non-modifiable risk factors
  • CVS risk factors should be identified and treated aggressively
  • Intermittent claudication
  • Severe: Critical limb ischaemia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What are the risk factors for PVD?

A
  • Smoking
  • Hypercholesterolaemia
  • Diabetes
  • Age
  • FMH
  • Cardiovascular risk: IHD
  • Cerebrovascular Disease
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What is intermittent claudication?

A
  • Chief feature of PAD
  • Pain in muscles of lower limb caused by walking
  • Pain relieved by rest
  • Common in calf muscles
  • Superficial femoral artery occlusion - most common
  • Buttock claudication - femoral/ iliac - less common
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What are some of the signs of intermittent claudication?

A
  • Absent femoral/ popliteal pulse/ foot pulses
  • Cold/ white leg
  • Ulcers / gangrene
  • Postural dependent colour change
  • Increased capillary refilled time (>15 seconds)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What causes the pain in intermittent claudication?

A
  • Reduced arterial supply/ arterial insufficiency
  • Pain of anaerobic metabolites
  • Increase in substance P
22
Q

What are the differentials intermittent claudication?

A
  1. Spinal stenosis
  2. Lower limb arthritis
  3. Sciatica
23
Q

What questions should be asked in history taking of PVD?

A
  • Where in the leg is the pain?
  • When did it start?
  • Does it relieve itself at rest?
  • What distance can a pt walk without having to stop?
  • Does it interfere with your lifestyle?
  • What RFs does the pt have?
24
Q

What should a PVD examination involve?

A
  • Inspect: colour, skin breakdown, ulcers, gangrene
  • Palpation: temperature, cap refill, peripheral pulses
  • Auscultation: bruits (aorta, iliacs, femoral, adductor) and carotid bruits
25
Q

What bloods tests should be done for PVD?

A
  • Glucose: exclude DM arteritis (esr/crp)
  • FBC (anaemia, polycythaemia)
  • UE (renal disease)
  • Lipids (dyslipidaemia)
26
Q

What classification system is used for peripheral arterial disease? How is it divided?

A

Fontaine classification

  1. Assymptomatic
  2. Intermittent claudication
  3. Ischaemic rest pain
  4. Ulcer/ gangrene -> critical limb ischaemia
27
Q

What investigations are used for patients with PVD?

A
  • Blood tests: FBC, UE, lipids, glucose (DM)
  • ABPI: Ankle Brachial Pressure Index
    • Normal: >1.1
    • Arterial disease: <0.9
    • Critical limb ischamia: <0.5
  • Exercise Test: For patients with claudication but palpable peripheral masses
  • Imaging:
    • Arterial Duplex USS Scan: USS for stenosis+ occulsion
    • CT/ MRI Angiogram: Proximal disease when arterial tree not visualised
28
Q

What are the different steps involved in treatment of PVD?

A
  1. Conservative: RF modification: smoking cessation, lower cholesterol (statin), control DM, BP, IHD
    • Antiplatelet: 75mg clopidogrel
    • Supervised exercise programmes: 2h per wk for 3 months
  2. Vasoactive drugs: naftidrofuryl oxalate - modest benefit ​only.
    • ​​Only after supervised exercise has not led to satisfactory improvement
    • + Person prefers not to be referred for consideration of angioplasty or bypass surgery

​Surgery (Balloon or Bypass)

  1. Pericutaneous Transluminal Angioplasty: Balloon inflation of the narrowed segment
  2. Surgery Bypass: If atheromatous disease is extensive but distal run-off is good (ie distal arteries filled by collateral vessels
    • ​​Femoral-popliteal bypass, femoral-femoral crossover, and aorto-bifemoral bypass grafts.
    • Autologous vein grafts better than prosthetic grafts (eg Dacron® or PTFE)
  3. Amputation
29
Q

What are the complications of peripheral arterial disease?

A
  • Leg/foot ulcers
  • Gangrene
  • Permanent limb pain
  • Permanent limb weakness/numbness
30
Q

What is critical limb ischaemia?

A
  • Arterial insufficiency is so bad
  • Increased risk of limb loss (w/o intervention)
31
Q

What are the symptoms of critical limb ischaemia?

A
  • Rest pain
  • Nocturnal rest pain - relieved by dangling feet out of bed
  • Skin breakdown of toes and gangrene
32
Q

What are the signs of critical limb ischaemia (clue: 6Ps)?

A
  • Perishingly cold
  • Pulseless
  • Painful
  • Paraethesia
  • Pale

Mottling - implies irreversible!

33
Q

How is critical limb ischaemia treated?

A

Surgical emergency: revascularization required in 4-6h

Do urgent arteriography: if diagnosis is in doubt,

Balloon, bye bye

  • Balloon: Angioplasty: alone +/- endarterectomy
    • Or open surgery
  • Bye Bye: Amputation: if bypass and angioplasty fail or extensive distal disease
  • Surgical Embolectomy: If the occlusion is embolic, or local thrombolysis
  • Remember to anticoagulate with heparin
34
Q

What are the risk of surgery for critical limb ischaemia?

A
  1. Reperfusion injury
  2. Compartment syndrome
35
Q

What is the vascular supply to the lower limb and which artery is usually a target for PAD/ intermittent claudication?

A

Superficial Femoral Artery

36
Q

What are Varicose Veins?

A
  • Long, tortuous, & dilated veins of the superficial venous system
  • Usually affect the long or short saphenous veins
37
Q

What is the pathophysiology of varicose veins?

A
  • Incompetent venous valve
  • Blood flows back from the deep -> superficial veins
  • Sacculation, lengthening and tortuous veins
38
Q

What are the different types of varicose veins?

A
  1. Trunk: Dilated, tortuous veins of long or short saphenous
  2. Reticular: permanently dilated bluish intradermal veins 1-3mm in diameter
  3. Telangiectasia: permanently dilated intradermal venules < 1mm in diameter
39
Q

What are the aetiology of varicose veins?

A
  1. Primary/ simple: valvular failure -> distended superficial veins in lower limb. Most common
  2. Secondary varicose veins: superficial veins carry reversesd flow. Compensating for obstructed deep vein
  3. Arteriovenous fistula: Increased pressure causes engorgement of supervial veins in area of arteriovenous fistula
40
Q

What are some of the symptoms of varicose veins?

A
  • Cosmetic appearance: ‘My legs are ugly.’
  • Pain, cramps, tingling, heaviness, and restless legs
  • Leg discomfort
  • Nocturnal cramps
41
Q

What are some of the signs and complcations arising from varicose veins?

A
  • Varicose veins: haemorrhage + thrombophlebitis
  • Venous hypertension:
    • Lipodermatosclerosis
    • Oedema/ swelling
    • Eczema
    • Pigmentation: haemosiderin
    • Venous ulceration
42
Q

How do the following arise in varicose veins?

  • Pigmentation
  • Venous Ulceration
  • Atrophie blanche
  • Lipodermatosclerosis
A
  • Pigmentation: haemosiderin from RBCs
  • Venous Ulceration: Failing nutritional exchange in capillaries -> necrosis
  • Atrophie blanche: White skin secondary to venous hypertension
  • Lipodermatosclerosis: inflammatory process -> fibrosis of subcut fat
43
Q

What are the treatment options for varicose veins?

A

Conservative: Avoid prolonged standing, Elevate legs wherever possible, support stocking, lose weight, regular Walks

Surgical

  1. Endovascular treatment: of long or short saphenous vein
    • Foam sclerotherapy
    • ​Endovenous laser ablation
  2. Open Surgery:
    • Saphenofemoral disconnection and ligation.
    • Multiple avulsions; stripping from groin to upper calf
44
Q

When are varicose veins indicated for surgery?

A

When there is:

  • Bleeding, pain, ulceration, superficial thrombophlebitis, or ‘a severe impact on quality of life’
  • Not for cosmetic reasons alone
45
Q

What are the causes of leg ulcers?

A
  • Venous disease - most common
  • Arterial - artherosclerosis and arteriovenous malformations
  • Vasculitis - SLE, RA, wegener granulomatosis
  • Lymphatic insufficiency
  • Neuropathic pain - diabetes
  • Haematological
  • Traumatic
  • Neoplastic
46
Q

What is the pathophysiology of leg ulcers?

A
  • Chronic venous hypertension -> oedema
  • Impaired tissue perfusion
  • Oxygen metabolites diffuse greater distance to get to tissues
  • Tissues around ankles are ischamic
  • Reperfusion injury on walking or leg elevations (which reduces venous hypertension or tissue fluid)
  • Inflammatory process -> Oedema/ tissue fibrosis
  • This then causes symptoms of: aching, heaviness around the legs + itching
47
Q

How do you examine and investigate ulcers?

A
  • Examine patient lying and standing
  • Document size and appearance of ulcer
  • Look around the skin: is there chronic venous hypertension or insufficiency
  • Assess peripheral pulses + ABPI
  • Blood tests: exclude DM
  • Venous duplex scan
  • Arterial duplex scan (in pt w reduced ABPI)
  • Microbiology
  • Leg ulcer biopsy
48
Q

How do you manage venous ulcers?

A
  1. Compression bandaging - if arterial circulation is ok
  2. Leg elevation
  3. Improve immobility
  4. Reduce obesity
  5. Improve nutrition
  6. Varicose vein surgery
  7. Skin grafting (in selective pt)
49
Q

What is carotid disease? What is the underlying disease process?

A
  • Major cause of ischaemic stroke as a result of thromboembolism due to disease in ICA or MCA
  • Commonest site: ICA
  • Underlying disease: atherosclerosis
  • RFs same as PVD
50
Q

How can carotid disease present?

A
  • Assymptomatic: bruits (so stenosis)
  • Symptomatic: TIA + ischaemic stroke
51
Q

How can carotid disease be investigated?

A
  1. Carotid artery duplex scan
  2. CT / MRI angiogram
52
Q

How would you manage symptomatic CAD?

A
  1. Conservative: RF management.
  2. Medical: statin and anti platelet (clopidogrel 75mg)
  3. Surgical: Carotid endarterectomy

Year 3 - Surgery (10 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions