Vascular surgery Flashcards
what is a true aneurysm
abnormal dilatation of an artery involving all 3 layers of the arterial wall (intima, media, adventitia)
what is a false aneurysm / pseudoaneurysm
breach in the arterial wall resulting in an accumulation of blood between the tunica media and adventitia of the artery
mucosal outpouching through weakness in artery
signs of aneurysm
pulsating
bruit
expansile
how can you classify aneurysms
location - abdominal, thoracic, popliteal, cerebral
shape - fusiform, saccular
size
aetiology - congenital, acquired
where might you find a saccular aneurysm
cerebral
where might you find a fusiform aneurysm
abdominal aorta
congenital causes of aneurysms
Marfans
Ehlers Danlos
PKD - cerebral
acquired causes of aneurysms
vasculitis
infectious - syphilis, TB
idiopathic
trauma
RF for aneurysms
smoking HTN obesity cholesterol atherosclerosis M>F age FH ethnicity - european
complications of aneurysms
rupture and retroperitoneal leak
embolism from thrombus build up in aneurysm
local pressure effects
risk of rupture increases due to which law?
LaPlace’s law
as the artery wall expands, it becomes thinner
What is the AAA screening programme
men >=65 get an abdominal USS
what imaging do you do if there is a suspicion of asymptomatic AAA
Abdo USS
what imaging do you do for symptomatic / suspected rupture of AAA
CT angiogram
non-surgical management of AAA
stop smoking
manage HTN
statin and aspirin
weight loss and exercise
what is the work up for elective repair of AAA
CTA from aortic arch to femoral arteries
bloods, ECG, ECHO, PFTs, frailty score, METS
there is no benefit to early repair, true or false
true
symptoms of AAA rupture
abdominal pain radiating to the back collapse / sudden death acutely unwell hypotension renal colic expansile abdominal mass peripheral pulses
why do you get renal colic in AAA rupture
retroperitoneal
bleeding can result in:
grey turners
cullens
management of acute AAA rupture
ABCDE MHP activation IV access IV fluids - too much can cause retroperitoneum to burst therefore you do permissive hypotension G+S, crossmatch
permissive hypotension
ignore BP
maintain SBP 70-80
as long as they can perfuse their brain that is enough
which imaging to diagnose AAA rupture
CT angiogram
surgical management of ruptured AAA
EVAR
laparotomy
what happens if you leave the graft exposed
formation of adhesions between graft and bowel which can break down the graft –> aortoenteric fistula
complications of a higher up AAA
involvement of renal arteries –> renal failure
coeliac trunk and SMA
what is EVAR
Endoscopic vascular aneurysm repair
Xray guided stent via peripheral artery
EVAR complications
endoleak from lumbar arteries
ongoing filling of aneurysm sac from an incomplete seal around the aneurysm
stent migration
what is an aneurysm
abnormal dilatation of a blood vessel by more than 50% of its normal diameter
features of symptomatic AAA
abdominal pain
back / loin pain
distal embolisation resulting in limb ischaemia aortoenteric fistula (UGI bleed)
what is an important differential of renal colic to rule out
AAA rupture
what is the follow up for patients in AAA screening
<3cm - nothing
3-4.4cm - annual USS
4.5-5.4cm - 3 monthly USS
>=5.5cm OR >=4cm and grown by >=1cm in the last year - consider surgical intervention
what is involved in an open repair of AAA
midline laparotomy exposing the aorta, clamping it proximally and the iliac arteries distally and grafting the segment in between
causes of pseudoaneurysms
following damage eg cardiac catheterisation, repeated injections, vasculitis
3 main patterns of presentation in someone with peripheral arterial disease / chronic limb ischaemia
intermittent claudication
critical limb ischaemia
acute limb threatening ischaemia
features of intermittent claudication
aching / burning in leg muscles following walking
relieved after stopping for a few minutes
absent on rest
what ABPI reading would indicate intermittent claudication
0.6-0.9
what is chronic limb ischaemia
peripheral arterial disease that results in symptomatic reduced blood supply to the limbs
RF for chronic limb ischaemia
smoking HTN DM obesity ^ lipids age FH
what is Buerger’s test
involves lying the patient supine and raising their legs until they go pale and then lowering them until the colour returns
define critical limb ischaemia aka limb threat
3 definitions:
- ischaemic rest pain > 2 weeks requiring opiate analgesia +- tissue loss
- presence of ischaemic lesions or gangrene attributable to arterial disease
- ABPI <0.5
what is acute limb ischaemia
clinical features less than 14 days
presents within hours
acute embolus
what are varicose veins
tortuous dilated segments of vein associated with valvular incompetance resulting in venous hypertension and dilatation
RF for varicose veins
pregnancy
prolonged standing
obesity
FH
what is the vascular supply to the brain
internal carotids
vertebral arteries
anastamose to form circle of willis
CN blood supply is contra/ipsilateral
ipsilateral
which cerebral hemisphere is in charge of speech
dominant hemisphere
usually the left
causes of emboli
carotid artery disease AF Post MI ventricular thrombus patent foramen ovale and DVT endocarditis valvular disease
initial management approach to TIA
ABCDE history neuro exam ECG carotid dopler USS CT scan head
ICA doesn’t branch outside the skull, true or false
true
Where do the vertebral arteries branch off from
subclavian artery
management of carotid artery disease
dual antiplatelets statin HTN management CT head CA duplex CTA / MRA for vascular assessment
what % stenosis of the internal carotid artery is indicated for carotid endarterectomy within 2 weeks
70-99%
why does 100% carotid stenosis not get surgery
because there is no flow
why do a carotid endarterectomy within 2 weeks
maximal risk of stroke in first 2 weeks
after then, if you have not had a stroke, you are unlikely to
what can carotid duplex USS tell you
flow rate for degree of stenosis
size of plaque - endpoint cephalic extent of plaque
vertebral artery flow
carotid endarterectomy is a preventative/curable manoeuvre
preventative
patients are asymptomatic
done to prevent future stroke
surgical approach to carotid endarterectomy
incision to ant border of SCM, through skin and platysma to SCM
open carotid sheath
how can you open the internal carotid artery
proximal and distal control
how can you supply the brain during carotid endarterectomy surgery
bypass / shunt
ways of monitoring cerebral function
shunt - under GA
squeezy ball - under LA
what is the primary aim in carotid endarterectomy, what is done
remove plaque, intima and media and leave adventitia
how can you close the ICA at the end of carotid endarterectomy
put a patch
risks of carotid endarterectomy
vagus nerve damage hypoglossal nerve recurrent laryngeal nerve facial nerve infection haematoma bleeding
management of haematoma in the neck in terms of airway compression
open up the wound to release the pressure
lower limb venous system is low/high pressure
low
what aids venous return in the lower limbs to the IVC
calf muscle pump
intermittent
what prevents backflow of venous blood
valves
saphenous system is superficial/deep
superficial (S)
where does the long saphenous drain
saphenofemoral junction
where does the short saphenous drain
popliteal vein
pathology of varicose veins
valves become incompetent
superficial veins fill up
Presentation of varicose veins
dilated tortuous superficial veins bleeding bruising superficial thrombophlebitis chronic venous insufficiency throbbing, worse at end of day swell up cosmetics
what is thrombophlebitis
it is an inflammatory process, not an infection
red sore inflamed rubbery vein
no need for antibiotics -> side effects
what is chronic venous insufficiency
umbrella term from varicosities to venous ulcers
what is haemosiderin
RBC leakage and breakdown
release of iron - stains the skin
what is lipodermatosclerosis
inflammation and fibrosis from boggy veins and blood around the ankle
upside down champagne bottle
what is venous eczema
itchy from venous insufficiency
managed with emollients
features of venous ulceration
sloping edges
shallow
large
sloughy granulation tissue
what kind of ulcer do you find in the gaiter region
venous ulceration
features arterial ulcers
punched out
sore
deep
investigations for venous disease
history and exam
compare legs
RFs - obese, female, age, DVT, pregnancy, skin changes,
Trendelenbergs test = elevate leg to drain veins. occlude SFJ and see if it refills distally
Doppler USS - assess deep veins, level of competance and both systems
VV classification for who to treat
CEAP clinical aetiology anatomical pathophysiology
management options for varicose veins
nothing - advice, information, elevation…
conservative - graduated compression stockings (contraindicated in arterial disease)
surgical - foam sclerotherapy, endothermal ablation, mechano-chemical ablation, open surgery
what does compression bandaging improve
symptoms and ulcer healing
compression stockings are contraindicated in which group of patients
those with arterial disease / low ABPI
relative contraindication - seek specialist advice
what is graduated compression
4 layer bandaging
stockings
what is foam sclerotherapy
vascular lab and scan groin and inject foam into vein chemical ablation fibrovein USS guidance pushes blood out form vein risk of stroke
what is endothermal ablation
fry the veins - private practice
not appropriate for very tortuous veins
what is involved in open surgery for varicose veins
groin incision
SFJ ligation
strip vein
multiple stab avulsions
what nerve is associated with the long saphenous
saphenous nerve
what nerve is associated with the short saphenous
sural nerve
you give antibiotics for phlebitis, true or false
false
What is a Marjolins ulcer
malignant conversion of an ulcer
e.g. SCC from a scar or venous ulcer
what is reperfusion injury
following therapy of acute limb ischaemia with increased capillary permeability can cause compartment syndrome and release of metabolites from cells e.g. K, H, and myoglobin
list the “P’s” associated with acute limb ischaemia
Pain Pulselessness Pallor Perishingly cold Paralysis Paraesthesia
outpatient management for claudication
antiplatelets statin exercise diet smoking cessation
if you have a patient with a TIA causing right sided symptoms, which carotid side will you investigate further and potentially operate on?
left carotid
what causes primary varicose veins
incompetent venous valves
