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Phase 3b > Vascular surgery > Flashcards

Vascular surgery Flashcards

1
Q

what is a pseudoaneurysm ?

A

a “false aneurysm”, occurs when there is a breach to the arterial wall, resulting in an accumulation of blood between the tunica media and tunica adventitia of the artery

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2
Q

what causes pseudoaneurysms?

A

They typically occur following damage to the vessel wall, such as puncture following cardiac catheterisation or repeated injections to the vessel (from IVDU); other causes include trauma, regional inflammation*, or vasculitis. They are most common at the femoral artery, but can also occur at the radial artery, carotid artery, or abdominal/thoracic aorta.

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3
Q

what is the difference between pseudoaneurysm and normal aneurysm?

A

An aneurysm is an abnormal dilation of an artery that involves all three layers of the arterial wall (intima, media and adventitia), whilst a pseudoaneurysm is a collection of blood between the media and adventitia layers

Aneurysms are caused by dilatation of all layers of the arterial wall, and are more common in males, smokers, patients with a family history, and with increasing age, whilst pseudoaneurysms are typically caused by direct trauma to the vessel.

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4
Q

clinical features of pseudoaneurysm?

A

pulsatile lump - which can be tender and pain
common location = femoral artery
they may lead to limb ischaemia if there is compression from them

  • if infected - erythematous and tender, purulent material may be discharging from it
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5
Q

what investigations would you perform for a pseudoaneurysm?

A

imaging - duplex USS (will show turbulent forward and backward flow - termed yin-yang sign)
CT can be used if USS is hard to do
routine bloods, blood cultures and MC&S of discharge if infected

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6
Q

how is pseudoaneurysm managed?

A

small ones can be left alone
If larger - USS guided compression or thrombin injection

endovascular stenting or surgery - options but depend on the location of it

if infected - pressure dressing and urgent imaging obtained. They will require surgical ligation

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7
Q

what is classified as an aneurysm >

A

a persistent, abnormal dilation of an artery above 1.5 times its normal diameter

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8
Q

what are risk factors for aneurysms?

A

smoking
hypertension
hyperlipidaemia
family history

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9
Q

what investigations would you perform for aneurysms?

A

CT angiography
MR angiography
US duplex scans can be useful

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10
Q

what are the most common peripheral artery aneurysms?

A

popliteal and femoral

** Popliteal aneurysms are the most common site for peripheral aneurysms, accounting for 70-80%. They have a high risk of embolisation and/or occlusion.

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11
Q

how does popliteal aneurysm present?

A

usually as acute limb ischaemia - from aneurysm thrombosis or distal emboli
less commonly will present with intermittent claudication

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12
Q

what investigations do you perform for popliteal artery aneurysm?

A

USS duplex scan (helps to differentiate other causes of popliteal swelling e.g. bakers cyst or lymphadenpoathy)
CT angio or MR angio - good as allow anatomical assessment of the aneurysm and assessment of distal arteries to assess patency

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13
Q

how is a popliteal aneurysm managed?

A

due to risk of embolic events - they should be treated regardless of size if symptomatic
if asymptomatic anything greater than 2.5cm should be treated

In cases of thrombosis, if there is no patient tibial vessel then embolectomy or thrombolysis can be attempted to improve run off prior to/at the time of bypass surgery.

surgical intervention - endovascular repair or surgical repair

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14
Q

what are the two main causes of femoral artery aneurysm ?

A

percutaneous vascular interventions

patient self-injecting - IVDU

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15
Q

how does a femoral artery aneurysm present?

A

signs/symptoms are either from thrombosis, rupture or embolisation
In IVDU - concurrent infections may also be present

they may present with varying degrees of claudication or acute limb ischaemia
they could also have no symptoms other that a swelling in the groin

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16
Q

what investigations and management for femoral artery aneurysm?

A

US duplex scan, before requiring CT Angiography or MR Angiography for further anatomical imaging and operative planning.

open surgical repair (endovascular repair is rarely performed for such a pathology).

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17
Q

what visceral arteries are most commonly affected by aneurysms ?

A

splenic artery
hepatic artery
renal artery

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18
Q

what are the risk factors for splenic artery aneurysm?

A

Splenic artery aneurysms are the most common type of visceral aneurysm, comprising around 60% of the total.

female sex
multiple pregnancies
portal hypertension
pancreatitis
pancreatic pseudocyst formation.
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19
Q

how would a splenic artery aneurysm present?

A

vague epigastric or LUQ pain

Those that rupture will present with severe abdominal pain and haemodynamic compromise.

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20
Q

investigations and management for splenic artery aneurysm?

A

CT Angiography or MR Angiography
USS can sometimes be used for monitoring (only in thinner patients)

1st line management = endovascular repair - with embolisation or covered stent grafts

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21
Q

common cause of hepatic artery aneurysm?

A

Percutaneous instrumentation is associated in 50% of cases, yet the remainder of cases may be from trauma, degenerative disease, or post-liver transplant (false aneurysms forming around vessel anastomoses).

22
Q

presentation of hepatic artery aneurysm?

A

Most cases are usually asymptomatic, yet stable symptomatic cases can often present with vague RUQ or epigastric pain; jaundice can occur if there is any biliary obstruction.

23
Q

investigations and management for hepatic artery aneurysm?

A

CT Angiography or MR Angiography.

First line management is endovascular repair

24
Q

renal artery aneurysm

A
  • usually found incidentally
  • often asymptomatic
  • may have haematuria, resistant HTN, loin pain

CT/MR angio
repair with endovascular stent

25
Q

what are varicose veins?

A

tortuous dilated segments of vein associated with valvular incompetence

26
Q

what causes varicose veins?

A

98% of varicose veins are primary idiopathic varicose veins.

Secondary causes may include deep venous thrombosis, pelvic masses (e.g. pregnancy, uterine fibroids, and ovarian masses), or arteriovenous malformations (such as Klippel-Trenaunay Syndrome).

27
Q

risk factors for varicose veins?

A

Prolonged standing
Obesity
Pregnancy
Family history

28
Q

clinical features of varicose veins?

A

often just present with cosmetic issues

worsening ones may cause aching or itching
subsequent changes=skin changes, ulceration, thrombophlebitis or bleeding

29
Q

how are varicose veins classified?

A 
CEAP classification 
C - clinical features 
E-aetiology 
A- anatomical 
P - pathophysiology
30
Q

what investigations for varicose veins?

A

duplex USS

31
Q

how are varicose veins managed?

A

patient education - avoid prolonged standing, weight loss, and increased exercise

vein ligation, strippin and avulsion
foam sclerotherapy
thermal ablation

32
Q

when should a patient be referred to a vascular service according to NICE criteria?

A

Symptomatic primary or recurrent varicose veins
Lower‑limb skin changes, such as pigmentation or eczema, thought to be caused by chronic venous insufficiency
Superficial vein thrombosis (characterised by the appearance of hard, painful veins) with suspected venous incompetence
A venous leg ulcer (a break in the skin below the knee that has not healed within 2 weeks)

33
Q

what is deep venous insufficiency?

A

Deep Venous Insufficiency occurs as a result of a failure of the venous system, characterised by valvular reflux, venous hypertension and obstruction

The pathophysiology is similar to that of varicose veins but it affects the deep venous system, instead of superficial veins.

34
Q

what can cause deep venous insufficiency?

A

Primary, whereby there is an underlying defect to the vein wall or valvular component - Includes congenital defects and connective tissue disorders

Secondary, whereby defects occur secondary to damage - including post-thrombotic disease, post-phlebitic disease, venous outflow obstruction, and trauma

35
Q

risk factors for deep venous insufficiency

A 
increasing age 
female gender 
pregnancy 
previous DVT 
phlebitis 
obesity 
smoking

Those in jobs which involve long periods of standing or with a strong family history of venous disease are also at risk.

36
Q

how do patients present with deep venous insufficiency?

A

chronically swollen lower limbs - which can become pruritic and painful
They may also report venous claudication characterised by bursting pain and tightness on walking which resolves on leg elevation

Patients with prior DVT - may present with post thrombotic syndrome 
- heaviness 
- cramps 
- pain 
pruritic 
- paraesthesia 
- pretibial oedema 
- hyperpigmentations 
- venous ectasia 
- redness 
- ulceration
37
Q

what would you find on examination of someone with deep venous insufficiency?

A

On examination, several signs can indicate underlying DVI, including:

  • varicose eczema (dry and scaly skin)
  • Thrombophlebitis
  • haemosiderin skin staining
  • lipodermatosclerosis
  • atrophie blanche

varying degrees of pedal oedema,
may have varicose ulcers

38
Q

what investigations would you perform for deep venous insufficiency?

A

doppler USS - to assess the extent of venous reflux

routine blood tests
documentation of foot pulses and ankle brachial pressure index

39
Q

how should deep venous insufficiency be managed?

A

conservative - compression stockings and analgesia

40
Q

complications of deep venous insufficiency?

A

swelling,
recurrent cellulitis,
chronic pain
ulceration

41
Q

what is thoracic outlet syndrome?

A

Thoracic outlet syndrome refers to the clinical features that arise from compression of the neurovascular bundle within the thoracic outlet.

42
Q

what usually causes thoracic outlet syndrome?

A

hyperextension injuries
repetitive stress injuries
external compressing factors
anatomical abnormalities

43
Q

what are the clinical features of thoracic outlet syndrome?

A

The signs and symptoms that arise can be divided into neurological (nTOS, most common), venous (vTOS), and arterial (aTOS)

Compression of brachial plexus - paraesthesia and motor weakness (often in ulnar distribution), muscle wasting and pain which can radiate to neck and upper part of back

venous compression can lead to deep vein thrombosis and extremity swelling (paget-schrotter syndrome)

aterial - claudication or acute limb ischaemia through either occlusion, distal embolisation, or aneurysm formation

symptoms may worsen of certain movements

44
Q

what are the special tests for thoracic outlet syndorme?

A

Adson’s manoeuvre – Palpate the radial pulse on the affected side, with the arm initially abducted to 30 degrees, then ask the patient to turn their head and look at the affected side’s shoulder; fully abduct, extend, and laterally rotate the shoulder
Any decrease or loss of pulse is suggestive of TOS

Roo’s test – Abduct and externally rotate the shoulder on the affected side to 90 degrees, bend the elbow to 90 degrees, then ask the patient to open and close the hands slowly over a 3-minute period
Any worsening of symptoms will develop if TOS is present

Elvey’s test – Extend the arm to 90 degrees, with the elbow extended and wrist dorsiflexed, then tilt the patients ear to each shoulder
Any loss of the radial pulse or worsening symptoms is suggestive of TOS

45
Q

what investigations for thoracic outlet syndrome?

A

bloods (FBC and clotting)
CXR - look for bony abnormalities
venous and arterial duplex
nerve conduction studies

46
Q

how is thoracic outlet syndrome managed?

A

for nerve - physio is first line, botulinum toxin injections can be used to aid physio

Venous - they may need thrombolysis and anti-coagulation, surgical management to decompress

Arterial - urgent vascular input is needed

47
Q

what is subclavian steal syndrome?

A

rare condition
causes syncope/neuro deficits when blood supply to affected arm is increased through exercise

it is secondary to a proximal stenosing lesion or occlusion in the subclavian artery (usually on left)

48
Q

risk factors for subclavian steal syndrome?

A

Due to the offending lesion tending to be atherosclerotic, the main risk factors for the condition are increasing age, hyperlipidaemia, hypertension, smoking, and diabetes mellitus.

49
Q

clinical features of subclavian steal syndrome?

A

In periods of arm activity, reversal of the blood supply to the posterior cerebral circulation via the vertebral artery can result in a wide range of cerebral symptoms, including vertigo, diplopia, dysphagia, dysarthria, visual loss, or syncope.

Patients may also present with arm claudication due to the occluding lesions, such as arm pain or paraesthesia, made worse with arm movement.

50
Q

investigations for subclavian steal syndrome?

A 
duplex USS (will show retrograde flowing affected vertebral artery during exercise 
routine CXR can look for any external compression

CT angio

51
Q

how is subclavian steal syndrome managed?

A

All patients should be started on anti-platelet and statin therapy

modifiable CV risk factors should be addressed

occlusions may be treated either through endovascular or bypass techniques
percutaneous angioplasty +/- stenting is reported to be very successful

Phase 3b (34 decks)

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