Vascular Surgery Flashcards
modifiable and non modifiable atherosclerosis risk factors
Modifiable • Smoking • BP • DM control • Hyperlipidaemia • ↓ exercise Non-modifiable • FH and PMH • Male • ↑ age • Genetic
disease assoc with atherosclerosis and peripheral vascular diseae
- IHD: 90%
- Carotid stenosis:15%
- AAA
- Renovascular disease
- DM microvascular disease
intermittent limb claudication
Cramping pain after walking a fixed distance
• Pain rapidly relieved by rest
• Calf pain = superficial femoral disease (commonest)
• Buttock pain = iliac disease (internal or common)
critical limb ischaemia
Fontaine 3 or 4
• European working group definition (1991)
• Ankle pressure <50mmHg (toe <30mmHg) and
either:
§ Rest pain requiring analgesia for ³2 wks
- Especially @ night
- Usually felt in the foot
- Pt. hangs foot out of bed
- Due to ↓ CO and loss of gravity help
§ Ulceration or gangrene
Leriche’s syndrome
Leriche’s Syndrome: Aortoiliac Occlusive Disease
• Atherosclerotic occlusion of abdominal aorta and iliacs
• Triad
§ Buttock claudication and wasting
§ Erectile dysfunction
§ Absent femoral pulse
Buerger’s diseaes
Buerger’s Disease: Thromboangiitis Obliterans
• Young, male, heavy smoker
• Acute inflammation and thrombosis of arteries and
veins in the hands and feet → ulceration and
gangrene
clinical examination Buerger’s diseaes
• Pulses: loss of pulses and ↑ CRT (norm ≤2sec)
• Ulcers: painful, punched-out, on pressure points
• Nail dystrophy / Onycholysis
• Skin: cold, white, atrophy, absent hair
• Venous guttering
• Muscle atrophy
• ↓ Buerger’s Angle
§ ≥90: normal
§ 20-30: ischaemia
§ <20: severe ischaemia
• +ve Buerger’s Sign
§ Reactive hyperaemia due to accumulation of
deoxygenated blood in dilated capillaries
classification scores x 2 peripheral vascular diseas
Fontaine • Asympto (subclinical) • Intermittent claudication § >200m § <200m • Ischaemic rest pain • Ulceration / gangrene Rutherford • Mild claudication • Moderate claudication • Severe claudication • Ischaemic rest pain • Minor tissue loss • Major tissue loss
chonic limb ischaemia
Normal Doppler: triphasic
• Mild stenosis: biphasic
• Severe stenosis: monophasic
ABPI
claud at <0.8
rest pain at <0.6
ulcer/gangrene <0.3
NB. Falsely high results may be obtained in DM / CRF
due to calcification of vessels >1.4 ABPI
investigating suspected chronic limb ischaeia
Walk test
• Walk on treadmill @ certain speed and incline to
establish maximum claudication distance.
• ABPI measured before and after: 20% ↓ is sig
Bloods • FBC + U+E: anaemia, renovascular disease • Lipids + glucose • ESR: arteritis • G+S: possible procedure
Imaging: assess site, extent and distal run-off
• Colour duplex US
• CT / MR angiogram
• Digital subtraction angiography
§ Invasive \ not commonly used for Dx only.
§ Used when performing therapeutic
angioplasty or stenting
Other
• ECG: ischaemia
cons med surg mnagement chronic limb ischaemia
Conservative Mx
• Most pts. ¯c claudication can be managed conservatively
• ↑ exercise and employ exercise programs
• Stop smoking
• Wt. loss
• Foot care
• Prog: 1/3 improve, 1/3 stay the same, 1/3 deteriorate
Medical Mx
• Risk factors: BP, lipids, DM
§ β-B don’t worsen intermittent claudication but use
¯c caution in CLI
• Antiplatelets: aspirin / clopidogrel
• Analgesia: may need opiates
• (Parenteral prostanoids ↓ pain in pts. unfit for surgery)
Endovascular Mx
• Percutaneous Transluminal Angioplasty ± stenting
• Good for short stenosis in big vessels: e.g. iliacs, SFA
• Lower risk for pt.: performed under regional anaesthesia
as day case
• Improved inflow → ↓ pain but restoration of foot pulses is
required for Rx of ulceration / gangrene.
consdier surgical reconstruction if v v severe
surgical reconstruction of limb vasc PVD
if v bad claud on <100m walk
Pre-op assessment
• Need good optimisation as likely to have cardiorespiratory
co-morbidities.
Practicalities
• Need good proximal supply and distal run-off
• Saphenous vein grafts preferred below the IL
• More distal grafts have ↑ rates of thrombosis
Classification
• Anatomical: fem-pop, fem-distal, aortobifemoral
• Extra-anatomical: axillo-fem / -bifem, fem-fem crossover
Other
• Endarterectomy: core-out atheromatous plaque
• Sympathectomy: chemical (EtOH injection) or surgical
§ Caution in DM ¯c neuropathy
• Amputation
prognosis following chornic limb ischaemia or amputation
just FYI
1yr after onset of CLI • 50% alive w/o amputation • 25% will have had major amputation • 25% dead (usually MI or stroke) Following amputation • Perioperative mortality § BK: 5-10% § AK: 15-20% • 1/3 → complete autonomy • 1/3 → partial autonomy • 1/3 → dead
classify severity of limb ischaeia
• Incomplete: limb not threatened
• Complete: limb threatened
§ Loss of limb unless intervention w/i 6hrs
• Irreversible: requires amputation
causes of acute limb ischaemia
Thrombosis in situ (60%) § A previously stenosed vessel ¯c plaque rupture § Usually incomplete ischaemia • Embolism (30%) § 80% from left atrium in AF § Valve disease § Iatrogenic from angioplasty / surgery § Cholesterol in long bone # § Paradoxical (venous via PFO) § Typically lodge at femoral bifurcation § Often complete ischaemia • Graft / stent occlusion • Trauma • Aortic dissection
presentation of acute limb ischaemia
Pale • Pulseless • Perishingly cold • Painful • Paraesthesia • Paralysis
thrombosis vs embolus acute limb ischaemia
embolus more acute and sudden, more profound, but contralateral pulses present
need embolectomy and warfarin
for thrombosis they needthrombolysis and bypass surgery
investigating acute limb ischaemia
• Blood § FBC, U+E, INR, G+S § CK • ECG • Imaging § CXR § Duplex doppler § CT angio
management acute limb ischaemia
In an acutely ischaemic limb discuss immediately ¯c a
senior as time is crucial.
• NBM
• Rehydration: IV fluids
• Analgesia: morphine + metoclopramide
• Abx: e.g. co-amoxiclav if signs of infection
• Unfractionated heparin IVI: prevent extension
• Complete occlusion?
§ Yes: urgent surgery: embolectomy or bypass
§ No: angiogram + observe for deterioration
management of embolic acute limb ischameia
Embolus Mx 1. Embolectomy § Under regional anaesthesia or GA § Wire fed through embolus § Fogarty catheter fed over the top § Balloon inflated and catheter withdrawn, removing the embolism. § Adequacy confirmed by on-table angiography 2. Thrombolysis § Consider if embolectomy unsuccessful § E.g. local injection of TPA 3. Other options § Emergency reconstruction § Amputation Post-embolectomy • Anticoagulate: heparin IVI → warfarin • ID embolic source: ECG, echo, US aorta, fem and pop • Complications § Reperfusion injury - Local swelling → compartment syndrome - Acidosis and arrhythmia 2O to ↑K - ARDS - GI oedema → end
managemetn of thrombotic acute limb iscahemia
Thrombosis Mx • Emergency reconstruction if complete occlusion • Angiography + angioplasty • Thrombolysis • Amputation Manage Cardiovascular Risk Factors
carotid artery disease
Presentation • Bruit • CVA/TIA Ix • Duplex carotid Doppler • MRA Mx Conservative • Aspirin or clopidogrel • Control risk factors Surgical: Endarterectomy • Symptomatic (ECST, NASCET) § ≥70% (5% stroke risk per yr) § ≥50% if low risk (<3%, typically <75yrs) § Perform w/i 2wks of presentation • Asymptomatic (ACAS, ACST)
complications of cartoid endartecotmy
- Stroke or death: 3%
- HTN: 60%
- Haematoma
- MI
- Nerve injury
- Hypoglossal: ipsilateral tongue deviation
- Great auricular: numb ear lobe
- Recurrent laryngeal: hoarse voice, bovine cough
NB some would consider stenting instead but limited data yet
define and categorise aneurysm
Definition
• Abnormal dilatation of a blood vessel >50% of its
normal diameter.
Classification
• True Aneurysm
§ Dilatation of a blood vessel involving all layers
of the wall and is >50% of its normal diameter
§ Two different morphologies
- Fusiform: e.g AAA
- Saccular: e.g Berry aneurysm
• False Aneurysm
§ Collection of blood around a vessel wall that
communicates ¯c the vessel lumen.
§ Usually iatrogenic: puncture, cannulation
• Dissection
§ Vessel dilatation caused by blood splaying
apart the media to form a channel w/i the
vessel wall.
causes of aneurysm
Causes • Congenital § ADPKD → Berry aneurysms § Marfan’s, Ehlers-Danlos • Acquired § Atherosclerosis § Trauma: e.g. penetrating trauma § Inflammatory: Takayasu’s aortitis, HSP § Infection - Mycotic: SBE - Tertiary syphilis (esp. thoracic)
complications of aneurysms
Rupture • Thrombosis • Distal embolization • Pressure: DVT, oesophagus, nutcracker syndrome • Fistula (IVC, intestine)
summarise treatment etc of popliteal aneurysm
• Less common cf. AAA • 50% of pts. ¯c popliteal aneurysm also have AAA Presentation • Very easily palpable popliteal pulse • 50% bilateral • Rupture is relatively rare • Thrombosis and distal embolism is main complication § → acute limb ischaemia Mx • Acute: embolectomy or fem-distal bypass • Stable § Elective grafting + tie off vessel § Stenting
presentation AAA
Usually asympto: discovered incidentally • May → back pain or umbilical pain radiating to groin • Acute limb ischaemia • Blue toe syndrome: distal embolisation • Acute rupture
vascular rv size of AAA on USS
5.5cm+ is urgent referral
inv and exam AAA
Expansile mass just above the umbilicus • Bruits may be heard • Tenderness + shock suggests rupture Ix • AXR: calcification may be seen • Abdo US: screening and monitoring • CT / MRI: gold-standard • Angiography § Won’t show true extent of aneurysm due to endoluminal thrombus. § Useful to delineate relationship of renal arteries
management of AAA
Conservative
• Manage cardiovascular risk factors: esp. BP
§ <4cm: yearly monitoring
§ 4-5.5cm: 6 monthly monitoring
Surgical
• Aim to treat aneurysm before it ruptures.
§ Elective mortality: 5%
§ Emergency mortality: 50%
• Operate when risk of rupture > risk of surgery
• Indications § Symptomatic (back pain = imminent rupture) § Diameter >5.5cm § Rapidly expanding: >1cm/yr § Causing complications: e.g. emboli • Open or EVAR § EVAR has ↓ perioperative mortality
UK men screened once at 65yrs
AAA ruptured - managment
High flow O2
• 2 x large bore cannulae in each ACF
§ Give fluid if shocked but keep SBP
<100mmHg
§ Give O- blood if desperate
§ Blood: FBC, U+E, clotting, amylase, xmatch
10u
• Instigate the major haemorrhage protocol
• Call vascular surgeon, anaesthetist and warn theatre
• Analgesia
• Abx prophylaxis: cef + met
• Urinary catheter + CVP line
• If stable + Dx uncertain: US or CT may be feasible
• Take to theatre: clamp neck, insert dacron graf
thoracic aortic dissection
Sudden onset, tearing chest pain
§ Radiates through to the back
§ Tachycardia and hypertension (1O +
sympathetic)
• Distal propagation → sequential occlusion of branches § Left hemiplegia § Unequal arm pulses and BP § Paraplegia (anterior spinal A.) § Anuria
• Proximal propagation § Aortic regurgitation § Tamponade • Rupture into pericardial, pleural or peritoneal cavities § Commonest cause of death
classification system for aortic dissection
Stanford Classification Type A: Proximal • 70% • Involves ascending aorta ± descending • Higher mortality due to probable cardiac involvement • Usually require surgery Type B: Distal • 30% • Involves descending aorta only: distal to L SC artery • Usually best managed conservatively
inv and management aortic dissection
Resuscitate
Investigate
• Bloods: x-match 10u, FBC, U+E, clotting, amylase
• ECG: 20% show ischaemia due to involvement of the
coronary ostia
• Imaging
§ CXR
§ CT/MRI: not if haemodynamically unstable
§ TOE: can be used if haemodynamically unstable
Treat
• Analgesia
• ↓SBP
§ Labetalol or esmolol (short t½)
§ Keep SBP 100-110mmHg
• Type A: open repair
§ Acute operative mortality: <25%
• Type B: conservative initially
§ Surgery if persistent pain or complications
§ Consider TEVAR if uncomplicated
classify gangrene x 3
Classification • Wet: tissue death + infection • Dry: tissue death only • Pregangrene: tissue on the brink of gangrene Presentation • Black tissues ± slough • May be suppuration ± sepsis
gas gangrene
Clostridium perfringes myositis • RFs: DM, trauma, malignancy • Presentation § Toxaemia § Haemolytic jaundice § Oedema § Crepitus from surgical emphysema § Bubbly brown pus • Rx § Debridement (may need amputation) § Benzylpenicillin + metronidazole § Hyperbaric O2
synergistic gangrene
Synergistic Gangrene • Involves aerobes + anaerobes • Fournier’s: perineum • Meleney’s: post-op ulceration • Both progress rapidly to necrotising fasciitis + myositis Mx • Take cultures • Debridement (including amputation
cause of varicose veins
failure of valves between deep and superficial veins leads to engorgement of superficial veins
risk factors varicose veins
Primary • Idiopathic (congenitally weak valves) § Prolonged standing § Pregnancy § Obesity § OCP § FH • Congenital valve absence (v. rare) Secondary • Valve destruction → reflux: DVT, thrombophlebitis • Obstruction: DVT, foetus, pelvic mass • Constipation • AVM • Overactive pumps (e.g. cyclists)
signs varciose veins
Skin changes § Venous stars § Haemosiderin deposition § Venous eczema § Lipodermatosclerosis (paniculitis) § Atrophie blanche • Ulcers: medial malleolus / gaiter area • Oedema • Thrombophlebitis
varicose veins inv and referral
• Duplex ultrasonography § Anatomy § Presence of incompetence § Caused by obstruction or reflux • Surgery: FBC, U+E, clotting, G+S, CXR, ECG
Referral Criteria • Bleeding • Pain • Ulceration • Superficial thrombophlebitis • Severe impact on QoL
management varicose veins
Treat any contributing factors § Lose weight § Relieve constipation • Education § Avoid prolonged standing § Regular walks • Class II Graduated Compression Stockings § 18-24mmHg § Symptomatic relief and slows progression • Skin care § Maintain hydration ¯c emollients § Treat ulcers rapidly
can inject sclerosant or do radiofreq ablation
surg rarely done as ineffective but could ligate
complications varicose vein surgery /procedure
Post-op • Bandage tightly • Elevate for 24h • Discharged ¯c compression stockings and instructed to walk daily. Complications • Haematoma (esp. groin) • Wound sepsis • Damage to cutaneous nerve (e.g. long saphenous) • Superficial thrombophlebitis • DVT • Recurrence: may approach 50%
causes of leg ulcers
Venous: commonest • Arterial: large or small vessel • Neuropathic: EtOH, DM • Traumatic: e.g. pressure • Systemic disease: e.g. pyoderma gangrenosum • Neoplastic: SCC
venous vs arterial vs neuropathic ulcers
Venous: 75% painless, shallow usually medial ankle haemosiderin deposition and lipodermatosclerosis • RFs: venous insufficiency, varicosities, DVT, obesity
Arterial: 2% • Painful, deep, punched out lesions • Occur @ pressure points § Heel § Tips of, and between, toes § Metatarsal heads (esp. 5th) • Other signs of chronic leg ischaemia
Neuropathic
• Painless insensate surrounding skin
• Warm foot good pulses
Complications
• Osteomyelitis
• Development of SCC in the ulcer (Marjolin’s ulcer)
inv leg ulcers
ABPI if possible
• Duplex ultrasonography
• Biopsy may be necessary
§ Look for malignant change: Marjolin’s ulce
manage venous ulcers
• Refer to leg ulcer community clinic
• Focus on prevention
§ Graduated compression stockings
• Optimise risk factors: nutrition, smoking
Specific Rx • Analgesia • Bed Rest + Elevate leg • 4 layer graded compression bandage (if ABPI >0.8) • Pentoxyfylline PO § ↑ microcirculatory blood flow § Improves healing rates
DDx bilateral leg swelling
Bilateral right heart failure venous insufficiency drugs - nifedipine, amlodipine nephrotic syndrome liver failure myxoedema - thyroid hypo/hyperthyroid lymphoedema plasma protein loss (low albumin)
unilateral leg swelling DDx
Venous insufficiency
• DVT
• Infection or inflammation
• Lymphoedema
lymphoedema causes
can be familial
otherwise
• Fibrosis: e.g. post-radiotherapy • Infiltration § Ca: prostate, lymphoma § Filariasis: Wuchereria bancrofti • Infection: TB • Trauma: block dissection of lymphatics
