Vascular Surgical Presentations

Question 1

how should an acutely painful limb that is cold and pale be treated?

Answer 1

it should be treated as acute limb ischaemia until proven otherwise

Question 2

what are the ‘6 Ps’ of acute limb ischaemia?

Answer 2

• pain
• pallor
• pulselessness
• parasthesia
• perishingly cold
• paralysis

Question 3

what are the common risk factors for acute limb ischaemia?

Answer 3

AF, hypertension, smoking, diabetes, recent MI

Question 4

what imaging should you undertake if you suspect acute limb ischaemia?

Answer 4

CT angiogram

Question 5

at what point does irreversible tissue damage occur in acute limb ischaemia?

Answer 5

within 6 hours

Question 6

how should an acutely painful limb that is hot and swollen be treated?

Answer 6

it should be assessed for a DVT

Question 7

what are other causes of a hot, swollen, painful limb?

Answer 7

cellulitis and other MSK related infections that require treatment with antibiotics

Question 8

what other signs and symptoms would lead you to suspect a DVT?

Answer 8

if the pain is localised to the calf

if the pain is associated with calf tenderness and firmness

Question 9

what are the risk factors for developing a DVT?

Answer 9

virchow’s triad

• family history of pro-thrombotic disease
• recent immobility (e.g. surgery or flights >5hrs)
• pregnancy
• trauma
• smoking

Question 10

what is the Wells’ score and how is it used?

Answer 10

it is used when one suspects a DVT

a score >1 is an indication for an ultrasound Doppler scan

Question 11

how do you treat a confirmed DVT?

Answer 11

• therapeutic dose of LMWH (enoxaparin 40mg IV)

- start long-term anti-coagulation

Question 12

what is important to check for in a patient that attends with an acutely painful limb?

Answer 12

check for any signs or a history of trauma as patient may have a fracture

Question 13

how do you assess for a suspected fracture?

Answer 13

check for focal bony tenderness and an inability to weight bear

Question 14

true or false: neurological pathologies may present as an acutely painful limb

Answer 14

true.

Question 15

what are the categories for neurological causes of limb pain?

Answer 15

• central (MS)
• spinal (disc herniation)
• peripheral (infective or traumatic causes)

Question 16

what are associated signs and symptoms of a patient with a painful limb caused by a neurological issue?

Answer 16

• pain that radiates to the affected region
• pain that is worse on movement
• muscle weakness
• paraesthesia
• altered reflexes

Question 17

what is an ulcer?

Answer 17

abnormal breaks in the skin of mucous membranes

Question 18

true or false: most lower limb ulcers have an arterial origin

Answer 18

false.

most lower limbs ulcers have a venous origin

Question 19

what leads to a pressure ulcer?

Answer 19

prolonged or excessive pressure over a bony prominence

Question 20

how would one describe a venous ulcer?

Answer 20

shallow with a granulated base
irregular borders
located in the ‘gaiter region’ (shins and medial malleolus)

Question 21

how would one describe an arterial ulcer?

Answer 21

found distally in pressure areas with well defined borders
small, deep lesions
necrotic base

Question 22

how would one describe a neuropathic ulcer?

Answer 22

painless ulcers over areas of pressure, often secondary to joint deformity in diabetics
has a punched out appearance

Question 23

true or false: venous ulcers are highly prone to infection

Answer 23

true.

they tend to present with accompanying cellulitis

Question 24

what is the pathophysiology of a venous ulcer?

Answer 24

venous outflow obstruction causes poor venous return and venous hypertension.
this leads to a ‘trapping’ of WBCs in the capillaries, which then become activated due to lack of oxygen.
they release inflammatory mediators, injuring the tissue and causing poor wound healing and necrosis

Question 25

what are the risk factors for developing a venous leg ulcer?

Answer 25

- age - pre-existing venous problems (e.g. DVT or varicose veins) - pregnancy - obesity/ physically inactive - severe leg trauma

Question 26

what are the clinical features of a venous leg ulcer?

Answer 26

- painful (worse at the end of the day) - aching, itching, or bursting sensation will appear before the ulcer forms on examination there may be: - varicose veins and eczema - oedema

Question 27

what investigations would you do in a suspected venous leg ulcer?

Answer 27

it is a clinical diagnosis - a duplex USS to assess where the venous insufficiency is - an ABPI to assess for any arterial component to the ulcers and if compression therapy will help - swab cultures if you suspect an infection

Question 28

what are the most common areas for venous incompetence to occur?

Answer 28

- sapheno-femoral junction - sapheno- popliteal junctions (tends to occur at perforator)

Question 29

how would you manage a venous leg ulcer?

Answer 29

conservative: leg elevation and increased exercise which promotes calf pump action to aid venous return intervention: multi component compression bandaging changed once or twice a week

Question 30

how long does a venous ulcer take to heal?

Answer 30

after 6 months of compression therapy

Question 31

true or false: a patient’s ABPI must be greater than 0.6 before any compression bandaging is applied to treat a venous leg ulcer

Answer 31

true.

Question 32

why should concurrent varicose veins be treated with surgery in a patient wit a venous leg ulcer?

Answer 32

it will improve venous return helping the healing of the venous ulcers

Question 33

what is the pathophysiology of an arterial ulcer?

Answer 33

a reduction in arterial blood flow leading to decreased perfusion of tissues and causing poor wound healing

Question 34

what are the risk factors for developing an arterial ulcer?

Answer 34

same to those of peripheral arterial disease - smoking - diabetes mellitus - hypertension - hyperlipidaemia - age - family history - obesity

Question 35

what are the common clinical features of a patient with suspected arterial ulcer?

Answer 35

- previous history of intermittent claudication or critical limb ischaemia (pain at night) - ulcer develops over a long period of time with almost no healing (absence of granulation tissue) - signs of vascular disease (skin changes, hair loss, thick nails) on examination: - cold limbs - reduced pulses - sensation is maintained (unlike neuropathic ulcers)

Question 36

what investigations would you do in a patient with a suspected arterial ulcer?

Answer 36

- ABPI to measure extent of peripheral arterial disease | - duplex ultrasound, CT angiography, MRA to find location of arterial disease

Question 37

what are the measurement indications of an ABPI?

Answer 37

``` >0.9 = normal 0.9-0.8 = mild peripheral arterial disease 0.8-0.5 = moderate peripheral arterial disease <0.5 = severe peripheral arterial disease ```

Question 38

how would you manage a patient with an arterial ulcer?

Answer 38

- refer for a vascular review conservative: - lifestyle advice e.g. smoking cessation and weight loss medical: - pharmacological CV risk factor modification (statin and antiplatelet) - BP and BM control surgical: - angioplasty or bypass grafting - patients may be offered a skin graft if the ulcer continues to be non-healing

Question 39

what is the pathophysiology of a neuropathic ulcer?

Answer 39

occurs as a result of peripheral neuropathy. there is a loss of protective sensation leading to repetitive stress and unnoticed injuries forming. often occurs concurrently with vascular disease.

Question 40

what are the risk factors for a neuropathic ulcer?

Answer 40

- diabetes mellitus - B12 deficiency (any condition with peripheral neuropathy)

Question 41

what are the clinical features of a neuropathic ulcer?

Answer 41

- patients have a history of peripheral neuropathy or symptoms of peripheral vascular disease - signs of neuropathy (burning/tingling in the legs, muscle wasting) on examination - warm feet and good pulses - accompanied peripheral neuropathy (glove and stocking)

Question 42

what investigations would you do in a patient with a suspected neuropathic ulcer?

Answer 42

- blood glucose levels and serum B12 to find cause of neuropathy - ABPI +/- duplex to assess for concurrent arterial disease - swabs to assess for infection - x-ray to assess for osteomyelitis - assess extent of neuropathy by testing vibration sense

Question 43

how would you manage a patient with a neuropathic ulcer?

Answer 43

- specialised diabetic foot clinics manage neuropathic ulcers via MDT - advise on diabetic control - manage cardiovascular risk factors - educate on foot hygiene ischaemic or necrotic tissue will need surgical debridement or amputation

Question 44

what is Charcot’s foot?

Answer 44

a neuropathy where loss of sensation leads to continuous unnoticed trauma and deformity occurring

Question 45

true or false: patients with Charcot’s foot deformity predisposes them to neuropathic ulcer formation

Answer 45

true.

Question 46

how do patients with Charcot’s foot present?

Answer 46

- swelling - distortion - pain - loss of function

Question 47

how is Charcot’s foot managed?

Answer 47

requires specialist review for consideration of off-loading abnormal weight. may need immobilisation of the affected joint using plaster