Vascular (surgical shorts) Flashcards
Femoral vein anatomy
Femoral artery anatomy
6/7 (0-6) stages of CEAP classification
Clinical-Etiology-Anatomy-Pathophysiology
•Patients in finals almost always C4a at a minimum
What is lipodermatosclerosis
Lipodermatosclerosis: red blood cells stagnate, extravasate, consumed by inflammatory cells. Tissue fibrosis and atrophy in ascending pattern (where most venous pooling is)
NICE Guidelines: Venous Disease.
High Yield.
Summary:
- When to refer: symptomatic disease, (skin changes/venous ulcer) CEAP 4a onwards, superficial vein thrombosis
- Ultrasound Duplex: confirm disease, quantify reflux, plan treatment
Management: conservative, surgical
- Conservative: weight loss, compression bandages & alginate dressing for venous ulcers, do not routinely offer TEDS,
- Surgical in order:
- radiofrequency/laser ablation
- US foam sclerotherapy
- surgery
Complications of varicose veins:
- DVT, skin changes, leg ulcers, bleeding, thrombophlebitis
General approach to scar description
3 points
Sentence 1: general, detailed description of scar
Sentence 2: what is the likely name of the scar OR atypical?
Sentence 3: justification of your answer/possible indications for the scar: say what’s common and what anatomically significant areas lie beneath
Describe scar
5 discrete scars for CABG, saphenous vein harvesting.
Describe the scar
and then…
•‘I note a 12-15 cm well healed, linear scar on the medial aspect of this gentleman’s medial left thigh and a further 7-10 cm well healed, linear scar on the medial aspect of this gentleman’s medial left calf….
- 20 cm linear recent scar extending from the top of the manubrium to the bottom of the sternum
- Consistent with a midline sternotomy
- I note two 2-3 cm transverse port site scars located inferolateral to the main scar.
- Bruising, clips and appearance of the scar suggest recent surgery.
‘I note a 12-15 cm well healed, linear scar on the medial aspect of this gentleman’s medial left thigh and a further 7-10 cm well healed, linear scar on the medial aspect of this gentleman’s medial left calf….
(1) Coronary Artery Bypass Graft. Access to the saphenous vein as I note a median sternotomy scar and no signs of peripheral vascular disease in this gentleman’s left leg
(2) Left sided femoral-distal bypass. Access to the saphenous vein and femoral and popliteal arteries due to left sided disease.
(3) Right sided femoral-distal bypass. Access to the saphenous vein as I note right sided peripheral vascular disease and corresponding scars in this gentleman’s right leg (not visualized here)…
(4) Other rarer indications such as a fasciotomy and associated femoral arterial repair in the context of trauma
What do you see?
BKA of right leg with a 15cm horizonal scar in a symmetrical n shape across the stump consistent with a long posterior flap of bergess
Far more commonly seen technique for transtibial (below knee) amputation
Skin and gastrocnemius brought forward to cover shin bones after being divided
alt flap=skewed flap, kingsley robinson MUCH LESS COMMON
Scar line runs is anterior-posterior (antero-lateral to postero-medial)
The muscles of the calf are brought forward in the same way as in the posterior technique but the skin flaps are skewed in relation to the muscle.
suggest 1x
name of scar, anatomy it gives access too, pathology Rx
Paramedian Laparotomy: aorta
AAA
suggest 1x
name of scar, anatomy it gives access too, pathology Rx
Rooftop: aorta
AAA
suggest 1x
name of scar, anatomy it gives access too, pathology Rx
Oblique scar: iliacs. aka Rutherford Morrison.
Think renal transplant as a differential as in renal transplant, iliacs are accessed for grafting to donor kidney.
What do you see
Remember carotid endarterectomy scars heal really well and can become almost invisible according the the vascular registrars at CX
Define an aneurysm/pseudoaneurysm
A pathological swelling of a vessel to greater than 1.5 times its original diameter, involving all three layers of the vessel wall
Pseudoaneurysms don’t involve all three layers
Management of AAA
UKSAT trail?
- Elective surgical repair carries XX mortality rate
- <xx>
<li>>XX cm have an annual risk of rupture of XX</li>
</xx>
</xx>
- Indications for surgery* x3?
1. 2. 3. - EVAR vs open*
- Complications of AAA (3 categories)*
UK Small Aneurysm Trial (UKSAT) & US Aneurysm Detection & Management Study
- Elective surgical repair carries 5% mortality rate
- <5.5 cm AAA have annual risk rupture <1%
- >6 cm have annual risk of rupture of 25%
Indications for surgery
- AAA diameter > 5.5 cm in men
- AAA diameter growing > 1 cm per year
- Symptomatic AAA
EVAR vs open
- EVAR: significantly lower operative mortality than open surgical repair.
- No differences were seen in total mortality or aneurysm-related mortality in the long term.
(United Kingdom EVAR Investigators published in New England Journal of Medicine 2010)
Complications of AAA : NAVY & surrounding structures
- Artery: rupture (&exsanguination), dissection, thrombosis and embolisation from thrombus leading to trash foot.
- Surrounding structures:
- (1) fistulation into surrounding organs e.g. colon or vena cava,
- (2) retroperitoneal fibrosis (inflammation)
What scars will be seen in endovascular aneurysm repair
RF for PVD
- Modifiable:
- Smoking
- dyslipidaemia
- Obesity (BMI >30)
- Sedentary (lack of exercise)
- Poor diet
- Metabilic syndrome: Diabetes
- Hypertension
- Non-modifiable:
- Age
- Male
- Family history of PVD
- Genotype
- CKD
What are the three stages of Buerger’s test?
Stage 1: raise leg, develops pallor at a specific angle
Stage 2: lower leg, delay in return of colour
Stage 3: build up of vasodilator metabolites in ischemic leg causes reactive hyperemia: LEG GOES RED
What are the signs of limb ischemia?
6 P’s
- Pale
- Pulseless
- Painful
- Paralysed
- Paraesthetic
- Perishingly cold
Investigations of peripheral vascular disease
Bedside/bloods/imaging
Bedside:
(1) ECG: for ischemic heart disease and its complications
(2) ABPI: calculate relative blood flow/limb ischemia
(3) Doppler: screen for degree of stenosis
(4) BP: hypertension
(5) Urine dip: glycosuria for diabetes
Bloods:
(1) FBC: polycythemia
(2) U&E: renal failure if giving contrast (e.g. CT aortogram)
(3) Plasma glucose & BM: diabetes
(4) Group & Save, Cross Match: for surgery
(5) Clotting: to assess for safety for anticoagulant therapy
Imaging:
(1) Ultrasound duplex: degree of stenosis
(2) CT aortogram: reconstruct vessels in 3D
(3) Digital subtraction angiogram: location of stenosis, presence of collateral blood supply
Significance of ABPS (x5 categories)
>1.2 = calcification arteries, severe PVD
- 9-1.2 = normal/acceptable range
- 8-0.9 = some arterial disease, manage risk factors
- 5-0.8 = moderate arterial disease. Routine specialist referral.
<0.5 = severe arterial disease. Urgent specialist referral.
Management of PVD
conservative/med/surg
Conservative: diet, exercise program, smoking, diabetic specialist nurse, podiatrist for foot care
Medical:
- Aspirin 75 mg
- ACD treatment hypertension
- Statins
- Optimise insulin/oral hypoglycemics
Surgical:
- Endovascular: stents/grafts
- Endarterectomy
- Reconstructive surgery: anatomical or extra-anatomical bypasses
- Amputation
Types of amputations (in finals x6)
Digital: seen in finals, often auto-infarcted
Trans-metatarsal: never documented as seen in finals
Above ankle: never documented as seen in finals
Below Knee: seen in finals
Above Knee: seen in finals
Hindquarter: never documented as seen in finals
Q: What is Leriche’s Syndrome?
Aorto-iliac occlusive disease: blockage of aorta as it transitions into iliacs
Triad of:
- Claudication (buttock/thigh)
- Erectile dysfunction
- Absent or decreased femoral pulses
Treatment of leiche’s syndrome (x3)
- ‘kissing’ balloon angioplasty +/- stent (two baloon, reduce zone of plaque shift)
- Aorto-iliac bypass graft
- Axillo-bifemoral bypass and femoral-femoral bypass
Q: What is Huanman’s disease?
Subclavian steal syndrome
Retrograde (reversed) blood flow in vertebral or internal thoracic artery due to proximal stenosis and/or occlusion of subclavian artery
The arm is supplied with retrograde blood flow down the vertebral artery at the expense of the vertebrobasilar circulation
Q: What is Klippel-Treaunay Syndrome?
Rare congenital condition where blood vessels and/or lymph vessels are malformed
Triad of:
- Port-wine stain
- Venous & lymphatic malformation (incl. varicose veins)
- Soft-tissue hypertrophy of affected limb
Q: In renal failure, why do so many patients have aortic stenosis and peripheral vascular disease?
Often hypertensives/diabetics
Chronic hyperphosphatemia leads to calcification of vessels and valves
Define:
pathophys
Symptoms:
special tests:
causes:
Varicose veins: ‘Dilated, tortuous veins in the distribution of the superficial venous system’
Pathophys: failure of valves results in back flow from the deep to superficial circulation
Symptoms: Pain, heaviness, cramping, tingling, bleeding, itching, swelling
Special tests: torniquet and abdo exam
Causes:
- Primary
- Prolonged standing
- Obesity
- Pregnancy
- Secondary
- Valve destruction: DVT, thrombophlebitis
- Obstruction: pelvic mass DVT
- Syndromes
Name these 7 signs of venous disease
Arteial vs venous ulcer
