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
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 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
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
