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Surgery finals > Vascular surgery > Flashcards

Vascular surgery Flashcards

1
Q

Define abdominal aortic aneurysm

A

Abdominal aorta diameter >1.5x expected (eg >3cm)

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2
Q

Describe the epidemiology and RF of AAA

A

M >F

RFs: smoking, FHx, age, HTN, connective tissue disease, syphilis

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3
Q

Describe the pathophysiology of AAA

A

Loss of connective tissue in aortic wall eg. collagen + elastin
->dilatation

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4
Q

Describe the presentation of AAA

A

May be asymptomatic + unruptured: screening
Symptomatic + unruptured: abdo/flank pain, obstructive Sxs
-Can also cause complications such as thrombosis/emboli
Symptomatic + ruptured: collapse, shock, constant severe pain *may mimic renal colic

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5
Q

Describe the signs of AAA on examination

A

Ruptured AAA: hypotension, tachycardia, decreased GCS, pallor, abdominal distension + tenderness, pulsatile mass
Unruptured: pulsatile + expansile epigastric mass

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6
Q

Describe the investigations for AAA

A

Ruptured:
-Bloods (FBC, CRP, U+Es, amylase/lipase, clotting, CM)
-Imaging: USS or CTA
Unruptured: USS -> CTA/MRA

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7
Q

Describe the screening for AAA

A 
Men invited at 65 years 
<3cm: discharged for life
3-4.4cm: annual surveillance 
4.5-5.4cm: 3 monthly surveillance
>5.5cm: intervention
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8
Q

Describe the management of unruptured AAA

A

Depends on size
Conservative:
-Smoking cessation

Medical:

  • BP control
  • Antiplatelet (aspirin/clopi)

Surgical/interventional: >5.5cm or rapidly growing

  • EVAR
  • Open surgical repair
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9
Q

Describe the management of ruptured AAA

A 
A to E approach
-IV access, bloods, fluid resus + blood products (best)
-Make NBM, analgesia
-USS -> CTA 
Senior support, ITU, vascular 
Urgent surgical repair: EVAR or open
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10
Q

Describe the prognosis for AAA

A

Rupture is often fatal

Intervention has relatively high mortality rates

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11
Q

Describe the complications of AAA

A

Rupture (+death)
Thrombosis + emboli
Intervention: graft infection, limb occlusion, endoleak, erectile dysfunction

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12
Q

Describe the types of aneurysm

A

Aneurysm: ballooning in the wall of an artery
False: damage to blood vessel wall causing collection of between the layers
True: bulge comprising all 3 layers of the aortic wall

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13
Q

Describe the epidemiology of aortic dissection

A

Typical: male in 50s

Also younger patients (Marfan’s)

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14
Q

Define aortic dissection

A

A separation of the inner layer of the aortic wall (tunica intima + tunica media)
Leads to the creation of a false lumen

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15
Q

Describe the aetiology + RF of aortic dissection

A
  • Connective tissue disease eg. Marfan’s
  • Hypertension
  • Iatrogenic
  • Drug use (cocaine)
  • Smoking
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16
Q

Describe the classification of aortic dissection

A

Stanford A: affects ascending aorta/arch

Stanford B: affects descending aorta

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17
Q

Describe the presentation of aortic dissection

A
  • Sudden onset, severe, ‘tearing’, chest/back/abdo pain, radiates to back, relieved by sitting forwards
  • Sweating, nausea
  • Symptoms of limb ischaemia eg. limb pain, weakness, paraesthesia
  • Shock
  • Syncope
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18
Q

Describe the signs of aortic dissection on examination

A
  • General: tachycardia, hypotension, sweating
  • Reduced/absent pulses
  • Systolic BP difference between arms
  • Diastolic murmur
  • Focal neuro deficit (in stroke)
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19
Q

Describe the investigations for aortic dissection

A
  • If HD unstable: A to E approach
  • History + examination
  • Bloods: FBC, CRP, U+Es, trops, clotting, CM, lactate
  • ECG (DDx, also infarction may occur as complication)
  • CXR: widening of mediastinum, effusion
  • > TTE/CT (CT definitive, TTE if suspected + available)
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20
Q

Describe the management of aortic dissection

A
  • If HD unstable: A to E approach
  • IV access + fluid resus/blood products
  • NBM, analgesia

Medical:
-IV beta-blocker or CCB (if no AR present) -> vasodilator

Surgical/interventional:

  • Type A: emergency surgery
  • Complicated Type B: urgent TEVAR/open repair
  • Uncomplicated Type B: medical therapy, consider Sx
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21
Q

Describe the prognosis of aortic dissection

A

Untreated proximal dissection: death in 50% by 24 hours

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22
Q

Describe the complications of aortic dissection

A 
Cardiac tamponade
Aortic valve incompetence
MI 
Regional ischaemia eg. limb, cerebral, renal
Aneurysmal degeneration
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23
Q

Describe the epidemiology of peripheral vascular disease

A

Increases with age

Usually affects >40s

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24
Q

Define peripheral arterial disease

A

Symptoms caused by obstruction of the lower limb arteries

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25
Q

Describe the aetiology of PAD

A 
Atherosclerosis (almost always)
Buerger's disease
Aortic coarctation 
Dissection
Tumour etc
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26
Q

Describe the stages of PAD

A

Fontaine classification

  1. Asymptomatic
  2. Mild claudication
  3. Severe claudication
  4. Ischaemic rest pain
  5. Ulceration/gangrene
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27
Q

Describe the spectrum of PAD

A

Asymptomatic
Claudication
Chronic critical limb ischaemia: >2 weeks, rest pain/tissue loss
Acute limb ischaemia

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28
Q

Describe the classic signs of acute limb ischaemia

A

6 P’s

  • Pale
  • Painful
  • Pulseless
  • Parasthesia
  • Paralysis
  • Perishingly cold
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29
Q

Describe the presentation of PAD

A

Claudication:

  • Intermittent calf/buttock pain on exertion, relieves with rest
  • Reproducible, worse on incline/stairs

Erectile dysfunction (aortoiliac disease)

Critical limb ischaemia:

  • Rest pain
  • Gangrene/ulcers

Acute ischaemia: 6 Ps

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30
Q

Describe the signs of PAD on examination

A

Inspection:

  • Bypass scar
  • Pallor/dependent rubor
  • Loss of hair on dorsum
  • Skin changes: thinning (shiny/scaly), ulceration

Palpation:

  • Weak/absent pulses
  • Reduced sensation

Buerger’s test:

  • Reduced Buerger’s angle (<30)
    • Buerger’s sign (reactive hyperaemia)
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31
Q

Describe the investigations for PAD

A

Stable PAD:

  • History and examination
  • ABPI +/- exercise ABPI eg claudication
  • Bloods (for RFs): U+Es, HbA1c, lipids
  • Duplex USS
  • CTA/MRA/intra-arterial DSA

Acute limb ischaemia:

  • Bloods
  • Doppler USS
  • Imaging
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32
Q

Describe the interpretation of ABPI

A

<0.80: PAD
<0.6: severe PAD
1.0-1.2/3: normal
>1.2/3: calcification eg. age+ DM

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33
Q

Describe the management of chronic PAD

A

Conservative:

  • Lifestyle mod: smoking, diet + exercise
  • Claudication: 12 wk supervised exercise program

Medical:

  • RF management: BP, DM, statin
  • Antiplatelets (aspirin/clopi)
  • Claudication: consider vasodilator if unsuitable for revasc.
  • Critical limb ischaemia: analgesia

Surgical/interventional:

  • Revascularisation
    1) Endovascular techniques- angioplasty (stent/balloon)
    2) Anatomical bypass- eg aortobifemoral, fem-pop
    3) Extranatomical bypass eg. fem-fem crossover
  • Amputation: last resort
34
Q

Describe the management of acute limb ischaemia

A
  • History and examination
  • Make NBM, analgesia (morphine), IV fluids if needed
  • IV access and bloods: FBC, U+Es, clotting, G+S, CK
  • ECG
  • Doppler USS
  • Unfractionated heparin IV
  • Emergency revascularisation eg. endovascular, bypass, fasciotomy, amputation etc
35
Q

What is Buerger’s disease?

A

aka thromboangiitis obliterans
Acute inflammation + thrombosis of A in the hands + feet -> ulceration + gangrene
Typically affects young males who smoke

36
Q

What is Leriche syndrome?

A 
Aortoiliac occlusion 
Triad of: 
1. Buttock claudication + wasting 
2. ED
3. Absent femoral pulses
37
Q

Describe the differences between arterial ulcers and venous ulcers

A

Arterial:

  • Well-demarcated, ‘punched out’ lesions
  • Small + deep
  • Necrotic tissue
  • Painful
  • Signs of PAD eg. pale, thin, shiny skin + loss of hair

Venous:

  • Occur in the gaiter area
  • Rough, sloughy borders
  • Shallow + large
  • Signs of chronic venous disease: hyperpigmentation, venous eczema, lipodermatosclerosis, oedema
38
Q

Describe the appearance of diabetic ulcers

A
  • Usually occur over pressure areas eg. ball of foot
  • Deep, surrounded by callus
  • Loss of sensation
39
Q

Define chronic venous insufficiency

A

Changes in the lower extremities due to chronically raised venous pressures eg. skin changes, oedema, ulcers

40
Q

Describe the epidemiology of chronic venous insufficiency

A

Relatively common (7%)

41
Q

Describe the aetiology of chronic venous insufficiency

A

Abnormality in lower extremity veins

  • Typically reflux (valve incompetence), can also be chronic obstruction
  • Commonly occurs after DVT
42
Q

Describe the presentation of chronic venous insufficiency

A

Leg heaviness/aching + swelling
Skin changes, itching/flaking
Ulcers

43
Q

Describe the signs of chronic venous insufficiency on examination

A
  • Early: telangectasia, oedema, varicose veins
  • Skin changes: hyperpigmentation, eczema, lipodermatosclerosis, atrophie blanche
  • Ulceration: described above
44
Q

What is lipodermatosclerosis? Describe appearance

A

Changes that occur in chronic venous insufficiency due to inflammation and fibrosis of SC tissue

  • Atrophy + hardening of skin
  • Champagne bottle legs
  • Discolouration
45
Q

What causes hyperpigmentation in chronic venous insufficiency?

A

Haemosiderin deposition

46
Q

What is normal venous pressure in the lower extremities?

A

<20mmHg

47
Q

Describe the investigations for chronic venous insufficiency

A
  • History and examination (usually clinical Dx)

- Duplex USS (for finding reflux/obstruction)

48
Q

Describe the management of chronic venous insufficiency + varicose veins

A

Conservative:

  • Regular walks, leg elevation
  • Graded compression stockings
  • Skin care: moisturisers, ulcer dressings

Surgical/interventional:

  • Varicose veins: phlebectomy (under LA), foam sclerotherapy
  • Endovenous ablation (for GSV or SSV reflux)
  • Saphenectomy (stripping)
49
Q

Define ulcer

A

A discontinuity in the epithelial surface

50
Q

Describe the management of venous and arterial ulcers

A

Conservative:

  • Venous: graded compression stockings, analgesia, elevation, dressings
  • Arterial: lifestyle modification eg. exercise, smoking

Medical:
-Arterial: manage RFs

Surgical/interventional:

  • Venous: venous surgery
  • Arterial: revasc
51
Q

When are compression stockings contraindicated?

A

If ABPI <0.8 (indicates PAD)

52
Q

Define gangrene and the types

A

A complication of necrosis in which there is decay of tissues

  • Wet/infectious: necrotizing fasciitis, gas gangrene
  • Fournier’s gangrene: nec fasc of perineum
  • Dry/ischaemic
53
Q

Describe the aetiology of gangrene

A

Infection
-RFs: DM, IVDU, immunocompromise, trauma, wounds, surgery

Ischaemia: arterial or venous.
-RFs: atherosclerosis, DM, smoking, malignancy, APS, Raynaud’s

54
Q

Describe the signs of gangrene on inspection

A

Dry:

  • Tissue cold, shrunken, black and dry
  • Well-demarcated

Wet:

  • Tissue moist, soft, swollen and dark
  • No clear demarcation
  • Gas: crepitus
55
Q

Which organisms are responsible for infectious gangrene?

A

Necrotising fasciitis:
-Type I: Enterobacteria, anaerobes
-Type II: Grp A Strep, S aureus
Gas gangrene: Clostridium pefringens mostly

56
Q

Describe the presentation of gangrene

A

Pain!
Dry: symptoms of PAD- pain, parasthesia, paralysis
Wet:
-Fever, chills
-Nec fasc: severe pain out of proportion to clinical signs

57
Q

Describe the investigations for gangrene

A
  • History and examination
  • ABPI
  • Bloods (wet): FBC, CRP, U+Es, lactate, glucose, culture
  • Consider as appropriate: Doppler USS, Xray (gas gangrene), swab, biopsy
58
Q

Describe the management of gangrene

A

Ischaemic:
-IV heparin
-Revasc + RF management
+/- amputation (non-viable tissue)

Infectious:
-IV BS antibiotics
-Surgical debridement
+/- amputation

59
Q

Describe the risk factors for varicose veins

A
  • Obesity
  • Pregnancy
  • Older age
  • Family history
  • Connective tissue disease
60
Q

Describe the presentation of thrombophlebitis

A

Localised severe pain, warmth, erythema and swelling

Palpable cord-like mass/ varicose vein

61
Q

Describe the investigations for varicose veins

A

Same as venous insufficiency: Duplex USS

62
Q

Describe the arterial supply and venous drainage of the lower limbs

A

Arteries:
Aorta -> common iliac A -> internal + external A
-> femoral A -> popliteal A -> ant + post tibial A
-> Ant becomes dorsalis pedis

Veins:

  • Deep system: ant + post tibial -> popliteal -> femoral
  • Superficial system: great saphenous vein (medial) -> femoral vein, and small saphenous vein (posterior) -> popliteal vein
63
Q

Describe the aetiology of thrombophlebitis

A
  • Usually varicose veins

- Migratory/recurrent: malignancy, APS

64
Q

Describe the investigations for thrombophlebitis

A 
Doppler USS (important to rule out DVT)
Recurrent/above knee/large: bloods (thrombophilia screen), CTCAP
65
Q

Describe the management of thrombophlebitis

A

NSAIDs + compression stockings
+/- anticoagulation (>5cm or close to SFJ)
-Varicose vein surgery after resolution

66
Q

Describe the risk factors for DVT

A

Virchow’s triad:

1) Stasis:
- Bed rest, surgery, immobilisation, travel
2) Hypercoagulability:
- Pregnancy, malignancy, COCP, thrombophilia, sepsis
3) Vessel wall injury:
- Atherosclerosis, vasculitis

67
Q

Describe the presentation of DVT

A

Sudden onset swollen + painful calf

68
Q

Describe the signs of DVT on examination

A

Unilateral swollen leg (>3cm from normal leg)
Redness/discolouration
Tender
Dilated superficial veins

69
Q

Describe the investigations for DVT

A
  • History and examination
  • Calculate Well’s score: likely (2+)-> USS
  • Bloods: FBC, U+Es, CRP, clotting (D-dimer)
  • Imaging: Doppler USS
  • Confirmed: consider CTPA if signs/symptoms
70
Q

Describe the Well’s score for DVT

A 
Includes risk factors for DVT and clinical findings eg.
-Active cancer
-Bedridden 
-Calf swelling and tenderness
2+ is likely -> USS 
<2 is unlikely -> D-dimer (if + -> USS)
71
Q

Describe the management of DVT

A

Conservative:
-Graded compression stockings to prevent post-thrombotic syndrome

Medical: *mainstay

  • Anticoagulation: DOAC 1st line, LMWH, warfarin, UFH
  • Continue for 3 months min (3 mo for provoked, 6 mo active cancer, consider lifelong if thrombophilia)

Surgical/interventional:

  • IR thrombolysis
  • IVC filter
72
Q

Describe aneurysm repairs

A

Open:

  • Midline laparotomy incision
  • Clamp aorta, open aneurysm + suture in graft, close

EVAR (endovascular aneurysm repair):
-Catheter through groin -> place graft in aneurysm + fix

73
Q

Describe the complications of aneurysm repair

A

Intra-operative: haemorrhage, damage to surrounding structures, ischaemic injury, death
Anaesthetic
Short term post-op: pain, wound infection, endoleak, ileus, AKI
Long term post-op: graft infection, endoleak

74
Q

What is carotid endarterectomy?

A

Endovascular removal of atherosclerotic plaque buildup in the carotid arteries

75
Q

Describe the indications for carotid endarterectomy

A

Carotid artery stenosis >70%

Or >50% if low risk

76
Q

Describe the complications of carotid endarterectomy

A

Intra-op: stroke, death
Anaesthetic
Short term post-op: infection, bleeding, pain
Long term post-op: restenosis

77
Q

Describe the indications for amputation

A
  • Gangrene
  • Severe PAD unresponsive to revasc
  • Significant trauma
  • Tumours
78
Q

Describe the common types of amputation

A

Knee disarticulation: through knee joint
Transtibial amputation: through tibia, preserves knee
Ankle disarticulation etc.

79
Q

Describe the complications of amputations

A

Intra-op: bleeding, damage to surrounding structures
Anaesthetic
Early post-op: bruising, pain, wound infection, flap necrosis
Late post-op: phantom limb, depression

80
Q

Name some examples of bypass surgery and the 2 main types

A

Anatomical: aortobifemoral

Extra-anatomical: fem-fem crossover, axillobifemoral

Surgery finals (16 decks)

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