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3rd yr clinical > Vascular Surgery > Flashcards

Vascular Surgery Flashcards

1
Q

What are the 6Ps of acute limb ischaemia

A

Pain, pallor, pulseless, paralysis, paraesthesia perishing cold

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2
Q

What is Leriche Syndrome

A

Occlusion in the distal aorta or proximal common iliac artery

Thigh/ bum claudication
Absent femoral pulses
Male impotence

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3
Q

What is Buerger’s test

A
  1. Lie patient on back and life legs to 45 degrees at hip - hold 1-2 mins - pale = inadequate arterial supply

Berger’s angle - angle that leg goes pale

  1. Sit patient up with legs hanging over bed - healthy patient- legs will go pink

PAD- Legs will be initially blue- ischaemic tissue deoxygenates blood
Then
Dark red - rubor

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4
Q

What are the features of arterial leg ulcers

A

Small, deep, well defined, punched out, peripheral (on toes), reduced bleeding, painful, pale, pain worse at night or on elevating - helps to lower leg

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5
Q

What are the features of venous ulcers

A

Happen after minor leg injury, larger than arterial, more superficial, irregular sloping boarders, affect mid calf to ankle, less painful, skin changes, pain worse on lowering leg

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6
Q

What is a normal Ankle- brachial pressure index

A

0.9-1.3 - normal

Lower than 0.9= PAD

Above 1.3 = Calcification of arteries- diabetes

Ratio of Systolic BP in ankle compared with arm

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7
Q

What is the treatment for intermittent claudication

A

Exercise training

Medical- Statins 80mg , clopidogrel 75mg , peripheral vasodilators

Surgical- endovascular angioplasty and stenting

Bypass surgery

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8
Q

What is the management of critical limb ischaemia

A

Urgent revascularisation
Endovascular angioplasty and stenting
Endarterectomy
Bypass surgery
Amputation

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9
Q

What is the management of acute limb ischaemia

A

caused by a thrombus

Endovascular thombolysis
Endovascular thombectomy
Surgical thrombectomy
Bypass
Endarterectomy
Amputation

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10
Q

What are the main risk factors for a DVT

A

Immobility, surgery, long haul travel, pregnancy, Hormone therapy with oestrogen, malignancy, polycythaemia, SLE, thrombophilia

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11
Q

What are the two types of VTE prophylaxis

A
  1. LMWH- enoxaparin - contraindicated (active bleeding or existing anticoagulation with warfarin or DOAC)
  2. Anti-embolic compression stockings
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12
Q

How do you examine leg swelling

A

Circumference of the calf 10cm below tibial tuberosity more than 3cm difference between calves is signficiant

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13
Q

What is used to diagnose a DVT

A

Doppler USS to diagnose

Repeat negative USS 6-8 days after if D-Dimer is positive and Well’s score suggests that DVT is likely

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14
Q

What is used to diagnose a PE

A

CT pulmonary angiogram (preferred) or VQ scan

VQ scan in significant renal impairment

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15
Q

What is the initial management of a DVT or PE

A

Treatment dose apixaban or rivaroxaban (10mg) - started immediately

Catheter directed thrombolysis in patients with iliofemoral DVT that symptoms last less than 14 days

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16
Q

What long term anticoagulation is used in DVT/PE

A

DOACS- apixaban, rivaroxaban etc - most patients

Warfarin in patients with antiphospholipid syndrome
(APLS= weirdos- warfarin)

LMWH (enoxaparin) in pregnancy

Anticoag for
3 months if reversible cause
over 3 months in unclear cause, recurrent VTE or irreversible cause
3-6 months in active cancer

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17
Q

What are the features of chronic venous insufficiency

A

Brown discolouration of legs- blood pools in distal veins causing haemosiderin to leak into legs and get deposited around shins

Venous eczema due to pooling of blood in distal tissues causing inflam

Lipodermatosclerosis- fibrotic tight skin causing lower legs to become hard

Atrophie blanche- smooth white scar tissue

Cellulitis, poor healing, skin ulcers, pain

18
Q

What special tests are used for varicose veins

A

Tap test- pressure at saphenofemoral junction and tap distal varicose vein- thrill felt in SFJ suggests incompetent valve between these two points

Trendelenburg’s test- lie down and lift affected leg - apply tourniquet to thigh and stand up - if varicose veins appear then the valve is below the level of the tourniquet - keep moving tourniquet down

Duplex USS to assess extend of varicose vein

19
Q

What is the management of varicose veins

A

Weight loss, physically active, keep leg elevated, compression stocking

Endothermal ablation
Scleropathy
Stripping

20
Q

How is chronic venous insufficiency managed

A

Keep skin healthy- use emollients, topical steroids for venous eczema flares, potent steroids to treat lipodermatosclerosis

Keep active, compression stockings, keep legs elevated

Abs for infection
Analgesia
Wound care for ulcers

21
Q

What is the management of an arterial ulcer

A

Urgent referral for surgical revascularisation

22
Q

What is the management of venous ulcers

A

Good wound care
Cleaning, debridement, dressing

Compression therapy
Pentoxifylline to improve healing
Antibiotics to treat infection
Analgesia (not NSAIDs)

23
Q

How is lymphoedema assessed

A

Stemmer’s sign- Pinch skin at bottom of middle finger - lymphoedema if you can’t lift and tent the skin

Limb volume - calculated by circumference, water displacement, perometry

BIA

Lymphoscintigraphy

24
Q

What is the management of lymphoedema

A

Massage drainage techniques
Compression bandages
Weight loss
Good skin care

Lymphaticovenular anastomosis - attach lymph vessels to veins to help drainage

Don’t take bloods, cannulas or do BP in a limb with lymphoedema

25
Q

What is lymphatic filariasis

A

Infectious disease caused by parasitic worms spread by mosquqitoes- worms live in lymphatic system and cause lymphoedema - Africa and Asia

26
Q

How dilated does a triple A need to be and when are men screened

A

More than 3cm dilated
USS at 65 to detect asymptomatic AAA

27
Q

How is a AAA investigated and classified

A

USS urgent 1st line
CT angiogram if have time

Classification
Normal - less than 3
Small- 3-4.4
Medium 4.5-5.4
Large 5.5 <

28
Q

What is the management of a AAA

A

Treat modifiable risk factors
Yearly follow up scans if 3-4.4cm
3mnthly scans if 4.5-5.4cm

Elective repair if
-Symptomatic, diameter growing more than 1cm per yr, diameter over 5.5

Open repair or Endovascular aneurysm repair with stent via femoral arteries

Inform DVLA if Aneurysm over 6cm and stop driving if over 6.5cm

29
Q

What is the treatment for a ruptured AAA

A

Surgical emergency - repair

Permissive hypotension- aim for a lower blood pressure when giving fluid resus

Only use CT angio to exclude this diagnosis in haemodynamically unstable patients

30
Q

What are the features of aortic dissection

A

Tear in the inner layer of aorta
Blood enters between intima and media layers creating a false lumen

31
Q

What are the classifications for aortic dissection

A

Stanford system
A- Ascending aorta before brachiocephalic artery

b-Descending aorta after left subclavian

32
Q

What are the risk factors for aortic dissection

A

HTN
Weight lifting, cocaine- anythign that causes quick increase in BP

Bicuspic aortic valve, coartation of aorta, CABG, aortic valve replacement - anything that affects the aorta

Ehlers-Danlos Syndrome
Marfans syndrome
Think CT issues

33
Q

What are the features of aortic dissection, how is it investigated

A

Ripping/ tearing chest pain
HTN, differences in BP in arms , radial pulse deficit, diastolic murmur, focal neuro deficit, chest and abdo pain, syncope, hypotension as it progresses

CT angiogram first line

34
Q

What is the management of aortic dissection

A

Surgical emergency
Analgesia
BP and HR controlled on beta blockers - reduce stress on aorta
Type a- open surgery to remove section and replace with synthetic graft

Type b- Thoracic endovascular repair with a catheter in femoral vein

35
Q

How is carotid artery stenosis investigated

A

Usually diagnosed after TIA or stroke- carotid USS

Can do a CT or MRI angiogram to assess stenosis before surgical intervention

Can hear carotid bruit on examination

36
Q

What is the classification of carotid artery stenosis

A

Mild less than 50% reduction
Moderate 50-69% reduction
Severe 70% or more

37
Q

How do you manage carotid artery stenosis

A

Lifestyle choices
Anti-platelet meds - aspirin, clopidogrel, statins

Surgical when significant
Carotid endarterectomy <70% stenosis - first line and scapes out plaques- risk of stroke with this and nerve damage- facial nerve palsies etc

Angioplasty and stenting

38
Q

What are the features of Buerger disease

A

Inflam condition causing thrombus formation in small and medium vessels in hands and feet

Men aged 25-35 and associated with smoking

Features
Men under 50
No risk factors for atherosclerosis except smoking

39
Q

How does buerger’s disease present

A

Painful, blue discolouration of fingertips and toes, worse at night, ulcers, gangrene

Corkscrew collaterals found on angiograms - collateral vessels form to bypass affected arteries

40
Q

How is Buerger’s disease managed

A

Stopping smoking completely- no nicotine replacements
IV iloprost to dilate blood vessels

41
Q

What is the difference between acute limb ischaemia and critical limb ischaemia

A

Critical limb ischaemia- end stage PAD- inadequate blood supply to sustain limb- pain worse at night- risk of loosing limb

Acute limb ischaemia- rapid onset ischaemia caused by a clot

42
Q

What are some types of thrombophillias and what is a thrombophilia

A

Thrombophilia- predisposition to clotting

Factor V leiden- most common
Antiphospholipid
Antithrombin deficiency
Portein C/ S deficiency

3rd yr clinical (22 decks)

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