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Year 3 Surgery > Vascular > Flashcards

Vascular Flashcards

1
Q

Appearance of venous ulcers?

A

Shallow
Irregular boarders
Odema, haemosidrin deposition (brown), eczma, painless

Pt may also have varicose veins as these are secondary venous insufficiency

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2
Q

Where are venous ulcers commonly found?

A

Medial malleolus/gaiter region

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3
Q

What is the pathophysiology of venous ulcers?

A

Valvular incompitence/venous outflow obstruction
Impaired venous return
Venous HTN causes trapping of WBC in capillaries and the formation of a fibrin cuff around the vessel hindering oxygen transportation into the tissue
WBC activation
Release of inflammatory mediators
Tissue injury and poor healing necrosis

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4
Q

Clinical features of a venous ulcer

A 
Painful, worse at the end of the day
Before ulceration 
- Aching 
- Itching 
- Bursting sensation
Associated varicose eczma 
Haemosiderin skin staining 
Thrombophlebitis 
Lipodermatosclerosis
Atrophie blanche
Ankle/leg odema
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5
Q

Management of venous ulcers

A 
Leg elevation 
Exercise 
Weight loss
Improved nutrition 
Abx if clinical evidence of wound infection
Multicomponent compression bandaging changed 1-2 times a week (ABPI>0.6 before bandaging applied)
Dressings and emollients 
Treatment of coccurent varicose veins
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6
Q

What are the causes of neuropathic ulcers?

A

Peripheral neuropathy (DM, B12 def)
Alcohol
Concurrent peripheral vascular disease
Foot deformity

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7
Q

Neuropathic ulcer appearance

A

Punched out appearence

Variable size/depth

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8
Q

Clinical features of neuropathic ulcers

A

Single nerve invovlement
Amotrophic neuropathy
Peripheral neuropathy, glove and stocking distribution with warm feet
Burning/tingling

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9
Q

Where do neuropathic ulcers usually occur?

A

Pressure areas

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10
Q

Management of neuropathic ulcers

A 
Specialised diabetic foot clinics
Diabetic and CVS disease control optomisation 
Improved diet 
Exercise 
Regular chiropody 
Ischemic/necrotic tissue debridment 
Amputation of necrotic didgits
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11
Q

What is Charcots Foot

A

Neuroarthopathy where by a loss of joint sensation results in continual unnoticed trauma and deformity occuring. Deformity predisposes patient to neuropathic ulcer formation.

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12
Q

How does Charcot’s Foot present?

A 
Swelling
Distortion
Pain
Loss of function 
Rocker bottom sole - deformity causing loss of the transverse arch
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13
Q

What do arterial ulcers look like?

A 
Small
Deep
Well definied 
Little granulation tissue compared to venous ulcers (more necrotic)
PUNCHED OUT
Will be on heels/toes

Cool extremities low APBI

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14
Q

Clinical features of arterialulcers

A 
Hx of imtermittent claudication/critical limb ischemia
Cold limbs with reduced/absent pulses
Thickened tonails 
Necrotic toes
Hair loss
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15
Q

Risk factors for arterial ulcers

A 
Obesity
HTN
FHx
Smoking
DM (microvascular and macrovascular complications) 
Hyperlipidemia 
Physical inactivity 
Increasing age
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16
Q

Pathophysiology of arterial ulcers

A

Atherosclerosis
Reduced tissue perfusion
Poor wound healing

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17
Q

Medical management of arterial disease

A

Statins
Antiplatelets
CBG optimisation
BP control

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18
Q

Surgical mamagement of arterial disease

A

Angioplasty +/- stenting

Bypass grafting in extensive disease

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19
Q

Management of arterial ulcers

A

Optimisation of underlying arterial disease

If non healing depsite adequete blood supply skin graft may be offered

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20
Q

Pressure ulcer staging

A

Stage 1 Epidermis
Stage 2 Dermis
Stage 3 Adipose and fascia
Stage 4 Muscle and bone

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21
Q

What are risk factors for DVT?

A 
Previous DVT 
Phlebitis
Smoking
Increasing age
Female
FHx
Obesity 
Pregnancy
Long periods of standing
Immobility 
Mallignancy 
Recent surgery
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22
Q

What is Virchow’s triad?

A

Endothelial injury
Stasis of blood flow
Hypercoagulability

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23
Q

Clinical features of DVT

A 
Lower limb swelling
Puritis
Pain
Thrombophlebitis 
Erythmatous 
Warm skin around painful
Lipodermatosclerosis
Haemosiderin skin staining 
Atrophi blanche 
Pedal odema
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24
Q

How is DVT investigated?

A

Doppler USS if D-dimer positive OR Wells>=2
Foot pulses
ABPI
D dimer if Wells score < 2 to rule out DVT

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25
Q

ABPI Values

A

Severe arterial disease < 0.5
Moderate arterial disease 0.8-0.5
Mild arterial disease 0.9-0.8

In diabetics/calcification ABPI will be higher than healthy patients

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26
Q

Initial management of DVT

A

Treatmet dose apixaban or rivaroxaban

Consider catheter directed throbolysis in oateitns with sympotmatic iliofemroal

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27
Q

Long Term Anticoagulation in VTE

A

DOAC
Warfarin
LMWH

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28
Q

How long should patients continue anticoagulation for after a DVT

A

3 months if reversable cause
Beyond 3 months of unclear cause or recurrent VTE
3-6 months in active cancer

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29
Q

What is the first line anticoagulant in pregnancy?

A

LMWH

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30
Q

Complications of DVT

A

PE
Chronic venous insufficiency
Post thrombotic sydrome

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31
Q

What are the mechanical methods of thromboprophylaxis

A

Antiembolic stockings

Imtermittent pneumatic compression

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32
Q

What are the pharmacological methods of thromboprophylaxis?

A

Low molecular weight heparin, enoxaparin, deltaparin, etc

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33
Q

What invesitgations should be carried out after an unprovoked DVT?

A 
Antiphospholipid syndrome (check antiphospholipid antibodies)
Hereditary thrombophilias (only if they have a first-degree relative also affected by a DVT or PE)
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34
Q

Risk factors for AAA

A 
Smoking
HTN
Hyoerlipedemia 
Family history
Male 
Increasing age 
NOTE DM IS PROTECTIVE
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35
Q

Patients with AAA are often asymptomatic, when they are not how might they present?

A 
Abdominal pain
Back pain
Loin oain
Distal embolisim producing limb ischemia 
Aortoenteric fistula 
Pulsatile mass at umbilical level
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36
Q

At what age is AAA screening offered to men?

A

65 years

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37
Q

What radiological investigations should be conducted in suspected AAA?

A
  1. USS

2. Ct scan with contrast if 5.5cm+ (determine suitability for endovascular proceedures)

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38
Q

Up to what size is an AAA suitable for USS monitoring?

A

5.5cm

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39
Q

How often should a 3-4.4cm AAA be monitored

A

Once a year

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40
Q

How often should a 4.5-5.4cm AAA be monitored?

A

Every 3 months

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41
Q

What size AAA disqualifies road users from driving until repaired?

A

6.5cm

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42
Q

What are the indications for surgical intervention in AAA?

A

AAA > 5.5cm
AAA expanding more than 1cm/year
Symptomatic

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43
Q

Treatment of AAA

A 
Open repair (midling laparotomy or long transverese incision, replaced with prosthetic graft)
Endovascular repair (graft via femoral arteries, stent fitted)
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44
Q

Compare endovascular vs open repair of an AAA

A

Endovascular: decreased hospital stay and 30 day mortarlity

Open: reduced rate of reintervention and aneurysm rupture

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45
Q

Complications of a AAA

A

Rupture
Retroperitoneal leak
Ebolisation
Aortoduodenal fistula

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46
Q

What are the risk factors for a AAA rupture?

A

Diamteter of aneurysm
Smoking
HTN
Female

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47
Q

How might a ruptured AAA present?

A 
Abdominal pain
Back pain
Syncope
Vommiting
Haemodynamical compromise
Pulsitile tender abdominal mass
48
Q

Management of a ruptured AAA

A

Highflow O2
Two large bore canula
Urgent bloods with crossmatch for 6U
Maintain permissive hypotension (<100mmHg, as to not dislodge any clots, but ensure oatient is cerebrating)
Transfer to vascular unit
Unstable: immediate theatre transfer for open repair
Stable: CT angiogram to determine whether endovascular repair may be suitable

49
Q

Stage 1 Chronic Limb Ischemia

A

Asymptomatic

50
Q

Stage 2 Chronic Limb Ischemia

A

Intermittent claudication

51
Q

Stage 3 Chronic Limb Ischemia

A

Ischemic rest pain

52
Q

Stage 4 Chronic limb ischemia

A

Ulceration and/or gangreen

53
Q

Pathophysiology of chronic limb ischemia

A

Atherosclerosis (or sometimes vasculitis) causes reduced blood supply to the limb

54
Q

Risk factors for chronic limb ischemia?

A 
Family hisotry 
DM
Increasing age
Obesity
Inactivity 
Hyperlipidemia 
Smoking 
HTN
55
Q

Describe and explain Buerger’s test

A

Lie patient supine, raising their legs until they have gone pale.
Lower the patients legs until colour retuens
The angle at which the limb goes pale is termed Beurgers angle (<20 degrees indicated severe ischemia)

56
Q

What is claudication distance?

A

Distance which can be tolerated before pain occurs (relieved by rest)

57
Q

Clinical features of intermittent claudication

A

Cramping pain

Calf/buttock/thigh

58
Q

What is critical limb ischemia

A

Ischemic rest pain >2 weeks, requiring opiate analgesia AND/OR presence of ischemic lesions or gangrene objectively attributable to the arterial occlusive disease +/- ABPI < 0.5

59
Q

Clinical signs that can be ellicited on exmaination of a patient with critical limb ischemia?

A 
Limb hair loss 
Atrophic skin
Ucleration 
Gangrene 
Thickened nails
60
Q

What is the difference between neurogenic claudication and intermitten claudication?

A

Neurogenic

Symptoms on initial movement

61
Q

What radiological investigations can patients with critical limb ischemia undergo?

A

Doppler USS to assess severity and location of any occlusion
Further imaging via CT angiogram or MRA

62
Q

What is a normal Doppler USS

A

Triphasic

63
Q

What is an occlusion on a doppler USS

A

Monophasic

64
Q

Medicalmanagement of CLI

A

Lifestyle
Statins
Antiplatelet therapy
Optomise diabtic control

65
Q

Surgical management of CLI

A

Angioplasty +/- stent
Bypass grafting
Amputation
Open surgery (endarectomy embolectomy)

66
Q

Which vessel does CLI usually involve?

A

SFA

67
Q

What does p1-3 mean in terms of artery involvemet in CLI

A

P1 above knee
P2 behind knee
P3 below knee

68
Q

What are varicose veins?

Which veins are usually involved?

A

Swollen superficial veins which recieve blood flow from the deep venous system due to incompitent valves.
Usually long and short saphenous veins.

69
Q

Risk factors for varicose veins?

A 
DVT 
Genetics
Surgery
Obestiy
Advancing age 
Pelvic masses
70
Q

Clinical features/presentation of Varicose Veins

A 
Skin discolouration 
Aching 
Itching
Ulceration 
Thrombophlebitis 
Haemosiderin deposition 
Venous eczma 
Bleeding 
Odema
71
Q

What is the management of varicose veins

A 
Exercise
Weight loss
Reduced standing
Compression stockings 
Four layered bandaging for any venous ulcers
Vein ligation, stripping
Foam sclerotheraoy 
Thermal ablation
72
Q

Varicose Veins + Concurrent DVT

A

Cannot treat superficial incompitence aa the venous blood will have no route back
Non surgical management

73
Q

How to homocysetine levels affect vascular disease?

A

Higher levels higher incidence

74
Q

Which test is a gold standard for diagnosis of peripheral vascular disease?

A

CT arteriogram

75
Q

What are the 5 P’s of arterial insufficiency?

A 
Pain
Pallor 
Perishingly cold
Paralysis
Pulselessness
76
Q

When should red cell tranfusion be given?

A

Hb<70g/L

Hb<80g/L + patient has ACS

77
Q

What is the immediate treatment for an aortic dissection?

A

IV labetalol

Allows for rapid control to slow progress of dissection

78
Q

Features associated with venous insufficiency?

A

Haemosiderin deposition (brown pigmentation)
varicose veins
Venous ulcers, usually above the medial malleolus
Lipodermatosclerosis (champagne bottle legss)
Eczma

79
Q

In peripheral arterial disease with critical limb ischemia what kind of surgical revascularisation is most suitable for low risk patients?

A

Open, e.g. open bypass graft

80
Q

What should all patients with peripheral arterial disease should take?

A

Clopidogrel

Atorvastatin

81
Q

How is claudication affecting the femoral vessels likely to present?

A

Calf pain

82
Q

How is claudication affecting the illiac vessels likely to present?

A

Buttock pain

83
Q

Treatment for Giant Cell Arteritis?

A

High dose steroids to prevent irreversable blindeness

60mg prednisolone OD

84
Q

Blood pressure findings in aortic dissection?

A

Difference of more than 20mmHg between the left and right arms

85
Q

What is Wegners granulomatosis?

A

Wegener’s granulomatosis is a vasculitis that affects both small and medium-sized vessels and therefore the presenting symptoms can vary hugely depending on the organ affected. For example, the patients may complain of nose bleeds and a saddle nose. This is secondary to nasal septum perforation. C-ANCA is specific for Wegener’s granulomatosis as it is present in over 80% of patients. Wegener’s granulomatosis can also be associated with P-ANCA in rare cases.

86
Q

In Raynaud’s phenomenon with extremity ischaemia, what condition should be considered?

A

Burgers disease - thromboangiitis obliterans

87
Q

Management of PAD with critical limb ischemia

A

Percutaneous transluminal angioplasty - This is used in patients who are at high risk and have short segment stenosis of <10cm.

Surgical bypass - This is indicated in patients with long segment stenosis of >10cm.

88
Q

Chronic limb ischemia vs critical

A

Chronic: IC - crampy, muscular, calf thigh (common iliac) or buttock (femoral), relieved on rest, hair loss and AD
Critical: chronic rest pain more than 2 weeks, ulceration, gangrene, absent foot pulses, hanging leg off bed

89
Q

Thrombus vs embolus

A

Thrombus clot in the blood vessel

Embolus a thrombus that has mobilised

90
Q

Buttock pain which artery

A

Common iliac

91
Q

Calf and thigh pain which artery

A

Femoral

92
Q

What is a clue as to whether or not a patient with critical limb ischemia has a salvageable limb?

A

Paralysis - not salvageable

93
Q

Progression of critical limb ischemia?

A 
Pain 
Pallor 
Cold 
Pulse absent 
Parathesia 
PARALYSIS - loss of limb
94
Q

What ABPI indicates heavy calfication

A

> 1.3

95
Q

What ABPI is normal

A

0.8-1.3

96
Q

What APBI is indicative of peripheral arterial disease

A

Less than 0.8

97
Q

What ABPI indicates severe peripheral arterial insufficiency

A

Less than 0.5

98
Q

Pharmacological management of peripheral arterial disease?

A

STATIN + CLOPIDOGREL (+ NAFTIDROFURLY OXALATE)

99
Q

What size abdominal aorta is an AAA?

A

Over 3cm

100
Q

What kind of expansion of an AAA warrants surgical intervention?

A

1 cm in a tear or 0.5cm over 6 months

101
Q

What size AAA warrants 2ww for surgery?

A

Over cm 5.5

102
Q

Following an intital screening of AAA which pts are called back in 12 months

A

3-4.4

103
Q

Which patients would be invited back for repeat AAA screening in 3 months?

A

4.5-5.4

104
Q

What is an aortic dissection?

A

A tear in the tunica intima of the aorta which creates a false lumen

105
Q

Classification of aortic dissection?

A

Stanford: Type A - ascending Type B - descending

106
Q

What might be seen on CXR in aortic dissection?

A

Widened mediastinum

107
Q

Pulse abnormalities in aortic dissection

A

Pulse deficits - 20mm/hg between arms
Radial radial delay
Absent peripheral pulses

108
Q

Common veins for varicose

A

Great saphenous and small saphenous

109
Q

Pathophysiology of varicose veins

A

Venous insufficiency
Valvular incompetence
Inc pressure in veins

110
Q

Indications for referral of varicose veins to secondary care?

A

Skin changes
Superficial vein grin is is
Ulcer

111
Q

What’s an atrophic Blanche

A

Star shaped ivory white atrophic scar
Clinical diagnosis

It occurs after a skin injury, when the blood supply is poor and healing is delayed.

112
Q

What is an ulcer?

A

Break in skin hasn’t healed for two weeks

113
Q

Brief pathophysiology of compartment syndrome

A

Hypoxia
Leaky vessels
Odema
Pressure increase compartment

114
Q

What intracompartmemt pressure is diagnostic of compartment syndrome

A

> 40mmHg

115
Q

What intracompartment pressure should raise suspicion of compartment syndrome?

A

> 20mmHg

Year 3 Surgery (6 decks)

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