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General Surgery > Vascular > Flashcards

Vascular Flashcards

1
Q

Arterial supply of the lower limb

A

1) common iliac -> external iliac -> common femoral

2a) common femoral -> profunda femoris -> perforating branches

2b) common femoral -> superficial femoral -> popliteal

3) popliteal -> anterior + posterior tibial

4) anterior tibial -> dorsalis pedis

5) posterior tibial -> peroneal -> medial & lateral plantar

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2
Q

Profunda femoris runs ___, supplies ___ and superficial femoral runs ___, supplies ___

A

posterolaterally, supplies muscles of thigh

anteromedially, exits femoral triangle into adductor canal, through adductor hiatus into popliteal fossa. Supplies adductor muscles

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3
Q

On angiogram at trifurcation of leg arteries, most lateral to medial ___, ___, ___

A

anterior tibial
peroneal
posterior tibial

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4
Q

Posterior tibial artery runs ___ and becomes plantar arteries

A

posterior to medial malleolus

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5
Q

Femoral artery landmark

A

Mid-inguinal point (b/w pubic symphysis and ASIS)

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6
Q

Popliteal artery landmark

A

Popliteal fossa, palpate against upper end of tibia

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7
Q

Peripheral artery disease includes disease of all the arteries except ___, ___

A

coronary arteries and aorta

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8
Q

Intermittent claudication means?

A

reproducible discomfort of a defined group of muscles that is induced by exercise and relieved by rest

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9
Q

Chronic limb threatening ischemia clinical diagnosis

A

1) Rest pain requiring opioid analgesia >2 weeks
AND/OR

2) gangrene/ulcers over foot
AND
3) objective indication of poor vascular supply to lower limbs (ABPI <0.5 , toe pressure, TcPO2)

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10
Q

Ischemic rest pain presentation

A

pain at night during sleep (BP drop, pts not in dependent position)

pain on lying down, relieved by getting up having a short walk

pain aggravated by lifting the limb

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11
Q

Ischaemic ulcers tend to occur on ___ of the foot, tend to be (characteristic)

venous ulcers occur over the ___, tend to be (characteristic)

Neuropathic ulcers occur over ___

A

lateral malleolus - dry, punctate, deep (punched out, well-circumscribed)

medial malleolus - moist, diffuse, superficial (sloping)

heel, metatarsal heads

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12
Q

Gangrene is ___ tissue that progresses to ___. Caused when ____.

A

cyanotic, necrosis
arterial pressure falls below minimum required for metabolic functions

Gangrene can be wet or dry

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13
Q

Patients with intermittent claudication tend to have symptomatic stabilisation due to

A

1) collateral development
2) patient alters gait to use non-ischemic muscles
3) metabolic adaptation of ischemic muscle

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14
Q

Risk factors of peripheral arterial disease

A

Diseases: diabetes, coronary artery disease, previous stroke

Non-modifiable: age, gender, ethnicity, FH

modifiable: smoking, HT, HLD, diabetes, obesity

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15
Q

Atherosclerosis tends to form at ___

A

branch points (points proximal to bifurcations), bends & tethered segments

*aortoiliac, femoropopliteal, tibial-peroneal segments

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16
Q

What is Buerger’s disease known as? Main treatment?

A

Thromboangiitis obliterans
- inflammatory vasculopathy, non-atherosclerotic

main treatment is smoking cessation

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17
Q

What is Leriche syndrome

A

Occlusion at bifurcation of terminal aorta into common iliac arteries

Pts present with buttock, hip claudication, erectile dysfunction (impotence) Reduced/absent femoral & distal pulses

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18
Q

Tibial-peroneal occlusive disease presents a higher risk of ____ than femoropoliteal occlusive disease due to ___

A

chronic limb threatening ischemia

lack of collateral blood flow to the foot

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19
Q

Tibial-peroneal occlusive disease patients have absent ___, lack of ___, and ___

A

dorsalis pedis & posterior tibial pulse

leg hair

shiny skin

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20
Q

Characteristic description of neurogenic vs vascular claudication

A

neurogenic - pain from “park bench to park bench” (sitting down relieves pain

vascular - pain from “shop window to shop window” (does not have to sit, not walking will relieve pain)

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21
Q

Risk factors for peripheral artery disease

A

Smoking/ex-smoker
Diabetes
HTN, HLD
Hyperhomocysteinemia
Family history of AAA

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22
Q

What is wet gangrene?

A

Infected gangrene - blistering, bacterial infection & putrefaction occurs.

Emergency surgical debridement or amputation required

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23
Q

What is diabetic dermopathy?

A

Atrophic hyperpigmented skin, usually on shin

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24
Q

What do you inspect for when examining PAD patient?

A
  • colour of skin
  • trophic changes (loss of hair, thickening of nails, skin dry)
  • loss of digits/foot
  • presence of ulcers
  • presence of gangrene
  • diabetic skin changes/joint deformities
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25
Q

Landmark of LL pulses

A

1) DP: 1/3 way down a line joining midpoint of two malleoli to 1st webspace

2) PT: 1/3 way between medial malleolus and heel

3) Popliteal: patient knee bent, press against superior part of tibia at popliteal fossa

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26
Q

How to perform Buerger’s test

A

1) Pt lie down. Lift leg straight up until toes turn white
2) Angle at which toes turned white is the Buerger’s angle. Less than 20deg = chronic ischemia
3) Drop patient leg over edge of bed. Should have reactive hyperemia (foot turns purple red)

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27
Q

What clinical classifications are used for Lower Extremity Arterial Disease?

A

Rutherford (Grade 0-6)
Fontaine (Stage I-IV)

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28
Q

Fontaine classification for LEAD

A

Stage I: asymptomatic
Stage IIa: mild claudication
Stage IIb: moderate to severe claudication (<200m walk)
Stage III: ischaemic rest pain
Stage IV: ulceration/gangrene

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29
Q

How to measure ABPI

A

Brachial pressure: higher arm systolic pressure (either left or right)

Ankle pressure: higher of ankle systolic pressure using DP or PT (only the leg you are trying to measure)

ABPI = AP/BP

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30
Q

Interpreting values of ABPI

A

Normal: >0.9
Claudication: 0.5-0.9
Critical ischemic rest pain: <0.5
>1.4 = non-compressible calcified vessel (perform toe pressure index instead)

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31
Q

Normal arterial waveforms on Arterial Duplex ultrasound are ___

A

triphasic

mono or biphasic waves are abnormal

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32
Q

What is acute limb ischemia?

A

Sudden decrease in limb perfusion that threatens limb viability

*ischemic ulcers, gangrene, ischemic rest pain

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33
Q

Risk factors for acute limb ischemia

A
  1. ***Arterial embolism - emboli from heart or DVT clots
  2. *Acute thrombosis - thrombosis of previously stenotic artery (less severe bc collaterals form). Pts tend to have had claudication history
  3. Arterial trauma
  4. Dissecting aortic aneurysm
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34
Q

Quickest to slowest tissues affected by ischemia

A

Nerves > muscle > skin > bone

so numbness comes first, then paralysis, then skin changes

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35
Q

Clinical presentation of ALI (6 Ps)

A

paresthesia
pain
pallor
poikilothermia (inability to regulate temperature)
pulselessness
paralysis

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36
Q

Acute limb ischemia can be classified using

A

Rutherford criteria (Stage I-III)

Stage I - viable: no immediate threat of tissue loss
Stage II - threatened: salvageable if properly revascularised
Stage III - non-viable: has to be amputated

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37
Q

Limbs will die after ___ during episode of ALI

A

6-8 hours

38
Q

Early ___ is required in acute limb ischemia

A

anticoagulation with heparin

prevents further clot propagation

39
Q

How does compartment syndrome occur?

A

Prolonged ischemia -> delayed reperfusion causes cell membrane damage, leakage of intracellular content out into interstitium -> swelling of muscle compartments

40
Q

What can carotid artery stenosis lead to?

A

amaurosis fugax (transient vision loss in one/both eyes)

TIA

ipsilateral ischemic stroke - hemimotor/hemisensory signs, higher cortical dysfunction

41
Q

Carotid ___ (surgery) is indicated for ___

A

endarterectomy

symptomatic pts with 70-99% stenosis

symptomatic MALE pts with 50-69% stenosis

asymptomatic with >80% stenosis

42
Q

What is an arteriovenous access? Two types?

A

Abnormal connection b/w artery & vein that is surgically created.

AV fistula - connecting native vein to adjacent artery (autogenous)

AV graft - synthetic or biologic grafts

43
Q

When is AV fistula/graft needed?

A

Pts with impending/established renal failure requiring chronic haemodialysis

44
Q

Types of AV fistula

A

Brescia-Cimino: cephalic vein + brachial artery

Gratz: cephalic vein + radial artery

45
Q

AV grafts have higher risk of ____ than AV fistulas

A

thrombosis - 10x risk

46
Q

Difference between aneurysm & pseudoaneurysm

A

Aneurysm - intact attenuated vessel where wall is formed by 3 normal elements: intima, media, adventitia

Pseudo - breach to arterial wall, blood accumulates between media and adventitia

47
Q

True aneurysms can be ___ or ___

A

saccular: only part of circumference

fusiform: circumferential dilatation

48
Q

Berry aneurysms occur at ___. Increased incidence in ____.

A

junction of vessels at Circle of Willis

HTN, PCKD, Ehlers-Danlos Syndrome

49
Q

What can cause a false aneurysm?

A

Iatrogenic - needle, endovascular procedures

Trauma

50
Q

Dissecting aneurysm caused by

A

intimal tear -> blood flows into media -> forces intima and adventitia apart -> formation of a false lumen

blood will flow back into the true lumen distally OR ruptures externally

51
Q

What are charcot-bouchard aneurysms?

A

Microaneurysms that occur at basal ganglia, cerebellum, pons, thalamus

Can cause intracerebral haemorrhage

52
Q

Most common aneurysm complication above and below inguinal ligament

A

above: rupture
below: thrombosis & embolism

53
Q

Abdominal aorta bifurcates at __

A

L4

trachea: T4
common carotid: C4

54
Q

Risk factors for aortic dissection

A

HTN
Age (60-70)
Gender (male)
Collagen conditions - Marfan’s, Ehlers Danlos
Pregnancy

55
Q

Which part of the aorta most at risk of dissection?

A

Ascending and proximal descending

Subjected to high pressure blood flow on aortic wall

56
Q

S___ classification of aortic dissection

A

Stanford

Stanford A: involves ascending aorta
Stanford B: does not involve ascending aorta

57
Q

D___ classification of aortic dissection

A

Debakey

Type I: involves ascending, arch and descending aorta
Type II: involves ascending aorta only
Type IIIa: involves descending only, confined to thoracic
Type IIIb: involves descending, all the way to abdominal aorta

58
Q

Differential diagnosis for aortic dissection

A

Heart: myocardial infarction, pericarditis, Aortic aneurysm w/o dissection

Respi: pulmonary embolism

GIT: acute pancreatitis, GERD, perforated ulcer, PUD

59
Q

Gold standard for diagnosing aortic dissection is ___

A

CT aortogram

60
Q

Abdominal aortic aneurysm is when abdominal aorta is ___ larger than normal

A

50%

normal: 2cm
AAA: >= 3cm

61
Q

Risk factors for AAA

A

Modifiable: smoking, HTN, HLD

Non-modifiable: age, gender (M), connective tissue disorders, family history

62
Q

AAA masses are ___ - fingers are pushed ___ when palpating

A

expansile

upwards & outwards (contracts and expands)

vs pulsatile (only transmits pulse)

63
Q

AAA commonly develops (where)___. Should check for concomitant ___ or ___ aneurysm.

A

below renal arteries

femoral/popliteal aneurysm

64
Q

Pts at higher risk for AAA rupture

A

female
COPD
saccular aneurysms
rapid rate of enlargement

65
Q

Indications for asymptomatic AAA surgery

A

aneurysm >= 5.5cm
increased diameter >5mm/6 months
Saccular aneurysm

66
Q

AAA tends to rupture ___ into the ___

A

posterolaterally
retroperitoneal space

67
Q

What is permissive hypotension

A

maintain systolic BP just high enough to maintain clinically alert patient & sufficient end organ perfusion

But not normal BP so can reduce bleeding

68
Q

Two superficial veins of the leg

A

great and small saphenous vein

69
Q

Course of the great saphenous vein

A

Medial side of the dorsum -> in front of medial malleolus -> medial side of leg -> posterior leg -> medial thigh -> pierces cribiform fascia at saphenofemoral junction, empty into femoral vein (2.5cm inferolateral to pubic tubercle)

70
Q

What veins join tgt at the saphenofemoral junction?(4)

A

Great saphenous vein
superficial epigastric vein
superficial circumflex iliac vein
superficial external pudendal vein

71
Q

Course of small saphenous vein

A

lateral dorsum -> posterior to lateral malleolus -> midline of calf -> pierces deep fascia over popliteal fossa -> empty into popliteal vein

72
Q

How does blood get pushed up the veins of the leg?

A

1) Calf muscle contraction pushes venous sinuses -> squeeze blood into popliteal vein

2) Intramuscular deep veins open during calf relaxation, pulls blood in from superficial veins through communicating veins

3) Valves in communicating and deep veins prevent backflow of blood into superficial veins

73
Q

Locations of communicating veins

A

SFJ
mid-thigh (Hunterian perforator)
distal thigh (Dodd’s)
below knee (Boyd’s)
5,10,15cm above medial malleolus (cockett)

74
Q

Chronic venous insufficiency can result from venous hypertension. Causes of VHT?

A

1) obstruction to flow: pelvic tumours, pregnancy, DVT

2) failure of venous valves

3) Failure of “venous pump” - inadequate muscle contraction from stroke/muscular weakness

75
Q

What is telangiectasias

A

spider veins/venous stars - intradermal veins

76
Q

What are varicosities and where do they tend to form?

A

Dilated, tortuous superficial veins

Main tributaries of the saphenous veins - no strong coat of smooth muscle, more superficial

77
Q

What is corona phlebectatica

A

network of small dilated venules beneath lateral/medial malleolus with severe venous HTN, indicates severe venous disease

78
Q

Hallmark of CVI

A

pitting oedema

79
Q

Phlegmasia ___ Dolens - caused by ___

Phlegmasia ___ Dolens - caused by ___

A

Alba - obliterated major deep venous channel (DVT) with sparing of collateral veins. Painful, pitting oedema, blanching (white appearance)

Cerulea - obliterated major deep venous channels + collateral veins. Painful, oedema, cyanotic, arterial insufficiency, venous gangrene (blue appearance)

80
Q

What is atrophie blanche?

A

avascular fibrotic scars (ivory white area with hyperpigmented borders)

prone to venous ulcers

81
Q

What is lipodermatosclerosis

A

Fibrosing area of subcutaneous tissue - firm area of tender, indurated, hyperpigmented skin

from severe venous HTN. starts at gaiter region and wraps circumferentially around leg

causes “inverted champagne bottle” appearance

82
Q

Characteristics of venous ulcer

A

Occurs at gaiter region
sloping edges, shallow, flat, moist
base may be sloughy/granulating

83
Q

CVI is classified by ___

A

CEAP

Characteristic
Etiology - congenital, secondary, primary
Anatomy - deep, superficial, perforator
Pathophysiology - reflux, obstruction, both

84
Q

Risk factors for varicose veins

A

Age
Obesity, parity
occupation - long standing
posture - crossing legs
increased abdominal pressure
pelvic tumour
family history

85
Q

what is thrombophlebitis

A

inflammation of wall of a vein with associated thrombosis

86
Q

Symptoms of varicose veins

A

nonspecific pain, tingling, burning, muscle cramps

itchy skin, swelling

worsens throughout course of the day, relieved with compression stockings or elevating legs

87
Q

What is a saphena varix

A

compressible lump at the inguinal region that refills when released

88
Q

landmark of saphenofemoral junction

A

2.5cm inferolateral to pubic tubercle

89
Q

Investigations for PAD

A

ABPI
TBI (<0.7 abnormal)
Arterial duplex ultrasound
Transcutaneous oxygen pressure
Angiogram

90
Q

What is angiogram with digital subtraction?

A

Images of underlying bone removed to better visualise arteries

Gold standard for evaluating arterial tree prior to revascularisation

General Surgery (13 decks)

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