Vascular

Question 1

What is the definition of an aneurysm?

Answer 1

> 150% dilatation of its original diameter.
True aneurysms involve all layers
Pseudo-aneurysms are collections of blood around a vessel wall - haemtoma in the adventitia

Question 2

Where are the common sites to have aneurysms?

Answer 2

Aorta (infra renal), iliac, femorl, popliteal

Question 3

What is the definition of a AAA?

Answer 3

> 3cm across.

Question 4

How are unruptured AAA treated?

Answer 4

Treat any HTN
Monitor aneurysm size
Elective surgery/ stenting - >5.5cm or growing by >0.5cm/6months

Question 5

What are the causes of aneurysms?

Answer 5

Due to degeneration of the arterial media - particularly a reduction in elastin.
Contributing factors:
Elastin degradation due to increased levels of metalloproteinases
Flow dynamics
Hypertension
Atherosclerosis
Collagen defects
Genetic
Smoking
Infections and inflammation can play a part also (Takayasu’s aortitis, and syphilis)

Question 6

What is the indication for a carotid endarterectomy?

Answer 6

Stensosis >70%.

Should be performed within 2 weeks of first presentation

Question 7

What are the risks of carotid endarterectomy?

Answer 7

Neck haematoma 5%
Cervical and cranial nerve injury 7% (hypoglossal, vagus, recurrent laryngeal, marginal mandibular and transverse cervical nerves)
Stroke 2%
MI
False aneurysm 
Infection of prosthetic patch 
Death 1%

Question 8

Which artery is normally affected in acute mesenteric ischemia?

Answer 8

Superior mesenteric artery:

supplies the small bowel and up to the splenic flexure of the large bowel

Question 9

What is the classic triad of acute mesenteric ischemia?

Answer 9

Acute severe abdo pain, no abdominal signs, rapid hypovolaemia.

Question 10

What causes acute mesenteric ischemia?

Answer 10

Arterial: thrombotic, embolic
Non occlusive (in renal failure or low CO)
Venous
Other: trauma, vasculitis, radiotherapy, strangulation

Question 11

What causes chronic colonic ischemia?

Answer 11

Low flow in the inferior mesenteric artery

Question 12

What are the causes of Raynaud’s?

Answer 12

SLE
Systemic sclerosis 
RA
Cold Aggluntins
Polycythaemia
Oral contraceptives 
B blockers 
Occupational - vibrating tools
Cervical rib

Question 13

Describe the colour changes seen in Raynaud’s.

Answer 13

White - digital artery spasm causes blanching
Blue - accumulation of deoxygenated blood
Red - reactive hyperaemia

Question 14

What are the signs of acute limb ischemia?

Answer 14

Pale
Pulseless
Painful 
Paralysed 
Paraesthetic 
Perishingly cold 

If fixed mottling occurs this implies irreversibility

Question 15

What are the causes of acute limb ischemia?

Answer 15

Thromobis in situ
Emboli - AF, atrial myxoma, underlying malignancy
Aneurysmal disease
Trauma

Question 16

What is the management of acute limb ischemia?

Answer 16

Give heparin and resuscitate with IV fluids
Angiography
Either local thrombolysis or embolectomy

Question 17

What is thoracic outlet syndrome?

Answer 17

A collection of symptoms relating to arterial, nerve and venous compression as they exit the chest.
Compression occurs normally in the area betwee the clavicle, the first rib and the scalenus anterior muscle.

Question 18

What are the symptoms and signs of thoracic outlet syndrome?

Answer 18

Neurological - sensory and motor deficit in the distribution of C8/T1, exacerbated by movement, worse at night

Arterial - claudication or rest pain. distal arterial disease may be due to emboli from an are of dilatation or frank aneurysm.

Venous - venous hypertension

Question 19

What is the hallmark symptoms of chronic limb ischemia?

Answer 19

Intermittent claudication - pain in the leg that gets better at rest, is worse on an incline. Seems to occur at a fix distance.

Question 20

What symptoms would make you think a limb is critically ischemic?

Answer 20

Pain at rest, ulceration and gangrene.

Question 21

What ankle brachial pressure index values suggest disease?

Answer 21

Normal >1
Claudication =0.9-0.6
Rest pain = 0.3 - 0.6
Impending gangrene <0.3

NB: calcified vessels are not compressible so will give a falsely high reading - DM, severe atheroscerlosis

Question 22

What examintion can be used to assess limb ischemia?

Answer 22

Burger’s test:

lifting the leg to an angle of 20 degrees and it going pale indicated critical ischemia

Question 23

What is the management of chronic limb ischemia?

Answer 23

Mainstay is reducing risk factors:
Stop smoking, statins, antiplatelets, BP control, good diabetes control

Angioplasty, and bypass surgery can be carried out
Amputation is used for relief of intractable pain, and releif of sepsis

Question 24

What is an ulcer?

Answer 24

An ulcer is a dissolution of an epithelial surface.

Question 25

What are the causes of ulcers?

Answer 25

``` Venous disease Arterial disease (small and large vessel disease) Neuropathy (diabetes, neuropathic) Lymphodema Vasculitis Malignancy Infection (TB, syphilis) Trauma Pyoderma gangrenosum Drugs ```

Question 26

Describe how the site of an ulcer gives you an idea of its cause:

Answer 26

Above the medial malleolus - venous Toes - arterial Sacrum, greater trochanter, heel - pressure

Question 27

What does the edge of an ulcer tell you about it?

Answer 27

``` Eroded = active and spreading Shelved/ slopping = healing Punched out = ischemic or syphilis Rolled/ everted = malignant Undermined = TB ```

Question 28

When bypassing an artery in the leg what is the preferred graft?

Answer 28

Autologous vein - usually the long saphenus vein unless it has been used for previous surgery, or is smal in calibre, then other veins can be used (arms or short saphenous)

Question 29

What are the complications of bypass surgey?

Answer 29

Early: Haemorrhage, graft thrombosis, compartment syndrome, DVT/PE, CVR complications ``` Late: Graft stenosis/ occlusion Delayed wound healing Graft sepsis Anastomatic false aneurysms Limb loss ```

Question 30

What is the differential diagnosis for a swollen leg?

Answer 30

``` Unilateral: Long standing venous disease Acute DVT Lymphodema (primary or secondary) Extrinsic pressure (pregnancy, tumour, retroperitoneal fibrosis) Klippel - Trenaunay syndrome Lipoedema Disuse / hysterical oedmea ``` Bilateral: Heart, renal, liver failure Hypoproteinaemia, Hereditary angioedema

Question 31

What are the causes of primary and seconday lymphodema?

Answer 31

Primary: isolated or familial Secondary: surgical excision/ radiotherapy of local lymph nodes, tumour, trauma, filiraisis,

Question 32

What is the pathological basis of varicose veins?

Answer 32

They are dilated tortuous veins. Primary are most common, ?due to weakness within the vein that allows it to stretch and therefore render the valve incompetent. Secondary veins can be caused by: obstruction to venous flow (prengnany, fibroids, abdominal lymphadenopthy, pelvic cancer etc) valve destruction (DVT) high flow and pressure (AV fistulae)

Question 33

What is the route of the long saphenous vein?

Answer 33

Drains the medial aspect of the leg and anterior aspect of thigh.

Question 34

What is the route of the short saphenous vein?

Answer 34

Drains the posterior aspect of the calf

Question 35

What are the signs that suggest there has been chronic venous incompetency?

Answer 35

Odema, eczema over the venous area, haemosiderin skin staining, lipodermatosclerosis (hard skin from subcutaneous fibrosis caused by chronic inflammation and fat necrosis.

Question 36

What is the trendelenburg's test?

Answer 36

Tests the competence of the saphenofemoral junction. Lie patient down and raise leg to empty the vein, place two fingers on the SFJ (5cm below the femoral pulse). Ask the patient to stand and if the varicosities are controlled they will not refill, release fingers to confirm they re fill - demonstrating SF incompetence.

Question 37

What is a saphena varix?

Answer 37

The dilatation of the saphenous vein at its confluence with the femoral vein. It transmits a cough impulse and may be mistaken for a hernia

Question 38

How do you treat varicose veins?

Answer 38

``` Treat any underlying cause Education - avoid long periods of standing up, wear support stockings, lose weight, walk regularly. Injection sclerotherapy Laser coagulation Surgery ```

Question 39

What is an aortic dissection?

Answer 39

It is when there is a tear in the aortic media and blood runs through it tearing it further. It presents with tearing chest pain and as the disection unfolds the branches of the aorta become occluded resulting in hemiplegia (carotid), acute limb ischemia (subclavian) or paraplegia (spinal arteries)

Question 40

What is the difference between type A and type B dissections?

Answer 40

Type A involve the ascending aorta, irrespective of site of tear Type B do not involve the ascending aorta

Question 41

What is the difference between wet and dry gangrene?

Answer 41

Wet gangrene is tissue death + infection Dry gangrene is just tissue death