Flashcards in Vascular Deck (65)
A 62-year-old non-insulin dependent diabetic man has presented with a penetrating plantar ulcer of his left foot.
On examination he has no palpable pulses below the level of the femoral artery. The ulcer on his foot is necrotic and oozing pus. He is also noted to have a second large ulcer on the posterior aspect of his left leg.
An angiogram is performed which shows patent vessels to the distal popliteal artery. No vessels are seen distal to the trifurcation.
Robinson (skew flap)
This man requires a below knee amputation. Two operations exist:
The Burgess long posterior flap
The skew flap technique, as described by Kingsley Robinson.
A controlled clinical trial of the two techniques showed no difference in healing rates, with a slightly earlier limb fitting and mobilisation with skew flaps.
A long posterior flap is not an option for this man due to the ulcer on the posterior aspect of the lower leg.
A 39-year-old type 1 insulin dependent diabetic has presented to the vascular clinic with a right inter-digital ulcer between the second and third toe. He has been treated with oral antibiotics. A plain radiograph revealed osteomyelitis six months before.
On examination all pulses in the right leg are palpable. A repeat radiograph confirms marked destruction of the head of the third metatarsal.
This man requires amputation of the toe and metatarsal (Ray amputation). This amputation is useful in diabetic gangrene when osteomyelitis has developed.
A 78-year-old man with extensive peripheral vascular disease has previously undergone a right above knee amputation.
He presented to the vascular clinic six weeks previously with critical ischaemia of his left foot. He underwent a femoro-distal bypass which was unsuccessful. His left lower leg is no longer viable. He has been wheel chair bound following his first amputation.
Gritti-Stokes (knee disarticulation)
Gritti-Stokes knee disarticulation, or above knee amputation, is indicated for this patient. Because he is wheel chair bound as a single amputee he is unlikely he rehabilitate as a double amputee. If he undergoes a second above knee amputation, he will loose the pendulum affect of the left (unamputated) leg, which makes transferring from the wheel chair difficult.
A through knee disarticulation is a quick procedure in a sick patient, and leaves the patient with the pendulum effect due to the longer stump.
A 73-year-old man presents to the emergency unit with a fever and history of being unwell over the preceding six weeks. On examination he is found to have a warm pulsatile mass in the epigastrium. A CT scan confirms a 6.2 cm infra-renal abdominal aortic aneurysm. An abdominal ultrasound scan performed the previous year showed no evidence of an aneurysm. Blood cultures are positive for Staphylococcus.
Mycotic. A mycotic aneurysm develops from infection in a native artery. Infection develops in the wall of the artery weakening the media causing the artery to become aneurysmal. The condition occurs more commonly in atheroscelortic arteries as these already have a weakened resistance to infection. If reconstruction is attempted, it should be with vein grafts or antibiotic bonded grafts.
A 29-year-old female presents on the medical take as an emergency. She has suffered with malaise, fever and arthralgia for a month. She is found to be hypertensive and is now complaining of abdominal pain following food. On examination she has a pulsatile/expansile mass in the epigastrium.
Takayasu’s aortitis is an inflammatory process which is transmural and granulomatous and if left untreated will lead to occlusion through fibrosis. The male: female ratio is 1:7, affecting younger adults. The commonest presentation affects the arch vessels and abdominal aorta. This young woman has developed a focal aneurysm due to disruption of the media. Her hypertension is due to renovascular involvement. The abdominal pain is due to mesenteric ischaemia. She should be treated at least in the acute phase with high dose steroids with or without methotrexate or cyclophosphamide.
A 38-year-old man is referred by his GP to the vascular outpatients with a palpable mass in the epigastrium. He has suffered with joint hypermobility since childhood. His brother died of a ruptured abdominal aneurysm aged 42 years. On examination he is of normal height, with marked scarring over his knees and elbows. An ultrasound scan confirms a thoraco-abdominal aneurysm.
Ehlers-Danlos. Ehlers-Danlos type IV is associated with aneurysm formation. The case is more likely to represent Ehlers-Danlos than Marfan's as he is of normal height, and suffers with joint hypermobility and poor healing, all hallmarks of Ehlers-Danlos.
A 66-year-old man presents to the vascular outpatients clinic with buttock and thigh claudication on the right. He has a claudication distance of 50 m. He is an ex-smoker of six months.
On examination all pulses in the left leg are palpable with no pulses palpable on the right. An angiogram is performed which shows a 10 cm occlusion of the right common and external iliac arteries, with no other abnormalities detected.
This man requires a left to right femoro-femoral bypass graft (or ilio-femoral bypass from the external iliac artery to give better flow dynamics and avoid one femoral incision [higher infection rates with groin versus abdominal incisions]). Another option would be an angioplasty plus a stent (angioplasty alone for such a long occlusion would not work).
An aorto-bifemoral bypass is a very major reconstruction, which is unnecessary as the aorta and left iliac system are healthy.
A 72-year-old man with marked peripheral vascular disease presents to the vascular outpatients clinic. He has previously undergone bilateral femoro-popliteal bypasses, both of which have occluded. He continues to smoke. He is now complaining of bilateral rest pain. On examination no pulses are palpable in either leg. An angiogram reveals no options for angioplasty, stenting or arterial reconstruction.
This man is at risk of losing both legs. A lumbar sympathectomy involves excision of the second and third lumbar ganglia. This can be performed laparoscopically. Chemical sympathectomy is more practical and less invasive, particularly as the results are so poor.
The indications for lumbar sympathectomy are
Lumbar sympathectomy often fails to produce any symptomatic improvement. Any benefit may only be temporary.
A 78-year-old woman presents to the vascular outpatients clinic with bilateral buttock pain. She has a claudication distance of 50 m but usually gets breathless before achieving this distance. She suffers with stable angina, having had a myocardial infarction six years previously.
An angiogram reveals a severely narrowed aorta with multiple stenotic lesions in both iliacs. Both femoral arteries are patent with good run off below the knees.
An extra-anatomic bypass is indicated in this patient to restore blood flow to both femoral arteries. Aorto-bifemoral bypass grafts have a better long term patency rate but this patient is less likely to survive such an invasive procedure.
The question asked you to choose a vascular procedure. In reality this patient's severe breathlessness means that her quality of life and walking distance are not going to be improved very much, if at all, by any operation.
Claudication is not a life or limb threatening condition so the best management for her would be best medical treatment alone. There would then be no operative risks to worry about. Primum non nocere.
A 55-year-old lorry driver presents to the vascular outpatients clinic complaining of left calf claudication. He has a claudication distance of approximately 400 m. He continues to smoke. On examination all pulses are palpable.
Behaviour modification programmes
Behaviour modification programme - this man has a sedentary life style and he continues to smoke. His employment is not compromised by his claudication. With stopping smoking, increased exercise and control of hypercholesterolaemia it is likely that his symptoms will remain stable or improve.
A 59-year-old insulin dependant diabetic presents 2 weeks post MI to the vascular unit. He suffers with bilateral rest pain and has developed an area of dry necrosis on his right foot. His ABPI on the right is 0.3 and 0.45 on the left. A CT angiogram shows long occlusions of the posterior tibial and anterior tibial arteries in the right leg.
This is a difficult problem. This man is suffering critical ischaemia, that is,rest pain for more than two weeks, ulceration or gangrene or ankle systolic blood pressure of less than 50 mm Hg. Normally this man would be offered reconstructive surgery depending on the angiogram findings. However, as he has had an MI within two weeks he has a high risk of a further MI under anaesthetic. Iloprost is contraindicated within 6 months of myocardial infarction. Iloprost is a prostacyclin analogue given by intravenous infusion. Improvements are usually only temporary.
A 51-year-old postman presents to the vascular outpatients clinic complaining of left calf claudication. His claudication distance is approximately 100 m. He is an ex-smoker of two years. On examination he has a palpable femoral pulse on the left with no foot pulses being palpable. An arterial duplex scan confirms a 25cm occlusion of the left superficial femoral artery. He refuses a femoro-popliteal bypass, as he is concerned that he may loose his job.
Cilostazol (pletal) was thought to be more effective than Naftidrofuryl oxalate (Praxilene) but NICE recommends only naftidrofuryl oxalate. Most vascular surgeons advise patients with claudication to avoid surgery and modify their behaviour rather than take expensive medication. However, the surgeon in this case has offered surgery as the patient's employment is severely impacted by his claudication.
A 45-year-old woman presents to the emergency unit with a swollen right leg two weeks following a total abdominal hysterectomy. She complains of an extreme bursting pain from the leg. On examination the leg has a blue discolouration. A venous duplex scan confirms an extensive iliofemoral deep vein thrombosis (DVT).
Phlegmasia caerula dolens
Phlegmasia caerula dolens. Severe and extensive iliofemoral DVT causes a swollen and painful leg, which is typically pale/erythematous, a syndrome known as phlegmasia alba dolens. Phlegmasia caerula dolens (as described above) results when the thrombosis extends to the venular and capillary levels with secondary development of acute arterial ischaemia. Fifty percent of these patients will go on to develop venous gangrene.
A 49-year-old woman presents to the vascular outpatients clinic with a longstanding swollen left leg. She reports that the swelling developed after the birth of her last child, 14 years ago. On examination there is moderate swelling of the left leg, which is non-pitting, with no pigmentation present. The right leg is normal to examination. A venous duplex shows an occluded left superficial femoral vein. The superficial venous system is dilated. No valvular incompetence is seen.
Post-phlebitic syndrome. This woman has developed chronic venous insufficiency from a DVT that was not diagnosed or treated 14 years ago. Post-phlebitic syndrome is also referred to as post-thrombotic syndrome. DVT management should not only be aimed at preventing clot propagation/pulmonary embolus but also at the prevention of this syndrome
A 59-year-old woman presents to the vascular outpatients clinic with longstanding bilateral varicose veins. The skin on both lower legs has become indurated and tender. She describes that the skin changes developed from dry scaly skin over both gaitor areas, which was extremely itchy, which resulted in her scratching continually. The legs have a brown discolouration.
Lipodematosclerosis. The patient has given a classical description of the development of venous lipodermatosclerosis. The pigmentation is due to both melanin and haemosiderin deposits. Ulceration may develop spontaneously or from minor trauma.
A 39-year-old man was recently diagnosed with renal failure and has been placed on the renal transplant list. He works as a computer programmer and is keen to return to work. He is therefore keen to undergo continuous peritoneal dialysis. A silastic non-irritant double cuffed catheter has been placed in the peritoneal cavity by means of a long subcutaneous tunnel.
Tenkoff continuous ambulatory peritoneal dialysis (CAPD) has the advantage of being relatively cheap, simple to set up, and relatively easy to run. Disadvantages are obesity due to glucose absorption, peritonitis and catheter failure (approximately 50% in three years). CAPD is used in young adults expected to be transplanted within two years, elderly and diabetics where vascular access is difficult. Initially, catheters (Trocath) were passed blindly into the abdomen with a trochar, Tenkoff type catheters have now superseded these.
A 69-year-old man is two days post emergency open abdominal aortic aneurysm repair. He suffers with ischaemic heart disease having undergone a coronary artery bypass grafting two years ago. Following his aneurysm repair, he was transferred to the intensive care unit. Monitoring has shown a rising CVP which has been put down to a failing myocardium by the cardiologist.
A CVP line alone will not provide information on cardiac function. A pulmonary artery balloon flotation catheter (now a historical technique but one that demonstrates understanding of cardiac physiology) is a multiple lumen catheter with an inflatable balloon just proximal to the tip. When the catheter is correctly placed, the balloon is inflated and the pressure at the tip reflects the pressure in the left atrium. Changes of pressures at the tip reflect changes in intravascular volume, filling pressure and left ventricular function.
The cardiac output/index can be calculated by using a thermodilution technique. Placement of Swan-Ganz catheters is associated with a number of major complications. Transoesophageal echocardiography is now the standard method of cardiac physiological assessment.
A 52-year-old woman has recently undergone a left mastectomy and axillary node clearance for a node positive grade III invasive ductal carcinoma. The oncologist has recommended chemotherapy. A double lumen catheter with a single cuff is placed in the right subclavian vein under local anaesthetic.
Hickmann line. Most chemotherapies are given at intervals over a number of weeks. Many of the agents are highly irritant and are required to be given centrally where there is high flow. The most commonly used catheter for this purpose is a Hickmann line. The cuff is placed just under the skin preventing the catheter from becoming dislodged. The double lumen has the advantage of allowing blood samples to be taken as well as drug administration.
A 59-year-old man is undergoing a femoro-distal bypass graft for critical ischaemia. A venous conduit is used. The vascular surgeon wants to avoid a size mismatch between the ends of the conduit to be anastomosed. A valvulotome cutting knife is pulled back through the graft to disrupt the valves in the vein lumem.
Insitu grafting is the method of choice for vessels around the knee or near the foot. The vein tributaries are ligated and the upper end is then freed and mobilised from the femoral vein which is oversewen. The vein is then anastomosed to the artery. The clamps are then divided and the vein is allowed to distend proximal to the first competent valve. The valvulotome is then passed up the vein to the distended segment and is then gently withdrawn disrupting the valves one by one. The distal end is then anastomosed to the artery.
A 67-year-old man presents to the vascular outpatients clinic with right foot rest pain and bilateral short distance claudication. He underwent a coronary artery bypass grafting two years before in which the long saphenous vein was harvested from the right leg. He unfortunately developed an extensive iliofemoral DVT in the left leg in the postoperative period following the CABG. A vascular procedure is planned on his right leg.
This man has no leg veins available to act as a conduit. Most commonly a PTFE graft is used. However, there is a lower patency rate at one year with synthetic grafts compared to venous grafts. Some vascular surgeons recommend harvest of arm veins when leg veins are not available.
A 63-year-old man presents to the physicians following a transient ischaemic attack, on examination he has a fever. Initial blood cultures grew Streptococcus. An abdominal CT scan showed a 5.7 cm infrarenal abdominal aortic aneurysm, there are signs the aneurysm may be mycotic.
The diagnosis of a mycotic organism can only be definitely made when organisms are cultured from the aneurysm wall. As the aneurysm is greater than 5.5 cm, it requires repair. If a synthetic graft is to be used it should be impregnated with antibiotics. The patient will require a prolonged course of iv antibiotics based on cultures pre-operatively and for at least two weeks post-operatively. Some surgeons still advocate a two-stage approach with an axillo-bifemoral graft being formed first and then ligation of the abdominal aorta a number of weeks later.
A 39-year-old female secretary presents to the vascular outpatients clinic with an intermittently cold left hand. She is right hand dominant. She complains that her left hand becomes painful after minimal typing or other light duties. Recently the symptoms have become worse. Radial and ulnar pulses are present on the left but are reduced compared to the right. She has a positive Roos test (aka elevated stress test - slow repetitive finger clenching in the 'surrender' position, that is, replicates the symptoms in less than three minutes. On examination she has a palpable mass in the left neck.
Thoracic outlet syndrome
Thoracic outlet syndrome - the mass in the neck represents a cervical rib. The subclavian artery can be compressed between the clavicle and either a cervical rib or band or scalenus anterior. Symptoms range from asymptomatic through to incapacitating ischaemia. A chest radiograph should be performed to identify any cervical ribs and a duplex scan should be performed at rest and in the Roos position/test.
A 75-year-old man is being nursed on the coronary care unit following a recent myocardial infarction (MI). He is found to have a cold right hand. He has had no previous similar symptoms. On examination neither the ulnar or radial pulses are palpable.
Embolic. The most likely diagnosis is embolic as he is likely to have developed a mural thrombus following his recent MI. The diagnosis is confirmed by an arterial duplex of the arm and an echocardiogram. If he has signs of acute ischaemia, he will require an embolectomy or thrombolysis.
A 32-year-old man presents to the vascular outpatients clinic with recurrent paronychias and signs of digital ischaemia. He also complains of claudication type pain from both legs. He smokes 20 cigarettes a day.
Buerger's disease - the condition is also known as thromboangiitis obliterans, the symptoms are characterised by segmental occlusions of small and medium sized arteries of the arms and legs. The condition was traditionally more common in young men who smoked from the Middle East or Indian sub-continent. However, the incidence is now also increasing in women and older men due to the increased incidence of smoking in these groups.
A 76-year-old man presents to the vascular outpatients clinic. He describes 'drop attacks' usually following excessive use of his right arm. He also complains of worsening vertigo, diplopia, dysphagia and dysarthria. On examination all pulses are palpable. A supraclavicular bruit is heard on the right. An arterial duplex scan identified a significant stenosis of the right subclavian artery.
Steal syndrome - this is a classical description of subclavian steal syndrome. Vertebrabasilar symptoms develop when exercising the affected limb, as there is a reversal of flow in the vertebral artery on the side of the stenosis, which acts as a collateral to supply blood to the ischaemic arm 'stealing' blood from the circle of Willis and cerebral arteries. Duplex scanning shows reversal of flow in the vertebral artery on exercise.
A 74-year-old woman presents to the vascular outpatients clinic with hoarness, back pain and venous congestion of the left neck. On examination she has a pulsatile mass in the left supraclavicular fossa and an audible bruit. Clinically she has Horner's syndrome on the left. A chest radiograph shows a left mediastinal shadow.
Aneurysm - this woman has an intrathoracic subclavian artery aneurysm. Subclavian artery aneurysms represent 1% of all peripheral aneurysms. Intrathoracic aneurysms are mostly asymptomatic. Distal embolisation is seen in two thirds of patients with extrathoracic subclavian aneurysms. Steal syndrome may be seen with larger aneurysms.
A 40-year-old woman has been referred from the upper GI clinic to the vascular outpatients clinic. She was investigated for dysphagia that has been present since childhood. A barium swallow showed an oblique indentation in the anterioposterior view. An OGD showed a pulsatile mass narrowing the lumen.
Aberrant - this woman is more likely to have an aberrant (congenital anomaly) subclavian artery and not an aneurysm, as the symptoms have been present since childhood. Aberrant subclavian arteries are common, being found in 1% of post-mortem examination. They were also a common incidental finding when arch aortograms were used to assess carotid artery disease. They are usually asymptomatic and rarely require surgery.
A 75-year-old man undergoing an open repair of a 6 cm aortic aneurysm is found at operation to have a 3.5 cm aneurysm of his right common iliac artery. Which method of repair should be chosen?
Whereas isolated abdominal aortic aneurysms are repaired using a straight (tube) graft, aneurysms which involve both the aorta and iliac arteries are repaired using a bifurcated (trouser) graft. The grafts which are made from Dacron are anastomosed at the infrarenal neck in an end to end fashion and in the iliacs in either an end to end or end to side fashion.
A 78-year-old man has collapsed at home. When reviewed in the resuscitation room he is pale and has a blood pressure of 90/60 mmHg. Examination of his abdomen reveals a pulsatile expansile mass in the epigastium. As he is haemodynamically unstable he is transferred to the operating theatre for emergency repair of his suspected ruptured abdominal aortic aneurysm. How should the aorta be approached?
The transabdominal approach through an extended midline incision is the standard approach for a ruptured aortic aneurysm. This approach gives good exposure of the aortic neck and iliac vessels. A disadvantage of this approach is that the small bowel mesentery requires dissection off the aorta. The retroperitoneal approach gives better access to the supra-renal aorta, but takes longer to both position the patient and to expose the aorta. The retro-peritonael approach also has the disadvantage of poor access to the contralateral (right) iliac.