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Surgery Revision > Vascular > Flashcards

Vascular Flashcards

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1
Q

Sources of cardiac embolism

A
  • atrial and ventricular
  • paradoxical
  • endocarditis
  • cardiac tumour
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2
Q

Arterial sources of emboli

A
  • artheroembolism

- aortic mural thrombus

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3
Q

3 causes of thrombi

A
  • atherosclerosis
  • hypercoagulable states
  • bypass graft occlusion
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4
Q

When does irreversible limb necrosis start?

A

After 6-8 hours

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5
Q

How to classify acute limb ischaemia

A

Rutherford classification

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6
Q

Investigation of choice for acute limb ischaemia

A

CT angiography

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7
Q

Investigations for acute limb ischaemia

A
  • U/S
  • CTA
  • MRA
  • Echo
  • Transfemoral arteriography
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8
Q

Possible management modalities of acute limb ischaemia

A
  • anticoag alone
  • operative intervention
  • endovascular intervention
  • mechanical thrombectomy
  • thrombolysis
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9
Q

Definition of an aneurysm

A

A focal permanent dilatation of an artery greater than 1.5 times that artery’s normal diameter

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10
Q

Definition of Ectasia

A

A focal dilatation of an artery greater than the normal diameter of that artery, but less than 1.5 times the normal diameter

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11
Q

Definition of arteriomegaly

A

The entire arterial segment is diffusely dilated

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12
Q

Definition of aneurysmosis

A

Multiple aneurysms with intervening normal arterial segments

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13
Q

Complications of aneurysms

A
  • rupture
  • thrombotic occlusion
  • thrombo-embolism
  • pressure-related problems
  • spontaneous fistulisation
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14
Q

Causes of aneurysms

A
  • degenerative
  • infective
  • CTD
  • trauma
  • inflammatory
  • post-dissection
  • post-stenotic
  • congenital
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15
Q

Ways to classify arterial aneurysms

A
  • anatomical location
  • aneurysm type (T/F)
  • morphology
  • size
  • etiology
  • clinical presentation
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16
Q

Types of AAA

A
  • infra-renal
  • juxta-renal
  • para-renal
  • supra-renal
  • thoracoabdominal
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17
Q

Risk factors for AAA

A
  • uncontrolled HPT
  • hyperchol.
  • smoking
  • chlamydia pneumonia
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18
Q

Symptoms of AAA

A
  • abdo/back pain

- compression (vomiting, constipation, flank pain, venous disease)

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19
Q

First line investigation for AAA

A

Duplex doppler

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20
Q

Who to screen for AAA

A
  • caucasian males >65 yo
  • peripheral aneurysms
  • throacic aortic aneurysms
  • family history
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21
Q

Symptoms of a ruptured AAA

A
  • sudden onset acute backpain
  • shock
  • pulsatile abdo mass
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22
Q

Where is Cullen’s sign found?

A

Umbilicus

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23
Q

Where is Grey-Turner sign found?

A

Flanks

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24
Q

What is Hardman risk index for?

A

To predict who to intervene for with AAA

- >3 = 100% mortality

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25
Causes of Thoraco-abdominal aneurysms
- degen - Takayasu's - intimo-medial mucoid degen - HIV-related aneurysm - mycotic aneurysm - TB aortitis with aneurysm
26
Common peripheral aneurysms
- popliteal | - femoral
27
Uncommon peripheral aneurysms
- subclavian - extra-cranial carotid - mesenteric - renal artery
28
Deformities associated with diabetic motor neuropathy
- pes cavus | - hammer toes
29
Natural history of Charcot's osteoarthropathy
- ligamentous failure - subluxation and dislocation - swollen and red
30
What is a normal ABI?
0.9-1.1
31
Foot deformities of diabetic foot
- skin cracks, fissures, calluses - claw/hammer toes - Rocker bottom feet - Pes cavus - Hallux valgus/rigidis - Charcot's foot - fixed flexion deformity of PIPJ
32
How to classify treatment of diabetic foot
Wagner classification (Grade 0-5)
33
How to classify follow-up for diabetic foot
Foot-at-risk classification (Category 0-3)
34
Acute indications for referral for diabetic foot
- callus formation - ulceration - ischaemic changes - acute local sepsis - non-healing trauma
35
Chronic indications for referral for diabetic foot
- recurrence - worsening deformity - worsening neuropathy - worsening sugar control - ischaemic symptoms
36
Risk factors for venous thromboembolism
- age - obesity - varicose veins - family history - thrombophilia - majory surgery/immobility - acute illness/sepsis
37
Complications of venous thromboembolism
- PE - pulmonary HPT - post-thrombotic syndrome
38
Signs of a DVT
- phlegmasia alba dolens - phlegmasia cerulea dolens - Homan's sign
39
What is homan's sign?
Calf pain at dorsiflexion of the foot
40
How to know if it is likely a DVT
Well's score >2 D-dimer (neg excludes) Duplex US
41
Features of DVT on Duplex US
- venous compressability - intraluminal echoes - venous flow - filling defects
42
Methods of prophylaxis for DVT
General - hydration - early mobilization Mechanical - elastic compression stockings - intermittent pneumatic stockings Pharmacological - Unfractionated heparin - LMWH - oral Vit K antagonists
43
Clinical categorisation of PAD
- aorto-iliac - femero-popliteal - tibio-peroneal
44
Types of claudication
- intermittent - spinal - venous - atypical
45
Stratification of PAD
- Fontaine | - Rutherford
46
Pharmacotherapy for PAD
Cilostazol (phosphodiesterase type 3 inhibitor) Nafidrofuryl- hydroxytaptamine type 2 inhibitor
47
Classification for chronic venous disease
CEAP - clinical signs - etiology - anatomy - pathophysiology
48
Risk factors for chronic venous disease
- increasing age - pregnancy - family history - obesity - prolonged standing - caucasian race - poor dietary fibre
49
Clinical classification of chronic venous disease
``` 0 = no signs 1 = telangiectasia, reticular veins, malleolar flare 2 = varicose veins 3 = oedema without skin changes 4 = skin changes (pig, eczema, lipodermato) 5 = skin changes with healed ulceration 6 = skin changes with active ulceration ```
50
Causes of venous hypertension
``` Reflux (90%) - superficial - deep Obstruction (10%) - iliofemoral - superficial femoral ```
51
Cause of venous insufficiency
- varicose veins - DVT - external pressure - inborn valve def - prolonged muscle inactivity - muscle dysfunction/paralysis - skeletal poblems
52
Symptoms of venous insufficiency
- aching - throbbing - leg fatigue/ heaviness - swelling - worse at night
53
Complications of venous insuff
- thrombophlebitis and rupture | - oedema - ulceration
54
Where does the GSV run?
- medial calf and thigh
55
Where does the SSV run?
- posterolateral calf
56
Where does the pelvic vein run?
- upper medial thigh and labia
57
Investigation of chronic venous disease
- Duplex doppler | - CT venography for complicated cases
58
Treatment of chronic venous disease
- compression - sclerotherapy - surgery
59
Definition of a venous ulcer
A full thickness defect of the skin, present for >30 days that fails to heal spontaneously and is sustained by chronic venous disease
60
How to treat venous ulcer
Compression!
61
Clinical presentation of ischaemic ulcers
- over bony prominences - very painful at rest, relieved by gravity - punched out - surrounding skin changes - delayed cap refill
62
Presentation of neuropathic ulcers
- deep punched out over pressure points - usually painless - Charcot's foot
63
Describe Martorell ulcer
Very painful ulcer of lower leg associated with poorly controlled hypertension
64
Investigation of venous ulcers
- duplex doppler - ambulatory venous pressure - plethysmography
65
Why do people with upper limb ischaemia present later?
- good collaterals in the neck and less muscle mass
66
Etiology of upper limb ischaemia
- embolic (90%) - thrombosis - trauma - iatrogenic (invasive procedures) - Takayasu's - aortic dissection - hypercoagulable states
67
Management of upper limb ischaemia
- anticoag (unfrac, heparin) - analgesia - refer to vascular - embolectomy - thrombolysis (if acute on chronic)
68
How to manage embolisation after an intra-arterial injection
- irrigate with heparin-saline solution - inject vasodilator (nitroglycerine) - heparin - low mol weight dextran + dexamethasone
69
Explain subclavian steal syndrome
retrograde blood flow in the vertebral artery due to proximal stenosis/occlusion of the subclavian artery - leads to vertebrobasilar insufficiency
70
Etiology of chronic upper limb ischaemia (large vessel)
- atherosclerosis - aneurysms - arteritis - arterial thoracic outlet compression syndrome
71
Clinical findings in chronic upper limb ischaemia
- unilat Raynauds - BP difference between arms - palpable cervical rib - palpable subclavian artery - bruit of subclavian artery
72
Management of chronic upper limb ischaemia
- risk factor modification - anti-platelet therapy - percutaneous transluminal angioplasty + stent - bypass surgery
73
Causes of upper limb ischaemia (small vessel)
- vasospasm (Raynauds) - CTD - Beurger's disease - occupational injury - vasculitis - misc
74
Principles of treating digital ulcers
- conservative debridement - retain as much tissue as possible - avoid damaging blood supply - appropriate wound cover - treat vasospasic conditions - appropriate Ab - protection against further injury
75
Management of Raynauds
- general (warmth, gloves) - drugs (nifedipine 5mg tds) - sympathectomy
76
Causes of secondary hypertension
- endocrine disorders - renal parenchymal disorders - renovascular disorders
77
Causes of renovascular hypertension
- RAS - coarctation of the aorta - middle aortic syndrome
78
Features suggesting secondary hypertension
- early onset (<30) - late onset - severe HPT - malignant HPT - HPT needing multi-drug Rx - medically refractory - epigastric bruits - grade 3/4 HPT retinopathy - flash pulm oedema - refractory angina - stigmata of endocrine d/o
79
Endocrine screen for hypertension
- 9am serum cortisol - 24 hour urinary cortisol - serum aldo - plasma renin assays - 24hr urinary metaneph/catchol - plasma catechol - thryoid tests - parathyroid tests - serum Ca and Phos
80
Imaging for secondary hypertesion
- CT (abdo, brain, chest) - US of thyroid - radio-isotope scans - Duplex of kidneys - MAG 3 renogram - Captopril renogram - Vascular (CTA, MRA, DSA)
81
Pathophysiology of renovascular hypertension
- activation of the RAAS system
82
Ang II actions
- acts on ATII receptors - vasoconstriction | - aldosterone release - fluid retention
83
Anatomical classification of RAS
- ostial - parostial - truncal - accessory - segmental - mixed - renal artery occlusion
84
Pathological classification of RAS
``` Atherosclerotic Non-atherosclerotic - FMD - Takayasu's - renal artery dissection - RA aneurysms - trauma - radiation-induced ```
85
Treatment of RAS
- medical (ACE-I) - percutaneous transluminal renal angioplasty + stenting - surgical revasc - nephrectomy (if unilat)
86
Requirements for a nephrectomy for RAS
- 1 kidney <8cm | - single kidney GFR <10
87
What is FMD?
A degenerative condition of branchless vessels | - occurs in young women
88
Types of FMD
- medial - adventitial - intimal
89
Dx of FMD on DSA
- normal aorta - string of beads - mid and distal 1/3 of the renal artery
90
Gold standard treatment of FMD
- transluminal balloon angioplasty
91
What is Takayas's disease
Non-specific large vessel vasculitis
92
Findings of Takayasu's disease on CTA
- thick walled aorta - aortic occlusion - RAS
93
Gold stardard treatment of Takayasu's
Surgical revasc
94
Where does coarctation of the aorta usually occur
At the ligamentum arteriosum
95
Diagnosis of coartcation
- ECG (LVH) - Chest XRAY (post. inf. rib notching) - CTA/MRA/DSA - TOE
96
Classification of coarctation
- post-ductal - pre-ductal - interrupted
97
Surgical management of coarctation
- patch angioplasty - interpositional bypass graft - resection and re-anastomosis
98
Interventional management of coarctation
- balloon angioplasty - aortic stent - aortic stent grafting
99
What is mid-aortic syndrome
Acquired vascular condition - narrowing of the aorta
100
Disorders associated with mid-aortic syndrome
- Takayasu's - atherosclerosis - cong. hypoplasia - Von Recklinghausen's disease - FMD - tuberculous aortitits
101
Clinical features of mid-aortic syndrome
- upper limb HPT - radio-femoral delay - inter-scap/ abdo bruits - lower extremity claudication
102
Etiology of acute mesenteric ischaemia
- arterial embolism - arterial thromboembolism - venous thrombosis - non-occlusive mesenteric ischaemia - rare (aortic dissec, vasculitis)
103
Natural history of intestine in mesenteric ischaemia
- changes in villi - mucosa sloughs off - transmural necrosis - perforation - sepsis - death
104
Presentation of acute Mesenteric ischaemia
- severe abdo pain (sudden, colicky) - N+V - Hx of arrythmias/MI - atherosclerotic disease
105
Abdo XRAY findings in acute mesenteric ischaemia
- dilated small bowel - wall oedema - gas in wall
106
Management of acute mesenteric ischaemia
Resus and anticoag Surgical - exploratory lap - resection - revasc Endovasc - aspiration thrombectomy - thrombolysis - angioplasty + stenting
107
Associations with mesenteric vein thrombosis
- thrombophilia - portal HPT - intra-abdo malignancies - pancreatitis - preg
108
Causes of non-occlusive mesenteric ischaemia
- severe systemic illness | - usually in ICU on inotropes
109
Presentation of chronic mesenteric ischaemia
Mesenteric angina (post-prandial, peri-umbilical, recurrent) - LOW + food fear - N + V
110
Management of chronic mesentery ischaemia
Endovasc - balloon angioplasty and stenting Surgery - re-implantation techniwue - endarterectomy - bypass
111
Amaurosis Fugax
Temporary retinal artery ischaemia
112
How to predict likelihood of secondary ischaemic event
ABCD2 stroke risk score - age - BP - clinical features - duration - diabetes
113
Surgery for carotid artery stenosis
Carotid endarterectomy (local/GA)
114
Complications of endovasc. carotid angioplasty and stenign
- ipsilat ischaemic stroke - labile BP - ACS - death - local Hg - nerve injuries
115
What does the verebrobasilar system supply?
- occipital cortex - cerebellum - thalamus - brain stem
116
Presentation of vertebrobasilar insufficiency
- vertigo - visual disturbance - drop attacks - numbness/tingling
117
Surgical management of vertebrobasilar insufficiency
- endarterectomy | - bypass grafting/ direct arterial transposition

Surgery Revision (8 decks)

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