Vascular surgery Flashcards
(80 cards)
1
Q
Define abdominal aortic aneurysm
A
Abdominal aorta diameter >1.5x expected (eg >3cm)
2
Q
Describe the epidemiology and RF of AAA
A
M >F
RFs: smoking, FHx, age, HTN, connective tissue disease, syphilis
3
Q
Describe the pathophysiology of AAA
A
Loss of connective tissue in aortic wall eg. collagen + elastin
->dilatation
4
Q
Describe the presentation of AAA
A
May be asymptomatic + unruptured: screening
Symptomatic + unruptured: abdo/flank pain, obstructive Sxs
-Can also cause complications such as thrombosis/emboli
Symptomatic + ruptured: collapse, shock, constant severe pain *may mimic renal colic
5
Q
Describe the signs of AAA on examination
A
Ruptured AAA: hypotension, tachycardia, decreased GCS, pallor, abdominal distension + tenderness, pulsatile mass
Unruptured: pulsatile + expansile epigastric mass
6
Q
Describe the investigations for AAA
A
Ruptured:
-Bloods (FBC, CRP, U+Es, amylase/lipase, clotting, CM)
-Imaging: USS or CTA
Unruptured: USS -> CTA/MRA
7
Q
Describe the screening for AAA
A
Men invited at 65 years <3cm: discharged for life 3-4.4cm: annual surveillance 4.5-5.4cm: 3 monthly surveillance >5.5cm: intervention
8
Q
Describe the management of unruptured AAA
A
Depends on size
Conservative:
-Smoking cessation
Medical:
- BP control
- Antiplatelet (aspirin/clopi)
Surgical/interventional: >5.5cm or rapidly growing
- EVAR
- Open surgical repair
9
Q
Describe the management of ruptured AAA
A
A to E approach -IV access, bloods, fluid resus + blood products (best) -Make NBM, analgesia -USS -> CTA Senior support, ITU, vascular Urgent surgical repair: EVAR or open
10
Q
Describe the prognosis for AAA
A
Rupture is often fatal
Intervention has relatively high mortality rates
11
Q
Describe the complications of AAA
A
Rupture (+death)
Thrombosis + emboli
Intervention: graft infection, limb occlusion, endoleak, erectile dysfunction
12
Q
Describe the types of aneurysm
A
Aneurysm: ballooning in the wall of an artery
False: damage to blood vessel wall causing collection of between the layers
True: bulge comprising all 3 layers of the aortic wall
13
Q
Describe the epidemiology of aortic dissection
A
Typical: male in 50s
Also younger patients (Marfan’s)
14
Q
Define aortic dissection
A
A separation of the inner layer of the aortic wall (tunica intima + tunica media)
Leads to the creation of a false lumen
15
Q
Describe the aetiology + RF of aortic dissection
A
- Connective tissue disease eg. Marfan’s
- Hypertension
- Iatrogenic
- Drug use (cocaine)
- Smoking
16
Q
Describe the classification of aortic dissection
A
Stanford A: affects ascending aorta/arch
Stanford B: affects descending aorta
17
Q
Describe the presentation of aortic dissection
A
- Sudden onset, severe, ‘tearing’, chest/back/abdo pain, radiates to back, relieved by sitting forwards
- Sweating, nausea
- Symptoms of limb ischaemia eg. limb pain, weakness, paraesthesia
- Shock
- Syncope
18
Q
Describe the signs of aortic dissection on examination
A
- General: tachycardia, hypotension, sweating
- Reduced/absent pulses
- Systolic BP difference between arms
- Diastolic murmur
- Focal neuro deficit (in stroke)
19
Q
Describe the investigations for aortic dissection
A
- If HD unstable: A to E approach
- History + examination
- Bloods: FBC, CRP, U+Es, trops, clotting, CM, lactate
- ECG (DDx, also infarction may occur as complication)
- CXR: widening of mediastinum, effusion
- > TTE/CT (CT definitive, TTE if suspected + available)
20
Q
Describe the management of aortic dissection
A
- If HD unstable: A to E approach
- IV access + fluid resus/blood products
- NBM, analgesia
Medical:
-IV beta-blocker or CCB (if no AR present) -> vasodilator
Surgical/interventional:
- Type A: emergency surgery
- Complicated Type B: urgent TEVAR/open repair
- Uncomplicated Type B: medical therapy, consider Sx
21
Q
Describe the prognosis of aortic dissection
A
Untreated proximal dissection: death in 50% by 24 hours
22
Q
Describe the complications of aortic dissection
A
Cardiac tamponade Aortic valve incompetence MI Regional ischaemia eg. limb, cerebral, renal Aneurysmal degeneration
23
Q
Describe the epidemiology of peripheral vascular disease
A
Increases with age
Usually affects >40s
24
Q
Define peripheral arterial disease
A
Symptoms caused by obstruction of the lower limb arteries
25
Describe the aetiology of PAD
```
Atherosclerosis (almost always)
Buerger's disease
Aortic coarctation
Dissection
Tumour etc
```
26
Describe the stages of PAD
Fontaine classification
1. Asymptomatic
2. Mild claudication
3. Severe claudication
4. Ischaemic rest pain
5. Ulceration/gangrene
27
Describe the spectrum of PAD
Asymptomatic
Claudication
Chronic critical limb ischaemia: >2 weeks, rest pain/tissue loss
Acute limb ischaemia
28
Describe the classic signs of acute limb ischaemia
6 P's
- Pale
- Painful
- Pulseless
- Parasthesia
- Paralysis
- Perishingly cold
29
Describe the presentation of PAD
Claudication:
- Intermittent calf/buttock pain on exertion, relieves with rest
- Reproducible, worse on incline/stairs
Erectile dysfunction (aortoiliac disease)
Critical limb ischaemia:
- Rest pain
- Gangrene/ulcers
Acute ischaemia: 6 Ps
30
Describe the signs of PAD on examination
Inspection:
- Bypass scar
- Pallor/dependent rubor
- Loss of hair on dorsum
- Skin changes: thinning (shiny/scaly), ulceration
Palpation:
- Weak/absent pulses
- Reduced sensation
Buerger's test:
- Reduced Buerger's angle (<30)
- + Buerger's sign (reactive hyperaemia)
31
Describe the investigations for PAD
Stable PAD:
- History and examination
- ABPI +/- exercise ABPI eg claudication
- Bloods (for RFs): U+Es, HbA1c, lipids
- Duplex USS
- CTA/MRA/intra-arterial DSA
Acute limb ischaemia:
- Bloods
- Doppler USS
- Imaging
32
Describe the interpretation of ABPI
<0.80: PAD
<0.6: severe PAD
1.0-1.2/3: normal
>1.2/3: calcification eg. age+ DM
33
Describe the management of chronic PAD
Conservative:
- Lifestyle mod: smoking, diet + exercise
- Claudication: 12 wk supervised exercise program
Medical:
- RF management: BP, DM, statin
- Antiplatelets (aspirin/clopi)
- Claudication: consider vasodilator if unsuitable for revasc.
- Critical limb ischaemia: analgesia
Surgical/interventional:
- Revascularisation
1) Endovascular techniques- angioplasty (stent/balloon)
2) Anatomical bypass- eg aortobifemoral, fem-pop
3) Extranatomical bypass eg. fem-fem crossover
- Amputation: last resort
34
Describe the management of acute limb ischaemia
- History and examination
- Make NBM, analgesia (morphine), IV fluids if needed
- IV access and bloods: FBC, U+Es, clotting, G+S, CK
- ECG
- Doppler USS
- Unfractionated heparin IV
- Emergency revascularisation eg. endovascular, bypass, fasciotomy, amputation etc
35
What is Buerger's disease?
aka thromboangiitis obliterans
Acute inflammation + thrombosis of A in the hands + feet -> ulceration + gangrene
Typically affects young males who smoke
36
What is Leriche syndrome?
```
Aortoiliac occlusion
Triad of:
1. Buttock claudication + wasting
2. ED
3. Absent femoral pulses
```
37
Describe the differences between arterial ulcers and venous ulcers
Arterial:
- Well-demarcated, 'punched out' lesions
- Small + deep
- Necrotic tissue
- Painful
- Signs of PAD eg. pale, thin, shiny skin + loss of hair
Venous:
- Occur in the gaiter area
- Rough, sloughy borders
- Shallow + large
- Signs of chronic venous disease: hyperpigmentation, venous eczema, lipodermatosclerosis, oedema
38
Describe the appearance of diabetic ulcers
- Usually occur over pressure areas eg. ball of foot
- Deep, surrounded by callus
- Loss of sensation
39
Define chronic venous insufficiency
Changes in the lower extremities due to chronically raised venous pressures eg. skin changes, oedema, ulcers
40
Describe the epidemiology of chronic venous insufficiency
Relatively common (7%)
41
Describe the aetiology of chronic venous insufficiency
Abnormality in lower extremity veins
- Typically reflux (valve incompetence), can also be chronic obstruction
* Commonly occurs after DVT
42
Describe the presentation of chronic venous insufficiency
Leg heaviness/aching + swelling
Skin changes, itching/flaking
Ulcers
43
Describe the signs of chronic venous insufficiency on examination
- Early: telangectasia, oedema, varicose veins
- Skin changes: hyperpigmentation, eczema, lipodermatosclerosis, atrophie blanche
- Ulceration: described above
44
What is lipodermatosclerosis? Describe appearance
Changes that occur in chronic venous insufficiency due to inflammation and fibrosis of SC tissue
- Atrophy + hardening of skin
- Champagne bottle legs
- Discolouration
45
What causes hyperpigmentation in chronic venous insufficiency?
Haemosiderin deposition
46
What is normal venous pressure in the lower extremities?
<20mmHg
47
Describe the investigations for chronic venous insufficiency
- History and examination (usually clinical Dx)
| - Duplex USS (for finding reflux/obstruction)
48
Describe the management of chronic venous insufficiency + varicose veins
Conservative:
- Regular walks, leg elevation
- Graded compression stockings
- Skin care: moisturisers, ulcer dressings
Surgical/interventional:
- Varicose veins: phlebectomy (under LA), foam sclerotherapy
- Endovenous ablation (for GSV or SSV reflux)
- Saphenectomy (stripping)
49
Define ulcer
A discontinuity in the epithelial surface
50
Describe the management of venous and arterial ulcers
Conservative:
- Venous: graded compression stockings, analgesia, elevation, dressings
- Arterial: lifestyle modification eg. exercise, smoking
Medical:
-Arterial: manage RFs
Surgical/interventional:
- Venous: venous surgery
- Arterial: revasc
51
When are compression stockings contraindicated?
If ABPI <0.8 (indicates PAD)
52
Define gangrene and the types
A complication of necrosis in which there is decay of tissues
- Wet/infectious: necrotizing fasciitis, gas gangrene
* Fournier's gangrene: nec fasc of perineum
- Dry/ischaemic
53
Describe the aetiology of gangrene
Infection
-RFs: DM, IVDU, immunocompromise, trauma, wounds, surgery
Ischaemia: arterial or venous.
-RFs: atherosclerosis, DM, smoking, malignancy, APS, Raynaud's
54
Describe the signs of gangrene on inspection
Dry:
- Tissue cold, shrunken, black and dry
- Well-demarcated
Wet:
- Tissue moist, soft, swollen and dark
- No clear demarcation
- Gas: crepitus
55
Which organisms are responsible for infectious gangrene?
Necrotising fasciitis:
-Type I: Enterobacteria, anaerobes
-Type II: Grp A Strep, S aureus
Gas gangrene: Clostridium pefringens mostly
56
Describe the presentation of gangrene
Pain!
Dry: symptoms of PAD- pain, parasthesia, paralysis
Wet:
-Fever, chills
-Nec fasc: severe pain out of proportion to clinical signs
57
Describe the investigations for gangrene
- History and examination
- ABPI
- Bloods (wet): FBC, CRP, U+Es, lactate, glucose, culture
- Consider as appropriate: Doppler USS, Xray (gas gangrene), swab, biopsy
58
Describe the management of gangrene
Ischaemic:
-IV heparin
-Revasc + RF management
+/- amputation (non-viable tissue)
Infectious:
-IV BS antibiotics
-Surgical debridement
+/- amputation
59
Describe the risk factors for varicose veins
- Obesity
- Pregnancy
- Older age
- Family history
- Connective tissue disease
60
Describe the presentation of thrombophlebitis
Localised severe pain, warmth, erythema and swelling
| Palpable cord-like mass/ varicose vein
61
Describe the investigations for varicose veins
Same as venous insufficiency: Duplex USS
62
Describe the arterial supply and venous drainage of the lower limbs
Arteries:
Aorta -> common iliac A -> internal + external A
-> femoral A -> popliteal A -> ant + post tibial A
-> Ant becomes dorsalis pedis
Veins:
- Deep system: ant + post tibial -> popliteal -> femoral
- Superficial system: great saphenous vein (medial) -> femoral vein, and small saphenous vein (posterior) -> popliteal vein
63
Describe the aetiology of thrombophlebitis
- Usually varicose veins
| - Migratory/recurrent: malignancy, APS
64
Describe the investigations for thrombophlebitis
```
Doppler USS (important to rule out DVT)
Recurrent/above knee/large: bloods (thrombophilia screen), CTCAP
```
65
Describe the management of thrombophlebitis
NSAIDs + compression stockings
+/- anticoagulation (>5cm or close to SFJ)
-Varicose vein surgery after resolution
66
Describe the risk factors for DVT
Virchow's triad:
1) Stasis:
- Bed rest, surgery, immobilisation, travel
2) Hypercoagulability:
- Pregnancy, malignancy, COCP, thrombophilia, sepsis
3) Vessel wall injury:
- Atherosclerosis, vasculitis
67
Describe the presentation of DVT
Sudden onset swollen + painful calf
68
Describe the signs of DVT on examination
Unilateral swollen leg (>3cm from normal leg)
Redness/discolouration
Tender
Dilated superficial veins
69
Describe the investigations for DVT
- History and examination
* Calculate Well's score: likely (2+)-> USS
- Bloods: FBC, U+Es, CRP, clotting (D-dimer)
- Imaging: Doppler USS
* Confirmed: consider CTPA if signs/symptoms
70
Describe the Well's score for DVT
```
Includes risk factors for DVT and clinical findings eg.
-Active cancer
-Bedridden
-Calf swelling and tenderness
2+ is likely -> USS
<2 is unlikely -> D-dimer (if + -> USS)
```
71
Describe the management of DVT
Conservative:
-Graded compression stockings to prevent post-thrombotic syndrome
Medical: *mainstay
- Anticoagulation: DOAC 1st line, LMWH, warfarin, UFH
- Continue for 3 months min (3 mo for provoked, 6 mo active cancer, consider lifelong if thrombophilia)
Surgical/interventional:
- IR thrombolysis
- IVC filter
72
Describe aneurysm repairs
Open:
- Midline laparotomy incision
- Clamp aorta, open aneurysm + suture in graft, close
EVAR (endovascular aneurysm repair):
-Catheter through groin -> place graft in aneurysm + fix
73
Describe the complications of aneurysm repair
Intra-operative: haemorrhage, damage to surrounding structures, ischaemic injury, death
Anaesthetic
Short term post-op: pain, wound infection, endoleak, ileus, AKI
Long term post-op: graft infection, endoleak
74
What is carotid endarterectomy?
Endovascular removal of atherosclerotic plaque buildup in the carotid arteries
75
Describe the indications for carotid endarterectomy
Carotid artery stenosis >70%
| Or >50% if low risk
76
Describe the complications of carotid endarterectomy
Intra-op: stroke, death
Anaesthetic
Short term post-op: infection, bleeding, pain
Long term post-op: restenosis
77
Describe the indications for amputation
- Gangrene
- Severe PAD unresponsive to revasc
- Significant trauma
- Tumours
78
Describe the common types of amputation
Knee disarticulation: through knee joint
Transtibial amputation: through tibia, preserves knee
Ankle disarticulation etc.
79
Describe the complications of amputations
Intra-op: bleeding, damage to surrounding structures
Anaesthetic
Early post-op: bruising, pain, wound infection, flap necrosis
Late post-op: phantom limb, depression
80
Name some examples of bypass surgery and the 2 main types
Anatomical: aortobifemoral
| Extra-anatomical: fem-fem crossover, axillobifemoral
