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Y3 surgery old > Vascular Surgery > Flashcards

Vascular Surgery Flashcards

1
Q

What is peripheral arterial disease?

A

Significant narrowing of arteries distal to the arch of aorta, usually due to atherosclerosis

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2
Q

What are the RF of peripheral arterial disease?

A

Smoking, DM, hypertension, hyperlipidaemia, physical inactivity and obesity.

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3
Q

What are the symptoms of peripheral arterial disease?

A

Walking impairment, pain in buttocks and thighs relieved at rest.

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4
Q

What are the signs of peripheral arterial disease (PAD)?

A

Pale, cold leg
Hair loss
Ulcers
Poor wound healing
Weak or absent pulses

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5
Q

What are the investigations for PAD?

A

Full CVS risk assessment incl BP, FBC, blood glucose, lipids and ECG.

Ankle-brachial pressure index- uses doppler probe to find the systolic brachial blood pressure of the arms and comparing to ankle blood pressures

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6
Q

How do you non-surgically manage a patient with PAD?

A

Non-surgical: RF modification, supervised exercise program, smoking cessation and weight management

Managing CVS risk- clopidogrel 75mg, atorvastation 80mg, diabetes and HTN should be well controlled
Managing pain- Naftidrofuryl oxalate- vasodilator, only if exercise is ineffective and the pt does not want angioplasty or bypass

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7
Q

How do you surgically management a patient with PAD?

A

Intermittent claudication: endovascular revascularisation or surgical revascularisation, when RF modification has not improved sx

Critical limb ischaemia (rest pain, tissue loss etc.), referral to vascular MDT. Endovascular methods for small stenosis, surgical bypass for larger and more extensive stenosis and amputation if there no other option.

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8
Q

Define gangrene

A

Death of tissue specifically due to an inadequate blood supply

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9
Q

Define necrosis

A

Tissue death

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10
Q

Define ischaemia

A

Inadequate O2 supply due to inadequate blood supply

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11
Q

How does atherosclerosis cause ACS?

A

Plaques cause:

  1. stiffening of artery walls —> HTN and strain on the heart due to increased resistance
  2. stenosis —> reduced blood flow e.g. angina.
  3. plaque ruptures —> get thrombus in distal vessel —> cause ischaemia/ACS
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12
Q

What are non-modifiable RF for atherosclerosis?

A

Male gender, older age, FHx

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13
Q

What are modifiable RF for atherosclerosis?

A

Smoking
Alcohol consumption
Poor diet
Sedentary lifestyle
Obesity
Poor sleep

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14
Q

A patient who has a PMH of atherosclerosis is now presenting with chest pain. She also feels the pain in her abdomen and has mentioned her legs have been cramping. Braindump some differentials

A

Angina, MI, TIA, Stroke, PAD, Chronic mesenteric ischaemia

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15
Q

What is Leriche syndrome?

A

A term given for a group of symptoms caused by PAD of legs.

Occlusion in the distal aorta or proximal common illiac artery

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16
Q

What is the triad in Leriche syndrome?

A

thigh / buttock claudication, impotence and absence of femoral pulses.

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17
Q

How is Leriche syndrome managed?

A

Surgical revascularisation
Surgery - aortofemoral bypass or axillofemoral bypass with or without endartectomy (removing the plaque)

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18
Q

Describe the pathophysiology of Leriche syndrome

A

Severe atherosclerosis affecting the distal abdominal aorta, iliac arteries and femora-popliteal vessels. Can be bilateral depending on where the occlusion is.

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19
Q

What can PAD lead to?

A

Intermittent claudication.

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20
Q

What can intermittent claudication lead to?

A

Acute limb ischaemia or critical limb ischaemia.

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21
Q

Describe presentation of intermittent claudication

A

Crampy, achy, pain in calf, thigh or buttocks. Muscle fatigue when walking. Occurs at exertion and relieved at rest.

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22
Q

How can claudication be measured?

A

Claudication distance and Walking distance (maxima walking distance)

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23
Q

What is the claudication distance?

A

How long pt can walk until the pain starts

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24
Q

What is the walking distance (maximal walking)?

A

Once the pain has begun, this is how long the pt can continue to walk for

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25
Q

Define acute limb ischaemia

A

Rapid onset of ischaemia often due to a thrombus blocking blood supply to a limb

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26
Q

Define critical limb ischaemia

A

End stage of PAD - not enough blood supply to limb to allow a normal function at rest. Pt at risk of losing limb

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27
Q

How can pt present with critical limb ischaemia?

A

Pain at rest, non-healing ulcers, gangrene. Pain worse at night when leg raised. Pt hangs leg off bed to help. Burning pain.

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28
Q

What are the 6Ps of critical limb ischaemia?

A

Pain, pallor, pulselessness, paralysis, parasthesia, perishingly cold.

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29
Q

What is a VTE?

A

Formation of a blood clot in the venous system with potential to embolism causing a PE.

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30
Q

What is in Virchow’s triad?

A

Change in coagulability, stasis of blood, vessel wall injury

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31
Q

What are RF for VTE?

A

Immobility
Recent trauma
Long haul travel
Pregnancy
Hormone therapy containing oestrogen
Polycythaemia
SLE
Thrombophillia

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32
Q

What prophylaxis against VTE is given/carried out in hospital before surgical procedure?

A

VTE risk assessed
Prophylaxis given if risk is increased unless contraindicated.
Prophylaxis usually with LWMH - enoxaparin, dalteparin.
TED stockings given - unless contraindicated.

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33
Q

How does VTE present?

A

Unilateral calf or leg swelling
Dilated superficial veins
Calf tenderness
Oedema
Colour changes to leg

34
Q

What is a Wells score?

A

Predicts risk of DVT or PE in patient presenting with symptoms

35
Q

What investigations would you do for suspected VTE?

A

D dimer
Wells score
Doppler ultrasound
CT pulmonary angiogram

36
Q

Why is a D-dimer done for suspected VTE?

A

Helps exclude DVT but does not confirm it, as other conditions can cause a raised D dimer score

37
Q

Why is a doppler ultrasound done for suspected VTE?

A

Assess blood flow in the leg. Repeat 6-8days later if DVT suspected but initial scan -ve.

38
Q

Why is a CT pulmonary angiogram done in pt presenting with leg swelling, calf tenderness and colour changes to the leg?

A

Identify PE

39
Q

How is VTE initially managed?

A

Apixaban, rivaroxaban

40
Q

After a DVT, how are they managed?

A

Long term anticoags - doac, warfarin, LWMH

41
Q

What are varicose veins?

A

Distended superficial veins >3mm in diameter. Usually in the legs

42
Q

Describe the pathophysiology of varicose veins

A
  1. incompetent valves in perforating veins
    connecting deep and superficial veins.
  2. backflow of blood from deep veins into
    superficial veins
  3. superficial veins overloaded and become
    dilated and engorged
43
Q

What are RF for varicose veins?

A

Increasing age, FHx, female, pregnancy, obesity, prolonged standing, DVT causing damage to valves

44
Q

What are symptoms of varicose veins?

A

can be asymptomatic

heavy dragging sensation in legs
aching
itching
burning
oedema
muscle cramps
restless legs

45
Q

Name two conservative options for varicose veins

A

Weight loss
Physical activity
Elevate leg
Compression stockings

46
Q

What are surgical options available for varicose veins?

A

endothermal ablation
sclerotherapy - inject irritant causing vein
closure
stripping- veins ligated and removed

47
Q

What are complications associated to varicose veins?

A

Excessive bleeding post trauma
Superficial trombophlebitis
DVT
Issues associated to venous insufficiency

48
Q

What is chronic venous insufficiency?

A

Blood does not drain efficiently back to the heart,
pools in the veins in the leg and causes venous
hypertension.
This can lead to changes in the skin

49
Q

What are RF for chronic venous insufficiency?

A

increased age
immobility
obesity
prolonged standing
DVT causing damage to valves
association with varicose veins

50
Q

Where are skin changes in chronic venous insufficiency?

A

In gaiter area - below knee and above the ankle

51
Q

What skin changes are seen in chronic venous insufficiency?

A

Haemosiderin staining
Venous eczema
Lipodermatosclerosis
Atrophie blanche

52
Q

What complications can arise from chronic venous insufficiency?

A

Cellulitis
Poor wound healing
Skin ulcers
Pain

53
Q

How is skin managed in chronic venous insufficiency?

A

Monitor skin health, regular emollients, topical steroids for flare of venous eczema or lipodermatosclerosis

54
Q

How can venous drainage be improved in chronic venous insufficiency?

A

Weight loss
Physical activity
Elevate legs
Compression stockings

55
Q

How can complications of chronic venous insufficiency be managed?

A

Infection - abx flucloxacillin
Analgesia
Wound care and dressings

56
Q

Causes of venous leg ulcers?

A

Venous hypertension, chronic venous insufficiency

57
Q

Features of venous ulceration?

A

oedema, brown pigmentation, lipodermatosclerosis, eczema

58
Q

Where do venous uclers commonly form?

A

Above the ankle

59
Q

What is deep venous insufficiency related to ?

A

previous DVT

60
Q

What is superficial venous insufficiency related too?

A

varicose veins

61
Q

Management of venous ulcers?

A

cleaning, debridement and dressing, 4 layer compression banding

Elevate the legs

Use emollients to protect skin barrier

if non healing - tissue viability.

62
Q

Where do arterial ulcers commonly form?

A

Toes and heels

63
Q

Cause of arterial ulcers?

A

insufficient blood supply to skin due to peripheral arterial disease

64
Q

Features of arterial ulcers?

A

Cold with no palpable pulses, low ABPI index, possibly pitting oedema due to co-morbities

65
Q

Cut offs for arterial disease in APBI?

A

<0.5 severe arterial disease
0.5-0.8- arterial disease or mixed arterial venous disease

66
Q

Management of arterial ulcers?

A

Urgent vascular review
Conservative- smoking cessation, lose weight, exercise, CVS modification- anti-platelets, statins
May need bypass or graft

67
Q

Common sites for neuropathic ulcers?

A

Plantar surface of metatarsal head and plantar surface of hallux

68
Q

Cause of neuropathic ulcer?

A

Pressure- lack of sensation (i.e loss of protective sensation) so injuries go unnoticed, immunocompromised and increased blood glucose leads to impaired wound healing

69
Q

Management of diabetic foot ulcer

A

referral to diabetic foot ulcer clinic
optimise diabetic control
improve diet and exercise if approriate
regular chiropody to ensure good foot hygiene and
appropriate footwear
may need surgical debridement
skin swabs and Abx (flucloxacilin) if infection suspected
amputation in severe necrotic/infected cases

70
Q

What is an abdominal aortic aneurysm

A

Dilation of abdominal aorta greater than 3cm

71
Q

RF for AAA?

A

Male
Increased Age
Smoking
Hypertension
Family history
Existing CVS disease

72
Q

Screening for AAA

A

All men in England at age 65 offered screening.
Pts with aortic diameter over 3cm referred to vascular team

73
Q

Investigations for AAA

A

US is initial diagnosis
CT angiogram gives more detailed picture of aneurysm for repair

74
Q

Management AAA

A

Risk of progression:
Stop smoking
Healthy diet and exercise
Optimising mx of hypertension, diabetes, hyperlipidaemia

Surveillance:
Yearly for pts with aneurysm 3-4.4cm
3monthly for pts with 4.5-5.4cm

Elective repair for patients:
greater than 5.5cm
Symptomatic aneurysm
Growing more than 1cm a year

75
Q

Classification of AAA

A

No aneurysm- less than 3 cm
Small aneurysm- 3-4.4cm
Medium aneurysm- 4.5-5.4cm
Large aneurysm- above 5.5cm

76
Q

Presentation of ruptured AAA

A

Severe abdo pain radiating to back or groin
Haemodynamically unstable (hypotension and tachycardia)
Pulsatile and expansile mass in abdo
Collapse
LOC

77
Q

Driving rules for AAA?

A

Inform DVLA if aneurysm is above 6cm
Stop driving is above 6.5cm
Stricter rules if driving heavy vehicle

78
Q

What is permissive hypotension in AAA management?

A

Allowing lower than normal blood pressure when fluid resuscitating as increased BP= increased blood loss

79
Q

Location of diabetic foot ulcers?

A

Heel of foot, metatarsal heads

80
Q

Investigations for diabetic foot ulcer?

A

ABPI, doppler to assess blood flow, blood glucose including HbA1c, skin swabs. XR if concerned of osteomyelitis.

81
Q

Management of venous ulcers

A

compression bandaging, usually four layer (only treatment shown to be of real benefit)

oral pentoxifylline, a peripheral vasodilator, improves healing rate

82
Q

Polycyaethmia vera presentation?

A

Venous/arterial thromboembolism, raised haemoglobin, red cell count and haematocrit (red and white lines are also usually raised too)

Y3 surgery old (6 decks)

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