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Y3 Surgery > Vascular surgery > Flashcards

Vascular surgery Flashcards

1
Q

What is the difference between acute limb ischemia and chronic limb ischaemia?

A

Collaterals
Chronic disease- body has time to create collaterals

Acute is an emergency- no way to perfuse the tissues

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2
Q

What is arterial insufficiency?

A

Any condition that hinders the flow of blood to tissues

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3
Q

Is PAD more common in men or women?

A

More common in men
As we get older the incidence in men increases.
Generally a disease of middle age to older people

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4
Q

What is the first symptom they present with?

A

Intermittent claudication

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5
Q

What layer does atherosclerosis affect?

A

Tunica intima

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6
Q

Why are arteries more susceptible to weakness with atherosclerosis?

A

Plaque disrupts oxygen supply to aerobic cells
Causes weakness in the walls
Why it causes aneurysms and diltations

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7
Q

Why is atherosclerosis more common in arteries than veins?

A
  • Oxidative stress. More oxygen in the arteries
  • Shear stress- endothelial injury and dysfunction
  • Endothelial thickness- more likely to trigger formation of plaques
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8
Q

Umbrella term- arteriosclerosis. What are the three categories in it

A

Smaller arteries
hyaline and hyperplastic

Arteriosclerosis: Thickening and hardening of arteries
Types:
Atherosclerosis: Plaque buildup in artery walls
Monckeberg’s sclerosis: Calcium deposition in middle artery layer
Arteriolosclerosis: Thickening of small arteries and arterioles
Impacts blood flow and can lead to cardiovascular diseases

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9
Q

Describe the process of atherosclerosis

A

Large and medium-sized arteries
Atherosclerosis process:
Damage to endothelium
Cholesterol enters artery wall
Cholesterol oxidizes
Macrophages consume oxidized cholesterol, become foam cells
Inflammation and healing occur
Deposition of extra cellular matrix (ECM) and smooth muscle cells
Formation of fatty streaks
Fatty streaks progress to atherosclerotic plaques
Plaques have necrotic lipid core and fibrous 1. Large and medium sized arteries

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10
Q

What are the words of the day!!

A

Collateral and remodelling

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11
Q

What is the consequence of turbulent blood flow?

A

Blood will clot

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12
Q

Virchow’s triad?

A
  • Stasis of blood flow
  • Endothelial damage
  • Hypercoagulability
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13
Q

How do you classify PAD?

A

Fontaine classification
Google it

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14
Q

What is intermittent claudication?

A

IC is a cramp-like pain felt in the muscles
Usually the calf muscles
Superficial Femoral Artery- most commonly affected.
Immediately distal vessels

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15
Q

What vertebral level does the aorta bifurcate?

A

L4

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16
Q

How do you describe IC?

A
  • Brought on by walking
  • Not present on taking the first step (unlike OA)
  • Relieved by standing sill (unlike neuropathy)
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17
Q

What classification is used for IC

A

Boyd’s
Google it
Compare it to fontaine’s

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18
Q

What is critical stenosis?

A

Critical stenosis
If the vessel is >70% occlusion
Critical limb ischemia

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19
Q

How to describe gangrene

A

Clear line of demarcation between the de-vitalised tissue and healthy tissue
Forefoot
Nails are intact

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20
Q

What imaging would you request for gangrenous toes?

A

Foot x-ray

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21
Q

Acronym for lifestyle interventions?

A

DATES

Diet
Alcohol
Tobacco
Exercise
Stress

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22
Q

Why should you encourage exercise with PAD?

A

Will promote angiogenesis

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23
Q

Best medical therapy?

A

Anti-platelets (high risk of stomach ulcers)
Statins
PPI

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24
Q

How do statins work?

A
  • Increased LDL-receptor expression
  • Decreased liver cholesterol
  • Decreased plasma LDL
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25
Q

What are the side effects of statins?

A
  • Myalgia, myopathy
  • Rhabdomyolysis
  • Hepatotoxcity
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26
Q

Why no TED stockings?

A

Already have crap blood supply- stockings will compress the vessels and further decrease the blood supply to tissue.

Use DOAC instead for VTE prophylaxis

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27
Q

Why is CT good?

A

CT angiogram with contrast- IV, where there isn’t good blood supply, will show up
Give us a good idea of the circulation

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28
Q

Three things to check before CT scan?

A
  • Renal function
  • Pregnancy
  • Allergies
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29
Q

What are the main two imaging?

A

Ultrasound duplex (peripheral) and CT angiogram- aorto/iliac is better (may be bowel gas).

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30
Q

Three methods to treat PAD?

A
  • Bypass
  • Angioplasty
  • Conservatively
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31
Q

How do you do an angioplasty?

A

Groin vessel
Catheter- inflate the balloon or release stent

DEB- drug encoded balloon, have an anti-platelet coat the balloon

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32
Q

Why would you do a bypass?

A

Conduit/graft
More than 10cm of occlusion will be difficult to pass a catheter through a clot

When the motorway is blocked- open up the slip road.

What conduits would you use?- long saphenous vein (longer, greater calibre of result)
PTFE, omniflow (synthetic grafts)

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33
Q

Problems with using a vein as a graft?

A

Problems?
Veins have valves- they are reversed- pointing in the direction of the blood flow
The vein is given time to arteriolise- checked to make sure there is no signs of poor hemostasis. Makes sure there is no leaks, etc.

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34
Q

What is a collateral vein to an artery called?

A

Venia commitantes

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35
Q

What are the two venous systems?

A

Superficial and deep systems

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36
Q

Which blood vessel is most commonly affected by PAD?

A

SFA

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37
Q

Which of the following vessels is least likely to be involved in PAD?

A

Brachial artery

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38
Q

What symptoms is not associated with CAI?

A

Warm peripheries
Chronic arterial insufficiency

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39
Q

Which of the following is not a component of BMT?

A

Best medical treatment
Anticoagulants

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40
Q

What is ambulatory venous hypertension?

A
  • During relaxation of calf muscles, blood flows from superficial- deep system through perforators.
  • Each time this occurs the pressure in the superficial veins reduces
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41
Q

How can you clarify varicose veins?

A

CEAP classification
Clinical
Etiology
Anatomy
Pathophysiology

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42
Q

Surgery for a varicose vein (superficial)

A

Why do you need to check the competency of the deep venous system if you are changing a superficial vein?
Blood flows from the superficial to the deep system.
IF there is a blockage in the deep, if you remove the superficial there will be no drainage to the leg- oedema

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43
Q

What are invasive methods for varicose veins?

A

EVLA (endovenous laser abation)

ERFA (radiofrequency ablation)

Radiofrequency ablation: Destruction of the vein endothelium via a high-temperature catheter
Endovenous laser ablation: Destruction of the vein using a laser

Saphenofemoral high tie and long/short saphenous venous stripping (likely to damage the surrounding structures, nerve damage)

Injection sclerotherapy: Injection of a sclerosant substance at several points in the vein, leading to occlusion
Surgery: Avulsion therapy or stripping of the vein

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44
Q

What are symptoms of varicose veins?

A
  • Aching/heaviness
  • Worse with prolonged standing
  • Relieved by elevation/compression
  • swellings
  • Itching
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45
Q

Who gets referred for a varicose vein?

A
  • Symptomatic primary or symptomatic recurrent varicose veins
  • Lower limb skin changes
  • Superficial vein thrombosis (characterised by the appearance of hard painful veins and suspected venous impotence.
  • A venous leg ulcer (a break in the skin below the knee that has not healed within 2 weeks)
  • A healed venous leg ulcer
46
Q

What is the gold standard investigation for varicose veins?

A

Duplex ultrasound

47
Q

What nerve is damaged with stripping the short saphenous?

A

short saphenous- sural nerve

48
Q

What nerve is damaged with stripping the long saphenous vein?

A

Long saphenous- saphenous nerve

49
Q

How can you tell a vein from an artery using ultrasound?

A

The artery will pulsate

50
Q

What is the sclerosant used in varicose veins?

A

STS
Re-check with the ultrasound to make sure the vein is occluded

51
Q

How do you treat minor varicose veins- no complications?

A

Reassure/cosmetic therapy

52
Q

How do you treat symptomatic uncomplicated varicose veins?

A

In those without deep venous insufficiency options include: endothermal ablation, foam sclerotherapy, saphenofemoral/poplitea disconnectin, stripping and avulsions, compression stockings

53
Q

How do you manage varicose veins with skin changes?

A

In those without deep venous insufficiency options include: endothermal ablation, foam sclerotherapy, saphenofemoral/poplitea disconnectin, stripping and avulsions, compression stockings.

Class 1 stockings.

54
Q

How do you manage chronic venous insufficiency or ulcers?

A

Class 2-3 compression stockings, ensure no arterial disease.

55
Q

What do you do with a bleeding varicose vein?

A

Compress and elevate

56
Q

What are post-op complciations?

A
  • Haemorrhage
  • Recurrence
  • Wound infections
  • Injury to adjacent structures (saphenous/sural nerve)
  • Scar
  • Paraesthesia

In surgery always divide complications into pre op, intra op and post op

57
Q

What is the difference between duplex and doppler?

A

Duplex uses ultrasonography and doppler, images surrounding structures

Doppler- presence of blood flow in the studied vessels, its direction, speed and turbulence.

58
Q

Where is the most common location for a venous ulcer?

A

Medial malleolus

59
Q

What is the most common ulcer?

A

Mixed- venous and arterial.

60
Q

What is a normal ABPI?

A

1.0-1.4

61
Q

As per NICE guidelines, what is the 1st line surgical management for varicose veins?

A

Endovenous surgery

62
Q

How can you define a vessel that is aneurysmal?

A

Any vessel that is 1.5x normal diameter= aneurysmal

63
Q

Waht ibfections cause AAA?

A
  • Syphillis
64
Q

Why are women more likely to get AAAs?

A
  • Women have smaller aortas
65
Q

What is a large AAA?

A

> 5.5cm

66
Q

What is a small AAA?

A

3.0-4.4cm

67
Q

What is a medium AAA?

A
68
Q

What is a pseudoaneurysm?

A

Hole in the connective tissue and blood leaks out of the arterial wall into the surrounding tissue

69
Q

What is characteristic of AAA?

A

Pulsatile abdominal mass

70
Q

In how long should a AAA be seen if it is 5.0cm in women and 5.5cm in males?

A

2 weeks

71
Q

What are the two main types of surgery for AAA?

A

EVAR- the graft/stent is inserted into a blood vessel in your groin and then carefully passed up into the aorta, opened and fixed in place.

Open surgery- surgeons compare it to being hit by a bus, the graft is placed in the aorta through an abdominal incision. Prognosis is better.

72
Q

Triad of ruptured AAA?

A
  • Pain
  • Hypotension
  • Pulsatile abdominal mass
73
Q

Where is the blood more likely to pool in a ruptured AAA?

A

Peritoneal space

74
Q

How do you manage ruptured AAA?

A
  • A-E assessment
  • BP control: permissive hypotension
  • Cannula, bloods (FBC/group and save, X matach), VBG, IV fluid resus
  • Catheter
  • USG/CT
75
Q

Open AAA repair follow up?

A

6-8 weeks
Out patient folow up

76
Q

Where are you most likely to find duodenal ulcers?

A

First quarter of the duodenum

77
Q

Where are you most likely to find gastric ulcers?

A

Lesser curvature and then the antrum

78
Q
A
  • Venous
  • Arterial
  • Arteritis
  • Trauma
  • Chronic infection
  • Neoplastic
  • Pyoderma gangrenosum
79
Q

How can you classify ulcers?

A

SUPER

Sloped edges- venous
undermined edge- subcutaneous tissue more than the epidermis- tuberculosis/pressure sores
Punched out- arterial ulcers and diabetic ulcers- chancre
Everted edge- squamous cell carcinoma tissue spills out and overlaps the skin
Raised edge- BCC

80
Q

Most common ulcer at the medial malleolus?

A

Likely venous, varicose ulcers
More likely to heal- need good arterial blood supply

81
Q

Most common site of diabetic foot ulcers?

A

Foot- usually sole, painless due to neuropathy

82
Q

Most common site of arterial

A

Digits of the lower limbs
Arterial will be more common

83
Q

What are features of venous ulcers?

A
  • Oedema, brown pigmentation, lipodermatosclerosis and eczema
84
Q

How do you manage venous ulcers?

A

4 layer compression banding after exclusion of arterial disease or surgery

85
Q

What happens if a venous leg ulcer fails to heal after 12 weeks of more than 10cm?

A

Skin grafting may be needed

86
Q

Features of arterial ulcers?

A
  • Occur on the toes and heel, dorsum of the foot
  • Painful
  • There may be areas of gangrene
  • Cold with no palpable pulses
  • Low ABPI measurements
87
Q

What are the features of neuropathic ulcers?

A
  • Commonly over plantar surface of metatarsal head and plantar surface of hallux
  • Due to pressure
  • Management- cushioned shoes- reduce callus formation
  • The plantar neuropathic ulcer is the condition that most commonly leads to amputation in diabetic patients
88
Q

3 Ds for doing an amputation

A
  • Dry gangrene, wet gangrene
  • Deadly!- Osteomyelitis, osteosarcoma, osteochondroma, necrotising fasciitis
  • Dead loss- paralysis (if they would benefit more with a prosthesis)
89
Q

Common locations for neuropathic ulcers to form

A

Areas of greatest pressure

5th metatarsal head
Bottom of big to
Heel of foot

90
Q

Where do you find long saphenous varicosity with ulcers?

A

Medial side of the leg

91
Q

Where do you find short saphenous varicosity with ulcers?

A

Lateral side of the leg

92
Q

What is defined as a chronic ulcer?

A

Any ulcer that stays more the 6 weeks
Not responding to medical and conservative managements

93
Q

What is the most common type of ulcer?

A

Mixed ulcer

94
Q

What is a marjolin’s ulcer?

A

SCC that develops in an area of non healing tissue (burns, osteomyelitis after 10-20 years)
Mainly occurs in the lower limb
You have to take a biopsy to confirm the diagnosis.

95
Q

What is pyoderma gangrenosum

A
  • Associated with inflammatory bowel disease/RA
  • Can occur at stoma sites
  • Erythematous nodules of pustules which ulcerate
  • To confirm the diagnosis- take a biopsy
96
Q

What is the most common predisposing factor to venous insufficiency?

A

Immobility

97
Q

What is a Marjolin ulcer?

A

A Marjolin ulcer is a cutaneous malignancy that arises in the setting of previously injured skin, longstanding scars, and chronic wounds.

98
Q

Where in the lower limbs does rest pain most typically occur?

A

Toes

99
Q

What is the cause of reactive hyperemia?

A
  • Severe ischaemia leads to the release of local vasodilators (ADP, potassium, hydrogen ions, lactate and carbon dioxide)
  • Subsequently increases the perfusion of the ischemic foot
100
Q

What is another cause of compartment syndrome apart from a tibial fracture?

A

Post thrombolysis for acute limb ischemia

This patient has developed acute compartment syndrome secondary to reperfusion injury. This is a known complication which must be monitored for. A key examination finding is pain to passive stretching of muscles which is due to ischaemia.

Pulses are usually still felt, unless it is severe late compartment syndrome where intra-compartment pressures have exceeded systolic pressure. This can help distinguish it from an acutely ischaemic limb, which is pale, pulseless etc.

Prompt fasciotimy is the treatment; there are four compartments in the leg which require fasicial division

101
Q

What is the triad for critical limb ischemia?

A
  • Gangrene
  • Burning pain that is worse at night and when the limb is elevated
  • Arterial ulcers
102
Q

What is the first line investigation for the treatment of varicose veins?

A

Duplex ultrasound

103
Q

In the case of a ruptured AAA, what imaging modality would you do if the patient was hemodynamically stable?

A

Patients who are haemodynamically stable may be sent for a CT angiogram where the diagnosis is in doubt - this may also assess the suitability of endovascular repair.

104
Q

What are some examples of contra-indications to thrombolysis?

A

Non-viable limb (irreversible ischaemic change – insensate/fixed skin mottling)
Internal bleeding
Suspected aortic dissection
Prolonged or traumatic CPR
Previous allergic reaction
Heavy vaginal bleeding
Pregnancy or < 18 wks postnatal
Acute pancreatitis
Severe liver disease
Active lung disease with cavitation
Oesophageal varices

105
Q

At what degree of carotid artery stenosis is carotid endarterectomy recommended in the context of symptoms (e.g.

stroke or transient ischaemic attack)?

A

50%

106
Q

What are the key investigations for carotid artery stenosis?

A

Duplex ultrasonography: This is the first line investigation and can evaluate blood flow and detect plaque in the carotid arteries.

CT angiography and MR angiography: These can provide further details about the extent and severity of the stenosis.

107
Q

Where would the scar be for an aorto-femoral bypass graft?

A

Mid-line down the abdomen

108
Q

Where would the scar be for ileo-femoral bypass graft?

A

Disease affecting the left external iliac (or proximal femoral artery) can be managed with an ileo-femoral bypass. This will result in an oblique scar to access the iliac arteries, and vertical groin scar to access the femorals

109
Q

What is the most common type of gangrene that would lead to sepsis?

A

Wet gangrene

In patients with peripheral arterial disease (absent pulses and skin changes), blackish, moist and blistering distal extremities raise concern for wet gangrene. In wet gangrene, patients may went on to develop sepsis due to superimposed infection, which needs to be urgently treated with IV antibiotics followed by surgical debridement or in most scenarios, amputation.

110
Q

Most common bacteria to cause gas gangrene?

A

Clostridium perfringens

Gram positive, bacilli, anaerobic

111
Q

What is the main difference between acute limb ischemia caused by embolus vs thrombotic cause?

A

Embolus= occurs within minutes

Thrombotic= occurs over days

112
Q

What are indications for patients having EVAR for a AAA instead of open surgery?

A

EVAR is generally offered to those who cannot undergo an open repair e.g. thosea major anaesthetic risk/medical comorbidities/structural co-pathology e.g. a horseshoe kidney, stoma, or hostile abdomen.

Y3 Surgery (7 decks)

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