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Flashcards in Vascular surgery Deck (53):
1

Definition of aortic dissecion

The entry of blood through an intimal tear in the thoracic aorta into an intima-media space creating a false lumen that extends ante- or retrograde

2

Risk factors for aortic dissection

Hypertension and old age!!

Connective tissue disorders (Marfan's)
Structural abnormalities (e.g. bicuspid aortic valve or coarctation - aortic root dilatation)
Turner syndrome
Pregnancy

3

Classifications of aortic dissection

DeBakey classifications:

Type I: involves both ascending and descending aorta (Stanford A)

Type II: involves ascending aorta only (Stanford A)

Type III: involves descending aorta only (Stanford B)

4

Stanford classification of aortic dissection

Stanford A = proximal to subclavian artery
IS AN EMERGENCY - as can become proximal leading to regurgitation, ST elevation and haemodynamic compromise

5

Which is more common, aortic dissection or ruptured abdominal aneurysm

Aortic dissection is twice as common as ruptured abdominal aneursym

6

Clinical features of aortic dissection

Tearing chest pain radiating to back
Often associated with episode of collapse
Symptoms of CHF, dysphagia, haemoptysis, haematemesis
+/- evidence of occlusion of aortic branches (paraplegia, acute limb ischaemia, CVA, inferior MI, acute renal failure)

Hypertension in 90%
R/L BP discordance
Red. or absent peripheral pulses
Soft early diastolic murmur (aortic regurgitation)

7

Imaging in aortic dissection

CXR:
- widened mediastinum
- double aortic contour
- Irregular aortic contour
- inward displacement of atherosclerotic calcification
Echo: confirms diagnosis
Post-contrast CT:
- intimal flap
- double lumen
- dilatation of aorta

8

Management of aortic dissection

IMMEDIATE MANAGEMENT OF HTN
Type A - usually require surgical intervention (unless evolving CVA or established renal failure)

Type B - may be managed nonsurgically
- fastidious BP control
- surg if evidence of aortic expansion

9

Definition of abdominal aortic aneurysm

An increase in aortic diameter by over 50% (usually regarded as diameter greater than 3cm)

10

Risk factors for development of abdominal aortic aneurysm

HTN
Peripheral vascular disease
Family history
Connective tissue disorders
Arteritis
Smoking
Hypercholesterolaemia

11

Risk factors for rupture of pre-existing abdominal aortic aneurysm

Large size
HTN
COPD
Female gender

12

Risk of AAA rupture at 5 years by size

5-6cm: 25%
6-7cm: 35%
Over 7cm: 75%

13

Clinical presentation of stable AAA

75% asymptomatic
Epigastric or back pain
Malaise and weight loss
Possible blue, painful toes (thromboemboli)
Wide AA pulse (3cm)

14

Clinical presentation of ruptured AAA

Sudden onset abdominal, flank or back pain (+/- radiation groin, back, legs)
Syncope
N+V
Rapid palpitations
Light-headedness
Tachycardia
Palpable pulsatile abdominal mass
Hypotension
Shock

15

Investigations of choice in AAA

USS: preferred for monitoring small aneurysms
CT angiogram:
- Draped aorta sign (sign of contained rupture)
- high attenuation crescent sign - sign of impending rupture (fresh blood insinuating into mural thrombus before penetrating wall)
- retroperitoneal haematoma

16

Indications for surgical repair of AAA

Rupture
Symptomatic aneurysm
Rapid expansion
Asymptomatic larger than 5.5cm

17

Conservative management of AAA before surgery is indicated

Management of Hypertension!

18

Definition of intermittent claudication

Intermittent, reproducible calf or thigh pain precipitated by exercise and relieved by rest, due to ischaemia of the lower limbs in the setting of peripheral arterial disease

19

Clinical features of intermittent claudication

Calf or thigh pain
- precipitated by exercise
- relieved by rest
- occurs after predictable distance
- "cramp" or "tightness"
- Exact location varies according to vessels involved

Buttock and hip = aortoiliac disease
Thigh = common femoral artery or aortoiliac
Calf = superficial or popliteal femoral artery

20

Management of intermittent claudication

Risk factor reduction
Anti-platelet medications (aspirin)

Surgical revascularisation
- aorto-iliofemoral reconstruction or bypass
- Angioplasty +/- stenting

indications for revascularisation;
- Refractory rest pain or claudiction limiting lifestyle
- Non-healing ulcers or gangrene

21

Definition of critical limb ischaemia

Persistently recurring ischaemic rest pain requiring regular adequate analgesia for more than two weeks OR tissue loss (ulceration or gangrene) of the foot or toes with an ankle pressure of less than 50mmHg or toe pressures less than 30mmHg

22

Cause of critical limb ischaemia

Atherosclerosis
Same mechanism as intermittent claudication but greater obstruction

23

Clinical features of critical limb ischaemia

Ischaemic pain at rest
- cramp/tightness
- increase when foot elevated (e.g. lying down in bed)
- relieved with dependency (putting put lower)
+/- ulceration or gangrene

Absent foot pulses
ABI less than 0.4

24

Management of critical limb ischaemia

Automatic indication for revascularisation (percutaneous angioplasty or bypass surgery)
Risk factor modification

25

Definition of acute limb ischaemia

A medical emergency caused by sudden arterial occlusion in a limb with inadequate collateral supply

26

Epidemiology of acute limb ischaemia

Rare
Mortality as high as 75%
Infrequent in those with established peripheral arterial disease due to inc. collateral circulation
VERY UNCOMMON in upper limb

27

Causes of acute limb ischaemia

Embolism (LA, mural thrombus, prosthetic/disease heart vlaves, aneurysm or atheromatous stenosis, tumour, foreign body)
Thrombosis
Trauma
Dissecting aneurysm

28

Clinical features of acute limb ischaemia

6 Ps:
- Pain
- paraesthesia
- pallor
- pulselessness
- paralysis
- perishing with cold
+ fixed staining/mottling (late sign)
+/- objective sensory loss (late sign!)

29

how to differentiate embolic v thrombotic limb ischaemia

Embolism:
- more rapid onset of symptoms
- potential source of embolus (e.g. known AF)

Thrombus:
- Pre-existing chronic arterial disease and comorbidities
- reduced pedal pulses in contralateral leg
- Foreign implants in peripheral artery (e.g. stent etc.)`

30

Management of acute limb ischaemia

Heparin + analgesia
treatment of associated cardiac disease

Embolic disease: embolectomy or intra-arterial thrombolysis

thrombotic disease:
Intra-arterial thrombolysis/angioplasty or bypass surgery

31

Clinical features of chronic mesenteric ischaemia

Recurrent acute episodes of abdominal pain:
- dull, crampy
- postprandial (within 1h)
- epigastric
- inc. severity after high fat meals
- pain subsides over 2h
Weight loss due to food aversion
Nausea, vomiting and early satiety

32

Diagnosing mesenteric ischaemia

CT and MR angiography
Duple ultrasound can detect high-grade stenoses

33

most common cause of peripheral leg ulcers

Venous leg disease

34

Clinical features of venous hypertension

Perimalleolar oedema
Pigmentation (haemosiderin staining)
lipodermatosclerosis (skin hard and woody)
Eczema
ulceration

35

management of venous ulcers

manage venous HTN:
- DVT prophylaxis (antiplatelets, compression therapy)
- refer to leg ulcer clinic
- wound debridement
- pain management (e.g. topical lignocaine)
- Elevation (red. oedema to inc. healing)
- exercise (inc. movement of blood)
Skin and ulcer hygiene
- regular washing, Cadexomer iodine
Management of comorbidities

36

Definition of varicose veins

Manifestation of superficial venous insufficiency characterised by bulging (over 3mm diameter) tortuous superficial veins, usually in the lower limb)

37

Definition of reticular veins

"feeder veins", blush subderma veins 1-3mm in diameter that give rise to telangiectasia

38

Definition of telangiectasias

"spider veins", very small (less than 1mm diameter) thread veins found commonly in clusters on the surface of the skin

39

distribution of varicose veins

Long saphenous vein:
- anteromedial distribution

Small saphenous vein:
posterior distribution

40

Indications for surgery of varicose veins

Mostly for cosmetics or minor symptoms

Absolute indications:
- lipodermatosclerosis leading to venous ulceration
- recurrent superficial thrombophlebitis
- bleeding from ruptured varix

41

Conservative treatment of varicose veins

Aerobic exercise
Elevation
Flex ankles frequently during prolonged durations of sitting
Weight control
Graduated compression stockings

42

Invasive therapies for varicose veins

Open surgery: LSV stripping
Radiofrequency ablation
Endovascular laser ablation
Sclerotherapy

43

Management of DVT

Prevent PE:
- anticoagulation - initially with LMWH (unless in setting of CKD)
- oral anticoagulation for at least 3-6m

Surgical thrombolectomy or thrombolysis is an option

44

Definition of superficial thrombophlebitis

Pain, tenderness, induration and erythema along the course of a superficial vein due to inflammation and/or thrombosis and less commonly, infection of the vein. Generally benign and self-limiting but can be complicated by DVT and PE

45

Management of superficial thrombophlebitis

Symptom alleviation
Prevention of thrombus propagation
For less extensive phelbitis (less than 5cm)
- elevation
- warm or cool compresses
- NSAIDs
More extensive (over 5cm or in saphenofemoral/saphenopopliteal junction)
- anticoagulation with heparin

46

Grading of carotid stenosis

Mild: less than 50%
moderate: 50-70% stenosis
Severe: 70-99%

47

clinical features of carotid stenosis

Focal neurological deficit in the carotid artery distribution
- amaurosis fugax
- contralateral weakness or numbness of a limb or face
- dysarthria or aphasia

48

Indications for carotid endarterectomy

Symptomatic and 70-99% stenosis (clear benefit)
Symptomatic and 50-69% stenosis (possible benefit)
Asymptomatic MALES with over 70% stenosis

49

Wet v Dry gangrene

Wet gangrene = infectious (i.e. necrotising fasciitis)
Dry gangrene = ischaemic

50

Management of dry gangrene

IV heparin
If threatened non-viable extremity with LE over 2y:
Surgical revascularisation +/- amputation
Threatened non-viable less than 2y LE - PCI +/- amputation
Viable extremity: thrombolytic therapy

51

Location of arterial v venous ulcers

Arterial: soles of feet, heels and toes
venous: inner part of ankles (medial malleoli)

52

Borders of arterial v venous ulcers

Venous: poorly defined
Arterial: well-defined, punched out

53

ABPI indicative of arterial disease

Less than 0.9