Flashcards in Vascular Surgery Deck (54):
Describe the clinical presentation of acute limb ischaemia
Poikilothermia (cold limb)
What is the etiology of acute limb ischaemia?
What are the classic angiographic finding of an embolism
Convex filling defect
Otherwise relatively normal vessels
No visible atherosclerosis
Often lodge at bifurcations
List some of the causes of a cardiac embolism
MI with mural thrombosis
List some of the causes of a thrombosis
Peripheral aneurysms - popliteal
What are the angiography findings of atherosclerosis
Tapered irregularly cutoff vessels
Well developed collaterals
List some risk factors for a hypercoaguable state
Heparin induces thrombocytopenia
Provide a DDx of acute limb ischaemia
Venous threatened limb
Acute compression neurology
Describe the Rutherford classification of acute ischemia for a 2b threatened limb
Salvageable if immediately treated
Slow/absent capillary refill
Partial muscle paralysis
Partial/complete sensory loss
Inaudible arterial Doppler signals
Audible venous Doppler signals
Describe the Rutherford classification of acute ischemia for a non-viable limb
Primary amputation needed
Absent capillary refill - fixed skin staining due to ruptured capillaries
Complete tense muscle paralysis - flexor rigidity (stiff ankle)
Complete sensory loss
Inaudible arterial Doppler signal
Inaudible venous Doppler signal
What special investigations would you do in a patient with suspected acute limb ischaemia?
Digital subtraction angiography (DSA)
Ultrasound - Doppler flow
What is the management of acute limb ischaemia?
Heparin 5000 IU - prevention of further thrombosis
What are the complications of revascularization?
Oxygen free radicals damage cell membrane
Systemic release of lactate, potassium and myoglobin
What are the risk factors for chronic arterial disease (critical limb ischaemia)
Males and post menapausal women
Chronic renal failure
What are the symptoms of chronic arterial disease?
Intermittent Claudication - ischaemic muscle pain induced by exercise and relieved by rest
Critical limb ischaemia:
Rest pain - severe burning pain in the forefoot or toes that’s worse at night and improves with walking or hanging the limb off the bed
Impotence - aortic-iliac/bilateral iliac disease
Acute on chronic vascular occlusion
Provide a DDx for claudication
Osteoarthritis of the hip/knee
Chronic compartment syndrome
Provide a DDx for rest pain
What is critical limb ischaemia (CLI)?
It implies impending limb loss
When the blood supply to a limb is critically diminished
Often a multilevel disease
What are the symptoms/signs of critical limb ischaemia?
Non-healing ischaemic ulcer
When assessing a patient the femoral pulse and all pulses below it are absent. What is anatomical level of disease?
When assessing a patient the highest pulse palpable is the popliteal pulse. What is anatomical level of disease?
When assessing a patient the highest pulse palpable is the foot pulse. What is anatomical level of disease?
When assessing a patient the highest pulse palpable is the femoral pulse. What is anatomical level of disease?
What special investigations would you do for a patient with chronic arterial disease?
Digital Subtraction Angiography
Discuss the management of claudication
Manage risk factors - DM, HPT, hypercholesteraemia (ACE inhibitors is HPT)
Supervised exercise program
Foot care in diabetes
Warn patients about symptoms of CLI and acute on chronic vascular occlusion
Refer for intervention is conservative treatment fails
Discuss the management of critical limb ischaemia
Need revascularization for limb salvage:
Imaging - duplex Doppler, CT angiography, DSA
Revascularization - endovascular, surgery
Amputation of gangrenous toes
Risk factor management
How do you manage a patient with critical limb ischaemia that is NOT a candidate for revascularization?
Amputate - Unbearable pain/progressive infection
Medical management - Stable pain
List the options for revascularization
How would you manage a patient with aorto-iliac disease?
Discuss the treatment of a septic diabetic foot
Diagnose and treat diabetic ketoacidosis
IV fluids - Ringers
IV antibiotics - Entrapenem/Vancomycin
Drainage and debridement of sepsis
What are the indications for amputation
Critical limb ischaemia with no bypass option
Foot no longer salvageable
Immobile or contracture of limb
What is the etiology of True aneurysms?
What is the etiology of False aneurysms?
Infective - TB, syphilis, staph aureus
Genetic - Marfan syndrome
Inflammatory - Giant cell arthritis
Classify Abdominal Aortic Aneurysms by CT measurements
Small AAA: 4-5cm
Moderate AAA: 5-6cm
Large AAA: 6-7cm (50% risk of rupture in 5 years)
Very large AAA: >7cm (100% risk of rupture in 5 years)
What are the complications of an AAA
Compression of surrounding structures
When is surgery indicated in an asymptomatic AAA
>1cm increase in size in a year
What are the indications for a stent placement in AAA
Neck is atleast 1cm below renal artery or normal aorta
<60% angulation of the neck
Must have adequate access
May not be too torturous or calcified
What are the surgical options for AAA?
What is the conservative management of an AAA
6 monthly follow-up for US
What are the symptoms of an AAA
Abdominal pain that radiates to the back
Tenderness over AAA
What are the complications of endovascular (stent) repair?
List the 3 components of Virchows triad
Changes in blood flow - stasis
Changes in blood composition - hypercoaguability
Changes in vessel wall - endothelial damage
What are the risk factors for DVT?
Describe the clinical picture of a patient with a DVT
Limb Pain and tenderness
Haman’s signs - pain in the calf on dorsiflexion of the ankle
Pulmonary embolism - SOB, chest pain
Provide a DDx for a unilateral swollen leg
Trauma - fracture, haematoma
How would you diagnose a DVT?
Clinically using Wells score
How is Wells score used to aid the diagnosis of a DVT?
Low probability: score of less than or equal to zero
Moderate probability: score of 1-2
High probability: score of more than 3
What are the complications of DVT?
Discuss the management of DVT
>unfractioned heparin till INR >2 for 24hours
Venous thrombectomy - if worsening of treatment/gangrene
Interruption of vena cava - prevent PE
What are the risk factors for varicose veins?
What are the signs and symptoms of complicated varicose veins?
Stasis and dermatitis
What are the indications for surgery for varicose veins?
Persisting or disabling pain
Skin erosion with bleeding
Chronic venous insufficiency
What are the Hard signs of vascular injury?
Bruits or arterial thrill
Cold pale limb