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Year 4 General surgery > Vascular surgery > Flashcards

Vascular surgery Flashcards

1
Q

what is a true aneurysm

A

abnormal dilatation of an artery involving all 3 layers of the arterial wall (intima, media, adventitia)

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2
Q

what is a false aneurysm / pseudoaneurysm

A

breach in the arterial wall resulting in an accumulation of blood between the tunica media and adventitia of the artery
mucosal outpouching through weakness in artery

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3
Q

signs of aneurysm

A

pulsating
bruit
expansile

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4
Q

how can you classify aneurysms

A

location - abdominal, thoracic, popliteal, cerebral
shape - fusiform, saccular
size
aetiology - congenital, acquired

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5
Q

where might you find a saccular aneurysm

A

cerebral

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6
Q

where might you find a fusiform aneurysm

A

abdominal aorta

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7
Q

congenital causes of aneurysms

A

Marfans
Ehlers Danlos
PKD - cerebral

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8
Q

acquired causes of aneurysms

A

vasculitis
infectious - syphilis, TB
idiopathic
trauma

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9
Q

RF for aneurysms

A 
smoking 
HTN
obesity 
cholesterol 
atherosclerosis
M>F
age 
FH
ethnicity - european
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10
Q

complications of aneurysms

A

rupture and retroperitoneal leak
embolism from thrombus build up in aneurysm
local pressure effects

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11
Q

risk of rupture increases due to which law?

A

LaPlace’s law

as the artery wall expands, it becomes thinner

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12
Q

What is the AAA screening programme

A

men >=65 get an abdominal USS

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13
Q

what imaging do you do if there is a suspicion of asymptomatic AAA

A

Abdo USS

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14
Q

what imaging do you do for symptomatic / suspected rupture of AAA

A

CT angiogram

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15
Q

non-surgical management of AAA

A

stop smoking
manage HTN
statin and aspirin
weight loss and exercise

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16
Q

what is the work up for elective repair of AAA

A

CTA from aortic arch to femoral arteries

bloods, ECG, ECHO, PFTs, frailty score, METS

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17
Q

there is no benefit to early repair, true or false

A

true

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18
Q

symptoms of AAA rupture

A 
abdominal pain radiating to the back 
collapse / sudden death 
acutely unwell 
hypotension
renal colic 
expansile abdominal mass 
peripheral pulses
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19
Q

why do you get renal colic in AAA rupture

A

retroperitoneal
bleeding can result in:
grey turners
cullens

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20
Q

management of acute AAA rupture

A 
ABCDE 
MHP activation 
IV access 
IV fluids - too much can cause retroperitoneum to burst therefore you do permissive hypotension 
G+S, crossmatch
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21
Q

permissive hypotension

A

ignore BP
maintain SBP 70-80
as long as they can perfuse their brain that is enough

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22
Q

which imaging to diagnose AAA rupture

A

CT angiogram

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23
Q

surgical management of ruptured AAA

A

EVAR

laparotomy

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24
Q

what happens if you leave the graft exposed

A

formation of adhesions between graft and bowel which can break down the graft –> aortoenteric fistula

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25
Q

complications of a higher up AAA

A

involvement of renal arteries –> renal failure

coeliac trunk and SMA

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26
Q

what is EVAR

A

Endoscopic vascular aneurysm repair

Xray guided stent via peripheral artery

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27
Q

EVAR complications

A

endoleak from lumbar arteries
ongoing filling of aneurysm sac from an incomplete seal around the aneurysm
stent migration

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28
Q

what is an aneurysm

A

abnormal dilatation of a blood vessel by more than 50% of its normal diameter

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29
Q

features of symptomatic AAA

A

abdominal pain
back / loin pain
distal embolisation resulting in limb ischaemia aortoenteric fistula (UGI bleed)

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30
Q

what is an important differential of renal colic to rule out

A

AAA rupture

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31
Q

what is the follow up for patients in AAA screening

A

<3cm - nothing
3-4.4cm - annual USS
4.5-5.4cm - 3 monthly USS
>=5.5cm OR >=4cm and grown by >=1cm in the last year - consider surgical intervention

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32
Q

what is involved in an open repair of AAA

A

midline laparotomy exposing the aorta, clamping it proximally and the iliac arteries distally and grafting the segment in between

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33
Q

causes of pseudoaneurysms

A

following damage eg cardiac catheterisation, repeated injections, vasculitis

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34
Q

3 main patterns of presentation in someone with peripheral arterial disease / chronic limb ischaemia

A

intermittent claudication
critical limb ischaemia
acute limb threatening ischaemia

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35
Q

features of intermittent claudication

A

aching / burning in leg muscles following walking
relieved after stopping for a few minutes
absent on rest

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36
Q

what ABPI reading would indicate intermittent claudication

A

0.6-0.9

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37
Q

what is chronic limb ischaemia

A

peripheral arterial disease that results in symptomatic reduced blood supply to the limbs

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38
Q

RF for chronic limb ischaemia

A 
smoking 
HTN 
DM 
obesity 
^ lipids 
age 
FH
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39
Q

what is Buerger’s test

A

involves lying the patient supine and raising their legs until they go pale and then lowering them until the colour returns

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40
Q

define critical limb ischaemia aka limb threat

A

3 definitions:

  1. ischaemic rest pain > 2 weeks requiring opiate analgesia +- tissue loss
  2. presence of ischaemic lesions or gangrene attributable to arterial disease
  3. ABPI <0.5
41
Q

what is acute limb ischaemia

A

clinical features less than 14 days
presents within hours
acute embolus

42
Q

what are varicose veins

A

tortuous dilated segments of vein associated with valvular incompetance resulting in venous hypertension and dilatation

43
Q

RF for varicose veins

A

pregnancy
prolonged standing
obesity
FH

44
Q

what is the vascular supply to the brain

A

internal carotids
vertebral arteries
anastamose to form circle of willis

45
Q

CN blood supply is contra/ipsilateral

A

ipsilateral

46
Q

which cerebral hemisphere is in charge of speech

A

dominant hemisphere

usually the left

47
Q

causes of emboli

A 
carotid artery disease 
AF 
Post MI ventricular thrombus 
patent foramen ovale and DVT 
endocarditis 
valvular disease
48
Q

initial management approach to TIA

A 
ABCDE 
history 
neuro exam 
ECG 
carotid dopler USS
CT scan head
49
Q

ICA doesn’t branch outside the skull, true or false

A

true

50
Q

Where do the vertebral arteries branch off from

A

subclavian artery

51
Q

management of carotid artery disease

A 
dual antiplatelets 
statin 
HTN management 
CT head 
CA duplex 
CTA / MRA for vascular assessment
52
Q

what % stenosis of the internal carotid artery is indicated for carotid endarterectomy within 2 weeks

A

70-99%

53
Q

why does 100% carotid stenosis not get surgery

A

because there is no flow

54
Q

why do a carotid endarterectomy within 2 weeks

A

maximal risk of stroke in first 2 weeks

after then, if you have not had a stroke, you are unlikely to

55
Q

what can carotid duplex USS tell you

A

flow rate for degree of stenosis
size of plaque - endpoint cephalic extent of plaque
vertebral artery flow

56
Q

carotid endarterectomy is a preventative/curable manoeuvre

A

preventative
patients are asymptomatic
done to prevent future stroke

57
Q

surgical approach to carotid endarterectomy

A

incision to ant border of SCM, through skin and platysma to SCM
open carotid sheath

58
Q

how can you open the internal carotid artery

A

proximal and distal control

59
Q

how can you supply the brain during carotid endarterectomy surgery

A

bypass / shunt

60
Q

ways of monitoring cerebral function

A

shunt - under GA

squeezy ball - under LA

61
Q

what is the primary aim in carotid endarterectomy, what is done

A

remove plaque, intima and media and leave adventitia

62
Q

how can you close the ICA at the end of carotid endarterectomy

A

put a patch

63
Q

risks of carotid endarterectomy

A 
vagus nerve damage 
hypoglossal nerve 
recurrent laryngeal nerve 
facial nerve 
infection 
haematoma 
bleeding
64
Q

management of haematoma in the neck in terms of airway compression

A

open up the wound to release the pressure

65
Q

lower limb venous system is low/high pressure

A

low

66
Q

what aids venous return in the lower limbs to the IVC

A

calf muscle pump

intermittent

67
Q

what prevents backflow of venous blood

A

valves

68
Q

saphenous system is superficial/deep

A

superficial (S)

69
Q

where does the long saphenous drain

A

saphenofemoral junction

70
Q

where does the short saphenous drain

A

popliteal vein

71
Q

pathology of varicose veins

A

valves become incompetent

superficial veins fill up

72
Q

Presentation of varicose veins

A 
dilated tortuous superficial veins 
bleeding 
bruising 
superficial thrombophlebitis 
chronic venous insufficiency 
throbbing, worse at end of day 
swell up 
cosmetics
73
Q

what is thrombophlebitis

A

it is an inflammatory process, not an infection
red sore inflamed rubbery vein
no need for antibiotics -> side effects

74
Q

what is chronic venous insufficiency

A

umbrella term from varicosities to venous ulcers

75
Q

what is haemosiderin

A

RBC leakage and breakdown

release of iron - stains the skin

76
Q

what is lipodermatosclerosis

A

inflammation and fibrosis from boggy veins and blood around the ankle
upside down champagne bottle

77
Q

what is venous eczema

A

itchy from venous insufficiency

managed with emollients

78
Q

features of venous ulceration

A

sloping edges
shallow
large
sloughy granulation tissue

79
Q

what kind of ulcer do you find in the gaiter region

A

venous ulceration

80
Q

features arterial ulcers

A

punched out
sore
deep

81
Q

investigations for venous disease

A

history and exam
compare legs
RFs - obese, female, age, DVT, pregnancy, skin changes,

Trendelenbergs test = elevate leg to drain veins. occlude SFJ and see if it refills distally

Doppler USS - assess deep veins, level of competance and both systems

82
Q

VV classification for who to treat

A 
CEAP 
clinical 
aetiology 
anatomical 
pathophysiology
83
Q

management options for varicose veins

A

nothing - advice, information, elevation…
conservative - graduated compression stockings (contraindicated in arterial disease)
surgical - foam sclerotherapy, endothermal ablation, mechano-chemical ablation, open surgery

84
Q

what does compression bandaging improve

A

symptoms and ulcer healing

85
Q

compression stockings are contraindicated in which group of patients

A

those with arterial disease / low ABPI

relative contraindication - seek specialist advice

86
Q

what is graduated compression

A

4 layer bandaging

stockings

87
Q

what is foam sclerotherapy

A 
vascular lab and scan groin and inject foam into vein
chemical ablation 
fibrovein 
USS guidance 
pushes blood out form vein 
risk of stroke
88
Q

what is endothermal ablation

A

fry the veins - private practice

not appropriate for very tortuous veins

89
Q

what is involved in open surgery for varicose veins

A

groin incision
SFJ ligation
strip vein
multiple stab avulsions

90
Q

what nerve is associated with the long saphenous

A

saphenous nerve

91
Q

what nerve is associated with the short saphenous

A

sural nerve

92
Q

you give antibiotics for phlebitis, true or false

A

false

93
Q

What is a Marjolins ulcer

A

malignant conversion of an ulcer

e.g. SCC from a scar or venous ulcer

94
Q

what is reperfusion injury

A

following therapy of acute limb ischaemia with increased capillary permeability can cause compartment syndrome and release of metabolites from cells e.g. K, H, and myoglobin

95
Q

list the “P’s” associated with acute limb ischaemia

A 
Pain 
Pulselessness 
Pallor 
Perishingly cold 
Paralysis 
Paraesthesia
96
Q

outpatient management for claudication

A 
antiplatelets
statin 
exercise 
diet 
smoking cessation
97
Q

if you have a patient with a TIA causing right sided symptoms, which carotid side will you investigate further and potentially operate on?

A

left carotid

98
Q

what causes primary varicose veins

A

incompetent venous valves

Year 4 General surgery (14 decks)

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