Vascular Surgery Flashcards

Question

causes of aneurysm

Answer 1

``` Causes • Congenital § ADPKD → Berry aneurysms § Marfan’s, Ehlers-Danlos • Acquired § Atherosclerosis § Trauma: e.g. penetrating trauma § Inflammatory: Takayasu’s aortitis, HSP § Infection - Mycotic: SBE - Tertiary syphilis (esp. thoracic) ```

Answer 2

``` Rupture • Thrombosis • Distal embolization • Pressure: DVT, oesophagus, nutcracker syndrome • Fistula (IVC, intestine) ```

Answer 3

``` • Less common cf. AAA • 50% of pts. ¯c popliteal aneurysm also have AAA Presentation • Very easily palpable popliteal pulse • 50% bilateral • Rupture is relatively rare • Thrombosis and distal embolism is main complication § → acute limb ischaemia Mx • Acute: embolectomy or fem-distal bypass • Stable § Elective grafting + tie off vessel § Stenting ```

Answer 4

``` Usually asympto: discovered incidentally • May → back pain or umbilical pain radiating to groin • Acute limb ischaemia • Blue toe syndrome: distal embolisation • Acute rupture ```

Answer 5

5.5cm+ is urgent referral

Answer 6

``` Expansile mass just above the umbilicus • Bruits may be heard • Tenderness + shock suggests rupture Ix • AXR: calcification may be seen • Abdo US: screening and monitoring • CT / MRI: gold-standard • Angiography § Won’t show true extent of aneurysm due to endoluminal thrombus. § Useful to delineate relationship of renal arteries ```

Answer 7

Conservative • Manage cardiovascular risk factors: esp. BP § <4cm: yearly monitoring § 4-5.5cm: 6 monthly monitoring Surgical • Aim to treat aneurysm before it ruptures. § Elective mortality: 5% § Emergency mortality: 50% • Operate when risk of rupture > risk of surgery ``` • Indications § Symptomatic (back pain = imminent rupture) § Diameter >5.5cm § Rapidly expanding: >1cm/yr § Causing complications: e.g. emboli • Open or EVAR § EVAR has ↓ perioperative mortality ``` UK men screened once at 65yrs

Answer 8

High flow O2 • 2 x large bore cannulae in each ACF § Give fluid if shocked but keep SBP <100mmHg § Give O- blood if desperate § Blood: FBC, U+E, clotting, amylase, xmatch 10u • Instigate the major haemorrhage protocol • Call vascular surgeon, anaesthetist and warn theatre • Analgesia • Abx prophylaxis: cef + met • Urinary catheter + CVP line • If stable + Dx uncertain: US or CT may be feasible • Take to theatre: clamp neck, insert dacron graf

Answer 9

Sudden onset, tearing chest pain § Radiates through to the back § Tachycardia and hypertension (1O + sympathetic) ``` • Distal propagation → sequential occlusion of branches § Left hemiplegia § Unequal arm pulses and BP § Paraplegia (anterior spinal A.) § Anuria ``` ``` • Proximal propagation § Aortic regurgitation § Tamponade • Rupture into pericardial, pleural or peritoneal cavities § Commonest cause of death ```

Answer 10

``` Stanford Classification Type A: Proximal • 70% • Involves ascending aorta ± descending • Higher mortality due to probable cardiac involvement • Usually require surgery Type B: Distal • 30% • Involves descending aorta only: distal to L SC artery • Usually best managed conservatively ```

Answer 11

Resuscitate Investigate • Bloods: x-match 10u, FBC, U+E, clotting, amylase • ECG: 20% show ischaemia due to involvement of the coronary ostia • Imaging § CXR § CT/MRI: not if haemodynamically unstable § TOE: can be used if haemodynamically unstable Treat • Analgesia • ↓SBP § Labetalol or esmolol (short t½) § Keep SBP 100-110mmHg • Type A: open repair § Acute operative mortality: <25% • Type B: conservative initially § Surgery if persistent pain or complications § Consider TEVAR if uncomplicated

Answer 12

``` Classification • Wet: tissue death + infection • Dry: tissue death only • Pregangrene: tissue on the brink of gangrene Presentation • Black tissues ± slough • May be suppuration ± sepsis ```

Answer 13

``` Clostridium perfringes myositis • RFs: DM, trauma, malignancy • Presentation § Toxaemia § Haemolytic jaundice § Oedema § Crepitus from surgical emphysema § Bubbly brown pus • Rx § Debridement (may need amputation) § Benzylpenicillin + metronidazole § Hyperbaric O2 ```

Answer 14

``` Synergistic Gangrene • Involves aerobes + anaerobes • Fournier’s: perineum • Meleney’s: post-op ulceration • Both progress rapidly to necrotising fasciitis + myositis Mx • Take cultures • Debridement (including amputation ```

Answer 15

failure of valves between deep and superficial veins leads to engorgement of superficial veins

Answer 16

``` Primary • Idiopathic (congenitally weak valves) § Prolonged standing § Pregnancy § Obesity § OCP § FH • Congenital valve absence (v. rare) Secondary • Valve destruction → reflux: DVT, thrombophlebitis • Obstruction: DVT, foetus, pelvic mass • Constipation • AVM • Overactive pumps (e.g. cyclists) ```

Answer 17

``` Skin changes § Venous stars § Haemosiderin deposition § Venous eczema § Lipodermatosclerosis (paniculitis) § Atrophie blanche • Ulcers: medial malleolus / gaiter area • Oedema • Thrombophlebitis ```

Answer 18

``` • Duplex ultrasonography § Anatomy § Presence of incompetence § Caused by obstruction or reflux • Surgery: FBC, U+E, clotting, G+S, CXR, ECG ``` ``` Referral Criteria • Bleeding • Pain • Ulceration • Superficial thrombophlebitis • Severe impact on QoL ```

Answer 19

``` Treat any contributing factors § Lose weight § Relieve constipation • Education § Avoid prolonged standing § Regular walks • Class II Graduated Compression Stockings § 18-24mmHg § Symptomatic relief and slows progression • Skin care § Maintain hydration ¯c emollients § Treat ulcers rapidly ``` can inject sclerosant or do radiofreq ablation surg rarely done as ineffective but could ligate

Answer 20

``` Post-op • Bandage tightly • Elevate for 24h • Discharged ¯c compression stockings and instructed to walk daily. Complications • Haematoma (esp. groin) • Wound sepsis • Damage to cutaneous nerve (e.g. long saphenous) • Superficial thrombophlebitis • DVT • Recurrence: may approach 50% ```

Answer 21

``` Venous: commonest • Arterial: large or small vessel • Neuropathic: EtOH, DM • Traumatic: e.g. pressure • Systemic disease: e.g. pyoderma gangrenosum • Neoplastic: SCC ```

Answer 22

``` Venous: 75% painless, shallow usually medial ankle haemosiderin deposition and lipodermatosclerosis • RFs: venous insufficiency, varicosities, DVT, obesity ``` ``` Arterial: 2% • Painful, deep, punched out lesions • Occur @ pressure points § Heel § Tips of, and between, toes § Metatarsal heads (esp. 5th) • Other signs of chronic leg ischaemia ``` Neuropathic • Painless insensate surrounding skin • Warm foot good pulses Complications • Osteomyelitis • Development of SCC in the ulcer (Marjolin’s ulcer)

Answer 23

ABPI if possible • Duplex ultrasonography • Biopsy may be necessary § Look for malignant change: Marjolin’s ulce

Answer 24

• Refer to leg ulcer community clinic • Focus on prevention § Graduated compression stockings • Optimise risk factors: nutrition, smoking ``` Specific Rx • Analgesia • Bed Rest + Elevate leg • 4 layer graded compression bandage (if ABPI >0.8) • Pentoxyfylline PO § ↑ microcirculatory blood flow § Improves healing rates ```

Answer 25

``` Bilateral right heart failure venous insufficiency drugs - nifedipine, amlodipine nephrotic syndrome liver failure myxoedema - thyroid hypo/hyperthyroid lymphoedema plasma protein loss (low albumin) ```

Answer 26

Venous insufficiency • DVT • Infection or inflammation • Lymphoedema

Answer 27

can be familial otherwise ``` • Fibrosis: e.g. post-radiotherapy • Infiltration § Ca: prostate, lymphoma § Filariasis: Wuchereria bancrofti • Infection: TB • Trauma: block dissection of lymphatics ```

Vascular Surgery Flashcards

(51 cards)