Vascular Surgery - Surgical Finals Flashcards Preview

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Flashcards in Vascular Surgery - Surgical Finals Deck (23):
1

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79 year old man presents to the Emergency department with a 4 hour history of sudden onset of severe pain and numbness in his left leg extending up to his mid-thigh. 

State your working diagnosis and predisposing vascular diseases (3 marks)

  • Diagnosis: acute limb ischaemia as a result of left common femoral arterial occlusion 
  • Predisposing factors:
    • AF leading to embolism
    • Thrombus on previously diseased artery
    • Aortic dissection

2

List the clinical findings in the limb supporting your diagnosis (3 marks)

  • Pallor
  • Skin mottling
  • Cold, puslelessness and pain
  • Reduced sensation
  • Loss of function (toes cannot move)
  • Venous guttering

3

What is your treatment plan (4 marks)

  • Emergency surgical work-up
    • FBCs
    • U&Es
    • CXR
    • ECG
    • Urethral catheterisation
    • Group and crossmatch 4 units
  • Treate as acute or acute-on-chronic occlusion with systemic anticoagulation,arterial embolectomy or thrombectomy (request angiogram)
  • Sometimes thromboembolytic therapy can be given to avoid surgery

4

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68 year old man complains of gradual onset of right calf claudication radiating up to his thigh on walking distances exceeding 75m. 

State your likely diagnosis and anatomical site of lesion (2 marks)

  • Peripheral vascular disease producing stenosis of the arteries of the right lower limb
  • Right common femoral artery or superificial and profunda femoral arteries 

5

Write a short explanation of the disease process underlying his pathology (3 marks)

  • Process is atherosclerosis
    • Adherent microthrombi and subintimal cholesterol deposits lead to atheromatous plaque formation and luminal narrowing 
    • Plaque haemorrhage leads to intimal ulceration
    • Thrombi form on the ulcerated surface
    • Give rise to thromboemboli producing distal vessel occlusion

6

Give five common risk factors for this disease (5 marks)

  1. Smoking
  2. Diabetes
  3. Hypercholesterolaemia
  4. Hypertension
  5. Family history 

7

What advise would you give this patient to stop progression of this disease? (3 marks)

  • Smoking cessation 
  • Close monitoring of diabetes and hypertension
  • Exercise to develop collateral circulation
  • Weight reduction
  • Low cholesterol diet 
  • Foot care - podiatry

8

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A 59 year old woman complains of rest pain in her left foot, keeping her awake at night. She also has difficult in walking. 

List the clinical findings that would lead to a working diagnosis (4 marks)

  • Pale, cold limb with loss of sensation, ischaemic skin changes
  • Reduced or absent femoral, popliteal, dorsalis pedis, posterior tibial pulse
  • Reduced ABPI
  • Neurological signs - reduced senation, tone, power and reflexes accompanied by muscle wasting. 

9

Discuss briefly the surgical options available to relieve her symptoms (3 marks)

  • Removal of arterial occlusive disease by endarterectomy
  • Bypass of occlusion using native vein or synthetic vascular grafts 

10

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A 68 year old man underwent a femoral arteriogram and balloon angioplasty for an external iliac arterial stenosis

List the symptoms and clinical findings that would have led to this procedure (3 marks) 

  • Claudication or rest pain extending up to the buttock 
  • Weak or absent distal pulses
  • Low resting and exercise ABPIs
  • Loss of muscle power 

11

Soon afterwards he complained of severe pain in the limb, which had become blanched and pulseless

State two likely causes for this complication (2 marks)

  • Thrombosis, dislodgement of atheromatous plaque 
  • Intimal dissection during or after angioplasty producing arterial occlusion

12

State your management (3 marks)

  1. Analgesia - anticoagulation with intravenous heparin
  2. Infusion of prostaglanding-derived thrombolytic agent (tPA)
  3. Thromboembolectomy - repair or removal of intimal flap

13

List the risk factors involved in the development of peripheral vascular disease

 

  • Smoking
  • Diabetes 
  • Hyperlipidemia 
  • Hypertension
  • Family History

14

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A 76 year old man presents with a pulsatile swelling in his right groin 3 days after a coronary angioplasty at the site where the cardiac catheter was introduced

State the most likely diagnosis (1 mark)

Pseudoaneurysm of the femoral artery

15

State one non-invasive investigation for confirmation (1 mark)

Duplex doppler scan

16

How would you treat this? (2 marks)

  • By presure occlusion with or without injection of a thrombotic agent into the sac
  • Failing this, by surgical repair of the arterial wall defect

17

The patient developed cold, painful and pulseless lower limb immediately after the coronary angioplasty.

State two probable causes (2 marks)

  • Thrombosis or embolus,
  • intimal plaque formation and intimal dissection

18

How would you treat these complications (2 marks)

  • Embolectomy, thrombectomy under imaging
  • Intimal repair 

19

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A 64 year old man is admitted to the Emergency Department complaining of severe back pain, radiating to the left loin, accompanied by nausea and feeling faint. He was found to be hypotensive with a rapid, thready pulse 

State your clinical diagnosis (1 mark)

Rupture of abdominal aortic aneurysm

20

Outline your resuscitatory measures (3 marks)

  • Admit to HDU/ICU for preoperative optimisation 
  • Maintain an airway, administer oxygen
  • Central and peripheral venous access
  • FBC and ABGs
  • Intravenous analgesia
  • Group and emergency crossmatch for 10-15 units of blood 
  • Monitor pulse, BP and respiration quarter hourly
  • Volume replacement with crystalloids and plasma expanders
  • Catheterise and monitor urine output
  • Inform surgical and anaesthetic teams and operating theatre in preparation for emergency surgery
  • CXR and AXR with ECG
  • Consent for surgery

21

State the surgical treatment for this condition (1 mark)

Dacron graft replacement of ruptured aortic aneurysm

22

If here were on long term warfarin therapy for atrial fibrillation and his INR was found to be >4.0 what would be your diagnosis? (1 mark)

Spontaneous retroperitoneal haemorrhage as a result of over-anticoagulation

23

State your specific treatment measures for this (3 marks)

  • Intravenous analgesia 
  • Stop warfarin therapy
  • Resuscitation and replace blood volume
  • Administer coagulation factors in the form of FFP and platelet concentrates
  •