Surgery.vascular

Front 1

PVD (LL Arterial) - Risk factors for atherosclerosis?

Back 1

Major Risk Factors:
1) Smoking
2) DM
3) HTN
4) FHx IHD/CVA
5) Hypercholersterolemia / hLipidemia

Minor:
1) Obesity
2) Sedentery lifestyle
3) Hyperhomocysteinemia

Hint 1

Non Modifiable:
- Age
- Sex (men, older women)
- FHx

Front 2

PVD (LL Arterial) - Lower limb occlusive disease - Presentation

Back 2

1) Asymptomatic
2) Intermittent claudication
3) Rest pain (critical limb ischaemia)
4) Acute occlusion

Front 3

PVD (LL Arterial) - Common Sites of occlusive disease on LL

Back 3

1) Superficial femoral artery (SFA)
2) Aorto-iliac region
3) Popliteal artery

Hint 3

1) Superficial femoral artery (SFA)
- 15cm below inguinal ligament
- Calf pain

2) Aorto-iliac region
- Buttock, thigh, calf pain

3) Popliteal artery

Front 4

PVD (LL Arterial) - Difference between intermittent claudication and rest pain?

Back 4

Intermittend Claudication:

WHAT? Cramp like pain
WHERE? SFA (=calf pain), iliac A (butt, thigh, calf)
WHEN? On ambulation
WHAT RELIEVES? Rest

OTHER: Claudication distance is usually constant
DDx: Neurogenic claudication, sciatica, OA
PROGNOSIS: 5% Limb loss @ 5y

Hint 4

Rest pain (critical limb ischaemia)

WHAT? Pain at rest
WHERE? Foot, toes
WHEN? At night, at rest
WHAT RELIEVES? Hanging foot over side of bed, standing/walking

OTHER: Ulceration and gangrene may be present
PROGNOSIS: Indicates imminent loss of limb (50%+ amputation)

Front 5

PVD (LL Arterial) - Lower Limb Ischaemia - O/E

Back 5

Look:
1) Skin Atrophy
2) Allopecia
3) Onycholysis
4) Muscle Atrophy
5) Ulceration (toes/feet)
6) Venous guttering

Feel:
1) Cool skin
2) Capillary refill >3s
3) Peripheral pulses reduced/absent
4) Buerger's sign

Listen:
- Auscultate main vessels: Systolic bruit indicates stenosis

Hint 5

Buerger's sign - eleveation of leg causes pallor

Affected limb regains color more slowly, followed by rubur due to reactive hyperaemia

Front 6

PVD (LL Arterial) - Lower Limb Ischaemia - Types of Gangrene

Back 6

1) Gangrene - necrosis due to compromised blood supply
2) Dry gangrene: dry necrosis w/o infection (mummified)
3) Wet gangrene: moist necrotic tissue w/ infection

Front 7

PVD (LL Arterial) - Lower Limb Ischaemia - Features of Gangrene

Back 7

- Well demarcated
- Patch to entire limb
- Gangrene = soft & boggy dead tissue w/ pus @ line of demarcation
- Starts distally on toes and extends proximally
- Senseless and painless

Front 8

PVD (LL Arterial) - Lower Limb Ischaemia - Ulceration

Back 8

- Begins in a pressure area on foot
- Dead tissue is present
- Granulation tissue absent

Front 9

PVD (LL Arterial) - Lower Limb Ischaemia - Ix

Back 9

Assess extent of PVD:

1) ABI - SBP ankle:brachial (N=>1, 0.6-0.9=claudication, 0.3-0.6=rest pain)

2) Duplex USS

3) DSA - gold standard but invasive (contrast digital subtraction angiography)

Look for a cause:

4) FBC, U&E, lipids, glucose, syphilis

Front 10

PVD (LL Arterial) - Lower Limb Ischaemia - Performing a DSA - Checklist?

Back 10

1) Allergies to contrast?
2) Medications?
3) Coagulopathies? Correct w/ FFP

4) Peripheral pulses - check and document
5) Baseline studies - PT, aPTT, U&E, FBC
6) Withhold aspirin, warfarin, metformin

Front 11

PVD (LL Arterial) - Lower Limb Ischaemia - Performing a DSA - Pre, intra, post-procedure?

Back 11

Pre:
1) Shave and prep groin
2) Clear liquids 8h
3) IV fluids

Intra:
1) Seldinger technique via femoral or brachial artery
Cannula > Guide wire > Catheter

Post:
1) Supine
2) Compress wound
3) Distal pulses check

Front 12

PVD (LL Arterial) - Lower Limb Ischaemia - Performing a DSA - Complications

Back 12

Contrast:
1) Anaphylaxis
2) Nephrotoxicity

Vascular access:
1) Bleeding
2) Infection
3) Thromboembolic event
4) AV fistula
5) Perforation
6) Nerve damage
7) Pseudoaneurysm
8) Dissection

Tx: Surgery, or amputate

Front 13

PVD (LL Arterial) - Lower Limb Ischaemia - Mx

Back 13

Conservative("PACE"):

1) Pentoxifylline (-- blood viscosity)
2) Aspirin
3) Cessation of smoking
4) Exercise

Surgical:

1) Angioplasty - balloon +/- stent
2) Endarterectomy - intima and media 'cored out'
3) Bypass graft - Fem-Pop; Fem-distal (peroneal, ant tib, post tib) ** Note Fem=SFA

Front 14

Acute limb ischaemia - 5 causes

Back 14

Intraluminal
- Atheroma
- Thrombus
- Embolis (AF, MI, IE)

Vessel wall:
- Aneurysm, intimal dissection, AV fistula

Extraluminal:
- Compartment syndrome
- Tumour

Hint 14

1) Embolization (AF, MI, endocarditis)
2) Thrombosis
3) Atheromatous lesion
4) Aneurysm (aorta, femoral, popliteal)
4) Vascular trauma
5) Compartment syndrome; fracture, circumferential burns

Front 15

Acute Limb Ischaemia - Clinical features

Back 15

P's:
1 (Look)) Pallor
2 (Feel)) Perishing cold
3 (Feel)) Parasthesia
4 (Feel)) Pulse decreased/absent
5 (Feel)) Perishing cold
6 (Move)) Paralysis

Front 16

Acute Limb Ischaemia - Ix

Back 16

1) Angiogram
2) ECG
3) USS

Front 17

Acute Limb Ischaemia - Emergency Mx

Back 17

1) Heparin bolus + infusion
2) Embolectomy / thrombolysis

Hint 17

<4-6 hours, otherwise irreversible tissue damage = amputation

1) Anticoagulate w/ IV heparin - Bolus followed by constant infusion (prevents further thrombosis)

Definitive Mx:
1) Surgical embolectomy (fogarty baloon catheter)
2) Thrombolysis (tPA)

Front 18

Draw the Lower Limb Venous System

Back 18

Front 19

What is the lesion? Describe it

Back 19

Venous Ulcer

Site: Gaiter of leg?
Size: 10mm?
Shape: round
Edge: Sloping with new epithelium
Base: Clear and pink (granulation tissue)
Surrounding tissue: normal

Front 20

Leg Ulcers - Types and their locations

Back 20

Arterial - Dorsum of foot, tips of toes, lateral malleolus
Venous - Gaiter area, medial side
Neuropathic - Weight bearing areas (plantar)
Neoplastic - Sun exposed areas

Front 21

Leg Ulcers - Edge characteristics

Back 21

Punched out - arterial (indicates rapid death and minimal healing)
Everted - SCC (rapid growth, carcinoma)
Rolled - BCC (slow growth, ROdent)
Sloping - Venous (indicates healing)

Front 22

Leg Ulcers - Describing

Back 22

1) Site (eg. gaiter=venous)
2) Size, shape, color & tenderness
3) Edge
4) Base/floor
5) Depth
6) Discharge
7) Surrounding skin
8) Regional lymph nodes

Hint 22

1) Site (eg. gaiter=venous)
2) Size, shape, color & tenderness
3) Edge (eg. punched out=arterial)
4) Base/floor
- Ischaemic = dry or necrotic eschar
- Venous - superficial w/ fibrinous exudate & ooze
- Color: Black=necrosis, yellow=sloguh, red=granulation, pink=epithelium
5) Depth (mm, structures involved)
6) Discharge (quantity, type=serous, sanguinous, purulent)
7) Surrounding skin (color, pulses, previous ulcers)
8) Regional lymph nodes (enlargement due to infection or neoplasia)

Front 23

Leg Ulcers - Causes

Back 23

1) Venous (75%)
2) Arterial
3) Neuropathic
4) Traumatic
5) Neoplastic
6) Hematological
7) Infective
8) Misc (pyoderma gangrenosum, insect bites)

Hint 23

1) Venous (75%) - varicose veins, post-thrombophelbitis

2) Arterial - Ischaemic (DM, therosclerosis, embolism); Vasculitic (Buerger's disease)

3) Neuropathic - DM, EtOH, spinal cord lesion

4) Traumatic - Pressure sores (decubitius)

5) Neoplastic - SCC, BCC, melanoma, Kaposi's sarcoma

6) Hematological -spherocytosis, sickle cell

7) Infective - Mycobacterial, post-cellulitis, chronic infected isius

8) Misc (pyoderma gangrenosum, insect bites)

Front 24

Leg Ulcers - Hx

Back 24

- Onset and duration
- Evolution?
- Suspected cause?
- Pain - ischaemic=painful, venous=some pain, neuropathic=painless
- Bleeding/discharge
- PHx:
Venous=DVT,PE,varicose veins,previous surgery
Arterial=Intermittent claudication,rest pain,CVD
Other:DM, RA, Vasculitis, IBD, chronic skin ulcers
Medications: B-Blockers,ergotamine,corticosteroids,NSAID
SHx - Smoking, EtOH

Front 25

Venous vs Arterial vs Neuropathic vs Pressure Ulcers

Hx

Back 25

Venous: Chronic

Ischaemic: Intermittent claudication, rest pain, IHD, CVD

Neuropathic: DM, EtOH

Pressure: Bed bound, immobilized

Front 26

Venous vs Arterial vs Neuropathic vs Pressure Ulcers

Site

Back 26

Venous: Medial side, gaiter area

Arterial: Dorsum of foot, toes, lateral malleolus

Neuropathic: Weight bearing areas (plantar)

Pressure Sores: Bony prominences - heels, malleoli, sacrum, hips

Front 27

Venous vs Arterial vs Neuropathic vs Pressure Ulcers

Pain

Back 27

Venous: Nil to mild

Arterial: Very painful

Neuropathic: Painless

Pressure: Painful

Front 28

Venous vs Arterial vs Neuropathic vs Pressure Ulcers

Ulcer features

Back 28

Venous: Depth=superficial; Edge=sloping; Base=granulation; Discharge=Seropurulent; Healing=some

Arterial: Depth=deep; Edge=punched out; Base=grey-yellow slough,dry; Healing=none

Neuropathic: Depth=Deep, Edge=Punched out, Base=infected

Pressure: Necrotic slough and granulation

Front 29

Venous vs Arterial vs Neuropathic vs Pressure Ulcers

Rest of limb

Back 29

Sensation/Pulses/Temp/Oedema

Venous: Present / Normal / Hot & tender / Present

Arterial: Painful / -- ABI / Cold / Absent

Neuropathic: Absent / Bounding / Warm / Absent

Pressure: Variable

Front 30

Venous vs Arterial vs Neuropathic vs Pressure Ulcers

Other features

Back 30

Venous: Varicose veins, lipodermatosclerosis, stasis eczema, atrophie blanch

Arterial: Allopecia, atrophy of skin, onycholysis

Neuropathic: Charcot's joints, high arch & clawing of toes

Pressure: Erythema at pressure site

Front 31

Diabetic Foot

Aetiology and Pathogenesis

Back 31

"DAMN"
Diabetes
Atherosclerosis
Microangiopathy
Neuropathy

Peripheral neuropathy >> lack of sensation >> trauma to MT and heels >> ischaemia >> pressure ulceration >> angiopathy + infection >> impaired healing

Hint 31

"DAMN"
Diabetes = Glucose ++ infection
Atherosclerosis = Vessel occlusion
Microangiopathy = Thickening of BM in arterioles and caps
Neuropathy = Sensory, motor, autonomic

Front 32

Diabetic Foot

Sequelae

Back 32

Gangrene
Infection
Ulceration
Deformity - Charcot joints

Front 33

Diabetic Foot

Vs Ischaemic

Back 33

Front 34

DVT

Risk Factors

Back 34

Surgery
Travel
OCP
Hypercoagulable state
Immobility
Malignancy

Hint 34

Prior DVT/PE
Thrombophilia
Major medical illness
Age >60y

Front 35

DVT

Prevention

Back 35

Cease OCP
Early mobilization post-op
Aspirin for 3/52
Mechanical support (TED, GCS)
Elevate foot

Anti-coagulants:
- SC Heparin 2hrs pre-op, 7-10d post
- High MW: 5000U BD: INR 2-3
- Low MW: enoxaprin 20mg/OD SC
- Warfarin

Front 36

DVT

Clinical Features

Back 36

1) Homan's Sign
2) Calf tenderness
3) Warmth and erythema
4) Swelling of calf and leg
5) Venous distension (superficial)
6) Fever & tachycardia
7) Chest signs: PE / MI

Front 37

DVT

How can heparin be administered? What to monitor?

Back 37

Administration:
- IV or SC
- Unfractionated (heparin) or LMW (enoxaparin)

- Monitor aPTT (intrinsic pathway) for unfractionated heparin

Front 38

DVT

Unfractionated Heparin

Back 38

- 5000-10000U IV lodaing dose
- Continuous infusion @ 1000-2000U/hr

- monitor APTT (target 1.5-2.5x normal)

- Duration: 5-10d

- Contraindications: pregnancy, PUD

- Complications: haemorrhage

Front 39

DVT

LMW Heparin (enoxaprin, SC)

Back 39

- 1 mg/kg BD for >5d

- No need for monitoring

Front 40

Varicose Veins

O/E.Inspection

Back 40

Look:

- Visible superficial veins (not site, size, course)
- Medial = great saphenous vein
- Posterior calf = short saphenous vein
- Oedema
- Venous stasis signs: induration, pigmentation, eczema & ulceration

Front 41

Varicose Veins

O/E.Palpation

Back 41

- Harvey's Test
- Cough impulse at sapheno-femora & sapheno-popliteal junctions; pulse=incompetent SC valves
- Pitting oedema, thickening/tenderness of SC tissues
- Tourniquet test
- Brodie-Trendelenburg test
- Perthe's test
- Tap test

Front 42

Varicose Veins

Harvey's test

Back 42

(Varicose Veins)

2 fingers on vein, slide proximal finger to empty, release distal finger to see which way the empty segment fills

Front 43

Varicose Veins

Tourniquet test

Back 43

(Varicose Veins)

1) Pt supine, elevate leg 90deg
2) Tourniquet upper 1/3 of thigh
3) Stand pt. If superficial veins above tourniquet RAPID fill = incompetent communicating vein.
4) Move vein distally to locate incompetent valve

Front 44

Varicose Veins

Brodie-Trendelenburg test (Tap test)

Back 44

(Varicose veins)
- Compress distal segment
- Pulse proximal segment
- If pulse felt distally = POSITIVE

Front 45

Varicose Veins

O/E.Auscultation

Back 45

- AV fistulae @ varicose veins produce bruits

Front 46

Varicose Veins

Pathophysiology

Back 46

- Superficial to deep
- Pressure of superficial > deep
- Calf pump
- Incompetent perforator valves = engorged and dilated superficial veins

Hint 46

- Blood flows superficial to deep
- When calf relaxed: Superficial pressure > Deep pressure
- When calf contracted: Blood transmitted PROXIMALLY
- Valves prevent retrograde flow
- Incompetent PERFORATOR veins cause muscle pump to force blood into the superficial system >> engorgement and dilation

Front 47

Varicose Veins

Aetiology

Back 47

- Idiopathic
- Pregnancy (hormones, ++ intrabdo pressure)
- Prolonged standing
- Pelvic mass
- AV fistula
- Thrombosis - superficial or deep
- Conginetally weak or absent valves (Klippel-Trelaunay syndrome)

Front 48

Varicose Veins

Ulceration pathogenesis

Back 48

- Hydrostatic pressure in superficial veins impair nutrition to SC and dermis
- Skin breakdown, ulceration, dermatitis

Front 49

Varicose Veins

Ix

Back 49

- Duplex USS (Gold standard)
- MR Venography
- CT
- Ambulatory venous pressures (needle measurement device)

Front 50

AAA

Aetiology

Back 50

1) Atherosclerosis (95%)
2) Degenerative aging
3) Congenital - Marfan's (CT disease)
4) Inflammatory / Infection (Syphillis)
5) FHx/genetic
6) ++ Collagenase/elastase activity
7) Trauma
8) Neoplastic
9) Metabolic / endocrine
10) Dissection

Hint 50

Atherosclerotic (95%)

Congenital:
1) Marfan's Syndrome
2) Ehlers-Danlos syndrome
3) Behcet's disease

Inflammatory
1) Mycotic - bacterial
2) Syphilitic

Front 51

AAA

Ehlers-Danlos syndrome

Back 51

CT disorder

Front 52

AAA

Triad indicating emergency surgery for ruptured AAA

Back 52

3 P's

1) Pain in the abdomen
2) Pulsatile abdominal mass
3) Pressure low (hypotension)

Front 53

AAA

Mx based on sizes

Back 53

- 5 cm = threshold for surgery
- Fusiform more likely to rupture than saccular
- Comorbidities: HTN, smoking, COPD

Front 54

AAA

Growth rates

Back 54

- <5cm = 4%/yr
- 5-7cm = 7%/yr
- >7cm = 20%/yr

- Larger aneurysms grow faster due to Laplace's law

Front 55

Laplace's Law

Back 55

Front 56

AAA

Causes for decrease in UO post AAA repair?

Back 56

Pre-renal
- Post-op ADH release
- Hypovolemia
- Hypotension
- 3rd spacing
- Pump failure: CCF, cardiogenic shock
- Bleeding

Intrarenal
- Kidney parenchyma dysfunction
- Tubular dysfunction: ATN
- Glomerular dysfunction: rhabdomyolysis (myoglobinuria)

Post-renal
- Foley catheter obstruction
- Ureteral/urethral injury
- BPH
- Bladder disfunction - iatrogenic
- Calculi

Front 57

Carotid Arterial Disease

Significance of a carotid bruit?

Back 57

1/3 by stenosis of carotid or vertebral arteries

1/3 radiation from aortic valve

1/3 insignificant

Other: Thyroid vessel bruits

- Bruit will not always be heard over a significant carotid stenosis

Front 58

Carotid Arterial Disease

Ix

Back 58

- Carotid Doppler USS
- DSA gold standard
- Angiography (risk of thrombus dislodging)
- MR angiography
- MRI/CT brain - space occupying lesion

Front 59

Carotid Arterial Disease

Mx

Back 59

General:
- Smoking cessation
- Control DM, hyperlipidemia, HTN
- Antiplatelet drugs

Surgical:
- Carotid endarterectomy - remove diseased intima + shunt

Front 60

Carotid Arterial Disease

Indications for endarterectomy

Back 60

- 70% stenosis +
- Recent TIA
- Recovered stroke
- amaurosis fugax

Front 61

Carotid Arterial Disease

Complications of endarterectomy

Back 61

- Bleeding (antiplatelet)
- Nerve damage; hypoglossal (CN12), facial (CN7, tongue deviates to ipsilateral side), Vagus (CN10, voice changes)
- Reperfusion syndrome
- Restenosis