Vascular Surgery

Question 1

ABI values

Answer 1

> 1.4: Calcification –> Refer

1-1.4: Normal

0.9-1: Acceptable

0.8-0.9: Mild Arterial disease –> treat risk factors

0.5-0.8: Moderate Arterial disease –>
- Treat risk factors
- Refer if signs of gangrene or pain on rest.

< 0.5: Severe –> Refer

Question 2

Heparin ischaemia monitoring

Answer 2

Activated partial thromboplastin time (aPTT)

Maintain 1.5 to 2.5xs the baseline value (21 to 35 seconds)

Question 3

Warfarin ischaemia monitoring

Answer 3

INR

Question 4

Abdominal aortic aneurysm (AAA) symptoms

Answer 4

Triad:
1. abdominal and/or back pain
2. pulsatile abdominal mass
3. hypotension

Question 5

Abdominal aortic aneurysm (AAA) screening

Answer 5

• family history 20%
• >50 years US

Question 6

Abdominal aortic aneurysm (AAA) mortality rate

Answer 6

• 80%

Question 7

Abdominal aortic aneurysm (AAA) surgical intervention

Answer 7

• Males > 5.5cm
• Females > 5cm
• Rapid growth > 1cm yearly
• Symptomatic (abdominal/back pain, tenderness, distal embolization)

Question 8

Abdominal aortic aneurysm (AAA) investigation

Answer 8

• >50 years fast US
• CT angiogram (before elective surgical repair)

Question 9

Abdominal aortic aneurysm (AAA) size screening

Answer 9

3-3.9cm = 2 yearly US

4-4.5cm = 1 yearly US

4.6-5cm = 6m US

> 5cm = 3m US

> 5.5cm (male) = surgical intervention

Question 10

Aortic dissection/aneurysm vs myocardial infarction

Answer 10

Check if patient stable
if stable:
Initial: ECG
Best: CT angio

If unstable: fast US

Question 11

Aortic dissection (AD) confirmation investigation

Answer 11

CT angio

Question 12

Pseudoaneurysm management

Answer 12

Ultrasound-guided thrombin injection

Question 13

Pseudoaneurysm complication

Answer 13

femoral artery catheterization 7.5%

Question 14

Acute limb ischemia most common cause

Answer 14

Thrombosis
- lower limbs 80%

Question 15

Acute limb ischemia symptoms

Answer 15

1, Paralysis
2. Paraesthesia
3. Pulselessness
4. Pain
5. pallor
6. Poikilothermia

Question 16

Acute limb ischemia investigation

Answer 16

• Measure ABI
• CT angiogram (gold standard) for surgical
  intervention

Question 17

Acute limb ischemia requiring surgical treatment

Answer 17

• Paralysis
• Paraesthesia
• Rest pain

Question 18

Acute limb ischemia LMWH vs UFH

Answer 18

• Preceding surgery/renal impairment: UFH
• Medical Mangement only: LMWH (enoxaparin)

Question 19

Acute limb ischemia treatment

Answer 19

embolectomy

Question 20

Acute limb ischemia reperfusion injury features

Answer 20

– Acute renal failure
– Hyperkalaemia.
– Myoglobinemia.
– Metabolic acidosis.
– CK elevation

Question 21

Chronic limb ischemia diagnostic symptoms

Answer 21

-Shiny, hyperpigmented skin.
-Hair loss and ulceration on the legs
-Thickened nails.
-Muscle atrophy.
-Vascular bruits.
-Poor pulses are the hallmark of the chronic obstructive arterial disease

Question 22

Chronic limb ischemia symptoms that require surgical intervention

Answer 22

– Rest Pain
– Ischemic ulceration
– Gangrene
– Claudication symptoms limiting day to life & work, no improvement
with risk factor modifications, exercises, medical management > 6 months

Question 23

Peripheral arterial disease (PAD) manifestation of

Answer 23

atherosclerosis

Question 24

Peripheral arterial disease (PAD) affects ____ of general population

Answer 24

10–15%

Question 25

How many px with PAD are asymptomatic

Answer 25

approximately 50% - worse prognosis if symptomatic

Question 26

Peripheral arterial disease (PAD) symptoms

Answer 26

- calf muscle intermittent claudication (IC) 10%

Question 27

Peripheral arterial disease (PAD) complications

Answer 27

- AAA 10% - Popliteal aneurysm (prominent popliteal pulses) - diabetic foot ulcers

Question 28

Peripheral arterial disease (PAD) investigation

Answer 28

- Initial: ABI - **US doppler** -CT angio if aneurysm suspected

Question 29

Peripheral arterial disease (PAD) management

Answer 29

< 0.9: -Anti-cholesterol (even in absence of dyslipidaemia) - Antihypertensives: ACEI or ARBs - Statins - Supervised exercise program NOTE: -Antiplatelets: aspirin or clopidogrel ONLY is evident cardiovascular disease - avoid beta-blockers unless for cardio protection

Question 30

Peripheral arterial disease (PAD) conservative management failed

Answer 30

Revascularization by: – Endovascular angioplasty or stenting – Open surgical reconstruction by bypass or endarterectomy

Question 31

Thrombophlebitis complications

Answer 31

- DVT - PE

Question 32

Thrombophlebitis management

Answer 32

- LMWH (spontaneous superficial) 4 weeks - NSAIDs (superficial)

Question 33

Varicose veins investigation

Answer 33

Venous duplex ultrasound (gold standard)

Question 34

Varicose veins referral indications

Answer 34

CEAP > 3 - thrombophlebitis - chronic venous insufficiency - Venous ulcer - Venous eczema - bleeding - severe discomfort

Question 35

Chronic venous ulcers management

Answer 35

compression stockings

Question 36

Compression sticking contraindications

Answer 36

- **ABI < 0.8** - cardiac, renal or liver failure - cellulitis - acute DVT

Question 37

Internal carotid artery stenosis divided into

Answer 37

Asymptomatic Symptomatic

Question 38

Asymptomatic internal carotid artery stenosis

Answer 38

< 80% - yearly follow up with CDUS >80% = refer

Question 39

Symptomatic internal carotid artery stenosis

Answer 39

Stroke or TIA < 49%: medical therapy with antiplatelets + follow up >50%: surgery (1-2 weeks after event) + medical therapy

Question 40

Carotid artery stenosis stroke prevention surgery

Answer 40

Carotid endarterectomy

Question 41

Fibromuscular dysplasia renal artery stenosis management

Answer 41

Renal artery angioplasty

Question 42

Atherosclerotic renal artery stenosis management

Answer 42

- unilateral: **ACE inhibitors and ARBs** to reach goal blood pressure - if goal blood pressure not reached: - thiazide diuretic (chlorthalidone or indapamide) - calcium channel blocker - mineralocorticoid receptor antagonist - beta blocker

Question 43

Deep Vein Thrombosis (DVT) risk factors

Answer 43

– > 60 years – Obesity especially BMI > 40 – Smoking – Prolonged immobilisation due to surgery (total knee replacement) – Pregnancy – HRT or OCP – Malignant diseases – Congestive cardiac failure – Inflammatory bowel disease (Crohn’s and ulcerative colitis)

Question 44

Deep Vein Thrombosis (DVT) investigation

Answer 44

Doppler venous ultrasound

Question 45

Deep Vein Thrombosis (DVT) prophylaxis

Answer 45

- Enoxaparin 24-48 hours - Warfarin after 24-48 hours

Question 46

Thromboembolism risk factors before surgery

Answer 46

- Cardiac failure (VTE) - acute bowel inflammation

Question 47

Pulmonary Embolism (PE) symptoms

Answer 47

- Hx of long flight, pregnancy - acute shortness of breath - sinus tachycardia

Question 48

Pulmonary Embolism (PE) investigation

Answer 48

CTPA (radiation risk in pregnancy) - V/Q (**normal chest X-ray**), pregancy

Question 49

Inferior vena cava filter placement

Answer 49

1. Absolute contraindication to therapeutic anticoagulation. 2. Failure of anticoagulation when there is acute proximal venous thrombosis (failure to maintain INR)