Vascular surgery

Question 1

What are the symptoms of acute limb ischaemia?

Answer 1

6 P’s
- Pale
- Pulseless
- Painful
- Paralysed
- Parasthesia
- Perishing with cold

Question 2

What are the causes of acute limb ischaemia?

Answer 2

• Embolism
• Thrombus / thrombosis
• Trauma
• Compartment syndrome

Question 3

What is the management of acute limb ischaemia?

Answer 3

Embolic cause:
- Embolectomy
- Thrombolysis

Other:
- Open surgery
- Angioplasty

Question 4

What are the indications for carotid endarterectomy?

Answer 4

➜ 50 - 99% stenosis of the internal carotid artery
- < 50%: no need for surgery;
- 50 - 70%: surgery beneficial;
- 70 - 99%: surgery VERY beneficial;
- 100% (ocludded): No benefit in surgery.

- 100% (ocludded): means no blood flow, hence no risk of emboli.

Question 5

What are the symptoms of carotid artery stenosis?

Answer 5

• Loss of consciousness (cerebral hypoperfusion)
• TIA
• Stroke

Question 6

What are the investigations done in carotid artery stenosis?

Answer 6

Initial test
- Duplex ultrasound

Gold standard
- CT/MR angiography

Question 7

What are the NEONATAL symptoms of aortic coartaction?

Answer 7

• Presents within the first 3 weeks of life;
• Systolic murmur on left infraclavicular area;
• Poor feeding;
• Lethargy;
• Tachypnoea;
• Congestive heart failure.

Question 8

What are the Late presentation symptoms of aortic coartaction?

Answer 8

• Usually asymptomatic;
• Hypertension;
• ⬆︎ BP in the arms and ⬇︎ in the legs;
• Radiofemoral delay (weak pulses in the lower extremities);
• Nose bleeds;
• Headaches.

Question 9

Leg ulcers

In regards to venous ulcers, describe:
- Causes
- Location
- Presentation
- Rx

Answer 9

◉ Causes:
- Varicose veins
- DVT
- Pregnancy

◉ Location:
- Medial malleolus

◉ Presentation:
- Haemosiderin deposits

◉ Rx:
- Compression
- Elevation
- Mild exercises
- Dressing
- Surgical Rx of varicose veins.

Question 10

In regards to arterial ulcers, describe:
- Causes
- Location
- Presentation
- Rx

Answer 10

◉ Causes
➜ Peripheral artery disease: (risk factors)
- Smoking
- Hypertension
- DM
- ↑ cholesterol

◉ Location:
- Lateral malleolus
- Toes
- Feet

◉ Presentation:
- Deep and punched out

◉ Rx:
- Perform ABPI;
- Treat peripheral artery disease (statins, antiplatelets);
- Surgical revascularisation.

Question 11

In regards to neurophatic (diabetic) ulcers, describe:
- Causes
- Location
- Presentation
- Rx

Answer 11

◉ Causes
- DM
- Pressure points on bottom of feet

◉ Location:
- Plantar surface of feet
- Toes

◉ Presentation:
- Deep
- Ulcer surrounded by callous

◉ Rx:
- Manage DM
- Remove pressure (podiatrist).

Question 12

What are the causes of inferior vena cava syndrome?

Answer 12

• Tumours (renal cell carcinoma);
• Pregnancy;
• Thrombosis (within the vena cava itself).

Question 13

What are the symptoms of inferior vena cava syndrome?

Answer 13

• Oedema in the lower extremities;
• Tachycardia.

Question 14

What are the causes of superior vena cava syndrome?

Obstruction of blood flow through the SVC.

Answer 14

• Lung cancer;
• Malignacies affecting the lymph nodes of the chest:
  ◆ Lymphoma
  ◆ Breast cancer
  ◆ Oesophageal
• Clot formation in the SVC.

Question 15

What are the symptoms of superior vena cava syndrome?

Answer 15

• Difficulty breathing
• Coughing

Dilated (superficial) veins of:
- Neck
- Arms
- Anterior chest wall;

Oedema:
- Face
- Neck
- Upper limbs

Question 16

What are the investigations done in superior vena cava syndrome?

Answer 16

• Chest X-ray;
• Contrast CT

Question 17

What is the management of superior vena cava syndrome?

Answer 17

Initial
- O₂
- Corticosteroids

Other:
- Stenting / angioplasty
- Treatment of specific cancer
- If clot: anticoagulants

Question 18

What is the cause of peripheral artery disease?

Answer 18

Atherosclerosis.

Question 19

What is the symptoms of peripheral artery disease?

Answer 19

• Intermittent claudication (relieved by rest)
• Weak or absent pulses
• Ulceration and gangrene
• Skin and hair changes

Question 20

What is the risk factors for peripheral artery disease?

Answer 20

• Hypertension;
• DM;
• Smoking
• High cholesterol.

Question 21

What is the investigation done in peripheral artery disease?

Answer 21

1st line
- Ankle brachial pressure index (ABPI)

After ABPI
- Doppler/duplex ultrasound

Question 22

What is the management of peripheral artery disease?

Answer 22

• Quit smoking
• Exercise
• Treat hypertension
• Atorvastatin 80 mg
• Clopidogrel 75 mg
• Naftidrofuryl oxalate (if exercise failed and patient denies revascularisation)
• Angioplasty / stenting
• Bypass surgery

Question 23

What is the management of ASYMPTOMATIC abdominal aortic aneurysm?

Answer 23

• < 5.5 cm without speedy growth ⟶ Ultrasound surveilance
• > 5.5 cm ⟶ endovascular repair
• > 4 cm with more than 1 cm yearly growth ⟶ endovascular repair

Question 24

What are the symptoms of SYMPTOMATIC abdominal aortic aneurysm?

Answer 24

• Sudden severe abdominal and back pain
• Tender pulsatile abdominal mass

Question 25

What is the `management` of **SYMPTOMATIC abdominal aortic aneurysm**?

Answer 25

**Initial if SBP < 90** - Fluids ➜ **Urgent surgical** repair

Question 26

How is the `diagnosis` of **SYMPTOMATIC abdominal aortic aneurysm**?

Answer 26

**Unstable** - FAST scan **Stable** - CT

Question 27

What is the `symptom` of **femoral artery aneurysm**?

Answer 27

Painless pulsatile mass in the groin. | Femoral hernia is non-pulsatile.

Question 28

What is **Buerger's disease**?

Answer 28

Thrombosis of small and medium size arteries.

Question 29

What are the `symptoms` of **Buerger's disease**? ## Footnote **Associated with `SMOKING`.**

Answer 29

- Claudication pain (legs or hands) - Discoloration of affected limb - Numbeness and tingling - Ulcers - Gangrene

Question 30

What is the `management` of **Buerger's disease**?

Answer 30

- Quit smoking; - Iloprost.

Question 31

What are the `symptoms` of **bilateral renal artery stenosis**?

Answer 31

- Resistant hypertension - Worsening renal function after starting ACEi/ARB

Question 32

What are the `causes` of **bilateral renal artery stenosis**?

Answer 32

- Atherosclerosis - Fibromuscular dysplasia

Question 33

What is the `investigation` of **bilateral renal artery stenosis**?

Answer 33

**Ultrasound:** Bilateral reduced size of kidneys with smooth borders **Gold standard:** Renal angiography

Question 34

What is the `management` of **bilateral renal artery stenosis**?

Answer 34

- Angioplasty - Stenting