Vascular surgery

Question 1

High risk and low risk AAA features and management?

Answer 1

Low risk

• < 5.5cm, asymptomatic
• USS surveillance and Cardiovascular management (e.g. hypertension)

High risk

• > 5.5cm, symptomatic, or rapidly enlarging (>1cm a year)
• Elective endovascular repair (EVAR) or open if unsuitable.

Question 2

Risk factors and causes for AAA?

Answer 2

Smoking and hypertension.

Rare but important causes include syphilis and connective tissues diseases such as Ehlers Danlos type 1 and Marfan’s syndrome.

Question 3

Normal parameters for Abdominal aorta?

Answer 3

1.7cm in males (1.5 in F)

> 3cm is considered aneurys

Question 4

Interpretation of ABPI?

Answer 4

> 1.2 calcified (advanced age or PAD)

0.9-1.2 is acceptable

<0.9 is likely PAD, urgent if <0.5

Compression banding (for venous ulcer) usually acceptable if above >0.8

Question 5

Types of lower leg ulcers and their features?

Answer 5

Venous leg ulcers

• Most due to venous hypertension, secondary to chronic venous insufficiency (other causes include calf pump dysfunction or neuromuscular disorders).
• Ulcers form due to capillary fibrin cuff or leucocyte sequestration.
• Features of venous insufficiency include oedema, brown pigmentation, lipodermatosclerosis, eczema
• Location above the ankle, painless.
• Deep venous insufficiency is related to previous DVT and superficial venous insufficiency is associated with varicose veins.
• Doppler ultrasound looks for presence of reflux and duplex ultrasound looks at the anatomy/ flow of the vein

Management: 4 layer compression banding after exclusion of arterial disease or surgery.
- If fail to heal after 12 weeks or >10cm2 skin grafting may be needed.

Marjolin’s ulcer

• Squamous cell carcinoma
• Occurring at sites of chronic inflammation e.g; burns, osteomyelitis after 10-20 years
• Mainly occur on the lower limb

Arterial ulcers

• Occur on the toes and heel
• Painful
• There may be areas of gangrene
• Cold with no palpable pulses
• Low ABPI measurements

Neuropathic ulcers
- Commonly over plantar surface of metatarsal head and plantar surface of hallux
- The plantar neuropathic ulcer is the condition that most commonly leads to amputation in diabetic patients
Due to pressure
- Management includes cushioned shoes to reduce callous formation

Pyoderma gangrenosum

• Associated with inflammatory bowel disease/RA
• Can occur at stoma sites
• Erythematous nodules or pustules which ulcerate

Question 6

Three main classifications of PAD?

Answer 6

Intermittent claudication
Critical limb ischaemia
Acute limb-threatening ischaemia

Question 7

What are the features of acute limb-threatening ischaemia?

Answer 7

Features - 1 or more of the 6 P’s

pale
pulseless
painful
paralysed
paraesthetic
'perishing with cold'

Question 8

Features of intermittent claudication?

Answer 8

intermittent claudication: aching or burning in the leg muscles following walking.

• Patients can typically walk for a predictable distance before the symptoms start.
• Usually relieved within minutes of stopping
  not present at rest.

Question 9

Assessment of intermittent claudication?

Answer 9

Check the femoral, popliteal, posterior tibialis and dorsalis pedis pulses.

Check ankle brachial pressure index (ABPI)

Duplex ultrasound is the first line investigation

Magnetic resonance angiography (MRA) should be performed prior to any intervention

Question 10

General management of peripheral arterial disease?

Answer 10

STOP SMOKING

Treat:

• Hypertension
• Diabetes mellitus
• Obesity

Atorvastatin 80mg

Clopidogrel

Exercise training

Surgical intervention

• Angioplasty
• Stenting
• Bypass

Question 11

Critical limb ischaemia features?

Answer 11

Critical limb ischaemia presents as pain at rest for greater than 2 weeks, often at night, not helped by analgesia

Question 12

What is the screening for AAA?

Answer 12

Single US at 65 years in males

Question 13

What is the first line imaging modality in PAD?

Answer 13

Duplex USS

Question 14

What is subclavian steal syndrome?

Answer 14

Subclavian steal syndrome is associated with a stenosis or occlusion of the subclavian artery, proximal to the origin of the vertebral artery. As a result the increased metabolic needs of the arm then cause retrograde flow and symptoms of CNS vascular insufficiency.