1
Q
What is an AAA?
A
- Permanent pathological localised dilatation >50% (>1.5 times) of its original diameters
- Or >3cm
- Aneurysms may be fusiform (eg most aaas) or sac-like (eg Berry aneurysms
- More than 90% of aneurysms originate below the renal arterie
2
Q
How does a triple AAA present?
A
- Assymptomatic -> till tupture
- Incidental discovery
- Intermittent or continuous abdominal pain (radiates to back, iliac fossae, or groins; don’t dismiss this as renal colic)
- Expansive, pulsatile abdominal mass
- Malaise
- Collapse
- Shock and hypotension possible
- Weight loss: inflammatory aneurysm
- Mild abdo sx + tenderness -> retroperitoneal rupture
3
Q
What are some of the differentials of AAA and how would you investigate these?
A
- MI - ECG
- Acute pancreatitis - serum amylase
4
Q
How is AAA diagnosed?
A
- 1st: Abdominal USS
- Others: Bloods: ESR, CRP, FBC,
- Imaging:CTA/ CT, MRA/MRI
5
Q
When should you decide to repair a AAA?
A
- Symptomatic
- Rapidly expanding/ expansion of >1cm per year
- Ruptures
- Diameter >5.5cm
6
Q
When is USS surveillance used instead of treatment for AAA?
A
- Assymptomatic
- AAA <5.5cm in diameter
7
Q
For small AAA (<5.5cm) USS is used, how often?
A
- Yearly - 3.5-3.9cm
- 3 months - 4-5.5cm
8
Q
How are small AAA (<5.5cm managed)
A
- Manage RFs: smoking, hypertension, high cholesterol
- Pharmacologically: doxycycline + statin - awaiting clinical trial results
9
Q
What is involved in the peri-operative assessment of AAA?
A
- CT/ MRI
- Pre op assessment:
- Haematology
- Biochemical
- CXR
- ECG (IHD)
10
Q
How is AAA managed surgically? What are the two options
A
- Conventional Open Repair
- Endovascular Repair - Stenting
11
Q
What does conventional open repair of a AAA involve?
A
- Midline/ transverse incision
- Peritoneal contents examined
- Aneurysm repair after proximal and distal arterial control
- Use prosthetic graft (Dacron/ PFTE) inserted by classic inlay
- Ask whether iliacs are involved?
12
Q
What does endovascular repair of AAA involve?
A
- Insertion of a stent graft, via femoral artery using X ray
- Aim: exclude aneurysm sac from circulation
- 1.5cm typically below renal arteries to allow for implantation and good seal
- Avoids: laparotomy, infra peritoneal manipulation, aortic occlusion time
- Clinical results: improved survival
- Long life surveillance is required after
13
Q
Who are AAA screenings given to and how?
A
- USS
- Men over 65 years
14
Q
The most common location of AAA?
A
Below the kidneys
15
Q
What is the emergency management of a AAA?
A
- Summon a vascular surgeon + warn theatre.
- ECG, Bloods: amylase, Hb, crossmatch
- Catheterize
- IV access with 2 large-bore cannulae
- Give blood for shock: O Rh−ve blood (if not cross matched)
- Take the patient straight to theatre
- Give prophylactic antibiotics, eg co-amoxiclav 625mg iv.
- Open repair: surgery involves clamping the aorta above the leak, and inserting a Dacron® graft (eg ‘tube graft’ or, if significant iliac aneurysm also, a ‘trouser graft’ with each ‘leg’ attached to an iliac artery).
16
Q
The mortality rate for AAA surgey is 5-7%. What are the causes of death?
A
- Cardiac complications
- Haemorrhage
- Respiratory failure
- PE/ thromboembolism of distal arterial tree
- Impotence / graph injection
17
Q
What is Peripheral Vascular Disease?
A
- Occurs due to atherosclerosis causing stenosis of arteries
- Multifactorial process involving modifiable and non-modifiable risk factors
- CVS risk factors should be identified and treated aggressively
- Intermittent claudication
- Severe: Critical limb ischaemia
18
Q
What are the risk factors for PVD?
A
- Smoking
- Hypercholesterolaemia
- Diabetes
- Age
- FMH
- Cardiovascular risk: IHD
- Cerebrovascular Disease
19
Q
What is intermittent claudication?
A
- Chief feature of PAD
- Pain in muscles of lower limb caused by walking
- Pain relieved by rest
- Common in calf muscles
- Superficial femoral artery occlusion - most common
- Buttock claudication - femoral/ iliac - less common
20
Q
What are some of the signs of intermittent claudication?
A
- Absent femoral/ popliteal pulse/ foot pulses
- Cold/ white leg
- Ulcers / gangrene
- Postural dependent colour change
- Increased capillary refilled time (>15 seconds)
21
Q
What causes the pain in intermittent claudication?
A
- Reduced arterial supply/ arterial insufficiency
- Pain of anaerobic metabolites
- Increase in substance P
22
Q
What are the differentials intermittent claudication?
A
- Spinal stenosis
- Lower limb arthritis
- Sciatica
23
Q
What questions should be asked in history taking of PVD?
A
- Where in the leg is the pain?
- When did it start?
- Does it relieve itself at rest?
- What distance can a pt walk without having to stop?
- Does it interfere with your lifestyle?
- What RFs does the pt have?
24
Q
What should a PVD examination involve?
A
- Inspect: colour, skin breakdown, ulcers, gangrene
- Palpation: temperature, cap refill, peripheral pulses
- Auscultation: bruits (aorta, iliacs, femoral, adductor) and carotid bruits
25
What bloods tests should be done for PVD?
* Glucose: exclude DM arteritis (esr/crp)
* FBC (anaemia, polycythaemia)
* UE (renal disease)
* Lipids (dyslipidaemia)
26
What classification system is used for peripheral arterial disease? How is it divided?
**Fontaine classification**
1. Assymptomatic
2. Intermittent claudication
3. Ischaemic rest pain
4. Ulcer/ gangrene -\> *critical limb ischaemia*
27
What investigations are used for patients with PVD?
* **Blood tests:** FBC, UE, lipids, glucose (DM)
* **ABPI: Ankle Brachial Pressure Index**
* Normal: **\>1.1**
* Arterial disease: **\<0.9**
* Critical limb ischamia: **\<0.5**
* **Exercise Test:** For patients with claudication but palpable peripheral masses
* **Imaging:**
* **Arterial Duplex USS Scan:** USS for stenosis+ occulsion
* **CT/ MRI Angiogram**: Proximal disease when arterial tree not visualised
28
What are the different steps involved in treatment of PVD?
1. **Conservative**: RF modification: smoking cessation, lower cholesterol (statin), control DM, BP, IHD
* **Antiplatelet**: 75mg **clopidogrel**
* **Supervised exercise programmes:** 2h per wk for 3 months
2. **Vasoactive drugs: naftidrofuryl oxalate -** *modest benefit only.*
* *Only after supervised exercise has not led to satisfactory improvement*
* *+ Person prefers not to be referred for consideration of angioplasty or bypass surgery*
***Surgery (Balloon or Bypass)***
1. **Pericutaneous Transluminal Angioplasty:** Balloon inflation of the narrowed segment
2. **Surgery Bypass:** If atheromatous disease is extensive but distal run-off is good (ie distal arteries filled by collateral vessels
* **F**emoral-popliteal bypass, femoral-femoral crossover, and aorto-bifemoral bypass grafts.
* **Autologous vein grafts better than** prosthetic grafts (eg Dacron® or PTFE)
3. **Amputation**
29
What are the complications of peripheral arterial disease?
* Leg/foot ulcers
* Gangrene
* Permanent limb pain
* Permanent limb weakness/numbness
30
What is critical limb ischaemia?
* **Arterial insufficiency** is so bad
* **Increased risk of limb loss** (w/o intervention)
31
What are the symptoms of critical limb ischaemia?
* **Rest** pain
* **Nocturnal** rest pain - relieved by dangling feet out of bed
* Skin **breakdown** of toes and **gangrene**
32
What are the signs of critical limb ischaemia (clue: 6Ps)?
* Perishingly cold
* Pulseless
* Painful
* Paraethesia
* Pale
**Mottling** - implies irreversible!
33
How is critical limb ischaemia treated?
Surgical emergency: revascularization required in **4-6h**
Do **urgent arteriography**: if diagnosis is in doubt,
Balloon, bye bye
* ***Balloon*: Angioplasty**: alone +/- endarterectomy
* Or **open surgery**
* ***Bye Bye*: Amputation**: if bypass and angioplasty fail or extensive distal disease
* ***Surgical Embolectomy:*** If the occlusion is embolic, or local thrombolysis
* *Remember to **anticoagulate** with **heparin***
34
What are the risk of surgery for critical limb ischaemia?
1. Reperfusion injury
2. Compartment syndrome
35
What is the vascular supply to the lower limb and which artery is usually a target for PAD/ intermittent claudication?
Superficial Femoral Artery
36
What are Varicose Veins?
* Long, tortuous, & dilated veins of the superficial venous system
* Usually affect the **long or short saphenous veins**
37
What is the pathophysiology of varicose veins?
* Incompetent venous valve
* Blood flows back from the deep -\> superficial veins
* Sacculation, lengthening and tortuous veins
38
What are the different types of varicose veins?
1. **Trunk:** Dilated, tortuous veins of long or short saphenous
2. **Reticular:** permanently dilated bluish intradermal veins 1-3mm in diameter
3. **Telangiectasia:** permanently dilated intradermal venules \< 1mm in diameter
39
What are the aetiology of varicose veins?
1. **Primary/ simple:** valvular failure -\> distended superficial veins in lower limb. Most common
2. **Secondary varicose veins:** superficial veins carry reversesd flow. Compensating for obstructed deep vein
3. **Arteriovenous fistula:** Increased pressure causes engorgement of supervial veins in area of arteriovenous fistula
40
What are some of the symptoms of varicose veins?
* Cosmetic appearance: ‘My legs are ugly.’
* Pain, cramps, tingling, heaviness, and restless legs
* Leg discomfort
* Nocturnal cramps
41
What are some of the signs and complcations arising from varicose veins?
* Varicose veins: haemorrhage + thrombophlebitis
* **Venous hypertension**:
* Lipodermatosclerosis
* Oedema/ swelling
* Eczema
* Pigmentation: haemosiderin
* Venous ulceration
42
How do the following arise in varicose veins?
* **Pigmentation**
* **Venous Ulceration**
* **Atrophie blanche**
* **Lipodermatosclerosis**
* **Pigmentation**: haemosiderin from RBCs
* **Venous Ulceration:** Failing nutritional exchange in capillaries -\> necrosis
* **Atrophie blanche**: White skin secondary to venous hypertension
* **Lipodermatosclerosis**: inflammatory process -\> fibrosis of subcut fat
43
What are the treatment options for varicose veins?
**Conservative**: Avoid prolonged standing, Elevate legs wherever possible, support stocking, lose weight, regular Walks
**Surgical**
1. **Endovascular treatment:** *of long or short saphenous vein*
* *Foam sclerotherapy*
* *Endovenous laser ablation*
2. **Open Surgery:**
* Saphenofemoral disconnection and ligation.
* Multiple avulsions; stripping from groin to upper calf
44
When are varicose veins indicated for surgery?
When there is:
* Bleeding, pain, ulceration, superficial thrombophlebitis, or ‘a severe impact on quality of life’
* Not for cosmetic reasons alone
45
What are the causes of leg ulcers?
* Venous disease - most common
* Arterial - **artherosclerosis** and **arteriovenous** malformations
* Vasculitis - SLE, RA, wegener granulomatosis
* Lymphatic insufficiency
* Neuropathic pain - diabetes
* Haematological
* Traumatic
* Neoplastic
46
What is the pathophysiology of leg ulcers?
* **Chronic venous hypertension** -\> oedema
* Impaired tissue perfusion
* Oxygen metabolites diffuse greater distance to get to tissues
* Tissues around ankles are ischamic
* Reperfusion injury on walking or leg elevations (which reduces venous hypertension or tissue fluid)
* Inflammatory process -\> Oedema/ tissue fibrosis
* This then causes symptoms of: aching, heaviness around the legs + itching
47
How do you examine and investigate ulcers?
* Examine patient **lying** and **standing**
* Document size and appearance of ulcer
* Look around the skin: is there chronic venous hypertension or insufficiency
* Assess peripheral pulses + **ABPI**
* Blood tests: exclude **DM**
* **Venous duplex scan**
* **Arterial duplex scan** (in pt w reduced ABPI)
* Microbiology
* Leg ulcer biopsy
48
How do you manage venous ulcers?
1. Compression bandaging - if arterial circulation is ok
2. Leg elevation
3. Improve immobility
4. Reduce obesity
5. Improve nutrition
6. Varicose vein surgery
7. Skin grafting (in selective pt)
49
What is carotid disease? What is the underlying disease process?
* Major cause of **ischaemic stroke** as a result of **thromboembolism** due to disease in ICA or MCA
* Commonest site: **ICA**
* Underlying disease: **atherosclerosis**
* RFs same as PVD
50
How can carotid disease present?
* **Assymptomatic**: bruits (so stenosis)
* **Symptomatic**: TIA + ischaemic stroke
51
How can carotid disease be investigated?
1. **Carotid artery duplex scan**
2. **CT / MRI angiogram**
52
How would you manage symptomatic CAD?
1. Conservative: **RF** management.
2. Medical: **statin** and **anti platelet** (clopidogrel 75mg)
3. Surgical: **Carotid endarterectomy**
Year 3 - Surgery
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