Vascular Surgery for Finals
Dr Jonathan Hodgkinson
CT1 Vascular SMH
Contents
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How to pass finals...
Objectives
Case 1 & 2 – Aneurysmal disease
Case 3 – Arterial Disease
Case 4 – Venous disease
Case 5 & 6 – Lymphoedema
Others
Conclusions
How to pass finals...
• Trying to pass you
• Justify everything you say
• Define and shine....
• Try and put off answering the question for as
long as possible!
• Framework is key.....
Objectives
• Understand vascular examination
• Describe management of aneurysmal disease
• Discuss the principles of arterial disease
management
• Discuss the features and management of
venous disease
• Diagnosis lymphoedema
Case 1
• 65yo Male
• PC
– sudden onset central abdominal pain
– Dizziness
– A/w painful right foot
• PMHx
– HTN, high cholesterol
– Smoker – 30 pack year history
Case 1
• O/E
– HR 110, BP 90/60, RR24, 95% on RA, afebrile
– Sweaty, distressed
– Diffusely tender abdomen
– No pulses on the right distal to
femoral
Ruptured AAA
• Surgical emergency
• Mortality – without surgery 100%; with 50-75%
• Rates
• Rupture/yr - <4.5cm = 9%; 4.5-7cm = 35%; >7cm = 75%
• Mx
• Fluid resus – aggrssive + CXM (10 units)
• Senior and anaesthetist
• If haemodynamically stable – CT scan
AAA
• Normal diameter 1.5-3cm; Aneurysm >3cm
• 95% infra-renal
• 75% asymptomatic
• Incidence – 5%
• Sex – M>F
Case 2
• 65yo male
• PC – incidental finding of aneurysm
• Asymptomatic
• Ix
– Imaging – CT/USS
– Bloods – renal function, cholesterol
– Work-up – ECG, ECHO, lung fn
Stable AAA
• Management
– Conservative
• Watch and wait - <5cm – serial USS/CT
• Risk factor management
• (MASS trial – screening beneficial and viable)
• Surgical – UK Small Aneurysm Trial
– Indications for surgery
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Symptomatic aneurysms
>5.5cm
Rapidly expanding - >1cm/year
Complicated by embolism
Stable AAA
• Surgical options
– Open vs EVAR
– EVAR trials
• 1 – lower 30 post-op mortility
• 2 – reduction in aneurysm related mortality but not all
cause
• Complications
– Haemorrhage, renal failure, embolism, graft
infection/migration, MI/infection, endoleaks
Case 3
• 65yo male
• PC – sudden onset left foot pain
• HPC
– 6hr history – severe pain on movement
– History of intermittent claudication – 100yds
• PMHx
• MI, HTN, Chole, diabetes
• SHx – mobile with stick
Case 3
• O/E
– Haemodynamically stable
– Cold
– Mottled & blanching
– Absent pulses distal to popliteal
– Painful
– Motor and sensation intact
Limb ischaemia
• Acute (on chronic)
• Emobilic (thrombotic)
– No claudication
– Sudden onset (sec/min)
– Recent MI/AF/AAA
• Chronic
• Thrombotic
– Claudication
– Gradual onset (hrs)
– Chronic vascular disease
Management
General – analgesia, rehydration, NBM, anti-coagulation
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Embolectomy
Thrombolysis
Emergency recon
Amputation (10-20%
mort)
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Thrombolysis
Angioplasty
Emergency recon
Amputation
Limb ischaemia
• Complications - Immediate
– Reperfusion injury
• Compartment syndrome
• Renal failure
• ARDs/toxic shock
• Long-term
– Further episodes
– Chronic pain syndromes
Chronic Limb ischaemia
• Def – persistently recurring
• Incidence – 5% males >50yo
• HPC
– Intermittent claudication – fixed/reducing
distance
– Rest pain
– Tissue loss
• RFs – HTN, chole, previous IHD, smoking, DM
Chronic Limb ischaemia
• O/E
– Inspection
• Cold, pale, increased capillary refill time
• Venous guttering
• Evidence of tissue loss/ulcers
– Pulses
– Buerger’s test/angle
– Doppler examination
• Triphasic, biphasic, monophasic
Chronic Limb ischaemia
• Conservative
– Risk factors management
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STOP SMOKING
Excerise – collateralisation
Obesity
Diet
Good BM control in diabetes
Foot care
Treat underlying cardiac disease
Chronic Limb ischaemia
• Medical
– Control HTN
– Anti-platelet therapy
• Aspirin 75mg
• Clopidogrel 75mg
– Control lipids
• Statins
– Diabetic control
Chronic Limb ischaemia
• Surgery
– Indications
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Short claudication distance – 50-100yds
Reducing claudication distance
Symptoms greatly effecting QoL
Rest pain/tissue loss
Chronic Limb ischaemia
• Surgery
– Interventional
• Angioplasty – balloon/stenting
– Iliacs – 90% 5yr patency
– Femoral – 70% 5yr patency
– Not effective distally or if ulcerative disease
– Reconstructive
• Reserved for critical ischaemia
• Autologous vs. synthetic
• Anatomical vs. extra-anatomical
– Endarterectomy – femorals
– Amputation
• Lethal limb
• Dead limb
• Useless limb
Case 4
Venous disease
• Features
– Pigmentation/haemosiderosis
– Visible veins
– Varicose eczema
– Lipodermatosclerosis – atrophic change (loss of
elasticity)
– Ulceration
– Atrophy blanch – healed ulcers
Venous disease
• Pathology
– Increased pressure in venous system
– Gradually become incompetent
• Incidence – 10-20% (F>M)
• Causes
– Primary
• Congenital absence of valves
– Secondary
• Thrombosis
• Increased abdominal pressure
– pregnancy/masses/ascites/obesity/constipation
• AV malformations
• Overactive muscle pumps (e.g. cyclists)
Venous disease
• Conservative
• Rx underlying cause – lose wt/constipation
• Skin care
• Class 2 compression stockings
• Surgical
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Injection sclerotherapy
Laser/radiofrequency ablation
Trendelenburg procedure – high tie and ligation
+/- phlebectomies
Venous disease
• Complications of surgery
– Bruising
– Infection
– Bleeding
– Neuropraxia
– Recurrence/no improvement in cosmesis
– DVT – 1/1000
Case 5
Case 6
Lymphoedema
• Features
– F>M
– Peripheral oedema worse on standing
– Non-pitting
– Hyperkeratosis, fissuring, secondary infection
– Squaring and thickening of nails
Lymphoedema
• Abnormal collections of interstitial fluid
• Types
– Primary – congenital absence of lymphatics
• Congenital
• Praecox – Milroy’s Syndrome - <35 – progressive
• Tarda - >35
– Secondary
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Infiltration – malignant disease
Fibrosis – radiotherapy
Previous surgery
Infections – TB/cellulitis
Lymphoedema
• Treatment
– Allow fn and decrease swelling
• Conservative
– COMPRESSION
– Skin care
– Physiotherapy
• Surgical
– Debulking of tumours
– Bypass
– Omental/mesenteric bridges
Others
• Carotid artery disease
– 15-25% of all CVAs/TIAs
– Ix – Doppler
– Management
• Conservative
– anti-platelet therapy
– Risk factor management
– Surgery in asymptomatic disease controversial
• Surgery – carotid endartectomy
– Symptomatic – 70 – 99% stenosis
– Urgent surgery within 2 weeks
– NASCET and ECST
Others
• Aortic dissection
– Split in intima and internal portion of media
allowing blood to enter and extend proximally and
distally
– Types
• A – 70%
– Affects arch and ascending aorta
– 10-20% mortality – 100% need surgery
– Aortic root replacement
• B – 30%
– Distal to left subclavian
– Conservative Mx unless evidence of visceral or limb ischaemia
Objectives
• Understand vascular examination
• Describe management of aneurysmal disease
• Discuss the principles of arterial disease
management
• Discuss the features and management of
venous disease
• Diagnosis lymphoedema
• Framework
References
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Multicentre aneurysm screening study (MASS): cost effectiveness analysis of
screening for abdominal aortic aneurysms based on four year results from
randomised controlled trial. BMJ. 2002 Nov 16;325(7373):1135.
The UK Small Aneurysm Trial. Ann N Y Acad Sci. 1996 Nov 18;800:249-51.
The UK EndoVascular Aneurysm Repair (EVAR) trials: randomised trials of EVAR
versus standard therapy. Health Technol Assess. 2012;16(9):1-218. doi:
10.3310/hta16090.
Lecture notes on general surgery – Harold Ellis
Oxford handbook of clinical surgery – 3rd edition
Browse’s Introduction to the symptoms and signs of surgical disease – 4th edition
Clinical cases and OSCE’s in surgery – Manoj Ramachandran
