Vascular Surgery for Finals

Dr Jonathan HodgkinsonCT1 Vascular SMH

Contents

• 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

• 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

– Embolectomy– Thrombolysis – Emergency recon– Amputation (10-20%

mort)

• Chronic• Thrombotic– Claudication– Gradual onset (hrs)– Chronic vascular disease

– Thrombolysis– Angioplasty– Emergency recon– Amputation

ManagementGeneral – analgesia, rehydration, NBM, anti-coagulation

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• 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• 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• 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• 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• 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