Vascular Surgery for OSCEs

Stewart Brown FY1

Aim to cover
History taking

Physical examination
Investigating vascular

disease
Management

Examination picture quiz

Xanthelasma (Wikipedia) Pedal Oedema (Medscape)

Tobacco Stains (Stanford School of Medicine)

AAA Repair (Flickr-deflam)

Case 1

62 Male

Cant walk as far usual gets cramps in the foot

Extends into the calf Left more than the right Worse going up hills

Case 1
Has to stop for a while, pain subsides and then he continues walking. Troubled by pain at night Leg gets hot Relief from hanging leg off the bed, and then gets up and walks on stone floor.

Case 1
Further questions

Specify distance
Specify rest time

Clarify timeline of symptom onset

How does it affect their day to day life?

Case 1
Further questions Do they get chest pain or SOB? Have they had a stroke? Some people ask about ED Family members with similar problems?

Case 1
Further questions Buttock pain

Past Medical History

CABG 2003

COPD

TII Diabetes

Humerus#

Medications
Aspirin 75mg Calcichew D3 Forte Alendronic Acid

Atorvastatin 40mg
Ramipril 10mg

ISMN 60mg BD
Clopidogrel 75mg Nicorandil 10mg BD

Bisoprolol 5mg
Furosemide 40mg

Medications
Seretide T BD Amlodipine 10mg Metformin 1gram BD

Salbutamol PRN
Ipratropium bromide

Gliclazide 40mg OD
Novomix 30 12units am 16 units pm

Amitriptyline 10mg
Fluoxetine 20mg

Medications
Codeine 30/500
Paracetamol 1gram QDS Gaviscon 10ml

Social History

Smoked 20 a day since he was 10 Drinks 2 cans of lager an evening + w/e Lorry driver Lives with wife in own flat

Holts Law

the rest
Father had fatal MI at 54
Mother T2 DM, CVA Brother IHD No Allergies

Examination
Inspection Palpation

(Percussion)
Auscultation Bedside tests

Examination
Inspection Palpation

(Percussion)
Auscultation Bedside tests

Examination
Inspection Palpation

(Percussion)
Auscultation Bedside tests

Comfortable at rest Breathing through pursed lips Midline sternotomy scar Hair loss noted over shins

Examination
Inspection Palpation

(Percussion)
Auscultation Bedside tests

Good femoral pulses but absent popliteal, PT but present DP. No evidence of a AAA

Examination
Inspection Palpation Radial Brachial Carotid AAA Femoral Popliteal Posterior tibial Dorsalis pedis

(Percussion)
Auscultation Bedside tests

Temperature Capillary refill Sensation

Examination
Palpation Radial Brachial Carotid AAA Femoral Popliteal Posterior tibial Dorsalis pedis

Examination
Palpation Radial Brachial Carotid AAA Femoral Popliteal Posterior tibial Dorsalis pedis

Examination
Palpation Radial Brachial Carotid AAA Femoral Popliteal Posterior tibial Dorsalis pedis

Examination
Palpation Radial Brachial Carotid AAA Femoral Popliteal Posterior tibial Dorsalis pedis

Examination
Palpation Radial Brachial Carotid AAA Femoral Popliteal Posterior tibial Dorsalis pedis

Examination
Palpation Radial Brachial Carotid AAA Femoral Popliteal Posterior tibial Dorsalis pedis

Lower Leg Vessels

Examination
Palpation Radial Brachial Carotid AAA Femoral Popliteal Posterior tibial Dorsalis pedis

Examination
Palpation Radial Brachial Carotid AAA Femoral Popliteal Posterior tibial Dorsalis pedis

Examination
Palpation Radial Brachial Carotid AAA Femoral Popliteal Posterior tibial Dorsalis pedis

Examination
Palpation Test for an (ascending) sensory deficit Ankle reflex Temperature Capillary refill Buerger s test

Examination
Inspection Palpation

(Percussion)
Auscultation Bedside tests

Examination
Inspection Palpation

(Percussion)
Auscultation Bedside tests Blood pressures (bilateral) and ABPI

Summary
62 year old arteriopath
History of intermittent claudication with a BG of IHD, DM and COPD.

On examination has weak peripheral pulses consistent with peripheral vascular disease

Investigations
Evaluating vessel disease (MRA, Angiogram USS vein mapping)
Suitability for theatre (FBC, U&E, Clotting, CXR, Echo, ECG) Potential for modifying disease (HbA1c, lipids)

Angiogram femoral stenosis MRA - Iliac stenosis

Management options
Conservative

Stop smoking, increase amount exercise

Medical

Statin & aspirin

Diabetic control

Management options
Angioplasty

Stenting
Endarterectomy Bypass (Fem-pop/fem distal, fem-fem crossover, aorto-bifemoral, axillo-fem)

Angioplasty (pta)

Endarterectomy

Stent insertion

Aorto-bifemoral

Femoral-popliteal

Femoral-distal

Summary

Case 2
72 year old lady Notices the water in the bath is rippling, ominously Goes to see her GP Palpates her abdomen Finds a large pulsatile mass

Case 2.1
68 year old man

Complained of abdominal pain

Collapsed at home

Shocked on arrival to A&E

Rushed to theatre

Case 2.2
54 year old retired banker

Routine medical
Doctor detects small pulsatile mass on examination. Asymptomatic

Abdominal Aortic Aneurysms

Varied history

May present with rupture, mass symptoms, or as an incidental finding. Examination: pulsatile abdominal mass.
Search for other aneurysms e.g. popliteal, iliac.

Aneurysms
Greek aneurusma = dilation

Definitions:
Aneurysm: an abnormal dilatation of a vessel Pseudoaneurysm: a haematoma formed as a result of leakage of blood from a puncture site.

AAA
Investigations:

USS (incidental)
CT to assess for leak/suitability for surgery. Theatre workup (echo, CXR, ECG, Usual bloods + 6 units x-matched)

Investigations

Investigations

Computer Tomography
CT Angiogram

Investigations

3D CT

Management
Nothing Open repair

EndoVascular Aneurysm Repair (EVAR)

Open Repair

EVAR

EVAR

Case 3
62 year old lady

Presents to A&E with a painful foot

3 hour history

Sudden onset
Feels sick with pain

Case 3
She cant move it as well as before
Its now cold Turned white

On Examination
White

Cold
No PT / DP pulses

Fistula in right arm

Cap refill un-recordable

6 Ps
1. Pain 2. Pallor 3. Pulseless 4. Paraesthesia 5. Paralysis 6. Perishingly cold

Causes of limb ischaemia

Thrombus compare to other leg, BG of PVD?

Embolus AF, proximal lesion, possibly w/o BG of PVD Vasospasm raynauds

Steele Syndrome

Management
MRA/USS
IV Heparin Embolectomy Investigate for cause e.g. echo

Complications

Monitor U&Es, especially K+