Vascular Surgery

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)

Chronic
Thrombotic

No claudication
Sudden onset
(sec/min)
Recent MI/AF/AAA

Claudication
Gradual onset (hrs)
Chronic vascular
disease

Thrombolysis
Emergency recon
Amputation (10-20%
mort)

Angioplasty
Emergency recon
Amputation

Management
General analgesia, rehydration, NBM, anti Embolectomy coagulation
Thrombolysis

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
Buergers 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 Milroys 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
Browses Introduction to the symptoms and signs of surgical disease
4th edition
Clinical cases and OSCEs in surgery Manoj Ramachandran