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Vascularforfinalyears ManishMandal FY1 VSGBI'Allyouneedtoknowabout vascular surgery' https://jvsgbi.com/all-you-need-to-know-about-vascular-surgery/Contents • Conditions:Arterial,Venous,Misc • PACESexamination • Procedures • Resources used oVSGBI textbook oNICE CKS oTeach mesurgery oEMRCS oGeekymedicsConditions Arterial Venous Misc AorticAneurysm DeepVeinThrombosis DiabeticFoot Syndrome+ Ulcers AorticDissection Venous Insufficiency Thoracic Outlet Syndrome PeripheralVascular Disease Thrombophlebitis SubclavianStealSyndrome CarotidArtery Stenosis LymphoedemaQuestion1 A66-year-oldmale returns to clinicforanabdominal USS.One year agoheattended theone- offUSSScreeningfor anAbdominal Aortic Aneurysm.Hewasfoundtohavean asymptomatic aneurysminferiortothe renal arteriesthatatitswidestpoint measured3.8 cmin diameter. Todayhereports thatheremainsasymptomatic anditis found to be4.9cmindiameter. His blood pressureiswell controlled Giventhe above findingswhatis the mostappropriate nextstepfor thispatient? 1) Followup AbdominalUSSIn 1year 2) Followup AbdominalUSSin3 monthsand commence atorvastatinODand Aspirin OD 3) Followup AbdominalUSSin3 months 4) Refertoclinic to discusssurgicalintervention forAAAmanagement. 5) Followup AbdominalUSSIn 1year and commenceatorvastatinOD and AspirinODQuestion2 A54-year-oldmanpresents toA&Ewithsevere chestpainthatiscrushinginnature for 4hours, healso had anepisode of LOCinthepasthourandhas mentioned terribleabdominalpainand painbetweenhis shoulder blades. ECGshows STelevation inanterior leads.Urgenttroponinis sent. What isthebestnext step? 1) Aspirin300mg 2) Fondaparinux 3) CTaortogram 4) Lying– standing blood pressure 5) ChestX-rayQuestion3 A61-year-oldmanisadmitted to A&E withsuddenonset of apainful, cold rightfoot.Hehasa radialpulse of 82bpmthatis notsinusrhythm. Anabdominalandcardiac examinationfind nothingelse of note.There are nopalpable pedalpulses inthe rightfoot.Ankle doppler signs areabsent.AnECGis performedand thereare noobvioussigns of acute ischemia. What isthemost likely diagnosis? 1) DVT 2) Abdominal Aortic Aneurysm 3) Aorto-iliacdissection 4) AF 5) MIQuestion4 52 yearoldwomenis inhospitalafterbeing admitted for anelectiveumbilical herniarepair. Shehas apast medicalhistory ofT2DM, wasa smokerfor20 yearsand,IBS.Sheis2 dayspost op.Onthe morningwardround younoticesomeerythemaoftherightclave. Onpalpation thereismild tenderness.Youorder ad-dimer whichis elevated and a subsequentlower limb USS is performedwhichconfirms aDVTinferiortothe saphenous-poplitealjunction. What isthemost appropriatemanagementfortheDVT? 1) 6-months Rivaroxaban 2) Compression stockingsand 3-months Aspirin 3) Compression stockingsand 6-months Apixaban 4) 3-months Apixaban 5) 3-months Clopidogrel AbdominalAorticAneurysm-presentation AAA - 80%infrarenal Risk factors o Vasculopaths TAA o Connectivetissue - 40%ascending o Europeanorigin - 60%descending o FHx Asymptomatic Symptomatic Rupture o Incidental o Lower back/abdo pain o Unstable o Screening o Tender pulsatilemass o BackpainAbdominalAorticAneurysm-screening NHSnational screening • Maleson65thbirthday • AorticUSS >3.0cm 3.0 -4.5cm 4.5 -5.4cm >5.5cm Intervention indications 12-month 3-month Vascular 1. >5.5cm 2. >4cm+ >1cm yrly growth F/U USS F/U scan referral 3. Symptomatic 4. Rupture Conservative Medical Surgical Smoking Aspirin Open Weightloss Statin Alcohol BP EVARNICEguidelines Open unless contraindicated EVAR (EndovascularAneurysmRepair) if: - Hostile abdomen - Anaestheticrisk - Pt specificfactors Pt specificfactors In trials,EVAR has: - Lower30d mortality - ShorterITUstay - Increaseddischarge directly home Therefore, favoured in olderpeople RupturedAAA Triad Bloods Unstable VBG(lactate +Hb) Back/abdopain FBC Pulsatilemass G&S+ XM U+E Other presentations Coag Flank/groin/scrotalpain POCUS CTangio Haematuria • Fast • Gold standard Collapse • Unreliable • EVAR Misdiagnoses Management Renalcolic Perforatedviscus - 30-minute rule Diverticulitis - Permissive hypotension - InterventionRupturedAAA Management 30-minute rule SuspectedrAAA: assess,scan, theatretransfer< 30 mins Permissive Systolic aimed80-100 hypotension Rebleed riskreduced(tamponade undisturbed) Intervention Open EVAR Conventionaltechnique Haemodynamically stable - Clampingaortaproximalto - Limited useofballoon rupturestops thebleed. occlusionofproximalaorta IMPROVEtrial: inthose suitable forEVAR, no mortality difference, shorterICU stay, more likely todischarge directly homeHaemorrhagicshock Aortic Dissection Sx O/E Chestpain - Classically BPdiscrepancy - Severe between arms (>20mmHg) - Tearing - Radiation to back Alsopotentially: Syncope, sweating - Absentfemoral pulse - Tamponade/effusionsigns Perfusion problems - ESM (narrowing oftrue lumen) - Paraesthesia, paralysis, - Aorticregurgitation(aortic root headache, neck pain dilatation) - Signsofhypovolaemic, cardiogenic or Brachiocephalic/iliac involvement cord ischaemia)k(neurogenicdue to - Radiationtolimbs Mesenteric ischaemia - Radiationtoabdomen RFs - HTN - Abruptincreasein BP (cocaine, ecstasy,weightlifting) - Ehlers-Danlos, Marfan's - ExistingTAA,bicuspidvalve,coarctation Management Troponin+ECG may falselyindicateACS. Aortic Dissection • R/O dissectionbefore ACSMx • Anticoagulationmay worsendissection Investigations TAAD: Bedside: BP,ECG - Urgent surgicalrepairbycardiothoracic surgeons - Prevent ruptureintopericardialsac (tamponade) Bloods: - D-dimer (>95%sensitive, usefulfor r/o) TBAD: - Troponin - Medicalmanagement (b-blocker) - Amylase (r/opancreatitis) - TEVAR - G&S+ XM - Life-longsurveillance - VBG(lactate +Hb) Imaging - TOE - CTA - CXR- widenedmediastinum - MRA (requires magnet safe monitoring)E/CTA) PVD–chronic • Atherosclerosiscausing stenosisresulting in ischaemia • RFs:vasculopath,diabetes Lerichesyndrome Concept:claudicationoccurs distaltostenosis Intermittent claudication Critical limb ischaemia Aortoiliacocclusion Sx • Muscular cramp-likepain • Painat rest Triad: • Onwalking • Disrupts sleep • Bilateral buttock • Relievedbyrest • Relievedbyhangingfootoff claudication bed • Impotence • Absent femoralpulses O/E • Difficult pulses • Difficult/nofoot pulses • Maybe normal • Arterialulcerations • ABPI<0.9 • APBImaybe <0.5 Spinal stenosis Compartment syndrome Sciatica Lumbarflexionreducespain Dermatomal tingling/numbness Dermatomal pain Muscle weakness LumbarflexionmainexacerbatorPVD-Mx Conservative Medical Surgical • Smoking Risk factorreduction IR • Diet &weight loss • Clopidogrel(75mg) • Angioplasty(stent) • Exercise • Statin(atorvastatin80mg) • Alcohol • Diabetes Open • HTN • Endarterectomy • Anticoagulationif • Bypass thrombotic/embolicevents • Amputation Symptomaticrelief • Iloprost infusion • Naftidrofuryloxylate Embolic Thrombotic PVD-AcuteLimbIschaemia 6 P's Some of6 P's Unilateral CLIsignsbilaterally AF, heart valve Plaquerupture Medical Surgical • High flow oxygen Embolic • LMWH • Embolectomy • Heparin infusion (requires • Thrombolysis rigorous monitoring of APTT • Bypass ratio) Thrombotic • Thrombolysis • Angioplasty • Bypass Tissue death • Amputation Reperfusion compartment syndrome:fasciotomyCarotidarterystenosis Presentation Ix TIA - DuplexUSS - Facialdroop - CTA - Unilateralweakness - MRA - Dysphasia Mx Amourosis fugax Symptomatic - Transient ipsilateralvisual - CAS(stent) loss - CEA (endarterectomy) RFs Asymptomatic - Vasculopath - Considerif>60%stenosis+ OE highriskstroke - Carotidbruits CASusedinolder more co- - Unilateralfocalneurology morbidpatientsDVT Presentation O/E DDx - Pain(throbbing) - Oedema - Trauma - Swelling - Redness - Venous insufficiency - Skinchanges - Warmth - Oedema - Riskfactors/provocation- Tender - Cellulitis - PE - Superficialvein- Lymphoedema - Maybeasymptomatic distention 0 or 1 ≥2 4hr 4hr D-dimer USSdoppler Interim anticoagulation, ASAPD-dimer D-dimer, Interim anticoagulation, 24hr USSdoppler + 4hr USSdoppler - ≥2 - + - Interim anticoagulation, 24hr USS doppler + Anticoagulate/continue Stopanticoagulation Anticoagulate/continue Stopanticoagulation anticoagulation ifstarted anticoagulation ifstarted Anticoagulation - Apixaban/rivaroxaban - 3mprovoked - 6munprovokedVenousinsufficiency RFsandaetiology Similar RFsto DVT +prolonged standing - Congestion in lowerlimbvenous system - Reducedmechanical pumping of blood upveins - Increased venous pressure causes dilation +valve failure - Leakageof fluid+ blood products outof vesselsVaricoseveins Criteriafor referral Venousinsufficiency 1. Symptomatic Arterialstatus 2. Skinchanges(ofvenous - Stockings insufficiency) 3. Superficialveinthrombosis Conservative 4. Active/healed venous - Weight loss ulceration - Avoid extended sitting/standing - Lightexercise Surgical management Bleeding varicosity - Vascular admission USSduplextomapveins • Radiofrequency/laser ablation • Foam sclerotherapy • Ligation,stripping,avulsion Thrombophlebitis Inflammationofa superficialvein, usually theGSVor LSV associatedwithvenousthrombosis Alsocalled SuperficialVeinThrombosis Management isNSAID,warm compress, stocking ifno arterialdisease Aetiology RFs Presentation DDx - Pain - DVT - Spontaneous Varicosevein(80-90%) - Itch - Cellulitis - Venous stasis - Venous stasis within - Trauma varicosity - Localisedswelling - Venous insufficiency - CanalsocauseDVT - Vasculitis O/E DVT RFs - Firmlump/cord - Erythema - IV cannulation/infusion - Tender - AI - Typically locatedat - Thrombophilia varicosity PVD Diabeticfootsyndrome Precipitant Neuropathy Poor perfusion (peripheral arterial disease) • Hyperglycaemia, oxidative stress, atherosclerosis • Reducestissuehealing Sensorimotor neuropathy 24hr DFUMDTreferral • Footdeformity • Loss of protective sensation High riskof sepsis, X-ray Mechanicaloffloading Precipitant osteomyelitis, MRI • Macrotrauma: standingon nail necrosis(gangrene) Debridement • Microtrauma: pressure damagedue Amputation to deformity/abnormalloadGangrene Dry • Arterialocclusion: ischaemia causesdryingof tissue • Good demarcationfromnormal tissue • Bacteria can'tsurvive Wet • Area ofpoor healingorvenous occlusion with cell death • Poordemarcation • Bacteria infectdeadtissue highrisk of sepsis Arterial Venous Neuropathic Cause Ischaemia (PVD, focal pressure) impaiVenousHTN< perfusionpressure Footdeformityand lossofprotective Oftenprecipitated bytrauma, oftendistRefluxorobstruction sensationallowsmacro/microtrauma to Chronic extravasationof ironand occuroftenatpressurepoints inflammatoryblood components Associated PVD, diabetes DVT,chronicvenous insufficiency Peripheralneuropathy e.g. conditions (varicoseveins etc.) diabetes, B12 deficiency Site Distal Gaiterregion Sitesofpressure Pain Severepain Achingpainrelieved by elevation Painless Character Punched out,deep Shallow Deep Border Welldefined Irregular Raised, calloused Associate Weak/absent foot pulses Varicoseveins Gloveand stocking LoS d signs Necrosis Haemosiderin deposits Footdeformity ABPI Lipodermatosclerosis Highorlow ABPI Ix ABPI USSduplex ABPI Angio Toepressure XR/MRI Mx Lifestyle Compressiontherapy DFUMDT DAPT, statin VaricoseveinMx Diabeticmedication Revascularisation Mechanicaloffloading Amputation ThoracicOutletSyndrome Aetiology: Anatomical variation, posture,cervicalrib Neurological Arterial Venous Presentation Pain Claudication Swellingof arm Paraesthesia Ischaemia Painwithexercise Weakness Weakpulses Cyanosis Pagett-Schroetter syndrome (subclavian DVTdue toTOS) DDx Disc herniation Raynaud's Tunnel syndromes Ix MRI USS duplex USS duplex Nerveconduction CTA/MRA CTA/MRA Mx Physiotherapy 1st/cervical rib Compression 1st/cervical rib resection Anticoagulation resection Arterialreconstruction Thrombolysis Thrombectomy 1st/cervical rib resectionSubclavianStealSyndrome Stenosis ofsubclavian artery PROXIMAL to vertebral artery Basilar • Useof ipsilateral arm increasesoxygen/blood demand • Ipsilateral vertebral arteryreversed flowprovides collateral blood supply Vertebral • This reduces brain perfusion Aetiology:atherosclerosis,TOS,vasculitis Presentation Ix Mx Subclavian Uponuse ofipsilateral • USS • Clopidogrel arm: • CTA/MRA • Statin • Syncope • CXR • Angioplasty • Focalneurology • Bypass • Arm claudicationLymphoedema • Primary:congenitallymphatic malformation • Secondary:radiotherapy,resection • Poorpitting NICE management: • Lymphovenous anastamosis duringaxillary node clearance • LiposuctionmayhaveutilityQuestion1 A66-year-oldmale returns to clinicforanabdominal USS.One year agoheattended theone- offUSSScreeningfor anAbdominal Aortic Aneurysm.Hewasfoundtohavean asymptomatic aneurysminferiortothe renal arteriesthatatitswidestpoint measured3.8 cmin diameter. Todayhereports thatheremainsasymptomatic anditis found to be4.9cmindiameter. His blood pressureiswell controlled Giventhe above findingswhatis the mostappropriate nextstepfor thispatient? 1) Followup AbdominalUSSIn 1year 2) Followup AbdominalUSSin3 monthsand commence atorvastatinODand Aspirin OD 3) Followup AbdominalUSSin3 months 4) Refertoclinic to discusssurgicalintervention forAAAmanagement. 5) Followup AbdominalUSSIn 1year and commenceatorvastatinOD and AspirinODQuestion1 A66-year-oldmale returns to clinicforanabdominal USS.One year agoheattended theone- offUSSScreeningfor anAbdominal Aortic Aneurysm.Hewasfoundtohavean asymptomatic aneurysminferiortothe renal arteriesthatatitswidestpoint measured3.8 cmin diameter. Todayhereports thatheremainsasymptomatic anditis found to be4.9cmindiameter. His blood pressureiswell controlled Giventhe above findingswhatis the mostappropriate nextstepfor thispatient? 1) Followup AbdominalUSSIn 1year 2) Followup AbdominalUSSin3 monthsand commence atorvastatinODand Aspirin OD 3) Followup AbdominalUSSin3 months 4) Refer to clinicto discuss surgical interventionforAAAmanagement. 5) Followup AbdominalUSSIn 1year and commenceatorvastatinOD and AspirinODQuestion2 A54-year-oldmanpresents toA&Ewithsevere chestpainthatiscrushinginnature for 4hours, healso had anepisode of LOCinthepasthourandhas mentioned terribleabdominalpainand painbetweenhis shoulder blades. ECGshows STelevation inanterior leads.Urgenttroponinis sent. What isthebestnext step? 1) Aspirin300mg 2) Fondaparinux 3) CTaortogram 4) Lying– standing blood pressure 5) ChestX-rayQuestion2 A54-year-oldmanpresents toA&Ewithsevere chestpainthatiscrushinginnature for 4hours, healso had anepisode of LOCinthepasthourandhas mentioned terribleabdominalpainand painbetweenhis shoulder blades. ECGshows STelevation inanterior leads.Urgenttroponinis sent. What isthebestnext step? 1) Aspirin300mg 2) Fondaparinux 3) CTaortogram 4) Lying– standing blood pressure 5) ChestX-rayQuestion3 A61-year-oldmanisadmitted to A&E withsuddenonset of apainful, cold rightfoot.Hehasa radialpulse of 82bpmthatis notsinusrhythm. Anabdominalandcardiac examinationfind nothingelse of note.There are nopalpable pedalpulses inthe rightfoot.Ankle doppler signs areabsent.AnECGis performedand thereare noobvioussigns of acute ischemia. What isthemost likely diagnosis? 1) DVT 2) Abdominal Aortic Aneurysm 3) Aorto-iliacdissection 4) AF 5) MIQuestion3 A61-year-oldmanisadmitted to A&E withsuddenonset of apainful, cold rightfoot.Hehasa radialpulse of 82bpmthatis notsinusrhythm. Anabdominalandcardiac examinationfind nothingelse of note.There are nopalpable pedalpulses inthe rightfoot.Ankle doppler signs areabsent.AnECGis performedand thereare noobvioussigns of acute ischemia. What isthemost likely diagnosis? 1) DVT 2) Abdominal Aortic Aneurysm 3) Aorto-iliacdissection 4) AF 5) MIQuestion4 52 yearoldwomenis inhospitalafterbeing admitted for anelectiveumbilical herniarepair. Shehas apast medicalhistory ofT2DM, wasa smokerfor20 yearsand,IBS.Sheis2 dayspost op.Onthe morningwardround younoticesomeerythemaoftherightclave. Onpalpation thereismild tenderness.Youorder ad-dimer whichis elevated and a subsequentlower limb USS is performedwhichconfirms aDVTinferiortothe saphenous-poplitealjunction. What isthemost appropriatemanagementfortheDVT? 1) 6-months Rivaroxaban 2) Compression stockingsand 3-months Aspirin 3) Compression stockingsand 6-months Apixaban 4) 3-months Apixaban 5) 3-months ClopidogrelQuestion4 52 yearoldwomenis inhospitalafterbeing admitted for anelectiveumbilical herniarepair. Shehas apast medicalhistory ofT2DM, wasa smokerfor20 yearsand,IBS.Sheis2 dayspost op.Onthe morningwardround younoticesomeerythemaoftherightclave. Onpalpation thereismild tenderness.Youorder ad-dimer whichis elevated and a subsequentlower limb USS is performedwhichconfirms aDVTinferiortothe saphenous-poplitealjunction. What isthemost appropriatemanagementfortheDVT? 1) 6-months Rivaroxaban 2) Compression stockingsand 3-months Aspirin 3) Compression stockingsand 6-months Apixaban 4) 3-monthsApixaban 5) 3-months ClopidogrelExamination Pulses: Special test: Inspection: Rate Sensation Habitus Extremities: Rhythm Buerger's Arterialsigns Temperature Character Venous signs CRT Volume Examcompletion: Scars Delay/symmetry BP ABPI • Upper or lower exam • 3 mins • Same pt as breast exam(probably no signs) • I personally start distal and do extremities first Inspection+extremities Inspect aroundroom Mobilityaids Arterial Upper limb Mobility aid Amputation Cyanosis Pallor Generalinspection Ulcer Tarstaining Surgicalscars, habitus Livedo reticularis Xanthomata Palloror rubor Swelling Venous Look at+ underlegs Surgery Surgicalscars, varicosities Varicosities Dressing Oedema Neck scar Lipodermato- Laparotomy Inspect betweentoes sclerosis GSV harvest Inspect plantar surface Haemosiderin Ulcer Femoral cutdown COUNT TOES Popliteal cutdown Ulcer, digital amputation Femoral access Diabetes Foot deformity Amputation CRT+ temp UlcerPulses Lowerlimb Upper limb Assessment Artery Dorsalispaedis Radial Rate Peripheral - radial Posteriortibial (Ulnar) Popliteal Brachial Rhythm Peripheral - radial Character Central - brachial, carotid, femoral Femoral (Axillary) Aorta (Subclavian) Volume Central - brachial, carotid, femoral Carotid In lower limbexam, comparepulse between sides Aorta Lowerlimb Upper limb Delay Offer radio-femoral Radio-radial Auscultation (Popliteal) Carotid Femoral Aorta Aorta Renals RenalsPedalpulses Posteriortibial Dorsalispaedis fromdistaltoproximalnd 2ndmetatarsal Palpate the posteroinferiorborderof medial malleolus,move1cm posteriorand1cm inferior Legpulses Popliteal Femoral Find ASISandpubic tubercle, pulse is1cm inferiortomidpoint Usefingersofbothhandstopressdeeply intothe popliteal fossa andpray. Best feltin inferiorpoplitealfossa.Brachialartery Brachialarteryhugs the medialborder ofbicep Easiesttopalpate at borderofantecubital fossa Followbicep distally to biceptendonandpalpate deeptotendononmedial side Canfeelbrachialpulse all the wayuparmintoaxillaSpecialtests • Gross distalsensation • Buerger's test oPt supine oBring both legsup to45 degreesfor1-2 mins oPallorindicatesPVD – noteangle palloroccursat (Buerger'sangle) • Hang leg offbed oLeg turnsblueishthenredduetoreactive hyperaemiaCompletingtheexamination • Cardio exam • Neuro exam • ABPI • Bloods • Imaging Equipment HowdoI actuallydoanABPI..? BPcuff Dopplerprobe Ankle Brachial PressureIndex Gel • Dopplerprobe/palpationoverartery • Inflatecuff20-30mmHg above SBP , slowly deflate, noteBP whenfirst hear/feel pulse • HighestSBP betweenDP and PT Ankle SBP ÷ Brachial SBP Use highest values,reportleft ABPI and right ABPIStenosissurgery(carotid&PVD) Carotid Open Interventional Endarterectomy Carotidstent Lower limb Open Interventional Endarterectomy Embolectomy Bypass Thrombolysis Amputation Angioplasty Embolectomy Thrombolysis AngioplastyEndarterectomy Bypass (stent)Amputations - Higher chanceofhealing - Worse functionaloutcomeFeedback