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Vascular SurgeryTeaching ProgrammeFigure 1 – Abdominal Aortic Aneurysm [1]Question 1 A screening ultrasound scan in an asymptomatic male demonstrates a 4.3 cm abdominal aortic aneurysm. What is the most appropriate next stage of management? A – Monthly ultrasound scan B – 3 monthly ultrasound scan C – Annual ultrasound scan D – Referral to vascular for consideration for repair E – Send to A&E for urgent vascular review & consideration for repairAbdominal Aortic Aneurysms Aneurysm – an abnormal dilatation of a blood vessel by more than 50% of its diameter AAA – dilatation of the abdominal aorta >3 cm Aetiology – atherosclerosis, trauma, infection, CTD’s or inflammatory disease Figure 2 – AAA on CTA [2] Risk factors – smoking, HTN, hyperlipidemia, FHx, male gender & increasing ageUnruptured AAA Presentation & Investigations Symptoms – asymptomatic, abdominal pain, back/loin pain, limb ischemia, aortoenteric fistula, syncope Signs – pulsatile mass, ischemic limbs Ix – ultrasounds scan (USS), CT aortogram AXR – not of use Figure 3 – Aortoenteric Fistula [3]AAA Screening & Management National abdominal AAA screening programme (NAAASP) – abdominal USS for men at 65 years of age: 3-4.4 cm – annual USS 4.5 cm – 5.4 cm – 3-monthly USS >5.5 cm, expanding >1 cm/year or symptomatic – refer to vascular & consider surgery >6,5 cm – notify the DVLA & disqualifies from driving until repair Medical management – smoking cessation, antihypertensives, statin & aspirin therapy, weight loss Surgical management: Open repair Endovascular repair Figure 4 – Endovascular Repair of AAA [4]Figure 5– Open Repair of AAA [5]The Ruptured AAA 85% die before reaching hospital Presentation – severe abdominal/back pain, syncope, vomiting, pulsatile mass in abdomen Hemorrhagic shock A-E assessment prioritizing: Early IV access & resuscitation cautiously – aiming BP 90-100 Figure 6 – Ruptured AAA on CTA [6] mmHg Oxygen supplementation Urgent surgical repairQuestion 2 A 68 year old gentleman presents to the Emergency Department with a 6 hour history of sudden onset tearing chest pain radiating through to this back. He has a past medical history of hyperlipidemia & hypertension for which he takes atorvastatin and amlodipine. Other than a tachycardia his observations are normal. A CT aortogram is conducted which demonstrates a Stanford B aortic dissection with no evidence of other vessel involvement. Which of the following is the most appropriate first line method of management? A – Oral ramipril B – IV labetalol C – Urgent transfer to cardiothoracic centre for repair D – 3 monthly CT aortogram E – AngioplastyAortic Dissection A tear in the intimal lining of the aortic wall, splitting the tunica intima & media apart Prolapse of the aortic valve Risk factors – HTN, CTD’s, male, atherosclerotic disease, bicuspid aortic valve Features – tearing chest pain, radiating through to the back, tachycardia, hypotension, new aortic regurgitation, signs of end-organ dysfunction Figure 7 – Schematic of Aortic Dissection [7]Dissection Classification Figure 8 – Aortic Dissection Classification [8]Aortic Dissection Investigations Baseline bloods – FBC, U&E, LFT, troponin, coagulation – 4 units packed RBC’s crossmatched ECG & echocardiogram – particularly useful if concerned there is retrograde extension with valve involvement or tamponade st CT angiogram – 1 line investigation to definitively diagnose & plan surgical intervention lumen, TL = true lumen) [9]n CTA (FL = falseAortic Dissection Management A-E assessment, high flow oxygen, IV access & cautious fluid resuscitation Type A dissections – cardiothoracic surgery Type B dissections: Medical management – HTN management (IV labetalol) Surveillance imaging – 1, 3 & 12 months post discharge with further scans 6-12 monthly after Surgical management – if complications e.g ruptured renal, visceral or limb ischemia, refractory pain or uncontrollable hypertension Figure 10 – Type A Dissection Repair [10]Question 3 A 76 year old lady presents to her GP with worsening right calf pain that was initially only associated with walking but over the last 2 months even affects her at rest, being particularly bad at night whilst lying in bed. The pain is not relieved by leaning forward, however is relieved by hanging her leg out the side of her bed. She also has a black, wet 5 toe that has gradually worsened over a similar time period. On examination she has a gangrenous 5 toe on her right foot. Dorsalis pedis & posterior tibial pulses are absent on palpation. She has an ABPI of 0.4. What is the most likely diagnosis? A – Compartment syndrome B – Vascular claudication C – Acute limb threatening ischaemia (ALTI) D – Neurogenic claudication E – Critical limb threatening ischaemia (CLTI)Limb Ischemia Definitions Chronic limb ischaemia – a symptomatic reduction in blood flow to the lower limb (often called vascular claudication) Critical limb threatening ischaemia - an advanced form of chronic limb ischaemia characterized by: Ischaemic rest pain for >2 weeks (worst when lying flat in bed) Presence of ischaemic lesions or gangrene attributable to arterial disease ABPI <0.5 Acute limb ischaemia – sudden decrease in limb perfusion that threatens limb viability Risk factors – smoking, diabetes, HTN, hyperlipidaemia, increasing age, obesity, FHxThe Ischaemic Limb Hair loss Thickened nails Absent peripheral pulses Cold Arterial ulceration Gangrene Buerger's test Figure 11 – Buerger’s Test [11]Investigating Limb Ischaemia Ankle-Brachial Pressure Index (ABPI): Normal >0.9 * Mild 0.8-0.9 Moderate 0.5-0.8 Severe <0.5 Doppler ultrasound study CT angiography or MR angiography Figure 12 – ABPI Measurement [12]Management of Limb Ischaemia Cardiovascular risk factor modification – lifestyle advice, statin therapy, anti-platelet therapy, diabetic control Supervised exercise programmes Indications for surgery – conservative treatment failure, or signs of critical limb threatening ischemia: Angioplasty +/- stenting Bypass grafting Amputation Figure 13 – Angioplasty Schematic [13]Acute Limb Threatening Ischaemia (ALTI) A sudden decrease in limb perfusion threatening limb viability Aetiology: Embolic Thrombosis in situ Trauma 6 P’s Figure 14 – ALTI Symptoms [14]ALTI Investigations Rutherford Classification Routine bloods including lactate, thrombophilia screen, G&S ECG Doppler USS CT angiography Figure 15 – Rutherford Classification [14]ALTI Management Surgical emergency – irreversible damage within 6 hours Conservative management – IV heparin Surgical management: Embolectomy Local intra-arterial thrombolysis Angioplasty Bypass surgery Amputation Long term management – reducing CV risk, anti-platelets Complications – compartment syndrome, reperfusion syndrome Figure 16 – Fogarty Catheter Embolectomy [15]Peripheral Aneurysms Aneurysm – an abnormal dilatation of a blood vessel by more than 50% of its diameter 70-80% of peripheral aneurysms are popliteal Aetiology – trauma, infection, CTD’s, inflammatory disorders Presentation: Often incidental findings Symptomatic – painful pulsatile mass +/- ALTI Ix – US duplex scan, CT or MR angiogram Figure 17 – Open Aneurysm Repair [16] Management – endovascular stent insertion, or open ligation & resection of aneurysm with bypass graftingQuestion 4 An 88 year old male with a past medical history of diabetes presents to his GP with a 1 month history of a painful, wet ulcer with irregular borders found on the medial aspect of his lower leg as seen in the image. He has an ABPI of 0.9. What is the first line method of management for this patients condition? A – Angioplasty & stenting B – Referral to diabetic foot clinic C – Venous stripping D – Compression bandaging E – Bypass graftingVenous Ulceration Ulceration secondary to venous insufficiency due to valvular incompetence or venous outflow obstruction Risk factors – age, varicose veins, Hx of VTE, pregnancy, obesity Features – shallow painful ulcers with irregular borders in the gaiter region associated with signs of venous insufficiency Ix – duplex USS, ABPI, cultures Management – leg elevation, exercise, compression bandaging +/- antibiotics Figure 18 – Venous Ulceration [17]Signs of Venous Insufficiency Figure 20 – Haemosiderin Staining [19] Figure 19 – Varicose Eczema [18] Figure 21 – Lipodermatosclerosis [20]Arterial Ulceration Ulceration secondary to a reduction in arterial blood flow leading to reduced lower limb perfusion & poor healing Risk factors – known PAD, smoking, diabetes, HTN, hyperlipidemia, increasing age, FHx Features – small deep lesions with well-defined border & a necrotic base at sites of trauma & pressure areas (punched out appearance) Ix – ABPI, duplex USS, CTA/MRA Management – conservative, CV risk modification, angioplasty or bypass Figure 22 – Arterial Ulcer [21]Neuropathic Ulcers Ulceration secondary to peripheral neuropathy Risk factors – poorly controlled diabetes, B12 deficiency Features – Sx of peripheral neuropathy, painless ulcers on pressure areas e.g. metatarsal heads or heels Ix – BM/HbA1c, B12 levels, ABPI, duplex USS, swab, XR Management – referral to diabetic foot clinic, Figure 23 – Neuropathic Ulcer [22] optimization of diabetic control, lifestyle improvement, chiropody +/- antibiotics, +/- amputationCharcot Foot Deformity Neuroarthropathy caused by peripheral neuropathy Loss of joint sensation in the foot leads to continual unnoticed trauma & deformity occurs – predisposes to neuropathic ulcer formation Features – ”rocker-bottom” sole deformity, swelling, distortion, pain, ulceration Figure 24 – Charcot Foot Deformity [23] Management – off-loading of foot & sometimes immobilisationQuestion 5 A 62 year old gentleman presents to his GP with dilated superficial veins across his legs associated with localized tenderness. On examination he has large torturous congested veins noted across both his legs, associated with some haemosiderin staining & venous eczema. He is diagnosed as having varicose veins. What is the first line method of investigation for the patients condition? A – Arterial duplex B – CT venogram C – ABPI D – Venous duplex E – CT arteriogramVaricose Veins Tortuous, dilated segments of vein caused by valve incompetence Aetiology – primary idiopathic, secondary to DVT or pelvic masses Features – cosmetic issues, aching, itching, bleeding, features of venous insufficiency Ix - duplex USS Management: Conservative - patient education, compression stockings Surgical criteria – symptomatic, with lower limb changes, associated with ulceration Figure 25 – Thermal Ablation [24] Thermal ablation, foam sclerotherapy, vein strippingTHANK YOU VERY MUCH FOR LISTENING! Please fill out the feedback form (QR code or link in the chat). Free slides will be sent out. 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Breast SurgeryTHANK YOU – Image References 1. https://westjem.com/articles/aortic-dissection-diagnosed-by-ultrasound.html 2. https://www.researchgate.net/figure/Surface-reconstruction-of-the-CTA-data-showing-the-two-positions-above-the-branching-of_fig1_5655764 3. https://www.maimonidesem.org/blog/potd-aorticenteric-fistula-aef 4. https://teachmesurgery.com/vascular/arterial/abdominal-aorta-aneurysm/ 5. https://www.jvscit.org/article/S2468-4287%2822%2900164-2/fulltext 6. https://radiologyassistant.nl/abdomen/aorta/aneurysm-rupture 7. https://teachmesurgery.com/vascular/arterial/aortic-dissection/ 8. https://pubs.rsna.org/doi/full/10.1148/rg.2021200138 9. https://www.researchgate.net/figure/Stanford-type-A-aortic-dissection-in-a-55-year-old-man-with-chest-pain-symptom-A-2D_fig2_335760314 10. https://www.spectrumhealthlakeland.org/population-health/health-library/Content/135/72/ 11. https://www.youtube.com/watch?v=4to5YGyFa9g 12. https://en.wikipedia.org/wiki/Ankle–brachial_pressure_index 13. https://www.healthlinkbc.ca/illnesses-conditions/heart-health-and-stroke/angioplasty-peripheral-arterial-disease-legs 14. https://teachmesurgery.com/vascular/peripheral/acute-ischaemia/ 15. https://nlstore.2023onlinesalebest.com/category?name=fogarty%20balloon%20catheter 16. https://www.sciencedirect.com/science/article/abs/pii/S0890509612000611 17. https://cvtsc.com/conditions/venous-ulcer/ 18. http://almawiclinic.com/2016/06/06/do-i-have-varicose-eczema/ 19. https://www.veinsvip.com/blog/ankle-discoloration/ 20. https://www.independentnurse.co.uk/content/clinical/diagnosing-lipodermatosclerosis/ 21. https://www.canadianmaple.org/2-arterial-ulcesnew-page 22. https://journals.sagepub.com/doi/10.1177/24730114231193418 23. https://belfastskinclinic.com/vascular/varicose-veins/