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Great. So I think we're live, so we should be recording. Oh, there we go. Welcome everyone to today's talk. So today we're going to do a talk on vascular surgeries, hopefully cover all the main presentations that will be useful for your final exams and just a quick introduction. My name is Kirsten. I'm an academic, I one at Saint George's Hospital and I'm currently rotating in vascular surgery. Um, so before we get started, we've got a quick message from um BMA. So, um Daniel is here to tell us a bit more about what the B can offer you as medical students and it seems to be f by one. Perfect. Thanks. Thanks, Kirsten. Um, yeah, hi, everybody. Um I will, I will be as quick as possible. Um Just a bit of an update on sort of things that are going on at the moment should be able to see my screen now. Um, so first things first. Um, yeah, important year to, to be, er, members, especially final years coming into F one. so if you're not already a member, um, a bit of a, a bit of a incentive to join. Um, if you join today using that QR code or link I put in the chat, you'll get a temp and Amazon Voucher memberships 3 lbs 75 a month. So it's like, it covers three months free. Basically this isn't on our website. This isn't, you won't find this anywhere else. So this is just exclusive to anyone watching, um, live or watching this back. Um, all you need to do is after you've joined, drop me a quick, er, email. Um, and I'll, and I'll, and I'll get that voucher sent out to you. So, yeah, best, best deal around, to be honest. Uh, we don't really run um, things like this um, in the mainstream. So, yeah, make, take advantage of it if you already remember. Um, so, yeah, so I'm from the BMA, um, sort of work on the member side of things in, in London. Um, I, I'm out and about most days, um, across trust hospitals. Um, a lot of organizing strikes and what not at the moment. Um, so, yeah, I'm sure everybody knows, um, what, what the BMA does. Um, you know, sometimes you get a bit of confusion with, with companies like MD and mps who are indemnity companies. Um, we're obviously your union so we, we cover sort of the nonclinical side of things. So for better, for worse, we negotiate the pay for all doctors in, in, in the NHS. Um, there's three ways really to think about what we do. Um, on an individual basis. So, so if you, if you have any issues with contracts, whatever, or, or, or sort of 1 to 1 at work or, or med school, um, and then on a local level, so when you are in trusts, um, or even at university, if there's, there's an issue going on for sort of a group of you, um, we come in and we sort of know who to talk to and how to, how to sort of sort things out. And then obviously on a, on a national level that you're seeing at the moment, we, we negotiate and, and, you know, we put, put everyone together. Um So yeah, so we've currently got 100 and 91,000 members who have made up of doctors and med students. Um And yeah, it's worth just remembering that the BMA is exclusively for doctors and med students. So we don't, we don't have anyone else in the NHS in, in membership. It's just, it's just for you as, as a very specific type of membership. So, yeah, just a quick update on what's going on at the moment. Um We are just beginning our re ballot for junior doctors. Um So our mandate comes our, this is our second mandate. Our second six months, it comes to an end in March. So what we did last time was we had a re ballot um as it was coming to an end. So there's a seamless transition. Um So, yeah, so we'll, we'll be, um, going around all the juniors again, make sure they, they voted and, and, and keeping up the, the pressure, um, no strikes announced for Juniors at the moment. Um But it's usually around this time where things get announced there will be um, II imagine there will be strikes in, in Feb. Um So probably towards the end of Feb at this point, um we were sort of waiting on what was gonna happen with the consultants office. So the consultants were given an offer by the government. We put out a membership to vote on. Um sorry. And last week we got the, we got the response from the er, response from the consultant who voted against the offer. So the consultants are going back on strike cos we have mandates to strike for the consultants. So that's, that would have informed a lot of the consultants that voted for that. It would have maybe paved the way for an end to this. But, but they, they voted against the offer, they were given, I won't go into the details of the offer cos it's quite complex. Um But yeah, it's quite tight, 51% voted against the offer. Um So it was, it was very, very tight in the end. Um But yeah, we, we, the consults will go back on, on strike now. Ok, just a few other little things and then, and I'll let you get on. So BMA library, if you remember, you get access to thousands of textbooks and, and journals. Um, we used to have BMA House, er, services so you could go there in person if you were in London or, or we'd send the books out to you. But now everything you can access, um, instantly through, um, through the, through our website, um, everything you could possibly need is on them. B MJ learning as well. I'm sure you got B MJ learning through uni anyway. Um But yeah, but obviously when that comes to an end, you'll have full access to B MJ learning through through your BMA membership um in F one. Um So yeah, I do use that for, for things like passing exams and, and revision tools um clinical key. So it's essentially a point of care tool. Um We've bought this uh this, this product. Um It's not ours but, but you get access to it through your BMA membership. Um So yeah, essentially a point of care tool um type in any condition. It will bring up every single journal book um video um to, to, to sort of go go through that condition with you um B MJ. So the actual, so now you're on your final year, you're actually entitled to getting the B MJ um every week. So as part of that 3 lbs, 75 a month, you get four copies a month, roughly, you know, so every, every Saturday, I get mine. Um, so, yeah, so even that alone works out as paying less than a pound for every B MJ you get through the post. So the thing is with that you need to a, er, opt into that. So if you're already a member and you're not getting it, you just need to give us a call because it's an opt in service, um, rather than everyone getting it. Um, and anyone who joins today, um you, you'd be letting sound little secret. So as soon as you join, um just drop us an out and we'll, we'll get that sent to you every week. Um We've got a great um wellbeing sports service. So that's open to everybody 24 7. Um And, and the, the unique thing about this is we've got a, the choice of you speak to a counselor or a peer support doctor. So somebody who's been through um similar, similar situations to you. Um But I used to be thinking about this maybe. Um But we've got a specially explorer tool. Um Essentially it's a psychometric test. Takes about 20 minutes to, to, to, to do, you'll ask all sorts of work life balance questions. And then at the end it'll break down all the top suit specialties according to the answers you've given. Um really good to do it sort of now. And then sort of when you start off, I want to just see how, how your sort of tastes change and your answers change. Um But yeah, so when it comes to making your choice, especially years to come, um, you, you've sort of been informed quite early on by, by doing this amongst other things. Rams. Yeah, it's, it's very important that, um you guys coming into F one cos it will come round very quickly. Uh our membership and, and, and we're strong in, in that regard. Um Yeah, so, so do join um and, and do get involved as much as you can um ahead of time. Um Because yeah, chances are it's gonna roll around to, to when you guys are there. Um So yeah, we just want everyone to be um as in this fight together as, as the, the current juniors are. Um that's it. I will stop sharing. Um Yeah, and I'll, and I'll hand you back to Kirsten. Let you crack on with the session. Thanks for having me. Perfect. Thank you so much Daniel for coming and sharing that with us. Um Obviously, it's very relevant at this moment in time, still very much in the heat of everything. So not just senior doctors but consultants too. Um Great. So I'm just gonna share the slides. Um Just let me know in the comments and you can see it. So I'm hoping for this session to be as interactive as possible. Um I've tried to condense all the key information finals into um the slides to make it as high yield as possible. So the stuff that comes up um year on year and then we'll talk through some cases just before I tell you about the condition. Just so we can cast our wide um thinking caps widely because obviously in your M CQ exam, it won't be flagged as a vascular surgery question. So it's important to consider other differentials as well. Um So it should start to help you get thinking and then towards the end of the presentation will also just cover how to do an arterial and venous exam, which should be helpful for your acies too. Um So any questions throughout the presentation just um pop them in the comments below and I'll try my best to answer them as soon as we get a lot. Um go along um just while we're waiting for this to load, just to let you know, I'm also part of mind the bleep and help run the final year content and we're currently in the process of running um putting together an online interactive osk series. Um So as always, all our events will be advertised on medal. So if you're interested in um developing your OSK technique and running through cases of the most common osk exams, they will be coming up in the next few weeks as well. Great. So let's get started. So, yeah, as I said, I'm an F one doctor at Saint George's and I'm currently on vascular surgery and the slides have been kindly reviewed by my supervising consultant Mr Desai. So this is what we're gonna cover today. Um Hopefully, um a good range of conditions. So we'll start off by what comes up most commonly. So, lower extremity arterial disease, also known as peripheral vascular disease, um acute limb ischemia compartment syndrome, which is a key one not to miss um chro stenosis and then we'll touch on venous disease and aortic disease as well. Um So this is your MLA curriculum. So we'll try to cover as many of the more vascular related pathologies here as possible as we go along. But just so you're aware and you have this for reference. So the first um topping on to talk about is lower extremity arterial disease. So, can anyone put in the chat name? Any risk factors that you know of that puts you at risk of developing arterial disease in your legs? Smoking, good diabetes. Well done. Yeah, good. Those are two of the really big risk factors that we see a lot of our vascular paths on the vascular ward having um a diagnosis of either diabetes or smoking. Absolutely hyperlipidemia. That's really good. So there are three main patterns of arterial disease that you get in your legs. So, intermittent claudication, chronic limb threatening ischemia, um and acute limb ischemia. So we'll just go through each of them and it's really important that you have it clear in your mind how these three are different um in terms of exams and then for risk factors, the main one to think about is atherosclerosis. So, fatty plaques on the walls of your artery and that makes sense because it narrows um the lumen of your artery affecting arterial supply. Um So, yeah, hyperlipidemia contributes towards that, of course. Um And then I'd like to break the risk factors down into modifiable and non modifiable. And this also helps um you in terms of thinking about management on how, how we can change some of these um modifiable factors. So, smoking, obesity and hypertension and hyperlipidemia, these all put you at higher risk developing arterial disease and then risk factors that you can't control and you can't modify in patients are their age. Um Males are more prone to it than females and personal history or family history of cardiovascular events. Um So yeah, these are your risk factors for lower extremity arterial disease. So, the first component that I want to talk about is intermittent claudication. So I have a case X up. So a 57 year old man who's been seeing his BP for the past four years of recurrent leg pain. The patient reports that the calf pain has recently gotten worse and he can only walk about 100 yards before the pain starts again. This means he has put on weight because he can't do as much exercise, but he says he doesn't have any pain when he's at rest. Um and doesn't have pain anywhere else just in the calf. So, given this presentation of very reproducible calf pain, what do we think this patient might be suffering from? So, what are your causes of calf pain? Probably arterial occlusion. Yeah, that's a good idea. Any other ideas? Thinking not just vascular surgery, any causes of calf pain that you can think of DVT. Absolutely, intermittent claudication. Anything else cellulitis good. So, um, well done everyone. Thank you for those who are contributing to the chat. This is really good to think beyond just vascular um pathology. So yeah, in this case, this is a typical in inter intermittent claudication um picture, but you can have other causes of calf pain too. So one thing that's really important to differentiate from vascular claudication is neurogenic claudication. Um So you do get this kind of cramp like pain on exertion that resolves within a few minutes and nothing at rest. And this is really typical of a vascular um type picture because when you exert yourself, there's increased demand in the leg. And so you develop the pain after a fixed amount of exertion. So patients are very specific in terms of their walking distance that they can tell you about. And the key part is that it's not at rest. So that's really good. Whereas neurogenic claudication is slightly different, um instead of being triggered by exercise, it can be triggered by kind of positional um movements. So like lumbar extension um is worse and it's better in lumbar flexion and pain can come with very minimal exertion, unlike vascular claudication where pain comes after lots of ex exertion. Um So yeah, just something to think about is that you can get these kind of localized pains in your limbs as well from nerves. Um to, just to think, is it vascular or is it neurogenic? And then yeah, other types of calf pain, if it was just a single event, I'd be thinking DVT and if it was also unilateral. So intima claudication can be unilateral or bilateral depending on the arterial disease in both legs, how bad each one is. Um But DVT is pretty much always unilateral and you wouldn't have such a long history of say four years. It'd probably be a more acute picture. And yeah, cellulitis absolutely again, would definitely be unilateral and would be accompanied by skin changes um as well as kind of tender skin rather than tender muscle, which you see in DVT, for example, and then you wouldn't see tender muscle in, in intermittent claudication. Um So this slide depicts depending on where the occlusion is in your artery, where you might develop pain just because of where that particular artery supplies. So when it comes to M CQ, questions really pay attention to where the ischemia is presenting in the patient because that will tell you where your obstruction is. So most commonly, you'll see obstructions in your femoral artery, which is your thigh, your calf pain pop to your artery as well. Calf and ankle. And then the one they like to say in MC Qs is buttock and hip pain, which tells you it's the iliac artery and that's been blocked. It's just one of those M CQ effects that's really useful to know. So once we know someone has intermittent claudication, how do we investigate them? So, what we want to do is assess all the lower limb pulses. So find out um doing an arterial exam just having a feel for the pulses at each level. Um because that will help to tell you if, where the blockage might be. And if you can't feel it, you can use a handheld Doppler at the bedside as well. Um Another thing you can do is an ankle brachial index. Um So this is your ankle systolic pressure divided by your brachial systolic pressure. And if you have a value of less than naught 0.9 that shows that you've got claudication and then the lower the value, the more severe your arterial disease is say, for example, when you get to naught 0.3 naught 0.4 then you start to develop breast pain and that kind of progresses into chronic limb threatening ischemia. If you have an ABP of over one, that means your um vessels are very hardened, which um is a result of calcification secondary to diabetes. So it's just a useful fact to know as well. And A BPI can really be helpful in terms of severity of arterial disease. Um also want to do an ECG um again, look for any kind of heart conditions that might. So a lot of people confuse inter claudication with acute limb ischemia, which we'll touch on in a bit. But again, just kind of screening your basic medical work up for patients and you wanna do blood tests. So full blood count, use knees, do your lipids to look for your risk factor to see if that's something you can medically manage and then send off inflammatory markers like E sr and C RP for vasculitis. And also to look for any um deranged clotting. But the most key part of um arterial disease is using a duplex ultrasound. So, does anyone know what duplex means? Why is it called duplex ultrasound? So you've got a question saying please, can you remind me of what an A BPI is and can tell you to distinguish venous from arterial and mixed etiologies. So A BPI just tells you about arterial disease because it's looking at your ankle, systolic pressure um divided by a brachial systolic pressure. So what you do is you put a um you put a BP cuff on your ankle and you put a BP cuff around your brachial artery just normally. And then you take those two values and divide one by the other. And then um So you want to divide ankle divided by your brachial and that just tells you the level of arterial disease. So for example, it should be one because there should be the same amount of arterial flow going from your arm to your leg. But the lower that um number is the poorer your arterial flow is. And if you have it higher, that means there's kind of propagation of arterial flow and it's because your vessels are really hardened in the arteries. And so it's a sign of calcification. So, does anyone want to contribute to what they think? Duplex might mean? So it's a very common term that we hear about in vascular surgery. But what does it actually mean? Don't worry if you guys don't know. So duplex is, I think of it as kind of two. So sorry, there's a question, it doesn't matter which hands break your pressure to use in case both hands have different systolic pressures. Um So theoretically in a healthy patient, you should have the same sys er brachial systolic pressure in both arms. Um If you don't, that's kind of a sign of a different pathology, which we'll talk about later. Um So yeah, you should have the same pressure in both arms. Otherwise that's a sign you might be having an aortic dissection. Um So yeah, it doesn't matter which hand you use in that case. So going back to a duplex. So duplex um means there's two modes or two elements to it. So the Doppler is just your ultrasound image that measures blood flow. So as you can see in the picture here, and then your B mode obtains an image of the vessel itself. So this is really useful, you can duplex arteries, you can duplex veins in your arms and legs, you can duplex your aorta. Um It's a really useful tool that we use every single day on the vascular ward and it can tell you about and the size of the vessel and also the type of flow. So you have triphasic flow, biphasic flow and monophasic flow. Does anyone know what triphasic flow means problem? So, triphasic flow is a sign of a really healthy artery because it means that you have three elements and phases to your arterial flow. So the peak um that comes rapidly is your kind of antegrade forward flow that peaks during systole. And then you have a transient reversal of the flow during early diastole. So this is just if you imagine a blood flowing through an artery, it's stretching and then kind of closing again. Um And then the last part is this kind of slow forward flow um during late gly. And that just means there's good elasticity in your peripheral arteries and this is considered normal. Whereas monophasic flow um which you can hear on a Doppler, it just sounds like one consistent sound. Um is a sign of an abnormal artery So duplex is really good at telling you um size of the vessel flow. And yeah, the characteristic, the character of the flow, which is just something important to me um good. And then how do we manage intermittent claudication? So, thinking back to our modifiable risk factors, so we can encourage patients to stop smoking um and to exercise and to lose weight and we can also stop people from preventing minor trauma. So what often happens is that um in lower extremity arterial disease, people will get um, like stub their toe and because they've got poor arterial supply, they don't heal very well and ulcers can progress um as a result of minor trauma. So good foot care is really important and then going back to our risk factors as well, how can we optimize their risk factors with best medical management can start patients on an antiplatelet therapy? So, clopidogrel, 75 mg, um, don't worry too much about the doses and course, will lower their lipids with a statin. So, atorvastatin is really commonly used, making sure they have good um, BP control to take away that hypertension risk factor and that they have good diabetic control. So, looking at their diabetes. So does anyone know how we can assess whether someone's diabetes is well controlled or not HBA1C? Exactly. So this is a blood test that tells us over a longer period of time because it's all based on the lifespan of the red blood cells and how um sugars get attached to them. So, glycosylated hemoglobin. Um then yeah, that gives us a kind of three month window of how kind of up and down someone's blood sugar control has been. Um Marriam asks, is it clopidogrel or aspirin? The preferred one? Um I think it depends on your trust. It depends on um each hospital but any kind of single anti therapy would be useful. So, yeah, either aspirin or clopidogrel. Um Great. So, moving on to chronic limb threatening ischemia. Um so this is slightly different. Um some you might come across this as cli so critical limb ischemia. But the new terminology is chronic limb threatening ischemia. So there are three main features to look out for. If you see 22 of these three features, you can be pretty confident that this is C LTI. So look for these buzzwords in your MC Qs. Um So rest pain um night. So pain when you're not doing anything pain at night. Um and tissue loss, so, ulceration or gangrene. So this is the bulk of what we see on the vascular ward. So what do we do with patients like this? We admit them, we do the same investigations as intermittent claudication. Um cos it's kind of an earlier part of that spectrum and then we think about how we can treat this ischemia. So there's a chronic pathology, there's nothing acute and urgent. So we wanna admit the patient do some investigations and imaging to find out at which level they've got blockages, how good their arteries look and then think about what's best for them. So, do you revascularize them to help open up some of those blocked arteries or is the tissue loss too great? Do we have to amputate to s, um, is the tissue non salvageable? And then again, thinking about antiplatelet and statin therapy after, um, someone's asked, when would you not give a patient Ted Stockings to prevent a DVT? Um So if someone has venous disease, we'll cover this later. You don't want to give them compression stockings if they also have arterial disease because if someone has arterial disease and you give them compression stockings that's going to make their pathology worse. So whenever you consider giving compression stockings to someone with venous disease, always do an A BPI to look for any signs of arterial disease before you proceed with compression. Just so you don't risk making that pathology worse. Ok. So let's talk a little bit about what revascularizing actually is. So, um you can use either an endovascular approach. So, um kind of you go through kind of like keyhole, you go through like arterial access, um or you can do it by surgery. So more open surgery. So what's really common in interventional radiology is to use a balloon, angioplasty plus or minus a stent. This can be done either under local anesthetic or general anesthetic but as the diagram shows you put in a catheter and then you inflate a balloon to expand the narrowed artery. And then you can also add a stent to help hold the artery um artery open for a longer period of time. So this is really useful when you've got um a big vessel and you've got a small area of occlusion. Whereas if you've got a long area of occlusion or multiple different small areas along the same artery, then a bypass is better. So what you do is you take one of the patient's own veins. So usually their long saphenous vein or you can use synthetic material. Um and you can use uh the vein to bypass the blocked area of arteries. So the vein will carry arterial blood in the new channel, but obviously, it requires good flow above and below the occlusion. Otherwise, it won't work. Um Obviously, both of these come with um complications. So for an endovascular approach, um you can get um like embolic events that happen um where you've gone in with the uh balloon and scent. You can have vessel dissection, pseudoaneurysm where the layers of the vessel will kind of balloon and perform an aneurysm. And because of how it's done, um lots of contrast is used to help visualize the vessels during the procedure um because it's not open, then you are at risk of renal failure from all that contrast you're using. And then with surgical bypass. The risk is that um it might not work. You might get emboli further down the graft itself, might thrombo, you might get what's called reactive hyperemia. So, like kind of reperfusion injuries. Um and you might have to change, um, revise the graft if the healing fails. So it's not always 100% successful. Um So you have to take into consider these risks and then also just thinking about the patient's general fitness surgery. If they can tolerate an open surgery, it's more time on the table. Um So you need kind of a fitter baseline and just going back to rectal hyperemia. This is when you have like a local vasodilation, um which occurs when there's been an interruption to blood flow and there hasn't been good oxygen supply and then you get kind of this reactive response once you increase blood flow to an area after a period of occlusion. So just something to think about just a common complication. Um Someone says, hi, there will sliding recording be made available with the feedback form, be posted in the chat here. Thanks. Yes. So there'll be a QR code at the end of this session that um you can give feedback on which will be really useful for us as we keep developing our series and please tell us if there's anything you'd like from our upcoming AY series. Um And yes, slides and um, recordings should be made available on med and there's a bit of a delay on the youtube because of just some technical difficulties, but we are trying to upload all of them. Ok. So that thinking about revascularisation, but sometimes we can always think about amputations. This is where um the tissue loss is not salvageable. We can't just revascularise and hope that helps heal the tissue. Um So we obviously aim to take off er as least as possible with amputation. So um if it's just toes, you can give toe, just chop, people's toes off and to help save the rest of their foot. Um or you can do what's known as a tran transmetatarsal amputation. So, put in a picture just to help visualize what this is. Cos it's quite a mouthful but you go across your metatarsals um and you cut along there. Um if the whole kind of forefoot is not salvageable and then you kind of move up depending on how severe and the infection is. But the whole idea of amputation is kind of um you want to cut away the infected tissue or ischemic tissue because they start to release toxins and they start to spread further up. So it's kind of life saving surgery and it needs to be done sometimes in an emergency. So we can do what's called a guillotine amputation. So you just cut straight across and then you go back a few days later once they're more stable. Um And yeah, once they're more stable and then you can kind of close it properly with a skin flap or kind of amputate her up. So, chronic limb threatening ischemia is often the first sign of end stage vascular disease. Um So the surgical options in these patients in the vascular past, usually have a high mortality because it's kind of a sign of end stage disease. Um So that's why the outcomes are not necessarily amazing with vascular patients because it's already a sign of quite severe disease. But if people do heal well from an amputation, there is potential for rehabilitation afterwards. Great oops. So we're gonna move on to talk about acute limb ischemia. But before I do, I wanted to ask you guys if you knew how an acute limb ischemia presents because this is something that should be that comes up year on year, the six ps of acute limb ischemia. Can anyone tell me what those six ps are? Cool? So pale pain, pulseless parathesia, personally, cold paralysis. Good. I think we've got all of them between us. So well done. Um Obviously been revising very well because this is what helps distinguish what acute limb ischemia is versus other types of arterial um pathology. So in the name, it's acute, it happens very quickly and this can be caused either by a thrombus in a vascular path or an embolus for someone with risk factors. Like for example, they might have uh atrial fibrillation or they might have infective endocarditis there's lots of other causes too, but those are your two main ones. Thrombus and embolus. Um So basically, if you just think about there's like a sudden blockage to arterial flow, how does that affect the limb? So, it's painful, it's pale, it's cold. You can't, you might be able to feel the pulses and then you might have some kind of damage to muscles and nerves. So, thinking about loss of power or paralysis and paresthesia. So this is an emergency surgically cause you want to try and take away what's causing the blockage immediately before you lose all blood supply to your limb. Um So key investigations would be to do a CT angiogram. So it's a CT that uses contrast to look at um your blood vessels. So an angiogram takes a picture of your blood vessels and then you want to prepare these patients straight to the theater. So keep them nail by mouth and aim to reperfuse within less than six hours if possible. Um So this is just something to be aware of. You don't need to um memorize all the details, but this is the rather third acute limb ischemia classification and it basically just tells you if um a limb is salvageable or not. Um So when you get to stage three, and these patients have a non salvageable, salvageable limb, so they have pretty much profound nerve sensory loss, they're paralyzed, can't hear any arterial Doppler signals. And so that's the key thing. Um OK. And then depending on how severe or how viable the tissue is, changes, how we treat it. So, if it is viable, then we'll give a dose of heparin to try and break down any clots. And if it's embolic, then we can consider a surgical um thrombectomy. So that's just using a surgical approach to take out the embolus or if it's thrombotic, then we can use medicine to throm to thrombolism. It. So, um giving medication to help break down the thrombus. And then afterwards, we can think about opening up the arteries with an endarterectomy or so kind of clearing out some of that atherosclerotic plaque or using a balloon and bypass. And again, we talked about perfusion injury. Um when muscles can swell if they've not had um blood supply to them, and then when you reintroduce blood supply, they might swell further. Um So you want to use a fasciotomy. So, making incisions down your lower leg to try and reduce compartment syndrome, which we'll touch on in a bit. If the tissue was non viable, then actually the reperfusion injury risk is too great. Um You don't wanna cause um it can result in death and mortality if you kind of reperfuse a dead limb. So, signs are that there's rigid limbs, they're very immobile. They might have a mottled purple color. And the option here is to go for an amputation again, removing as little tissue as possible obviously, this is a major surgery. So we need to consider functional impact and the premorbid status of patients. Um and it might make, might require revision if it doesn't heal well the first time. Great. So next, we'll talk about compartment syndrome. So again, I've got another case for you. Let me just find it. So Compartment syndrome. So a 37 year old man um develops, this develops in condition where he his MD thigh swells and starts to ache. Um There's mars tenderness and the pain developed one hour after sustaining a rugby injury to his right lower thigh, he got a blow to his um right anterior lower thigh and then he was admitted to hospital after. So if someone's had an injury to their leg and they've got kind of mild swelling and pain afterwards, what are some of our differentials might have given it away already? But thinking not just what we've talked about, what else could be the cause? Good soft tissue injury, hematoma? Yeah. So all your kind of classic orthopedic things? Great. So, obviously what we're getting at in a vascular surgery, talk is Compartment Syndrome, but it's really important to think about other things cos often this can present in the context of trauma and fractures. So the the swelling and the pain might just be from the injury itself. So just inflammation around the area. Is there a fracture? Is there um bruising muscle damage, is there a collection of blood. So, hematoma underneath. But the key thing to think about with compartment syndrome is that the pain is out of proportion to the injury. So it's an extreme level of pain to the patient and the pain gets worse when you stretch their limbs passively. And visually, the compartment looks very tense cos of all that pressure inside. Um So it's defined as raise pressure within a closed compartment, resulting in tissue ischemia. And if it's left untreated, it can cause um death of the tissue because you don't have good supply. When the pressure is so great, it can start affecting the um blood vessels and it has a very wide range of causes. So always have a low threshold of low suspicion of compartment syndrome. And how do we manage this? So, the definitive management is um decompressing the pressure with a fasciotomy. Um and then giving IVF fluids to prevent renal failure because um if there's some muscle death like rhabdomyolysis, um you might have renal injury from all the kind of dead muscle protein that is trying to clear. Um So yeah, compartments injury is something that we should try and not miss at all. Um Because um yeah, it can cause a very quick death of a muscle group within 4 to 6 hours. Um So yeah, but what happens in compartment pressure is that the pressure in the leg compartment is greater than the perfusion pressure. And so you get ischemia dead tissue and then your myoglobin circulates into your urine and then you get renal failure as well. Um Yeah, there's a technical diagnostic definition where you need a compartment pressure with an absolute value of 30 to 45. Um Mercury mm HD. Um So you can measure the compartment pressure but it's not um essential to the diagnosis. Um Millimeters, mercury is what I meant to say the mmhg unit um good. So fascia to me is where you just make incisions into the fascia. And that just helps release um the pressure inside your deep posterior compartment. And often you can use two incisions along your lower limb. Great. So, gonna move on to talking about venous disease now um just to touch upon this. So when people have issues with um their veins, so there's not a good flow back up through the veins. Um they can either have insufficiency in the superficial system or the deep system. So, thinking about the anatomy of um the veins and A DVT is your most common deep um deep venous system disease. And um varicose veins are your most common superficial and venous insufficiencies. Um Other signs of venous disease is um just think about um congestion in your lower limbs. So you might get edema. Um you also get deposition of hemosiderin. So you might get pigment, brown pigmentation in the skin. You might get some venous eczema venous ulcers, particularly in the gator region. So the lower shin kind of area. Um You might also get lipoderma, lipodermatosclerosis. So, um the classic like inverted champagne bottle shape um and this is due to inflammation and fibrosis of subcutaneous tissue. And you also obviously get varicose veins which are clusters and dilated clusters of veins and that you can see on the surface. Um So this is a picture of varicose veins. Um They're more common in females. The primary cause is due to valve insufficiency in the superficial valves and secondary can be after a DVT. So it affects your general venous system or if you have increased pelvic pressure, then that causes congestion. Um or again, trauma can affect the venous system and how this presents is someone will complain of painful legs, heavy legs or itchy legs. So areas where there is varicosities, they might experience an itch and usually it's just cosmetic and you'd only kind of think about intervening if there's complications such as bleeding from the varicose vein or thrombophlebitis. So, a non infective inflammatory process around the cluster of veins. Otherwise, you can just encourage people to elevate their legs or um wear compression stockings, but as I said, which will help return venous flow but make sure to check there's no arterial disease with a simple A BPI test. Um Two ways, two main ways to manage varicose veins is using ultrasound. You can pass down a guide wire and either use radio frequency or heat to kind of ablate parts of the vein or close it off using um injecting foam that reacts with the vein. So that closes off the dilated section or you can use a surgical approach so you can strip the varicose veins. Um So it really just depends. I think most commonly we like to use a minimally invasive approach. Um Just cos often the complications of varicose veins aren't too severe. So going for surgery, you've got to balance the risk. Um, but yeah, it can strip from the long saphenous vein to below the knee. Um The short saf vein is not usually stripped because there's a risk of injury to the nerve. It's very close to the common perineal nerve. The risk of stripping and veins is that it might reoccur, um, you might get some bruising and bleeding at the site, infection DVT and again, nerve damage as we said, and some skin discoloration from the intervention. Ok. So the next, the next, um, thing I want to talk about is carotid disease. So who can we expect to see carotid disease in what patient groups or what patients might have had if we like to find out they have car disease because usually people don't present or patients don't say I have carotid disease. They say that they've experienced something which then they later realize they had carotid disease. Does anyone know good a stroke or a tia a? Um, so because the carotid supplies the brain, um, uh stenosis of the carotid artery usually manifests as ati A or a stroke and 10 to 15% of ischemic strokes in ti A S um originate from cart stenosis. And another classic picture is um transient ipsi lateral blindness. So, a patient will describe just curtains coming down on their vision. This is when a small embolus just lodges in the retinal artery and then itself resolves. So this is a usually an atherosclerotic process at the bifurcation of the common carotid, which you can see in the picture. Um How do we investigate this? We can use an ultrasound test to look for the level of stenosis, how thick the plaque is in there. Um or we can use imaging. So, using a CT or MRI angiography imaging with contrast, how do we manage this? We often start dual antiplatelet therapy and then surgically what we can do is make an incision along the artery and then remove the diseased intima kind of physically remove it. And then you can also add a shunt if you want to keep it open to continue blood flow. But this is only indicated in patients with a high degree of stenosis. So, through imaging, we can see that if there's over 70% stenosis in your carotids, then we should intervene. So this is another um M CQ nugget that comes up quite often. Um It's like how much percentage of stenosis would you need to consider surgical intervention? And that's 70% great. Any questions so far? I know we've covered quite a lot. If not, I'm just gonna finish talking about a few aortic diseases. So, um got another case for you. So, a 75 year old female presents to a hospital with a headache and left leg pain which radiates to her lower back on the morning of the pain developing. She had some right foot numbness and multiple falls. What do we think might be causing all this pain in the back pain in the leg numb foot and falling and headache? What are your differentials? Yep. Aortic dissection. That's your main one. You can't even think of any other differentials based on that presentation. So you've got leg pain and back pain mainly AAA. Yeah, it's a good, a good suggestion, AAA rupture. Great. So, yeah, this is quite an obvious aortic dissection presentation or spinal cord injury. That's a really good one. So then if you think about some of your neurological um so, neuropathic pain and loss of sensation with your paresthesia. Um But yeah, good. So the main thing here is an aortic dissection. If it wasn't AAA rupture, you'd think the patient would be more hemodynamically unstable. Um So they would have more significant collapses and loss of consciousness rather than just a headache and a fall. But absolutely abdomen back pain is another sign of an aortic aneurysm rupture. But yeah, aortic dissection is your main differential. So, well done, uh just legs, great. So, aortic dissection is defined as a tear in the tunica intima of your blood vessel and blood dissects and forms a false lumen. Um Next to the actual true lumen of the vessel. So you can see it on imaging. So a CT angiogram would be your definitive type of injuring, imaging, sorry. Um to look for an aortic dissection cos you can kind of see that false lumen that's created. Um So it presents as a really severe and sudden tearing chest pain. So patients will say the pain radiates all the way to their back. And depending on which arterial branch it affects, can depend on the presentation. So this patient had um leg pain and foot numbness. So affected the arteries that are supplying the legs, which makes sense. Um And then as we touched on earlier, when you have different blood pressures in your arms, um it might be a sign of aortic dissection because it shows that there's kind of different out into each arm. So there might be a tear somewhere along the way. Um because otherwise you shouldn't have unequal BP and pulses in each arm. Um Other way to investigate it is looking at an ECG to see if there's any um changes towards the supply of the heart. Um A chest X ray looking for a widened mediastinum um which again will show you the dissection of the aorta um contrast CT is your most definitive way to see the flap or you can even use a toe. So, so a transesophageal echocardiogram um if the patient is too unstable for act. Um so yeah, if it blocks other main arterial branches, you can get things like coronary occlusion um resulting in kind of heart heart pathology. So, looking at an ecg for changes, you might get some neurological abnormalities, disappearances of peripheral pulses and mesenteric ischemia. So changes to your gut and pain in the stomach as well. All might affect your kidney function. So you might become anuric, so you stop producing urine output. Um and the way to define aortic section is like type A and type B. So that just referred to the location of the tear. So in type A, you have um a tear in your ascending aorta or arch and this is the most common. Type. Two thirds of cases are type A and the risk is your dissection extends back across your aortic root and can result in um cardiac tamponade and aortic incompetence. And then you've got type B, which is your descending aorta. Um So it's distal to your, where your left subclavian originates from. So that is your kind of type A type B. It's really important to remember A is for ascending, that's how I remember it. And depending on the type of aortic dissection uh influences the way in which you manage it. So if it's type A, um you can use surgical management. So you want to control the BP. So keeping it low, 100 to 100 and 20 just to prevent kind of bleeding. Um but you can introduce a prosthetic tube graft to prevent further tearing and dissection. So you can do it through an open approach or an endovascular repair approach. And then with the type B, you tend not to do surgery unless it's complicated. So for example, it's a, there's a rupture or there's a perfusion issue. So typically, what we do is give IV anti hypertensives like labetalol a little bit stronger and these patients will be in itu and we kind of reduce their systolic BP um a bit more aggressively to prevent the progression of the dissection. So, pretty much everything you need to know about aortic dissections um and then talk about uh abdominal aortic aneurysm. So AAA um a true aneurysm involves all layers of the vessel. So that's classic M CQ question is how can you define a true aneurysm versus a pseudoaneurysm? And risk factors are age. Um males versus females, males are more likely to get AAA, which is why they're screened, hypertension, smoking, diabetes, family history, all your typical vascular risk factors and then um Marfan's disease as well. So, connective tissue disease um makes you more likely, which makes sense because then your uh the connective tissue in your um aorta wall is more likely to dilate and stretch. Um it's usually asymptomatic, which is why they started screening people because often people don't seek help if they have an aneurysm. So they don't know it's there until it's too late, which is basically when it ruptures and you get pain in your abdomen and in your back and you become hemodynamically unstable. So, the screening program is another sq question favorite. So, always remember, um, this is in 75 year olds and males and it's done once and if they find a small aneurysm, um then if it's less than three centimeters, there's no action and you don't need to be screened. Again. If it's between 3 to 4.4 it's considered small. Um And you'd be screened yearly to monitor growth um if it's medium, so 4.5 to 5.4 then it's three monthly screening. Um And if it's large, so it's over 5.5 centimeters, then you need an urgent referral within two weeks. And also if it's rapidly growing. So for example, it's greater than a centimeter in a year, then that would also warrant a rapid referral. Great. So yeah, ultrasound is our main modality to image aortic aneurysms um can also use CT angiograms and MRI angiograms and not to diagnose but to help plan any operations and you repair if it's large basically, or it's rapidly growing or it's symptomatic. So you can either use an endovascular approach. So you pass a graft through the femoral vessel into the aorta and that helps kind of line the aorta or you can suture a graft in through an open approach. So the these are ways to kind of protect an aneurysm from bursting and say blood flows along the graft rather than flows into the aneurysm. And what do we do if it's ruptured? So, unfortunately, because of how severely hemodynamically unstable they get there is a 50% mortality in these patients before they even reach hospital. Um So they're very hypertensive, they're in a lot of shock. You want to avoid aggressive fluid replacement, which is what is intuitive when someone has kind of hypertension and low BP. But you want to avoid pushing the BP up too far because it would result in further bleeding. So you want to aim for a systolic of 90 millimeters of mercury and then management is emergency surgery to try to realign the aorta fix the rupture. Um So that comes to the end of the talk. So before we wrap up and finish, I just wanted to talk about um tips for the o and how to tackle the arterial and venous exams. Um To be honest, they're both quite straightforward exams. I think a lot of um, people get worried about these exams because they don't practice them that often when in reality, they're actually too very short and mostly straightforward exams. So with an the exam just think about the location of your arteries So where are the landmarks where you can feel the arteries and that will help you just guide you through um top to toe about the arteries. So, basically, just inspecting for signs of arterial disease palpate. Um So temperature tells you perfusion if it's warm and well perfused cap refill time and sensation because when you have poor blood supply, you start to lose some of that neurological sensation. Um and then just work through your pulses from top to toe. So, radial pulse, brachial pulse, um carotid and then your aorta femoral popliteal, behind your knees, your fetus and your posterior tibial. So these last two are the hardest to feel for um just because they're so distal um and the position is a bit trickier. So just included diagrams to help you find it. But if you ask the patient to point their big toe to the sky, and then you can find the dorsalis pedis quite easily kind of next to the ligament. Um and the posterior tibial is just um under kind of your um kind of medial malleolus. So just a little bit under and more posteriorly and then have a listen. So Stevie auscultate, the aorta and the renal arteries. So a couple of centimeters either side of the midline and in the groin and the femoral artery to look for any bruise. Um and then to complete you want to do a full cardiovascular exam, um full neurological exam in the lower limb. And then you can also ask about claudication distance, do A BPI and think about it. And then there's a few special tests you can do. So there's Berger's angle. So when the patient's lying, supine, you can raise their legs straight and the ang you raise it slowly and the angle in which it becomes white is the angle in which it loses its blood supply. So the smaller the angle, the greater the arterial disease. Um so you don't have to lift it by much and it's already lost its blood supply which shows um severe arterial disease and the Buerger's test. Um So moving on from finding the angle after you've found the angle, you swing the leg off the bed. Um So they're sat up and you hang it down and this test is positive if you get that reactive hyperemia. So that um the leg becomes purple, red and painful. So this is also just a sign of arterial disease and call it bergers test positive. Um So yeah, it's really quite straightforward with arterial exams. You just want to feel generally. Are they warm and well perfused? Feel all the pulses, listen for any bruise and when you're inspecting signs for arterial disease, so look at the color. Is it pale? Is it mottled? Is there any tissue loss and gangrene? Are there any ulcers? Um and is there any hair loss and shiny skin, which is a sign of peripheral arterial disease? Great. And then the last part is um the venous exam again, also quite a straightforward exam. So looking for signs of chronic venous disease. So, um lipodermatosclerosis, urine ver champagne bottle, venous eczema, venous ulcers in the gator region, edema varicose veins, all those things we've talked about so far today and then you just wanna have a look and inspect and then palpate along the course of the veins. So I've included a picture just to help, but you wanna feel along the long saphenous veins. So it runs up the medial aspect of your leg to join the femoral vein at the saf fe junction. And then you've got your short saphenous vein which runs posteriorly behind the lateral malleolus and joins the popliteal vein. So it runs kind of the back of your calf and then your safal junction is um just below and natural to your pubic tubercle. Um And you might get a sino varix there. So, again, feeling for at the S FJ um and then asking the patient to cough, there might be a cough impulse if they do have a swelling there. Um You can also percuss. So if you feel the S FJ and tap on the long sac vein at the knee, um if there is a distended varicose vein, it will transmit and give a palpable impulse at your S FJ. Um And you can also auscultate any clues of veins. This might sound like a machinery murmur you might get some murmurs. If there's, for example, an arteriovenous fistula, then the special tests you can offer if the patients have obvious varicose veins. Um but it's unlikely you actually do them in an AY cos they can be quite uncomfortable for patients. Um So first of all, you've got your Trendelenburg test. So you lie the patient down and then you raise their legs straight to 45 degrees and then you can massage the veins to try and empty them. And then you apply pressure on your Saem junction and ask the patient to stand. And then if the varicose veins immediately re refill, that means your valve incompetence is below the S FJ. But if they only refill after you release the pressure from the S FJ, this means your valve incompetence is at the level of the S FJ and that's a positive test. So tourniquet test is really similar. Um But what you do is you apply a tourniquet to your proximal thigh. Um And then you ask the patient to stand if they refill with the tourniquet on. It means the valve and competence is below the level of the tourniquet. And then you can keep applying the tourniquet more and more distally lower down until the veins don't rapidly refill. And then you can find your level of valve and competence that way. And then to complete your venous exam. Think about other things you might want to know about the patient. So, doing an A BPI or an arterial exam, look for a contraindication to compression stockings. Also think about some imaging like venous dupl and a Doppler ultrasound. So that concludes um this vascular surgery talk. I hope you guys have found it useful. I know we've covered a lot in the past hour, but hopefully it was um relevant to your upcoming exams and try to talk through a few cases and that will help you approach your MC Qs, not thinking just about vascular pathology, but other things that we've talked about today, like neurological pathologies and orthopedic pathologies, um because it's really important to cast a wide differential in an M when approaching an M CQ. So I'd really appreciate if you could um scan this QR code and give some feedback. I will also try to put um the feedback form link in the chat for those of you who are struggling with the QR Code. Um This talk is part of our final year series. Um We've done a whole host of talks covering all the essential topics for medicine and surgery for final years. Um We've got our next talk will be this Thursday. They tend to be Monday and Thursdays at 7 p.m. and just register through med all as usual. And there'll be a talk on Psychiatry on Thursday. As always, if you've got any questions, please feel free to email. Um, final year at mind the bleep.com and I can pick up your, um, emails and answer any questions that you might have. But otherwise I hope you guys have enjoyed the talk. And um, yes, this, well, this was recorded. I'll upload it to me afterwards and hopefully to youtube and once we've figured out the technical difficulties. But yeah, thank you all so much for coming. I'm glad um you found it useful. Um, so good. Oh, we'll leave it there. Thank you very much everyone.