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Ok. Hello. Hi, welcome. I think we'll just give it a few minutes, um, for people to come in. Mhm. Yeah. Ok. So I can't see my screen, um, at all I can see is the presentation. Um, so I can't tip anyone else there and we've got 1234. Yeah, we've got five people waiting. Um, ok. That's why we can give you a few moments. Yeah. Ok. 241. Oh, no times. Right. No. Yeah. Ok. Ok. Yeah, I guess, should we, uh, introduce ourselves? Maybe he started and see if people join afterwards. Yeah. Amazing. Ok. Um, so when would you like to go ahead? Yeah. Hi, everyone. Uh, my name is Ramon. Uh, I'm enough to, uh, currently working in a city hospital. Um, I'm currently on cardiothoracic surgery. Um, I guess my, some of my interests are mainly, uh, medical but II do love vascular surgery and that's why, uh, I wanted to get involved in this, uh, session. Amazing. And, uh, my name is Shay. I'm one of another f two also working in Nottingham. Um, uh, I'm currently on my academic block, um, and my interests are in anesthetics. Um, you know, and, uh, you know, it's still relevant to surgeries, which is why I'm also interested in this, um, er, in this group as well. And we are, uh, along with, uh, another eight of us are teaching up front here. So we're a group of um, foundation doctors and above that are um, creating a teaching series for finding your medical students, um, for revision, uh to help with, um, exam prep and to help prepare for F one. So we'll run a um a six month uh long teaching series. So we'll cover it surgery for eight, for eight weeks and then uh medicine and then also M and A as well. So to help prepare for you, prepare you for the future and then with the exams. So the first session we're doing is on vascular surgery. Um So, um myself and Ramon will do half and half of this. So if I just begin, uh and hopefully you can always see my screen. Uh um So the first part is on peripheral disease. So effectively, um if you look at the normal venous drainage system, um the veins drain blood from the peripheral organs um towards the heart. Uh it grows from the su superficial veins and they're connected via perfer veins and then they go into the deep veins. So there's an image over here um that shows the normal flow of blood. Um and then in terms of the muscles, so the muscles especially in like the legs, um, the muscles, er, the, the calf muscles will act as a venous pump. So when they contract, they squeeze the blood from the deep veins um up towards the heart. So, in and so that's aiding the venous return. Um, and then the veins have one way valve, so they prevent backflow. However, in PVD, um you get venous incompetence uh due to issues and defects within the vein or the valves. So things that can happen is obstruction. So by a thrombus, it's a blood clot or an embolus, uh or you can get weak or dilated veins or you can have insufficiency. And this all typically happens around the legs. Uh although it can happen elsewhere in the peripheries and most commonly you find them in the legs which we'll be talking a lot about the legs, the lower extremities. So the risk factors need to look out for um for people who have um peripheral venous diseases of um of females if they age. Um over 5060. Uh pregnancy also increases the risk of developing peripheral venous diseases if they're immobile their sedentary lifestyle, um or of fatal prolonged standing. Um and then also obesity. So you get chronic venous insufficiency when there's damage or weakened veins or valves. Um and this is due to uh due to DVTs that can cause this or varicose veins. Um and also leg injuries. Uh what happens is when there's inadequate, uh inadequate venous return due to um insufficient veins. Uh Do you get pooling of blood, um which leads to increased venous pressure. So you get venous hypertension. Um, when this happens, the, the veins, um they, they dilate, they er expand and then it uh allows it forces the fluid and the red blood cells to leak out of the capillaries, um and the veins and then they cause edema and inflammation. Um So the signs and symptoms, the main ones are pain, swelling and heaviness or that sensation. So, complications that you can also look out for are venous ulcers, er, which typically occur above the medial malleolus. Um and we'll talk a little bit more about ulcers in a bit. So I'll skip that for now. Um another, another complication to look out for is cellulitis. So when you get chronic inflammation, um uh and skin breakdown in the area, it can uh it can make the area more prone to bacterial infections. So signs to look out for would be a patient that presents with fever if they got a red or hot or tender leg. Um and they've got a spreading infection. So if you market demarcate an area with a, with a permanent pen and you can see if the infection is spreading. Um So that's another complication to look out for. Uh and you treat this with antibiotics and then, so skin changes, which you might get asked a lot about in the MC Qs or single best answer questions for your exams, um, to look out for the, in the gator area, which is the area between the mid calf, like the shins here. Um, and then above the ankles and so here you get sort of four things that you might get asked about. Which one of them is hematogen staining. Er, so that is one of the er, breakdown products of red blood cells when they leak into the tissues. Um and they break down um they uh the iron sort of leaks out and that stains um the tissues causing a brownish reddish discoloration. Um You can also get venous eczema um which is due to the chronic pooling of the blood. Um and the chronic inflammation that occurs, which leads to sort of eczema like you get in other parts of the body. Um but just sort of around this area. So you get itchy, dry, flaky red, cracked skin. Uh you can also get um atrophy blanches. So that's um smooth white, er, scar tissue um due to poor circulation in that area. And that, that's something you can also see which you can see in the middle picture here around this leg, which also shows um the venous eczema sometimes also called stasis dermatitis. Um And then, and then you can also get lipodermatosclerosis, which you may have seen a lot or heard about in medical school. Um So what happens is the uh chronic pulling and the um, inflammation causes the tissue to become fibrotic and loss of scarring. So then the skin becomes really tender, tight and hard. Um, and then you get this inverted champagne bottle appearance, so you get this narrow neck and then this sort of swelling around there. Um, so that's something else that you can look out for and also on the vascular wards. Um you'll see quite a few people with these as well. Er, So this third picture is lipodermatosclerosis, er venous eczema and um atrophy blanche and this is the hemogen staining. So how do you investigate and manage this? So, investigations, you do a duplex, ultrasound. Um So duplex has got two parts to where the Doppler part and then the B mode. So the Doppler part is basically showing the flow um of the flow of blood and the direction of the blood flow. Um And then the B mode sort of brightness mode is basically what shows if that the structure of it looking at the structure of the veins, if there's any clots, um the size and shape of the vein. Um you can also do a vy so you inject contrast and then you use X ray images to look for any obstruction. Um You can also do ad dimer if you're suspecting a DVT or a PE because a lot of the legs um that you end up seeing there's a different other differentials for um what they look like as well. So such as red um or hot and uh you can look for other things such as DVT or PE um here in management. Um it's broadly very much conservative. So the things you need to um sort of manage patients for and you know, educate them about is skin care. So if they, especially if they've got um eczema giving them ali or steroids, um and if they got dermato dermato microderma sclerosis, um then you can give them stronger um steroids as well if they've got flares, uh other things are to improve the venous return um back to the heart. So, uh you um talk about weight loss, increasing physical activity, uh let get the legs moving and then elevate the legs above the heart. So it improves venous return and then also compression stockings and tubular um er support bandages. Um uh which will uh uh which will help to also improve the venous return. Um However, before you put them on you to make sure they don't, they don't have peripheral arterial disease or other arterial diseases. Um because if you compress, if you compress their legs, then that will effectively reduce the blood flow to the area. So if they've already got arterial disease, it will only worsen them. So make sure you do an A BPI first. Um We'll talk about that as well later on. Um And then you just manage complications if they get them. So, wound care, if they've got any ulcers, um, antibiotics if they've got cellulitis and, and reduce it for any pain that they've got. Er, and then surgical, er, it's not very commonly done but you can do a venous bypass or repair or removal of the affected veins. So we'll talk about ulcers now. Um, so this has come up a lot in medical school. Um, and, uh, I've only included venous and arterial ones just so we can differentiate between them because they're the ones that we'll talk about in vascular surgery. Um, so we'll start with the venous ones. They're found um between the lower calf and the medial malleola so effectively in the gator region. Uh So they're shallower and they tend to be flat. Um They, they're quite fluffy with ganglion tissue and you can see quite a lot of exudate on them, so moderate to severe exudate, like you see in the picture, the yellow yellowness. Um And then you can get the, the features of chronic venous insufficiency such as he staining the thickening. Um, and the fibrosis that you get in lipodermatosclerosis, you get the eczema and the itchy skin, um, and you get normal cap refill and the management of that is um, compression stockings, basically, um, elevating the legs is basically just to improve the venous return. Um And then for arterial, they're normally found in areas where you might hit yourself. So on the bony prominences and then the tears in the feet. Um, they're more typically on electral malleolus as opposed to venous, which is the medial malleolus. Ok. And these ulcers are, you describe them in as punched out and deep? Um So if you see those words, you, um you can be quite confident in talking about arterial, um they're also irregularly shaped, you might get some necrotic tissue. So the black necrotic tissue that you see there. Um and there, there's not much egg to unless obviously there's an infection. Um the skin might be really cool, er, it might be white, you might have weak or absent um pulses um on examination and it might be gangrenous and you'll also get delayed cap refill due to um reduced blood flow to the area. Uh treatment for this uh is just revascularizing. Um yeah, revascularizing the patients. Um and then managing risk factors for atherosclerosis. Um and then giving them active platelets such as aspirin and clopidogrel. And there's an images um over here to show them both. Uh So we'll move on to varicose veins, which is another form of peripheral um venous disease. Um So these are distended, superficial veins, uh measuring uh over three millimeters in diameter and this happens due to the um incompetence in the perforating valves. Uh So these are the veins that communicate between the superficial and then and the deep. Um So if uh if they're not working properly, it means the blood doesn't er get drained from the deep ones and it back flows and overloads into the superficial veins. So then you get these tortuous um distended veins in the superficial er veins which um you end up seeing on patients. Uh and risk factors for these are similar to um or peripheral venous diseases such as age. If you have a family history of varicose veins, more likely to get varicose veins. If you're female pregnancy also increases it, obesity again, prolong standing. Uh and then DVT also because it damages the valves which effectively will lead to um uh poor drainage signs and symptoms. So we can see a picture of these tortuous engorged veins here. There they go there. Um So they're usually very symptom, um asymptomatic. Um However, patients can present with them or they be maybe concerned about them. Um May, they may complain of a heavy or dragging sensation in their legs. Um It can be itchy or it can burn at times. Um and they might complain of some cramps, restlessness and then, um they might have signs of other chronic venous insufficiency such as skin changes or ulcers that we talked about earlier and then investigations. Uh you do a duplex ultrasound. Uh So you look at the structure of the vein, the blood flow and then reflux. So whether the uh the the valves are um not working properly, so then the blood reflux is into the superficial of the deep veins. You can do some special tests. So you may get asked about these. You may not, um, in your exams but they're also, um, relevant for you working on the vascular wards. Um, you can do a tap test. So, um, the cough test and the dereg test, which I won't go into because we haven't got, um, too much time. Uh, but you can have a read of this as your, um, at your own pleasure. We can, uh, and in terms of management, uh conservative management includes um confession stockings, uh and then lifestyle modifications similar to what we talked about in chronic venous insufficiency. So, leg, leg elevation exile and weight management. Um and then if you've got symptomatic varicose veins or they're complicated varicose veins, then you can do interventional. So the first thing you can do is endothermal ablation. So you use heat or um radiofrequency ablation er to close off the um to close off those veins, you can do ultrasound guided foam sero therapy, which is you inject foam, the er and then this will help to er close off the, close off the vein and collapse it. Uh Other thing you can do is surgical, so you ligate and you strip the vein so you tie it off and then you remove it and then we'll go on to deep vein thrombosis. Um So this is when a blood clot forms in the deep veins, um you can have provoked E VT S or you can get unprovoked. So provoked ones are transient um are due to transient risk factors, but if you remove them, then the risk of them goes away. Um So this is things like immobility following motor surgery. Um If you had trauma to the veins, um pregnancy also increases the risk of DVT and then uh estrogen containing compounds such as the combined. Um OK, combined with and also dehydration as well. Uh And so these are transient risk factors. Uh It is important for management um or how you manage uh DVTs and then unprovoked uh are due to persistent risk factors or things that you can't really remove so easily. Um So these have an increased risk of recurrence due to that fact. So things like active cancer uh and then thrombophilia, so thrombophilia, things like uh antithrombin three deficiency and antiphospholipid syndrome, which you might get asked about a lot in the exams. I think they quite like that as well. Um uh and this the probability of getting a thrombosis um uh is explained in little bit by bronchos triad. So that the factors that contribute to thrombosis are things like endothelial damage. Um If the blood is poor, then it doesn't move anywhere. So the stasis and um hypercoagulable states. So, such as in pregnancy or cancer and the risk factors here are quite a few of them. Um So if you've had a previous VT E, so, uh previous pe or an embolism, um er, or a DVT before then you're more likely to get a DVT, er, if you're age over 60 if you've been immobile. So, a lot of questions we'll talk about if you've been a long haul flight, um, this will also increase your, um, chance of getting, uh, a deep vein thrombosis because the circulation isn't there and your legs or smoking also increases the risk as well. Um, because it damages the blood vessels. Uh, and then if your O BS are overweight, male sex, um and then heart failure, acute illness and then there's also other vas um vascular uh, so vasculitis type conditions. So, conditions such as vasculitis, IBD or SL E, that can also um increase that risk as well. And if you've also got varicose veins, you're more likely to get DVTs as well. So, signs and symptoms to look out for, er, usually unilateral. So if you end up getting like the bilateral, er, if you think is a bilateral DVT, it's very, very, very unlikely, I guess it can happen. Um, but you might look at other differentials for it. So it's typically unilateral, it's localized a throbbing pain, it's very tender. Um, you can get calf swelling, leg swelling, um and then skin changes. So, uh you can get uh edematous leg redness warmth. So, inflammatory changes basically. And then you can also get the stent of superficial veins and then for investigations, then you've all heard of these before. So well, school. So you do a two level DVT. Well, school and this is, uh, what assesses the probability of having a DVT if you've got, uh, if you've got a score of two or more, um, then a DVT is likely, uh, and if it's one or less then it's unlikely. So the, there's a list of, um, a combination of signs and symptoms as well as exam findings on examination that give you one or one point and then, and then you, er minus two points. If there's another diagnosis, that's as likely as DVT or more likely than DVT. Um So if you do, if you follow the diagram here, you do a DVT while school. So if a DVT is likely you do an ultrasound scan, so the proximal leg vein ultrasound within four hours, if you're unable to do that because the ultrasound is what's diagnostic. If you're unable to do that, you do a DD dimer in the meantime, and then you give um treatment dose anticoagulation and then you get the ultrasound within 24 hours. Er, and then if the, if it ends up being the ddimer, er D, if you end up finding that the D dimer is negative, um then you can stop the coagulation and then if you find the ultrasound scan doesn't show any um any, doesn't show any DVT, then you can also stop the coagulation as well. If you find the D, the DVT is unlikely using the, then you can do ad dimer with the result within four hours. And then you do an ultrasound within, within four hours as well. If it's positive, if the D dimer is positive, and then you do the same thing, give them um interim therapeutic anticoagulation and do the ultrasound within 24 hours to diagnose the DVT. Uh So you give, you give anticoagulation um to uh to break off that clot. Um And you can do baseline bloods, um such as F PC using these LFT S and then a baseline clotting screen as well. Um But you uh you shouldn't delay giving the co coagulation just to do these blocks. So, in terms of management, um so initial management. So this is the in the, in the therapeutic anticoagulation um in the interim that you give. So the first line is a DOAC um or you can give a low molecular weight heparin for five days and then you follow that with the Vatran or Noxaben. Alternatively, if they can't have a DOAC, then you can give them low molecular weight Heparin or Warfarin. Um So low, low molecular weight Heparin is used in pregnancy and then Warfarin is used as a first line for um antiphospholipid syndrome. And you also get that for five days. Er and then you uh if you do have a DVT, you go on to long term anticoagulation. So again, the first line is a DOAC. Um and then you can also also have low merle weight, heparin or Warfarin. So, as we talked about earlier, the provoked risk factors are the transient ones, the ones that you can remove and uh it will reduce the risk of having it again. If you have those, then it's a three month, an anticoagulation regime that you go on and then you can review it to with most people will tend to stop it after that. If you've got cancer, it's a six month, then a review and if it's unprovoked, um so things like a thrombophilia, um then you can give them for six months. Um and then longer if the um if the risk factors still persist. Uh And then another thing you can do is give them graduated compression stockings as well. Um And then other complication that you need to look out for is very important is for, is pe so this is effectively even a blood clot or you're getting a DVT if this s and it travels to the pulmonary arteries. Um And then here you get the patients sent in with um sudden onset of shortness of breath, chest pain, palpitations and you get signs of shock. If you see this, then you need to order a CTPA or if that's contraindicated. If they've got allergy to contrast or they're pregnant, you can do a VQ scan and then uh the management of that is anticoagulation, supportive care such as oxygen. And then um the treatment options, thrombolytic, giving them something they can order place if they've got a massive P OK. So now we move on from the sort of venous side and go on to arterial diseases. So these are slow and progressive um disorders of the blood due to the narrowing or occlusion um that you can see in this of the image. Um the lumen was nice and uh patent in the top one. And then due to the atherosclerotic disease, it's um this decease in size due to the plaque build up. It commonly affects the lower limbs. Um So the risk factors for atherosclerosis, I'm sure you know all of this um by now, but it's uh increasing age, male sex, um smoking hypertension dyslipidemia. So that's when you get more of the um the no uh the LDL non LDL and less of the HDL cholesterol um in the blood and then also diabetes melitis. So we're talking about limb claudication now. So this is sort of intermittent claudication, intermittent pain. So it's a muscle pain and cramping uh that people describe and it's brought on by activity and it's reproducible. So, if uh so patients will often be able to tell you their claudication distance, so the distance they can walk or do activity before they get the muscle pain and cramping. Uh and then, and then when they rest for a period of time, the pain goes away. So it's a bit like angina um in that sense. Uh And then, and then the, the area that they have the pain, it also indicates where the site of occlusion is, um, or the narrowing is. So, if you get sort of hip and, and buttock pain, then you, it's a suggestion that it's the narrowing is in the aorta or the ileac area and then so on and so forth. Uh, for investigations for this, you do. So, bedside bloods, uh, full blood count, um, using these, uh, to look for, um, any to look for renal function or ATI LFT S HBA1C for diabetes, look at um, uh, the lipid profile. Um, and then you do an ECG uh to look at the heart, uh, and your heart pathology and then using the ankle brachial pressure index. Um, so effectively, this is putting a, a BP cuff around the ankles to swell the ankles and then also, um, break your area like normal. Um, and then you do the ankle systolic divided by the brachy systolic to get a number. So if it's normal, it is between one and 1.4. So if you get something like, um, naught 0.9 or under, it suggests that there's elements of peripheral arterial diseases, er, if it's under naught 0.5 suggests there's chronic limb threatening ischemia, which we'll talk about, um, just in a bit and then if you've got over, uh, if you got over 1.4 it suggests the arteries are stiff. So things like calcification another thing you can do is so duplex ultrasound um to look at the arteries. So, as I said earlier, you've got the 222 modes. So Doppler and the BB mode. Um so one look at the speed and direction of flow and the other one visualizes the structure and the shape. Uh and then what else you can do is angiography for this. So that's effectively injecting um contrast er and taking images. So you can do a CT angio um magnetic residence angio or something called AD sa. So digital subtraction technique. So you inject inject contrast and then you take X ray images uh and the images are just the er they remove some of the background noise. So you can see er and visualize the vessels a bit better the management of them. Uh So I'd like to split them up into uh conservative medical and surgical. Um So when someone's got lymph aic medication, so you need to manage the risk factors. So, smoking cessation, um advice, diet and weight loss and there's also supervised exercise therapy, which is breast line um for patients. Uh and, and patients that also advise that if they walk through the claudication distance, it helps to form new collateral, new collateral vessels as well. Um So this is a very important thing that you and a lot of management for limbic medication is mainly conservative and medical. So these are very important. So, in terms of medical, uh you start them antiplatelet therapy. So, aspirin um and clopidogrel, uh first line one or the other. And then you gave a statin for lowering the cholesterol. Uh And then you also uh optimize your BP as well. And surgical, it's only if they've got really disabling claudication and it's affecting the daily function. So you can do endovascular uh endovascularly, you can do angioplasty and stenting. So, angioplasty is basically inject uh it's putting a wire, um uh wi wiring a balloon down to the area and in facing that balloon um to widen that lumen and then a stent is basically a thin mesh, um steel mesh, er, and then you leave that in there in that widened lumen. Um and then that will keep that area patent and open. So the blood can flow easy there. And then you can also do bypass surgery, which is open surgery to bypass the area of occlusion or narrowing. Uh And then the last thing I'll talk about today is chronic, limb threatening ischemia. So, um peripheral arterial disease is on a spectrum. So you get intermittent claudication. Um and then if that's left untreated, it can progress to chronic limb threatening ischemia. Um So, signs and symptoms to er, signs and symptoms to look out for uh uh rest pain or night pain. And this has to be um over two week history for it to be called chronic. So if uh questions, you might get are patients um complaining of night pain. Um And I think that's one of the key sign. As soon as you see that, I think you can just start to think about chronic lymph threatening ischemia. Um on examination, they'll have weak or absent lymph pulses, they will have non healing wounds or ulcers, potentially um due to poor circulation to the area. So poor healing after injury, um you can get uh tissue necrosis and gangrene. So just the, so it typically affects the sort of the toes. So they all look blackened, um and very necrotic and skin changes um of the leg or, or the area. So, discoloration. So they might have a dark or purply blue area. Um the color to it, if they're shiny or scaly or they, they might feel cold investigations very much the same as for lymph claudication. You do your best side bloods, ecg A BPI um Duplex ultrasound to visualize um the arteries and then the angio to have a more in depth look at them and then, and then conservative management is again the same thing. Um So, so to reduce the risk factors and then also because you've got chronic lymph in ischemia, a lot of these people um will, will end up having ulcers. So you have to make sure um you take proper care of wounds. So to prevent infection and gangrene from developing uh medical, the same. So, antiplatelet therapy with aspirin and clopidogrel. Um and then a statin and then controlling their BP and then surgical. The important thing is to revascularise within two weeks. Otherwise, it, it can get much worse and you might have to end up doing the amputation. So the aim is to revascularise within two weeks. Uh So do an endovascular procedure. So, angioplasty and stenting. So balloon and stent uh and then you can do a bypass. The important thing um with a bypass is to make sure that whatever vein um you're using to bypass has got a good inflow above it and then good outflow to wherever you're attaching it to. Um and this is usually done with the long pass eus vein and the outcomes, the five outcomes are better with using um autologous um sort of human veins rather than prosthetic vein. Uh And then if the above don't work or they're, they're contraindicated to the endovascular bypass, then you could um then you can go on to amputation. Er And if this is if they've got a significant disease and there's a non salvageable limb and this is why it's really important to do a CT um an angiography to visualize them before you do surgery. So you can see exactly where you're going. Ok. And I'll move uh hand it over to my, all right guys. So we're gonna keep going with the arterial theme. Um So we're gonna talk about acute limb ischemia. Next. Um So acute limb ischemia is a sudden decrease in arterial perfusion to, to the leg. Um So it uh progress, it, it, it could progress, it could progress to advanced limb ischemia and threaten the limb viability. Um uh the reported mortality for that or if it, if it gets to, that is between 20 to 50%. Um So it's quite serious. Um It's really important uh to get on treating these patients as quickly as possible. Um For signs and symptoms, they usually present with the six ps. So that's pain pallor, pulselessness, perishing cold, paraesthesia and paralysis. Uh paralysis is the date sign. Um And then it is, it is documented that parathesia is, is considered an early sign. Um And so a lot of people that present with paresthesia, high suspicion of acute limb ischemia. So you'd, you'd wanna start treatment as soon as possible. Um Sure. Do you mind? Thank you. Um And so the, the there's many causes. Yeah. Can you go to the next one? Thank you. Um So there's many causes of uh acute and ischemia. Um So it could be within a lu within the lumen and that presents with an embolus. Um So these, these patients tend to have a more acute presentation uh compared to people that present with thrombus uh or tr uh with thrombus. Uh just uh just like how she um discussed chronic limb ischemia. Uh These people can progress to, to acute limb ischemia. Um And then they could also uh present with trauma or dissection. Um They could also present um after a tight bandage or casts or tourniquets if they, especially if they have the history of chronic limb ischemia. Um You could also see acute limb ischemia in burns patients and in compartment syndrome. Um and then to investigate patients with acute and ischemia, you do a full set of bloods. Um uh you'd look at their clotting, which is important cause a lot of these people are more prone to, to clots. If they, if they um have a condition that puts them in a hypercoagulable state, uh you would do a troponin to exclude an M I that could have happened uh which would have caused uh thrombus which uh which would travel later on to, to the lower limbs and, and, and cause the acute limb ischemia. You could also perform a group and save um in case these patients have to go into, into theater. Um And again, uh you would do a duplex ultrasound to, to look at the narrowings and uh an angiography. And what you can see on the right is a CTA that shows narrowing of the vessel. And then uh you would also investigate for a source of this vessel um uh of this um of this embolus. Um If, if it's a very acute, um if it's a very acute presentation, uh you perform act aorta uh to see if they've had uh thoracic aneurysms, which could be um a slight uh you perform an echo to see valvular heart pathologies. Um And again, a thrombophilia scream. Um And so, uh acute limb ischemia is uh is classified by the Rutherford classification. Um I'm, I'm not gonna go through them again. Uh I'll let you guys do that on your own time. Um So it's 1 to 31 being, uh the limb is viable and not immediately threatened and three being um uh I reversibly damaged and uh you'd have sensory loss that is profound paralysis. Um And you'll get um inaudible uh Doppler signs for arterial uh arterial and venous blood flow and then management. Um So people that present with uh Rutherford classification type three sometimes are palliative. Um That's if uh the surgeon believes that the patient wouldn't survive an amputation because an amputation carries um cardiovascular risks as well. Um So for medical management, um anticoagulation with unfractionated heparin, um it's uh it's, it's a great choice because it has a short half life. Um And so if the patient needs to go into surgery as well, um uh they wouldn't be at in CRE increased risk of uh bleeding. So you'd give them a board of 5000 units and then you follow it up with the maintenance infusion. Um And then you could also do intra arterial uh thrombolysis with alte uh and then for surgical options, embolectomy, um again, using a balloon to, to kind of scrape out the vessel or aspirating the, the uh aspirating the, the thrombus uh or the embolus. And then last resort would be an amputation moving on to compartment syndrome. Uh So, compartment syndrome is uh an increased pressure within a compartment. Um And so this happens when the, when the pressure within the compartment exceeds the perfusion pressure, uh this restricts the blood flow um and it causes pain out of proportion to the injury. Usually. Um uh people that are prone to it are people with already reduced uh blood flow uh from acute limb ischemia or chronic limb ischemia. Um So it causes ischemia to the muscle group which causes the muscle group to, to, to kind of survive on anaerobic respiration, uh which uh produces oxidative species. We rather causing causes further damage. Um You get increased uh capillary permeability which causes uh protein leak into the extracellular fluid edema and again, more pressure. Um And then after that, um uh i it just leads to to more mo more reduction and worsening of symptoms. Um And so sign and symptoms, pain out of proportion to the injury. Um You'd suspect that with someone who's uh who's uh requirement for analgesia keeps going up and it's just not helping. Um uh you could get pain on pass flexion or stretch. Um You'd have a tense and firm uh lower limb and then the late signs would be the five ps again, pulse and pallor pas and paralysis and then investigation. Um it's largely clinical based on symptoms, um history of, of fracture, soft tissue injury. Um And then if you're still uncertain about the, the, the diagnosis, uh you can do an intracompartmental pressure. Um You usually see a pressure that's less than 10 milli uh millimoles mercury. Um if the difference in pressure between the diastolic BP and the intracompartmental pressure is less than 30 that means there's ade inadequate perfusion and that leads to, to ischemia. Um And the, the smaller the, the, the, the lower, the, the the difference in pressure is means the, the pressure within the compartment is higher. Um You could also uh look at CK in the bloods. Um It's a nonspecific marker but it could direct you in the right into the right to the towards the right direction. Um And then you could perform a urinalysis uh where you'd look for myoglobinuria, which is produced with muscle breakdown due to the uh schema and the management is time critical. Um uh You, you, you there, there is some um there is some controversy with it about the time where you get um muscle uh damage, permanent muscle damage, but you get nerve damage within 4 to 6 hours of ischemia. Um And the, the management, the definitive definitive management for um compartment syndrome is a fasciotomy. Um So it's a surgical incision uh within the compartment uh to decompress it and relieve the pressure. Um And then you would leave the wound open until the swelling subsides before causing it. Um And then you, you, you have to make sure that the uh incision is long enough to, to decompress of the, the entire involved uh compartment. All right. And we're gonna move on to carotid stenosis. Uh So, carotid stenosis is uh narrowing in the carotid arteries. It's usually secondary to um atherosclerosis which is a buildup of uh of a plaque uh that reduces the size of the, of the lumen. Um So, a consequence of this atherosclerosis is a part of the plague could break off and cause an embolic stroke. Um Some of the risk factors, they're the same, they're quite similar to the ones that, that she um that she explained. Um So it's age, male sex, uh smoking, you see a 10 time increase in the risk of carotid artery stenosis, um hypertension, poor diet, high cholesterol and diabetes. So, um the majority of these patients are asymptomatic. Um So you would usually uh they, they would usually pre uh it's either an incidental finding and if the patient presents with a stroke, then you would scan their carotids and, and find uh the, the stenosis. Uh you could also hear a carotid bruit um in the carotids uh because of tur turbulent blood flow. That's uh that's uh that's caused because of the atherosclerosis. Uh and then for diagnosis, uh carotid ultrasound initially and then act or mmr angiogram to an uh to assess the stenosis in more detail. So it's classified on severity of obstruction. So it's, it's mild if there's less than 50% reduction in the diameter of the vessel moderate when it's 50 to 69% and severe when it's more than 70% reduction for management. Uh We could work on the modifiable risk factors. Um uh medical medical management is antiplatelets such as aspirin clopidogrel, statins. Uh and then you manage the comorbidities such as hypertension diabetes. And then uh surgical is usually for the more severe uh stenosis that's 70% stenosis or more. First line is carotid endarectomy. Uh where you scrape out the plaque from the uh the plaque from the, from the carotid itself. Um It carries a risk of uh stroke and nerve injury. And then on the right, you can see a uh a table of nerve uh nerve inju nerves that could potentially be injured and what uh side effects um or what complications can happen after injury. Um Angioplasty and stenting could also be done and that's an endovascular procedure. So, carotid dissection, uh carotid dissection uh could be spontaneous, it could be traumatic or idiopathic uh trauma could be major or minor uh major such as gunshot or a car accident. A minor could be just going to the chiropractor and with the manipulation, it can cause a tear in the intima. Um some of the risk factors uh are male sex. Uh uh connective tissue diseases, family history and people uh that are prone to migraines are, are also at high risk of carotid uh dissection. So the process is a tear in the intima. Uh This creates a false lumen uh and it forms a hematoma. Uh This hematoma could uh could form towards the intima or towards the advent adventitia. Um The uh the hematoma towards the intima could cause the narrowing. It could c could also cause narrowing to blood flow to the brain. Um It's a pseudoaneurysm because it only involves uh it doesn't involve all the all the layers of the, of the vessel. Um And then uh it could lead to a stroke uh because of reduced blood flow. Uh and uh an obstruction of the true lumen from the false lumen. Uh It could be a site for thrombus formation and if the vessel ruptures, it could cause uh subarachnoid hemorrhage. So, again, these patients are usually asymptomatic. It's usually uh an incidental finding. But then uh you would see it in a young patient uh with uh who comes in with a cerebrovascular accident. Um uh You get it from the, from the history of, of trauma to the to the neck. Um If they uh if they are more prone to it, if they are diagnosed with a connective tissue disease as well, and then investigation, you do act angio and you would see the flame sign uh as you can see on the right on the CT angio. Um And that shows um that the blood flow to, towards the brain is cut off. Um You could also do an Mr Angio or a DSA like check. Yes. All right. Uh And then for the management, it depends, uh if it's spontaneous or traumatic or traumatic and it also depends on if uh the internal carotid or external carotid is involved. The options are thrombolysis with al altipes, anticoagulation and antiplatelets and then endovascular stenting. And the last uh topic we're gonna cover is uh AAA. Uh So a AAA is a balloon like dilation of the abdominal aorta, that's more than three centimeters. Um And the range of uh normal abdominal aorta is between 1.4 and three centimeters. So, it's a trans uh uh inflammatory change. Uh You'd get uh abnormal collagen remodeling, loss of elastin and smooth muscle cells. Um And as a consequence of that, um aortic wall thinning and progressive expansion. Um uh it's primarily due to atherosclerosis that causes the injury which causes the abdominal collagen remodeling and so on. Um So the risk factors are being a male, uh the male to female ratio is 9 to 1. Um an age over 65 smoking, uh collagen and gin defects um or connective tissue diseases as well. Got you. So it's usually asymptomatic again. Um it's um non tender, postal mass. Um and then uh as a consequence of enlarging, uh you could get abdominal flank or back pain. Uh You could also uh get compression of the surrounding viscera. Um Some people present with an upper gi bleed uh because of an uh aortoenteric fistula. Uh And then obviously, you get the, the worst presentations uh with a rupture where you can have a syncope shock, a large pulsatile mass and sis uh So for screening in the UK, um it's offered to all men aged 65 and above in the UK with an ultrasound. Um And the rate of expansion is directly proportional to the, to the size. So the bigger the, the aneurysm, the, the big, the larger the rate of expansion is. Um so the uh the investigation of choice if someone is going for a surgery is a ct abdomen, uh ct aorta with, with contrast. Um And over here on the right, you've got the, you've got the plan for follow ups depending on the size of the aneurysm. And so management. Uh you, you'd, you'd go for surgical management if the size of the aneurysm is 5.5 or above. Uh or if there is an enlargement of more than 0.5 centimeters in six months or more than one centimeter in, in one year, uh or if the patient's symptomatic. Um So the options are either endovascular for, for patients not suitable for open surgery. Um And then it's uh it's preferred more in emergencies uh such as in ruptures or you could go for open repair. Ok. And that's the end of the conditions that we're talking about today. So we thought we'd spend the rest of the time doing a few MC Qs. So if you could put your answers in the chat, um, and then someone will say with the answers that everyone's put in. So the first question is that there's a 68 year old man close to the clinic with a non healing ulcer on his left leg. He reports that the ulcer has been present for about six months and has gradually worsened. Um He describes a heavy aching sensation in his legs which worsens when he stands for long periods of time and improves when he elevates his legs on examination. Um There's a shallow ulcer located in a medial aspect of his lower leg just above the ankle. The edges of the ulcer are irregular and the surrounding skin is darkened and rough. Um With evidence of hemosiderin deposits, the pulses are palpable though slightly diminished. Based on this presentation, which of the following findings would most help to differentiate a venous from an arterial ulcer. You could put the answer in the chat and then, and then my mom can say because I can't see the chat if he could say what the answer is that people have put down. Yeah, we've only got one response. So for OK, what was the, what was the response? Um So it was a pain that improves with like elevation. Amazing. That is the right answer. Um So the other answers are more likely to be arterial. So, er as arterial was punched out, um and you can get cooler skin, er, and then the ulceration that happens on pressure points. Um So if you go back to the sliding s um it, those describe arterial ones and then with elevation is it's the venous, so pain improves it. Leg elevation, so great. Um Number two, so a 57 year old woman presents to the emergency department with sudden onset severe pain in her left leg. Started about six hours ago. She reports numbness and inability to move her toes. Um On examination, her left leg is cold and pale with mottled skin below the knee. There's no palpable pulse in the femoral or the popliteal or pedal arteries on the affected side. Um Sensation is markedly reduced below the knee. So, based on the Releford classification, um which category best describes the severity of her condition. I don't, there's any answers, but I'll just move on to the answer. Answer is it's a two B. So um this is because uh she's got um uh she's got uh pain. She um there's weakness uh and there's so severe pain in her left leg. So she's got numbness and she can't move her toes. Um And then there's no palpable pulses. So it's A two B and the mom can read a 52 year old woman presents to clinic for two weeks after undergoing carotid artery dissection surgery on the right side. She reports new onset hoarseness and difficulty speaking. Uh also experiencing mild aspirations when swallowing liquids on physical exam. Uh she's got weak phonation and, and examination of the vocal cord shows right sided vocal cord paralysis, which nerve would be uh is most likely to be injured after her carotid dissection surgery. There we go. Pull on. Yeah. No. OK. So uh b every almost everyone answered. B um So B is the right answer. Um One person put um glossopharyngeal. So with glossopharyngeal, I, I'm assuming you probably put glossopharyngeal because of the mild aspiration when swallowing uh liquids, which is, which is a very good point. Um And the question is, is kind of pushing you guys to think more about the recurrent uh laryngeal nerve. Um With glossopharyngeal, you'd, you'd also lose the, the question most likely would also mention losing sensation in the, in the posterior uh two thirds of your, of your tongue. And the next question, 70 year old man with a history of hypertension smoking uh has a follow up for A AAA, it was previously measured at 4.7 in diameter and then with a repeat ultrasound, six months later shows that the aneurysm is expanded to 4 to 5.4. He remains asymptomatic with no abdominal pain or other complaints. His vital signs are stable and then based on the current guidelines. What's the next appropriate uh step in management? Yeah. All right. So again, almost everyone got the uh referred for surgical intervention. Um And so that would be because the, the aneurysm has expanded uh greater than uh 0.5 centimeters in a period of uh six months. And so at that point, we would refer the person uh to surgeons uh if it was uh less than point point five or less, then we would follow up again in three months. Amazing. So that's our references and then thank you very much for listening um to presentation. Does anyone have any questions? You're welcome to put them in the chat and we can answer in the chat and, but it can, sorry, I'm just gonna quickly check if there's anything on the, on the chart. Yeah, there's nothing really amazing. So, um so with the interest of time, so we finished the presentation, we'd be very, very grateful if we can do a feedback form. Um So we can help to improve um when we do our next sessions as well. So it would be very grateful if you do this and then you for the forming. Um You'll also get access to the slides, we can send that to you. Um If you put your email in there and then you'll also get a certificate um for your attendance of the session as well. Um So thank you very much for listening and next week, um there is a, um, a registrar who is going to be delivering the talk on cardiac surgery. So, we'd love to have you there. We'll um, we'll put the, um, invitations out on the Instagram and then there'll also be um, an event on the medical page as well. So come back here and then, uh, you can have access to that as well. So it would be great to see you again as well. Thank you very much. Thank you guys. Thank you. So, just leave that up there for a, for a few moments if anyone can complete that. And if you have any issues um with getting this um form, just let us know in the chat and we can send that to you on there as well. And if anyone has any questions, feel free to put them in the chat now as well, we'll just leave this open for a little bit.