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Vascular Surgery for Finals

Vascular Surgery for Finals. Dr Jonathan Hodgkinson CT1 Vascular SMH. Contents. How to pass finals... Objectives Case 1 & 2 – Aneurysmal disease Case 3 – Arterial Disease Case 4 – Venous disease Case 5 & 6 – Lymphoedema Others Conclusions. How to pass finals. Trying to pass you

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Vascular Surgery for Finals

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  1. Vascular Surgery for Finals Dr Jonathan Hodgkinson CT1 Vascular SMH

  2. Contents • How to pass finals... • Objectives • Case 1 & 2 – Aneurysmal disease • Case 3 – Arterial Disease • Case 4 – Venous disease • Case 5 & 6 – Lymphoedema • Others • Conclusions

  3. How to pass finals... • Trying to pass you • Justify everything you say • Define and shine.... • Try and put off answering the question for as long as possible! • Framework is key.....

  4. Objectives • Understand vascular examination • Describe management of aneurysmal disease • Discuss the principles of arterial disease management • Discuss the features and management of venous disease • Diagnosis lymphoedema

  5. Case 1 • 65yo Male • PC • sudden onset central abdominal pain • Dizziness • A/w painful right foot • PMHx • HTN, high cholesterol • Smoker – 30 pack year history

  6. Case 1 • O/E • HR 110, BP 90/60, RR24, 95% on RA, afebrile • Sweaty, distressed • Diffusely tender abdomen • No pulses on the right distal to femoral

  7. Ruptured AAA • Surgical emergency • Mortality – without surgery 100%; with 50-75% • Rates • Rupture/yr - <4.5cm = 9%; 4.5-7cm = 35%; >7cm = 75% • Mx • Fluid resus – aggrssive + CXM (10 units) • Senior and anaesthetist • If haemodynamically stable – CT scan

  8. AAA • Normal diameter 1.5-3cm; Aneurysm >3cm • 95% infra-renal • 75% asymptomatic • Incidence – 5% • Sex – M>F

  9. Case 2 • 65yo male • PC – incidental finding of aneurysm • Asymptomatic • Ix • Imaging – CT/USS • Bloods – renal function, cholesterol • Work-up – ECG, ECHO, lung fn

  10. Stable AAA • Management • Conservative • Watch and wait - <5cm – serial USS/CT • Risk factor management • (MASS trial – screening beneficial and viable) • Surgical – UK Small Aneurysm Trial • Indications for surgery • Symptomatic aneurysms • >5.5cm • Rapidly expanding - >1cm/year • Complicated by embolism

  11. Stable AAA • Surgical options • Open vs EVAR • EVAR trials • 1 – lower 30 post-op mortility • 2 – reduction in aneurysm related mortality but not all cause • Complications • Haemorrhage, renal failure, embolism, graft infection/migration, MI/infection, endoleaks

  12. Case 3 • 65yo male • PC – sudden onset left foot pain • HPC • 6hr history – severe pain on movement • History of intermittent claudication – 100yds • PMHx • MI, HTN, Chole, diabetes • SHx – mobile with stick

  13. Case 3 • O/E • Haemodynamically stable • Cold • Mottled & blanching • Absent pulses distal to popliteal • Painful • Motor and sensation intact

  14. Limb ischaemia • Acute (on chronic) • Emobilic (thrombotic) • No claudication • Sudden onset (sec/min) • Recent MI/AF/AAA • Embolectomy • Thrombolysis • Emergency recon • Amputation (10-20% mort) • Chronic • Thrombotic • Claudication • Gradual onset (hrs) • Chronic vascular disease • Thrombolysis • Angioplasty • Emergency recon • Amputation Management General – analgesia, rehydration, NBM, anti-coagulation

  15. Limb ischaemia • Complications - Immediate • Reperfusion injury • Compartment syndrome • Renal failure • ARDs/toxic shock • Long-term • Further episodes • Chronic pain syndromes

  16. Chronic Limb ischaemia • Def – persistently recurring • Incidence – 5% males >50yo • HPC • Intermittent claudication – fixed/reducing distance • Rest pain • Tissue loss • RFs – HTN, chole, previous IHD, smoking, DM

  17. Chronic Limb ischaemia • O/E • Inspection • Cold, pale, increased capillary refill time • Venous guttering • Evidence of tissue loss/ulcers • Pulses • Buerger’s test/angle • Doppler examination • Triphasic, biphasic, monophasic

  18. Chronic Limb ischaemia • Conservative • Risk factors management • STOP SMOKING • Excerise – collateralisation • Obesity • Diet • Good BM control in diabetes • Foot care • Treat underlying cardiac disease

  19. Chronic Limb ischaemia • Medical • Control HTN • Anti-platelet therapy • Aspirin 75mg • Clopidogrel 75mg • Control lipids • Statins • Diabetic control

  20. Chronic Limb ischaemia • Surgery • Indications • Short claudication distance – 50-100yds • Reducing claudication distance • Symptoms greatly effecting QoL • Rest pain/tissue loss

  21. Chronic Limb ischaemia • Surgery • Interventional • Angioplasty – balloon/stenting • Iliacs – 90% 5yr patency • Femoral – 70% 5yr patency • Not effective distally or if ulcerative disease • Reconstructive • Reserved for critical ischaemia • Autologous vs. synthetic • Anatomical vs. extra-anatomical • Endarterectomy – femorals • Amputation • Lethal limb • Dead limb • Useless limb

  22. Case 4

  23. Venous disease • Features • Pigmentation/haemosiderosis • Visible veins • Varicose eczema • Lipodermatosclerosis – atrophic change (loss of elasticity) • Ulceration • Atrophy blanch – healed ulcers

  24. Venous disease • Pathology • Increased pressure in venous system • Gradually become incompetent • Incidence – 10-20% (F>M) • Causes • Primary • Congenital absence of valves • Secondary • Thrombosis • Increased abdominal pressure • pregnancy/masses/ascites/obesity/constipation • AV malformations • Overactive muscle pumps (e.g. cyclists)

  25. Venous disease • Conservative • Rx underlying cause – lose wt/constipation • Skin care • Class 2 compression stockings • Surgical • Injection sclerotherapy • Laser/radiofrequency ablation • Trendelenburg procedure – high tie and ligation • +/- phlebectomies

  26. Venous disease • Complications of surgery • Bruising • Infection • Bleeding • Neuropraxia • Recurrence/no improvement in cosmesis • DVT – 1/1000

  27. Case 5

  28. Case 6

  29. Lymphoedema • Features • F>M • Peripheral oedema worse on standing • Non-pitting • Hyperkeratosis, fissuring, secondary infection • Squaring and thickening of nails

  30. Lymphoedema • Abnormal collections of interstitial fluid • Types • Primary – congenital absence of lymphatics • Congenital • Praecox – Milroy’s Syndrome - <35 – progressive • Tarda - >35 • Secondary • Infiltration – malignant disease • Fibrosis – radiotherapy • Previous surgery • Infections – TB/cellulitis

  31. Lymphoedema • Treatment • Allow fn and decrease swelling • Conservative • COMPRESSION • Skin care • Physiotherapy • Surgical • Debulking of tumours • Bypass • Omental/mesenteric bridges

  32. Others • Carotid artery disease • 15-25% of all CVAs/TIAs • Ix – Doppler • Management • Conservative • anti-platelet therapy • Risk factor management • Surgery in asymptomatic disease controversial • Surgery – carotid endartectomy • Symptomatic – 70 – 99% stenosis • Urgent surgery within 2 weeks • NASCET and ECST

  33. Others • Aortic dissection • Split in intima and internal portion of media allowing blood to enter and extend proximally and distally • Types • A – 70% • Affects arch and ascending aorta • 10-20% mortality – 100% need surgery • Aortic root replacement • B – 30% • Distal to left subclavian • Conservative Mx unless evidence of visceral or limb ischaemia

  34. Objectives • Understand vascular examination • Describe management of aneurysmal disease • Discuss the principles of arterial disease management • Discuss the features and management of venous disease • Diagnosis lymphoedema • Framework

  35. References • Multicentre aneurysm screening study (MASS): cost effectiveness analysis of screening for abdominal aortic aneurysms based on four year results from randomised controlled trial. BMJ. 2002 Nov 16;325(7373):1135. • The UK Small Aneurysm Trial. Ann N Y Acad Sci. 1996 Nov 18;800:249-51. • The UK EndoVascular Aneurysm Repair (EVAR) trials: randomised trials of EVAR versus standard therapy. Health Technol Assess. 2012;16(9):1-218. doi: 10.3310/hta16090. • Lecture notes on general surgery – Harold Ellis • Oxford handbook of clinical surgery – 3rd edition • Browse’s Introduction to the symptoms and signs of surgical disease – 4th edition • Clinical cases and OSCE’s in surgery – Manoj Ramachandran

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