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Ch 7: Vascular Surgery (i) - Coggle Diagram
Ch 7: Vascular Surgery (i)
PAD
Critical limb ischaemia: rest pain >2wks or tissue loss
Leriche syndrome
occlusion @ aorta bifurcation
triad: ED, thigh/buttock claudication, weak/absent femoral pulses
Rutherford fontaine classification
I: asymp
IIa: claudication @ >200m
IIb: claudication @ <200m
III: rest pain
IV: tissue loss
Investigations
duplex US
CT/MR angiogram
Digital Subtraction angiography (fluoroscopic technique)
ABPI
0.9-1.1: normal
0.5-0.9: intermittent claudication
0.3-0.5: rest pain
<0.3: tissue loss
over 1.1: calcified arteries (usually in DM)
Tx
sx relief for IC: cilostazol or pentoxifylline
angioplasty (balloon + stents)
bypass: synthetic (dacron) or vein graft
amputation
Acute LL Ischaemia
Causes
thrombus (acute on chronic)
embolus (usually cardiac)
incl blue toe syndrome
if untxed - irreversible tissue damage in 6hrs
Tx
START UNFRACTIONATED HEPARIN ASAP
5000IU stat then 1000IU/hr infusion
check aPTT in 4-6hrs, aim for 60/90
amputation
embolectomy using a fogarty catheter
thrombolysis
angioplasty
comps of reperfusion
reperfusion injury (ROS)
rhabdomyolysis
elevated CK, elevated K, myoglobinuria, AKI
Tx: IV fluids, mannitol, alkalinisation of urine
compartment syndrome
AAA
diameter>3cm
true aneurysm: contains all 3 layers of vessel wall
95% infrarenal
surveillence
US every yr
every 3mo once >4.5cm
elective repair
when >5.5cm or expanded by >0.5cm in 6mo
open
laparotomy, synthetic graft, aorta clamped
EVAR
groin incisions
requires lifelong post op surveillance for endoleaks
Type 1: @ attachment site
Type 2: via collat vessels
Type 3: graft defect
Type 4: porosity of graft fabric
Type 5: no evidence seen on imaging
risk of distal peripheral embolisation, aorto-enteric fistula
CT abdo with IV contrast
high in determining aneurysm size, extent, presence of leaking
rupture
may be stable if contained in retroperitoneal space
don't aggressively hydrate - permissive hypotension
Varicose veins
comps
eczema
skin pigmentation
ulcers
bleeding
phlebitis
lipodermatosclerosis
How find point points of incompetence
Trendelenberg test
Duplex US of deep + superficial veins = gold standard
surgical tx
radiofrequency/laser ablation
sclerotherapy
local stab avulsions
open ligation
DVT
Virchow's triad
stasis
endothelial injury
hypercoagulable state (e.g. factor V leiden, Protein C/S deficiency, antithrombin deficiency)
Homan's sign (pain in calf when foot dorsiflexed)
don't do due to embolisation risk
duplex scan = investigation of choice
Well's probability score
Tx
uncomplicated: therapeutic LMWH, switch to warfarin for 3-6mo
complicated
IVC filter: recurrent PEs or if anticoag contraindicated
thombolysis (tPA) or thrombectomy if severe
IV unfractionated/LWMH, then warfarin