Common Cases in Vascular Surgery

8/8/2019 Common Cases in Vascular Surgery

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Miss Kaji SritharanSpecialist Registrar in General Surgery Northwest Thames, London Deanery

Dec 2009

Common History Cases: Lower Limb PVD AAA

Carotid Disease

Short Cases Varicose Veins

Establish:

Whether symptoms:

Acute on

chronic

Chronic

Viability of the limb

Acute Limb Ischaemia Pain

Pale or white

Perishingly cold

Pulseless

Paraesthesiae

Paralysis Dictates

urgency

Remember:

60% ‐ thrombotic occlusion of pre‐existing stenotic arterial segment

30% ‐ embolus (80% from left atrial appendage in assoc AF)

Blood tests

ECG CXR

Abdominal U/S Thrombophilia

screen

Arterial Duplex

Management of Acute Limb Ischaemia

Paralysis & ParaesthesiaParalysis & ParaesthesiaSensation &

Movement

intact

Sensation &

Movement

intact

1. Resuscitate

2. IV heparin

3. Urgent surgery – embolectomy/ bypass

1. Resuscitate

2. IV heparin

3. Urgent surgery – embolectomy/ bypass

1. Optimise patient

2. IV heparin

3. Arteriogram – plan for bypass

4. Observe limb for deterioration

1. Optimise patient

2. IV heparin

3. Arteriogram – plan for bypass

4. Observe limb for deterioration

History Claudication

(?deteriorated)

Rest pain

Tissue Loss

Pain calf, thigh or buttock,

after walking predictable distance

resolution of pain after rest

Not while standing or sitting.

Pain in the toes/forefoot at rest.

Initially only at night, relieved by

dependency

Progresses to constant pain

Can occur in areas of tissue loss

elsewhere

Dry/wet gangrene, usually painful

NB: diabetic foot wounds (not always painful)

Ulcers – can be of mixed aetiology

Amputations

‐ when and why? Diabetic? Was

revascularisation attempted

before?

Arterial Ulcers or Gangrene

ORRest pain of 2 weeks or more requiring Opiate

Analgesia

Absolute Ankle Pressure < 50mmHg

or Toe Pressure <30mmHg

Do you smoke or have you ever smoked? If yes, estimate pack year history, record how long cessation.

Are you diabetic? If yes, what do you use to control your blood sugar levels?

Do you have, or take medicine to control, high cholesterol or high blood pressure?

Have you ever suffered angina, had a heart attack,

treatment of

disease

(angioplasty

Have you ever suffered a stroke or ministroke ʹTIAʹ.

Have any

family

suffered

disease or PVD?

General approach

Inspect

- General- Focussed: look for evidence of adequate orinadequate perfusion

Palpate/Auscultate the major pulses to

work out the likely level of the problem

Wash/gel

Introduce

Permission

Explain

Position

Expose

Tender?

You must listen to the examiner as the

instructions may be more or lessexplicit about what is required

Even if the instruction is to examinethe lower limbs you must make a

reference to how you would usuallystart your examination at the hands

Look for clues around the bed

INSPECT FOR:

Nicotine staining

Pallor

Muscle wastingSplinter haemorrhage

Venous guttering

Fistula

Tissue loss

PALPATE FOR:

WarmthCapillary refill

Radial pulse(AF? R-R delay?)

Ulnar pulse

Allen’s Test

Brachial pulse

Axillary pulse

Subclavian abnormality

Carotid bruit

Colour

mottling, marbled, pallor, venous

guttering

Trophic changes hair loss, thin skin,

muscle atrophy

Amputations

Ulcers + Gangrene

Scars to note:

Carotid end‐arterectomyCABG

Thoraco‐abdominalMidline laparotomyVertical groinAbove‐knee medialBelow‐knee medial

distributionLateral calfFoot

Scars to note:

Fasciotomy

Temperature

difference CRT <2sec

Pulses

Femorals

Popliteals

Posterior Tibial

Dorsalis pedis

Auscultate Bruits

Buergers Test/Angle

angle foot goes white

< 20 degrees – severe ischaemia

To Finish: Examine

+ Fundoscopy

Examine the remainder Peripheral Vascular System

Examine Abdomen AAA

Measure ABPIs

Dipstick Urine

Simple: Blood tests: Cholesterol,

HbA1c, U&E

Duplex Ultrasound(CTA or MRA depending on localskills)

Angiography (like cardiac like to

perform intervention at same sitting)

Management of

Intermittent

claudicant

Critical

ischaemia

Medical therapies

Encourage exercise

STOP SMOKING

BP control

Statins & aspirin

Diabetic control

Watch retino/nephopathy

Revascularisation

Angioplasty +/- stenting

Bypass procedure

Revascularisation

Angioplasty +/- stenting

Bypass procedure

Sepsis control

Antibiotics + DM control

DebridementAmputation

+ Medical therapies

Definition: necrosis oftissue with mummificationor putrefaction

Types :1. Dry – well demarcated, auto-

amputate

2. Wet – due to trauma, acuteischaemia & infection. Poorlydemarcated and spreading.

Vascular (thrombosis, embolus, critical

ischaemia,

Buerger’s

disease,

Raynaud’s

disease)

Diabetes

Trauma – cold, heat, pressure Drug induced e.g. ergot poisoning

Indications:

“DEAD, DYING OR DANGEROUS”

Vascular (80

‐90%)

Infection (Osteomyelitis, Gas gangrene)

Trauma (Burns, Frostbite)

Malignancy

Definition

continuity

epithelial

surface

Aetiology

Vascular (arterial,

venous

mixed)

Neuropathic

Traumatic

Malignant

Size Shape

Surrounding Tissue

Site: overlies lateral malleolus Edge: punched out

Base: deep; often lacks granulation tissue;necrotic

Minimal exudate

Painful +/- cellulitis Gangrene

Medical

‐ Pain control‐ Optimise risk factors

‐ ?intravenous prostaglandins

‐ Antibiotics if infection

Surgical

‐ Debridement (surgical,dressings,maggots)/amputation‐ Improve blood supply

(lumbar sympathectomy,

angioplasty,

Site: gaiter area; lower 3rd medial aspect leg

Shape: varies – can be very large, irregular Edge: sloping and shallow

Base: often pink granulation tissue +/-seropurulant discharge

Surrounding skin: induration, pigmentation,

lipodermatosclerosis Painful

NB. Examine for VVs, check ABPI’s

Exclude arterial component

If mixed – correct arterial factor

Non-Surgical – high success (80-90% at 1 year)

Rest + elevate leg Four layer compression bandaging

Once healed – grade II compression hosiery

Surgical Exclude malignancy

Skin grafting if clean

Treat primary varicose veins

Site: pressure areas

Edge: even wound margins; callousaround ulcer

Base: granulation tissue present (unlessco-existing PVD); low to moderateexudate

Absence of pain Peripheral pulses present

Common: 10-20% population

Women > men

Definition

Tortuous, dilated, elongated veins of the superficial venous system

Superficial veins Long saphenous vein (LSV)

Short saphenous vein (SSV)

Deep veins

Perforator veins Giacomini vein

Aetiology

Acquired

Valve Muscle pump Venous return

Congenital

IncompetenceDeep vein thrombosis Immobility Pregnancy

Abdo/ pelvic mass

Focussed history

‘Primary LSV' +/- signs at ankle

Ulcer of unknown aetiology(venous/arterial/mixed)

Age, Occupation

How long have you had varicose veins? How do your veins trouble you?

Cosmesis

Swelling – typically end of day Aching

Pruritis

Cramps Ulcers +/- infection - periostitis

Female Family history (uncertain as to why!!!)

Pregnancy (impaired venous return as well as hormonal effect on vein wall)

PMH of DVT or long bone fracture

Contributing factors: HRT, OCP, obesity, sedentary lifestyles, and

professions that require prolonged standing or sitting

Listen to the examiner’s instructions

Wash/gel

Introduce

Consent

Explain

Position/Expose Pain or tenderness anywhere?

Inspect front and back for:

Obvious varicosities and their distribution

Signs (skin changes) at the ankle/calf

Signs of previous surgery

Saphenovarix

- Assess for coughimpulse

Feel- Tap test

- Temperature- Tethering

Tourniquet test versus Trendelenberg test

GIVE CLEAR INSTRUCTIONS

Elevate the limb, milk the veins

Apply tourniquet to upper thigh

Immediate filling of veins, release the tourniquetand tell the examiner:

'the filling of the varicose veins is not controllable atthe level of the SFJ'

Veins not immediately filled, very slow filling =

undo the tourniquet and tell the examiner:'the filling of the varicose veins is controlled at thelevel of the SFJ'

Auscultate the varicosities that do not emptylying flat ‘machinery murmur’ of AVM

Offer to palpate lower limb pulses +/- ABPIs

Perthes test

Offer to perform Abdo/Pelvic/Scrotal/rectal

examinations

Wash hands, ensure patient re-covered

Hand helddoppler

Duplex imaging

Venography

Abdo/Pelvisultrasound

Please examine this patients superficialvenous system in the lower limb.

TrendelenbergTrendelenberg

and tourniquetand tourniquet

test positivetest positive

How would you treat varicose veins?How would you treat varicose veins?

Leg elevation

Regular walking to improve calf muscle

pump Class II support stockings – above or below

Skin changes require - 4 layer bandaging(Charing cross)

Eczema – topical emolliants Thrombophlebitis – NSAIDs

Open Surgery:- High tie and strip – ligation of SFJ

+/- avulsions – removal of varicosities

Foam injections

Sclerotherapy:

- 1% Sodium tetradecyl sulphate

EVLT or VNUS

Accumulation fluid in interstitiumdue to problem with lymphatic

drainage Typically bilateral and non-pitting

Aetiology:

Primary: Milroy’s disease Secondary:

○ Lymphadenectomy

○ Malignancy

○ Post radiotherapy

○ Infections: Filiarisis

Common Cases in Vascular Surgery

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