Common Cases in Vascular Surgery
Transcript of Common Cases in Vascular Surgery
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Miss Kaji SritharanSpecialist Registrar in General Surgery Northwest Thames, London Deanery
Dec 2009
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Common History Cases: Lower Limb PVD AAA
Carotid Disease
Short Cases Varicose Veins
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Establish:
Whether symptoms:
Acute
Acute on
chronic
Chronic
Viability of the limb
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Acute Limb Ischaemia Pain
Pale or white
Perishingly cold
Pulseless
Paraesthesiae
Paralysis Dictates
urgency
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Remember:
60% ‐ thrombotic occlusion of pre‐existing stenotic arterial segment
30% ‐ embolus (80% from left atrial appendage in assoc AF)
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Blood tests
ECG CXR
Echo
Abdominal U/S Thrombophilia
screen
Arterial Duplex
DSA
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Management of Acute Limb Ischaemia
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
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History Claudication
(?deteriorated)
Rest pain
Tissue Loss
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Pain calf, thigh or buttock,
after walking predictable distance
resolution of pain after rest
Not while standing or sitting.
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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
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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?
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Arterial Ulcers or Gangrene
ORRest pain of 2 weeks or more requiring Opiate
Analgesia
AND
Absolute Ankle Pressure < 50mmHg
or Toe Pressure <30mmHg
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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
heart
disease
(angioplasty
or
CABG)
Have you ever suffered a stroke or ministroke ʹTIAʹ.
Have any
of
your
close
family
suffered
from
heart
disease or PVD?
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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
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Wash/gel
Introduce
Permission
Explain
Position
Expose
Tender?
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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
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Look for clues around the bed
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INSPECT FOR:
Nicotine staining
Pallor
Muscle wastingSplinter haemorrhage
Venous guttering
Scars
Fistula
Tissue loss
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PALPATE FOR:
WarmthCapillary refill
Radial pulse(AF? R-R delay?)
Ulnar pulse
Allen’s Test
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Brachial pulse
Axillary pulse
Subclavian abnormality
Carotid bruit
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Look
Colour
mottling, marbled, pallor, venous
guttering
Trophic changes hair loss, thin skin,
muscle atrophy
Scars
Amputations
Ulcers + Gangrene
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Scars to note:
Carotid end‐arterectomyCABG
Thoraco‐abdominalMidline laparotomyVertical groinAbove‐knee medialBelow‐knee medial
LSV
distributionLateral calfFoot
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Scars to note:
Fasciotomy
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Feel
Temperature
difference CRT <2sec
Pulses
Femorals
Popliteals
Posterior Tibial
Dorsalis pedis
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Auscultate Bruits
Buergers Test/Angle
angle foot goes white
< 20 degrees – severe ischaemia
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To Finish: Examine
Neuro
lower
limb
+ Fundoscopy
Examine the remainder Peripheral Vascular System
Examine Abdomen AAA
Measure ABPIs
Dipstick Urine
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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)
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Management of
PVD
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
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Definition: necrosis oftissue with mummificationor putrefaction
Types :1. Dry – well demarcated, auto-
amputate
2. Wet – due to trauma, acuteischaemia & infection. Poorlydemarcated and spreading.
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Vascular (thrombosis, embolus, critical
ischaemia,
Buerger’s
disease,
Raynaud’s
disease)
Diabetes
Trauma – cold, heat, pressure Drug induced e.g. ergot poisoning
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Indications:
“DEAD, DYING OR DANGEROUS”
Vascular (80
‐90%)
Infection (Osteomyelitis, Gas gangrene)
Trauma (Burns, Frostbite)
Malignancy
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Definition
Break
in
continuity
of
an
epithelial
surface
Aetiology
Vascular (arterial,
venous
or
mixed)
Neuropathic
Traumatic
Malignant
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Site
Size Shape
Edge
Base
Depth
Surrounding Tissue
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Site: overlies lateral malleolus Edge: punched out
Base: deep; often lacks granulation tissue;necrotic
Minimal exudate
Painful +/- cellulitis Gangrene
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Medical
‐ Pain control‐ Optimise risk factors
‐ ?intravenous prostaglandins
‐ Antibiotics if infection
Surgical
‐ Debridement (surgical,dressings,maggots)/amputation‐ Improve blood supply
(lumbar sympathectomy,
angioplasty,
BPG)
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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
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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
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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
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Common: 10-20% population
Women > men
Definition
Tortuous, dilated, elongated veins of the superficial venous system
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Superficial veins Long saphenous vein (LSV)
Short saphenous vein (SSV)
Deep veins
Perforator veins Giacomini vein
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Aetiology
Acquired
Valve Muscle pump Venous return
Congenital
IncompetenceDeep vein thrombosis Immobility Pregnancy
Abdo/ pelvic mass
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Focussed history
‘Primary LSV' +/- signs at ankle
Ulcer of unknown aetiology(venous/arterial/mixed)
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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
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Age
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
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Listen to the examiner’s instructions
Wash/gel
Introduce
Consent
Explain
Position/Expose Pain or tenderness anywhere?
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Inspect front and back for:
Obvious varicosities and their distribution
Signs (skin changes) at the ankle/calf
Signs of previous surgery
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Saphenovarix
- Assess for coughimpulse
Feel- Tap test
- Temperature- Tethering
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Tourniquet test versus Trendelenberg test
GIVE CLEAR INSTRUCTIONS
Elevate the limb, milk the veins
Apply tourniquet to upper thigh
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Immediate filling of veins, release the tourniquetand tell the examiner:
'the filling of the varicose veins is not controllable atthe level of the SFJ'
OR
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'
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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
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Hand helddoppler
Duplex imaging
Venography
Abdo/Pelvisultrasound
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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?
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Leg elevation
Regular walking to improve calf muscle
pump Class II support stockings – above or below
knee
Skin changes require - 4 layer bandaging(Charing cross)
Eczema – topical emolliants Thrombophlebitis – NSAIDs
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Open Surgery:- High tie and strip – ligation of SFJ
+/- avulsions – removal of varicosities
Foam injections
Sclerotherapy:
- 1% Sodium tetradecyl sulphate
EVLT or VNUS
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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