Vascular Surgery

4th February 2014 Elliott Cochrane FY1 in Acute Medicine

Introduction
Acute Limb Ischaemia Abdominal Aortic Aneurysms Chronic Limb Ischaemia Venous disease

Conclusion
Questions

Case Scenario 1- History

John 58, male. Truck driver 1 hour history of painful right foot which is becoming worse. Not able to move his foot as well as before.

PMH- T2DM, HTN, MI x 2 with 2 coronary stents, AF, COPD DH Metformin, Ramipril, Simvastatin, Digoxin, Atenolol, Seretide, Tiotropium FH- Father MI aged 50 SH- smokes 25/day, drinks 10 pints at weekends, lives with wife, independent ADLs.

Case Scenario 1 - Examination

Alert Obs- Temp 37.3, RR 18, Sats 91%, HR 100, BP 145/90 Examination of right foot
Pale Cold Tender Reduced sensation Reduced ROM Absent DP and PT pulses

Acute Limb Ischaemia

Surgical emergency revascularisation needed within 4-6 hrs. Causes;
Thrombosis (40%) Emboli (38%) Graft/angioplasty occlusion (15%) Trauma Dissection Intra-arterial injection

Features 6 Ps: Pale, Pulseless, Perishingly Cold, Painful, Paraesthesia, Paralysis

Mortality 22%.

Acute Limb Ischaemia

Investigations Bloods- FBC, U&Es, clotting, G&S, glucose, troponin Doppler Angiography ECG Chest xray Management Resuscitation- ABCDE.. Analgesia Heparin- bolus followed by infusion Definitive treatment
Irreversible- amputation (16%) Complete thrombolysis, angioplasty, embolectomy, arterial bypass Incomplete heparinisation, imaging, ?intervention

Identify and correct underlying cause

Acute Limb Ischaemia

Post ischaemic syndromes
Reperfusion injury
Generation of oxygen free radicals leading to neutrophil activation. Increased vessel permeability leads to compartment syndrome. Cell damage leads to acidosis and hyperkalaemia causing: arrhythmias, myoglobinaemia and endotoxic shock.

Compartment syndrome
Caused by increased capillary permeability and oedema Calf muscles in tight fascial compartments Increasing interstitial pressure leads to muscle necrosis Clinical features- swelling and severe pain on palpation/movement Management- fasciotomy

Chronic pain syndromes

Case Scenario 2 - History

James 70, male Retired engineer Sudden onset epigastric pain followed by collapse at home. PMH- T1DM, HTN, MI x 1 CABG DH Novomix 30, Ramipril, Atenolol, Simvastatin FH- nil relevant SH- Smokes 20/day, Drinks 1 pint/day, Lives with wife, independent in ADLs

Case Scenario 2 - Examination

Drowsy, GCS 13 Obs- Temp 36.8, RR 24, Sats 96%, HR 120, BP 85/48 Cool peripherally, CRT 5 seconds, Pale Tender epigastrium Expansile mass

Aneurysms
Definition = >150% dilation of the original diameter. True aneurysms = involve all 3 layers of the vessel wall. False aneurysms = collections of blood around the vessel wall in communication with the lumen. Common sites: aortic, iliac, femoral, popliteal Complications
Rupture Thrombosis Embolism Fistulae Extrinsic compression

Abdominal Aortic Aneurysms

Definition= abdominal aortic diameter >3cm M:F = 6:1 Incidence: 5% >65yrs Risk factors: smoking, hypercholesterolaemia, male sex, genetic Clinical features
May be asymptomatic (75%) Distal embolisation Rupture: intermittent/continuous abdominal pain, collapse/shock, expansile mass on palpation.

Abdominal Aortic Aneurysms

Investigations
Ruptured AAA
Bloods FBC, U+E, LFT, Amylase, Clotting, Xmatch 6 units ECG USS

Non-ruptured AAA
Bloods ABPI Chest xray ECG and Echo Pulmonary function tests/CPEX testing Imaging USS/CT

Abdominal Aortic Aneurysms

Management
Ruptured AAA - mortality: treated ~ 41%, untreated ~100%
ABCDE Permissive hypotension syst <100mgHg Consult vascular surgery team Prophylactic antiobiotics Cefuroxime and Metronidazole Emergency AAA repair

Unruptured AAA
Surgery offered when aneurysm >5.5cm Regular CT/USS follow up AAA screening programme Open AAA vs. EVAR

Abdominal Aortic Aneurysms

Open AAA repair

Abdominal Aortic Aneurysms

Complications of AAA surgery
Renal failure MI Distal embolisation Graft infection Death

Complications of EVAR
Endoleak Sac expansion Stent graft failure/migration Late rupture

Case Scenario 3- History

Jeff 58, male Taxi driver Has been experiencing cramps in his calves for the past 6 months. Worse over the past 3 weeks. Previous ET 80 yards. Now 20 yards. Frequently wakes during the night with similar pains Right great toe has turned black PMH T2DM, HTN, Hypercholesterolaemia, previous angioplasty for PVD DH- Metformin, gliclazide, atorvastatin, valsartan, aspirin, clopidogrel SH- smokes 35/day, drinks 15 units per week, independent ADLs

Case Scenario 3- Examination

Alert Obs: Temp 37.2, RR 16, Sats 96% RA, BP 148/86, HR 80 Inspection pale legs, shiny, loss of hair CRT = 4 seconds Absent foot pulses.

Chronic Limb Ischaemia

Affects 7% men aged >50 years M:F = 2:1
Risk Factors Hypertension Hyperlipidaemia Diabetes mellitus Smoking Positive family history Associations Obesity Diet Sedentary lifestyle Gender Occupation

Chronic Limb Ischaemia

Clinical features
Intermittent claudication, ulceration, gangrene, rest pain. Signs: absent pulses, cold limbs, atrophic skin, ulceration, postural colour change, delayed CRT.

Fontane Classification
1- Asymptomatic 2- Intermittent claudication 3- Ischaemic rest pain 4- Ulceration/gangrene

Chronic Limb Ischaemia

Investigations
Bloods: FBC, U&E, CRP/ESR, Lipids, glucose, clotting, syphilis serology, G+S ECG ABPI Imaging: contrast/ digital subtraction arteriography, duplex imaging, CT/MR angiography

Management
Conservative- exercise, weight loss, smoking cessation Medical- anti-platelet agents, optimise co-morbidities Surgical

Chronic Limb Ischaemia

Surgical treatment options
Percutaneous transluminal angioplasty
Good for short stenoses

Surgical reconstruction
For extensive atheromatous disease. Factors to consider- vessel inflow, vessel outflow, conduit. Vein grafts vs prosthetic grafts

Sympathectomy
For symptomatic relief Caution in diabetics

Amputation
To relieve intractable pain and reduce mortality from gangrene Following previous failed interventions

Case 4 - History
Jane 48, female Teacher 2 year history of tortuous swellings on her legs. Painful which are often worse at the end of the day becoming swollen. Intermittently itchy. PMH- Hyperlipidaemia, Gravida 4 Para 4 DH- Simvastatin, previously used the COCP. FH- Mother had varicose veins SH- Non-smoker, Drinks 8 units ETOH/week. Independent in ADLs

Case 4- Examination
Alert Obs: Temp 37.1, RR 14, Sats 98%, HR 78, BP 105/60 On inspection of the lower limbs

Varicose Veins
Definition: tortuous dilated segments of superficial veins associated with valvular incompetence. Affects up to 20% of the population F:M = 9:1 Causes
Primary (95%) unknown, congenital valve absence Secondary (5%)- obstruction, valve destruction, AVM, constipation

Risk factors: prolonged standing, obesity, pregnancy, family history, the Pill

Varicose Veins
Clinical features
Symptoms: unsightliness, pain, cramping, heaviness, itching, swelling. Signs: oedema, eczema, ulcers, discolouration (haemosiderin deposition), bleeding, phlebitis, atrophie blanche, lipodermatosclerosis, fat necrosis.

Investigation
Assessment predominantly clinical Doppler Colour duplex ultrasound

Varicose Veins
Indications for treatment- suggested by NICE
Symptomatic varicose veins Lower limb skin changes Current or healed venous leg ulcer Superficial vein thromboses

Management
Treatment of the underlying cause Conservative Medical Surgical

Varicose Veins
Conservative
Patient education- weight loss, regular walks, avoid prolonged standing

Medical
Compression stockings Sclerotherapy- laser/foam Laser coagulation/radiofrequency ablation

Surgical
Localised stab avulsions Subfascial endoscopic perforation ligation Long saphenous vein stripping Saphenofemoral/saphenopopliteal disconnection

Varicose Veins
Complications of varicose vein surgery
Bruising Recurrence 20% Haemorrhage Wound infection Saphenous nerve damage 8%

Superficial Thrombophlebitis
Definition = inflammation and thrombosis of superficial veins Pathogenesis: changes in Virchows triad Risk factors: Obesity, thrombophilia, smoking, OCP, pregnancy, IV drug abuse, IV infusion, trauma Clinical features: pain, oedema, erythema, palpable knot Investigations: Not required- clinical diagnosis

Management
Conservative: elastic support, exercise, limb elevation, hot compress Medical: analgesia, heparinoid creams, Fondaparinux, ?LMWH Surgical: recurrences associated with varicose veins

Conclusion
Acute limb ischaemia and ruptured AAAs are surgical emergencies. They both require prompt assessment, investigation where appropriate and management. The management of chronic limb ischaemia is based upon thorough work up to define disease extent and anatomy. Varicose veins are common and management is multifactorial so remember conservative, medical and surgical.

Good luck for your exams!

Any Questions!

Questions
1. A 65 year old gentleman attends A+E with a 10 hour history of a pain right foot. On examination the foot is cold with a delayed capillary refill time of 6 seconds with fixed mottling of the skin. Q- What is the most appropriate definitive management? A- Embolectomy B- Thrombolysis C- Below knee amputation D- Femoral popliteal bypass E- Percutaneous transluminal angioplasty

Questions
2- A 60 year old gentlemen who underwent open AAA repair for a 6.2cm infrarenal AAA 6 weeks ago presents to A&E with a 4 hour history of generalised abdominal pain. On examination his abdomen is soft with no localised peritonism. Within the following hour he becomes tachycardic at 115 and hypotensive with a BP of 75/40.

Q- what is the most likely cause for this presentation

A- Acute appendicitis B- Large bowel obstruction C- Mesenteric ischaemia D- Acute pancreatitis E- Sigmoid diverticulitis

Questions
3- A 58 year old gentlemen with known peripheral vascular disease presents with a 6 month history of worsening leg cramps with a claudication distance of 80 yards. On examination, there is no ulceration or gangrene. ABPI is 0.7. Angiography demonstrates a 3cm superficial femoral artery stenosis with good vessel run off.

Q- What is the most appropriate definitive management?

A- Embolectomy B- Aorto-iliac bypass C- Femoral-femoral crossover D- Percutaneous transluminal angioplasty E- Below knee amputation

Questions
4- A 67 year old lady with known varicose veins is referred by her GP to the surgical assessment unit regarding a palpable lump in her groin. On examination, there is a small 4x4cm lump inferior and lateral to the pubic tubercle with a bluish tinge. It is non-tender, soft and compressible. It transmits a cough impulse.

Q- What is the most likely diagnosis?

A- Femoral hernia B- Reactive lymph node C- Psuedoaneurysm of the femoral artery D- Saphena Varix E- Lipoma

Questions
5- A 68 year old gentleman is brought into A&E having collapsed at home. On examination he is hypotensive (BP 80/50), tachycardic (115) and cool peripherally. He is tender in his epigastrium and there is an expansile mass palpable. Q- What is the most appropriate initial action? A- Contact the vascular surgery team B- Get an urgent abdominal ultrasound C- Contact theatres D- Get IV access with 2 large bore cannulae and begin fluid resuscitation E- Secure airway and breathing