Surgery Marrow Pg 487-496 (Vascular Surgery)
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Questions and Answers

Which type of amputation has the best chance of allowing a patient to walk again?

  • Above Knee amputation
  • Transmetatarsal amputation
  • Skew flap amputation
  • Below Knee amputation (correct)

    • The first phase of Raynaud's phenomenon results in the hands appearing red.

    False

    What are two early complications that can occur after an amputation?

    Hemorrhage, Infection

    In Raynaud's phenomenon, the second phase results in hands appearing ______ and being painful.

    <p>blue</p> Signup and view all the answers

    Match the amputation techniques with their descriptions:

    <p>Long posterior flap = Preferred method with 10 cm mark below tibial tuberosity Skew flap = One of the amputation techniques Above Knee amputation = Requires a cut not less than 20 cm from the knee Below Knee amputation = Best chance for post-operative walking</p> Signup and view all the answers

    What is the most common site for an abdominal aortic aneurysm?

    <p>Infra-renal abdominal aorta</p> Signup and view all the answers

    A descending thoracic aortic aneurysm has a critical diameter of 5.5 cm.

    <p>False</p> Signup and view all the answers

    What is the most common cause of mycotic aneurysm?

    <p>S. aureus</p> Signup and view all the answers

    The most common risk factor for abdominal aortic aneurysm is __________.

    <p>Atherosclerosis</p> Signup and view all the answers

    Match the types of aneurysms with their respective critical diameters:

    <p>Abdominal aortic aneurysm = 5.5 cm Ascending thoracic aortic aneurysm = 5.5 cm Descending thoracic aortic aneurysm = 6 cm Thoracic aortic aneurysm in Marfan patients = 4.5-5 cm</p> Signup and view all the answers

    What is the primary goal of conservative management in the arterial system?

    <p>To prevent the need for surgical intervention</p> Signup and view all the answers

    Conservative management is only applicable for patients who have undergone amputation.

    <p>False</p> Signup and view all the answers

    What is one potential complication that may arise from poor management of arterial conditions?

    <p>Amputation</p> Signup and view all the answers

    In conservative management, the emphasis is on minimizing ______ before considering surgical options.

    <p>risk</p> Signup and view all the answers

    Match the following management strategies with their descriptions:

    <p>Lifestyle modifications = Changes in diet and exercise to improve arterial health Medication = Drugs prescribed to relieve symptoms or prevent complications Physical therapy = Rehabilitation techniques to improve mobility and circulation Surgical intervention = Procedures performed to treat severe arterial issues</p> Signup and view all the answers

    What is a common clinical feature of chronic arterial occlusion resulting from intermittent claudication?

    <p>Cramping pain after walking certain distances</p> Signup and view all the answers

    Rest pain from chronic arterial occlusion is relieved by elevating the leg.

    <p>False</p> Signup and view all the answers

    What is the management procedure to relieve compartment syndrome?

    <p>Fasciotomy</p> Signup and view all the answers

    Intermittent claudication leads to a progressive decrease in the distance one can walk, known as the ______.

    <p>claudication distance</p> Signup and view all the answers

    Match the following conditions with their symptoms:

    <p>Intermittent claudication = Cramping pain after walking a certain distance Osteoarthritis = Maximum pain on the first step Neurogenic claudication = Pain relieved when bending forwards Compartment syndrome = Pain on passive flexion</p> Signup and view all the answers

    What does a decrease in the Ankle Brachial Pressure Index (ABPI) greater than 20% after exercise indicate?

    <p>Arterial disease</p> Signup and view all the answers

    A TBI less than 0.6 indicates significant arterial lesions.

    <p>True</p> Signup and view all the answers

    What is the primary indication for performing a procedure that includes the Cattell-Braasch Maneuver?

    <p>Renal cell carcinoma with metastasis to the IVC</p> Signup and view all the answers

    Cardiovascular complications are the most common cause of death after aneurysm surgeries.

    <p>True</p> Signup and view all the answers

    What are two common causes of arterial disease?

    <p>Buerger's disease and Atherosclerosis</p> Signup and view all the answers

    What is the common complication of aneurysm surgeries that can lead to bloody diarrhea?

    <p>Colonic ischaemia</p> Signup and view all the answers

    A decrease of 0.1 in ABPI increases the risk of ____ mortality by 10%.

    <p>cardiac</p> Signup and view all the answers

    The instrument typically used in open graft surgery is a __________ graft.

    <p>Dacron/PTFE</p> Signup and view all the answers

    Match the following diseases with their primary characteristics:

    <p>Buerger's disease = Thromboangitis obliterans, affects small to medium vessels, strongly associated with smoking Atherosclerosis = Involves medium to large vessels, associated with lifestyle factors such as stress and dyslipidemia</p> Signup and view all the answers

    Match the following surgical maneuvers to their descriptions:

    <p>Mattox Maneuver = Left medial visceral rotation exposing the aorta Cattell-Braasch Maneuver = Right medial visceral rotation exposing the IVC Kocherization = Mobilization of the duodenum</p> Signup and view all the answers

    What is the primary pharmacological treatment for managing Raynaud's phenomenon?

    <p>Calcium channel blockers</p> Signup and view all the answers

    Primary Raynaud's is associated with autoimmune rheumatic disease (AIRD).

    <p>False</p> Signup and view all the answers

    What condition can result from retrograde blood flow during exercise in subclavian steal syndrome?

    <p>Syncopal attacks</p> Signup and view all the answers

    Secondary Raynaud is generally associated with __________.

    <p>ANA (Antinuclear antibody)</p> Signup and view all the answers

    Match the features of Raynaud's phenomenon with their correct descriptions:

    <p>Prevalence = Common in Primary Raynaud Association with AIRD = Yes in Secondary Raynaud Microangiopathy in PUC = Generally in Secondary Raynaud Family history = Occasionally in both types</p> Signup and view all the answers

    What is the clinical sign associated with Class 4 in Boyd's Classification?

    <p>Pain at rest</p> Signup and view all the answers

    Bruit over the iliac region is a clinical finding in femoropopliteal obstruction.

    <p>False</p> Signup and view all the answers

    What does a duplex scan help to assess in vascular surgery?

    <p>Blood flow and vascular structures</p> Signup and view all the answers

    The Ankle Brachial Pressure Index (ABPI) for intermittent claudication is __________.

    <p>&lt; 0.9</p> Signup and view all the answers

    Match the site of disease with its clinical findings:

    <p>Aortoiliac obstruction = Claudication in buttocks, thighs, and calves; absent femoral and distal pulses Iliac obstruction = Unilateral claudication in thigh and calf; bruit over iliac region Femoropopliteal obstruction = Unilateral claudication in the calf; palpable femoral pulse Distal obstruction = Absent ankle pulses; claudication in calf and foot</p> Signup and view all the answers

    What is the primary cause of dry gangrene?

    <p>Tissue desiccation due to gradual slowing of blood flow</p> Signup and view all the answers

    Wet gangrene has a well-defined line of demarcation between living and dead tissue.

    <p>False</p> Signup and view all the answers

    List one indication for amputation as per the mnemonic 'Dead, deadly, damn nuisance.'

    <p>Gangrene</p> Signup and view all the answers

    The line of demarcation in dry gangrene is described as ______ if the bone is involved.

    <p>conical stump</p> Signup and view all the answers

    Match the types of gangrene with their characteristics:

    <p>Dry gangrene = Tissue desiccation due to gradual blood flow reduction Wet gangrene = Venous blockade with added infection Gas gangrene = Caused by clostridial infection Contractures = Often a result of prolonged immobility</p> Signup and view all the answers

    What is the first step in managing atherosclerosis?

    <p>Endovascular stenting</p> Signup and view all the answers

    Buerger's disease can be managed effectively with angioplasty due to the presence of distal target blood vessels.

    <p>False</p> Signup and view all the answers

    Name one medication used to manage Buerger's disease.

    <p>Pentoxyphylline</p> Signup and view all the answers

    Aorto-bifemoral graft is commonly used for treating __________ syndrome.

    <p>Leriche</p> Signup and view all the answers

    Match the following graft types with their descriptions:

    <p>Reversed saphenous vein graft = Natural graft material PTFE graft = Synthetic graft material Iliac block = Site of grafting Femoral block = Site of grafting</p> Signup and view all the answers

    Study Notes

    Amputation Techniques

    • Below Knee: Transmetatarsal amputation is used when several toes are affected.
    • Below Knee Amputation: The preferred method is the long posterior flap, where the anterior mark is 10 cm below the tibial tuberosity.
    • Above Knee Amputation: Should not be less than 20 cm below the knee.
    • Complications: Early complications include hemorrhage, infection, flap necrosis, and DVT. Late complications include pain and phantom limb.

    Raynaud's Phenomenon

    • A condition characterized by episodic vasospasm of digital vessels.
    • Phases of Raynaud's Phenomenon:
      • Phase 1: Arterial and venous spasm, resulting in white hands.
      • Phase 2: Arterial relaxation with continued venous spasm, leading to blue and painful hands.
      • Phase 3: Arterial and venous relaxation, resulting in red hands.

    Abdominal & Thoraco-Abdominal Aneurysm

    • Aneurysm: Dilatation of a vessel.
    • Types of Aneurysms: Fusiform.
    • Vessels Involved: Circle of Willis, infrarenal abdominal aorta, popliteal artery, splenic artery.
    • Mycotic Aneurysm: Most commonly associated with S.aureus infection in the aorta.

    Abdominal Aortic Aneurysm

    • Location: Most commonly found in the infrarenal abdominal aorta.
    • Risk Factor: Atherosclerosis.

    Critical Diameter

    • (Less by 0.5 cm in females)
      • Abdominal aortic aneurysm: 5.5 cm
      • Ascending thoracic aortic aneurysm: 5.5 cm or 0.5 cm increase in size per year.
      • Descending thoracic aortic aneurysm: 6 cm.
      • Thoracic aortic aneurysm in Marfan patients: 4.5-5 cm.

    Clinical Features

    • Often Asymptomatic
    • Abdominal pain
    • Pulsatile mass
    • Blue Toe Syndrome: Gangrene due to emboli blocking toe vessels.

    Rupture

    • Most commonly occurs in the left retroperitoneum.
    • Presents with shock.
    • 50% mortality rate.

    Investigations

    • Screening: Ultrasound (USG)
    • Diagnostic: CT Angiography

    Management

    • Conservative Management:
      • Blood pressure control
      • Lipid-lowering agents
      • Smoking cessation.

    Chronic Arterial Occlusion

    • Caused by swelling of muscles.
    • Compartment Syndrome: Presents with pain, specifically pain on passive flexion. Management involves fasciotomy.
    • Distal Runoff: Structures distal to the blockage are nourished by collaterals.
    • Clinical Features:
      • Intermittent Claudication: Cramping pain after walking a certain distance, known as the claudication distance.
      • Rest Pain: Relieved by hanging the leg down from the bed at night.
      • Gangrene:
      • Walking/Exercise: Increased demand for blood cannot be met due to arterial blockage.

    Differential Diagnosis

    • Intermittent Claudication: Cramping pain after walking, usually in one muscle group lower than the blockage. Progresses to rest pain.
    • Osteoarthritis: Maximum pain on the first step, primarily affecting the affected joint.
    • Neurogenic Claudication: Pain varies with posture and is relieved when the patient bends forward.

    Open Graft Surgery

    • Mattox Maneuver: Rotation of the left colon medially to expose the aorta.
    • Cattell-Braasch Maneuver: Right medial visceral rotation (ascending colon medially) to expose the IVC.
    • Kocherization: Mobilization of the duodenum.

    Complications of Aneurysm Surgeries

    • Cardiovascular: Most common cause of death.
    • Renal Failure:
    • Aorto-duodenal Fistula: Rare cause of upper GI bleeding usually detected with CT angiography.
    • Colonic Ischemia: Mostly affects the left side of the colon. Symptoms include bloody diarrhea.
    • Paraparesis: Damage to the anterior spinal artery (supplied by the artery of Adamkiewicz).
    • Mortality: Elective repair: 2-3%. Ruptured aneurysm: 50%.

    Overview of Instruments

    • ABPI (Ankle Brachial Pressure Index):
      • Decreases > 20% after exercise: Indicates arterial disease.
      • < 0.5: Twice more likely to deteriorate than those with > 0.5.
      • Gradually decreasing ABPI: Sign of imminent limb loss.
      • Every 0.1 decrease in ABPI: Increases the risk of cardiac mortality by 10%.

      • 1.4: Associated with diabetic mellitus, calcified vessels, and chronic renal failure.

    • TBI (Toe Brachial Pressure Index):
      • Digital arteries are more resistant to sclerosis.
      • TBI + ABPI: Reliable for large vessel occlusions in diabetic patients.
      • < 0.6: Significant arterial lesion.
    • DSA (Digital Subtraction Angiography):
      • Provides dynamic arterial flow information.
      • Potential complications: Bleeding, thrombosis, aneurysm, dissection, renal dysfunction.
      • Indication: Intervention is planned.

    Causes of Chronic Arterial Occlusion

    • Buerger's disease
    • Atherosclerosis

    Buerger's disease vs Raynaud's Disease

    • Buerger's Disease (Thromboangitis obliterans): Primarily affects men in their 3rd-4th decade. Risk factors include smoking. Affects small to medium arteries.
    • Atherosclerosis: Affects both men and women, typically in the 5th decade. Risk factors include stress, smoking, alcohol, and dyslipidemia. Affects medium to large arteries.

    Boyd's Classification

    • Class 1: Pain upon starting to walk but decreases as the individual keeps walking (due to washout of substance P)
    • Class 2: Pain on walking but the patient continues to walk despite the pain.
    • Class 3: Pain necessitates stopping walking.
    • Class 4: Pain at rest.

    Symptoms based on Location

    • Aortoiliac Obstruction: Claudication in the buttocks, thighs, and calves. Femoral and distal pulses absent in both limbs. Bruit over the aortoiliac region. Impotence (Leriche syndrome)
    • Iliac Obstruction: Unilateral claudication in the thigh and calf, sometimes the buttock. Bruit over the iliac region. Unilateral absence of femoral and distal pulses.
    • Femoropopliteal Obstruction: Unilateral claudication in the calf. Femoral pulse palpable with absent unilateral distal pulses. Femoral & popliteal pulses palpable.
    • Distal Obstruction: Ankle pulses absent. Claudication in calf and foot.

    Complications

    • Arterial Ulcer: Punched-out ulcer, loss of pulsation, loss of muscle mass.
    • Shiny skin/loss of hair
    • Sensations intact

    Investigations

    • Duplex scan (IOC):
    • ABPI (Ankle brachial pressure index):
      • 0.9-1.4: Normal
      • < 0.9: Intermittent claudication
      • < 0.4 : Chronic limb threatening ischemia (CTLI) - Ischemic rest pain +/- ulceration/gangrene. Requires urgent revascularization

    Primary v/s secondary Raynaud's

    • Primary Raynaud's: Common, not associated with autoimmune disease, no antinuclear antibodies, no microangiopathy in periungueal capillaroscopy, no family history of Raynaud's, no pharmacological treatment needed (rarely). No complications (rarely)
    • Secondary Raynaud's: Rare, associated with autoimmune rheumatic diseases (Aird), presence of antinuclear antibodies (ANA), microangiopathy in periungueal capillaroscopy (PUC), no family history of Raynaud's (occasionally), frequently requires pharmacological treatment. Complications are possible.

    Triggers for Primary Raynaud's

    • Cold
    • Vibrating tools
    • Heavy machinery

    Management

    • DOC: CCBS (Calcium channel blockers)

    Differential Diagnosis

    • Acrocyanosis: Seen in females, painless, not episodic, mottled cyanosis followed by paraesthesia.

    Subclavian Steal Syndrome

    • Stenosis: In the first part of the subclavian artery.
    • Etiology: Thrombus or thoracic outlet obstruction.
    • Pathophysiology (during exercise): Retrograde blood flow from the basilar/vertebral artery leading to decreased perfusion to the brain, resulting in syncopal attacks.

    Management

    • Angioplasty

    Gangrene

    • Macroscopic and microscopic death of tissue.

    Types of Gangrene

    • Dry Gangrene: Tissue desiccation due to gradual slowing of blood.
    • Wet Gangrene: Venous blockade or super-added infection.

    Amputation

    • Indications:
      • Gangrene
      • Gas gangrene
      • Soft tissue sarcoma
      • Contractures
    • Key Points:
      • Local digit amputation: Used in diabetic patients.
      • Ray excision: Indicated when the MTP joint is involved.

    Buerger's Disease Management

    • Cessation of smoking:
    • Pentoxyphylline: Reduces viscosity
    • Conservative Amputations:
    • Lumbar Sympathectomy: Reduces rest pain

    Atherosclerosis Management

    • Angioplasty (endovascular stenting): First-line treatment
    • Bypass Graft: Used if stenting fails.

    Angioplasty

    • Procedure: Balloon inflated for 30 seconds, then deflated.
    • Success: More likely to be successful in above knee vessels than below knee vessels.
    • Complications:
      • Failure
      • Hematoma
      • Bleeding
      • Thrombosis

    Grafting

    • Aorto-bifemoral graft: Indicated for Leriche syndrome (blockage at aortic bifurcation)
    • Types
      • Site: Iliac block, femoral block, ilio-popliteal grafting.
      • Materials:
        • Natural: Reversed saphenous vein graft
        • Synthetic: PTFE graft

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    Description

    This quiz covers critical topics related to amputation techniques such as below knee and above knee procedures, as well as complications associated with these surgeries. It also addresses Raynaud's phenomenon and abdominal aneurysms, highlighting their phases and characteristics. Test your knowledge on these important medical subjects!

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