Surgery Marrow Pg 497-506 (Vascular Surgery)

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Questions and Answers

What is the primary causative organism for acute lymphangitis?

Escherichia coli

Streptococcus/Staphylococcus (correct)

Pseudomonas aeruginosa

Clostridium difficile

Surgery is the primary treatment for large cystic hygroma.

True

What is the main feature of lymphedema?

Excessive interstitial fluid (ISF)

Acute lymphangitis is characterized by pain and a __________ streak.

reddish Signup and view all the answers

Match the types of lymphedema with their characteristics:

Primary = Defective lymphatics/valves Secondary = Increased interstitial fluid production Post-surgical = Complication following surgery Infectious = Due to infection causing lymphatic damage Signup and view all the answers

What is a common complication associated with the use of the reversed great saphenous vein graft in CABG?

Saphenous nerve injury Signup and view all the answers

The Nicoladoni/Branham sign indicates an increase in pulse rate when pressing on the feeding vessel.

False Signup and view all the answers

What type of imaging is used in vascular surgery for patients requiring angiography?

MR angiography or Digital subtraction angiography (DSA) Signup and view all the answers

In coronary artery bypass grafting (CABG), a significant stenosis greater than 70% in a patient with significant anginal symptoms despite maximal medical therapy is an indication for _____ .

CABG Signup and view all the answers

Match the following grafts with their respective uses in CABG:

Reversed great saphenous vein = Most common graft used Left internal mammary artery (LIMA) = Used for left anterior descending artery (LAD) Right internal mammary artery (RIMA) = Alternative arterial graft Radial artery = Used in select patients for grafting Signup and view all the answers

What is the most common cause of carotid artery aneurysm?

Atherosclerosis Signup and view all the answers

Popliteal aneurysms are typically bilateral in 50% of cases.

True Signup and view all the answers

What is the management strategy for asymptomatic popliteal aneurysms larger than 2 cm?

Graft repair or EVAR Signup and view all the answers

A common presentation of carotid artery aneurysm is a transient ischemic attack (TIA), which is often considered the m/c ______.

presentation Signup and view all the answers

Match the aneurysm types to their management strategies:

Popliteal aneurysm = Graft repair/EVAR for asymptomatic >2 cm Femoral artery aneurysm = Surgical repair for 3 cm Carotid artery aneurysm = Carotid endarterectomy for ≥70% stenosis All aneurysms = Observation for asymptomatic cases Signup and view all the answers

What is the primary management option for a symptomatic cirsoid aneurysm?

Surgery Signup and view all the answers

Congenital A-V fistulas can occur due to conditions such as Parkes Weber syndrome.

True Signup and view all the answers

What is the most common cause of iatrogenic A-V fistula?

Cimino fistula Signup and view all the answers

A cirsoid aneurysm is located in the region of the ________ temporal vessels.

superficial Signup and view all the answers

Match the following investigations to their purposes:

CT angiography = Used to investigate A-V fistulas CXR = Used to check for cervical rib Modified Allen's test = Assesses artery patency Physiotherapy = Relieves neurological symptoms Signup and view all the answers

What type of aortic dissection does Type I of the DeBakey Classification involve?

Ascending and descending aorta Signup and view all the answers

Most cases of vascular surgery are more common in females than males.

False Signup and view all the answers

What is the initial investigation commonly performed for suspected aortic dissection?

Chest X-ray Signup and view all the answers

The most common symptom of vascular surgery is chest pain radiating to the __________.

back Signup and view all the answers

Match the following aortic dissection types with their corresponding features:

Type A = Involves the ascending aorta Type B = Limited to the descending aorta Type I = Involves both ascending and descending aorta Type III = Only descending aorta Signup and view all the answers

What is the gold standard for quantification of lymphedema?

Water plethysmography Signup and view all the answers

Lymphedema tarda presents at an early age, typically between 2-35 years.

False Signup and view all the answers

What is the incidence rate of post mastectomy lymphedema?

2-10% Signup and view all the answers

The ____ type of lymphedema is present at birth and can involve multiple limbs.

lymphdema congenita Signup and view all the answers

Match the type of lymphedema with its corresponding age of onset:

Lymphedema congenita = 0-2 years Lymphedema praecox = 2-35 years Lymphedema tarda = >35 years Signup and view all the answers

Which type of thoraco abdominal aortic aneurysm extends from the left subclavian to the aortic bifurcation?

Type 2 Signup and view all the answers

Marfan's syndrome is a known cause of thoraco abdominal aortic aneurysms.

True Signup and view all the answers

What is the critical diameter at which symptomatic thoraco abdominal aortic aneurysms typically require graft repair?

5.5 cm Signup and view all the answers

The common clinical feature associated with pressure symptoms in thoraco abdominal aortic aneurysms is __________.

Dysphagia Signup and view all the answers

Match the following types of thoraco abdominal aortic aneurysms with their respective locations:

Type 1 = Left subclavian to renal artery Type 2 = Left subclavian to aortic bifurcation Type 3 = Mid descending aorta to aortic bifurcation Type 4 = Upper abdominal aorta to infra-renal aorta Signup and view all the answers

What is the primary site commonly affected by cystic hygroma?

Neck Signup and view all the answers

The thoracic duct opens into the right internal jugular vein.

False Signup and view all the answers

At which gestational week does the lymphatic system begin to develop?

6-7 weeks Signup and view all the answers

Cystic hygroma commonly presents as a __________ swelling that is brilliantly transilluminant.

fluctuant Signup and view all the answers

Match the following features of cystic hygroma with their descriptions:

Partially compressible = Swelling can be pressed down partially Fluctuant = Contains liquid lymph Brilliantly transilluminant = Light passes through swelling clearly Common site = Most frequently found in the neck Signup and view all the answers

Which of the following is a symptom of brachial plexus compression in Thoracic Outlet Syndrome?

Neurological symptoms, primarily ulnar nerve dysfunction Signup and view all the answers

The ADSON test involves lowering the arm while turning the head away from the affected side.

False Signup and view all the answers

List one risk factor associated with Thoracic Outlet Syndrome.

Cervical rib, weak musculature, or trauma Signup and view all the answers

Subclavian artery thrombosis can lead to ______ which results in claudication.

emboli Signup and view all the answers

Match the test with its primary result:

ADSON test = Decrease or absence of ipsilateral radial pulse EAST test = Precipitates pain, paresthesias, heaviness or weakness ULTT = Symptoms on the ipsilateral side during positions 1 and 2 Paget-Schroetter syndrome = Swelling of the upper limb due to vein thrombosis Signup and view all the answers

What is a characteristic of Grade II Non-pitting Edema?

Edema does not pit and is associated with irreversible skin changes Signup and view all the answers

Stewart-Treves syndrome can occur after a duration of 8-10 years of untreated lymphedema.

True Signup and view all the answers

What are potential complications of lymphedema?

Infection, skin changes, cancer (Stewart-Treves syndrome) Signup and view all the answers

In the initial stage of lymphedema, the condition may present with a __________.

Buffalo Hump Signup and view all the answers

Match the stages of lymphedema with their descriptions:

Stage 1 = Initial stage; possibly with a Buffalo Hump Stage 2 = More advanced stage of swelling Stage 3 = More pronounced swelling Stage 4 = Significant swelling Signup and view all the answers

Study Notes

Vascular Surgery

502
- Features: Pulsatile swelling, congenital fistula
- Signs: Nicoladoni/Branham sign, High output cardiac failure (hyperdynamic state), Hypertrophy of limb
  - Nicoladoni/Branham sign: ↓ fistula size, ↓ pulse rate, ↑↑ SBP, ↓ bruit upon pressing feeding vessel
- Imaging: IOC: MR angiography/DSA
- Management: Embolization, surgery if contraindicated (infected patients or IV drug abusers)

Coronary Artery Bypass Grafting (CABG)

Indications:
- Left main disease >50%
- Three-vessel coronary artery disease >70% with or without proximal LAD involvement
- Two-vessel disease: LAD plus one other major artery
- One or more significant stenosis > 70% in a patient with significant anginal symptoms despite maximal medical therapy
- One vessel disease > 70% in a survivor of sudden cardiac death with ischemia-related ventricular tachycardia
CABG grafts:
- Reversed great saphenous vein (most common)
  - Complication: saphenous nerve injury
- LIMA-LAD: Left internal mammary artery for left anterior descending artery
- RIMA: Right internal mammary artery
- Radial artery

Vascular Surgery - 504

Management:
- IOC: FNAC
- Rx: surgery, Sclerotherapy for large cystic hygroma: ↓ size
Nerve injury during resection: Spinal accessory nerve

Acute Lymphangitis

Features: Acute infection of lymphatics, Causative organism: Streptococcus/Staphylococcus
C/F: Pain, Reddish streak
Management:
- Clinical diagnosis
- Rx: Antibiotics, Limb elevation, Pain control, Drainage if pus is present

Lymphedema

Excessive interstitial fluid (ISF)
Pathology: Inability of lymphatic system to clear ISF compartment
Types:
- Primary: Defective lymphatics/valves, Clearing defect
- Secondary: ↑ ISF production & Damage to lymphatics
  - 2° to inflammation, Post Surgery, Infection
Clinical Features: Pain (Dull or sharp), Swelling of the limb, Chronic: Skin changes

Other Types of Aneurysms

Popliteal aneurysm: Most common peripheral vessel aneurysm, 50% bilateral
- C/F: Swelling behind knee, Loss of contour
- Management: Graft repair/EVAR if asymptomatic >2 cm, Surgery if symptomatic (Pain, Emboli)
  - Investigations: Duplex/CT angiography
Femoral artery aneurysm: Cause: Puncture (blood draws/stenting procedures)
- Management: Surgical repair if > 3 cm
Carotid artery aneurysm: Site: Aortic bifurcation, Cause: Atherosclerosis (most common)
- C/F: Asymptomatic, Transient ischemic attack (TIA): most common presentation
- Management: Carotid end arterectomy for ≥ 70% stenosis
  - Indications:
    - I/L amaurosis fugax/mononuclear blindness
    - C/L facial paralysis
    - Arm/leg paralysis
    - Hemianopia
    - Dysphasia
  - Investigations: IOC: Duplex scan

Cirsoid Aneurysm

Description: Aneurysm in the region of superficial temporal vessels
C/F: Pulsatile swelling
Management: Surgery if symptomatic

A-V Fistula

Description: Abnormal communication between arteries and veins
Causes:
- Traumatic
  - Iatrogenic (most common): Cimino fistula, Radiocephalic fistula
  - Modified Allen's test done prior to creation (Radio ulnar patency)
- Congenital:
  - Parkes Weber syndrome
  - Sturge Weber syndrome
Investigations: IOC: CT angiography, CXR for cervical rib
Management:
- Cervical rib: Excision
- Relieve neurological symptoms: Physiotherapy, Arterial block: Stenting, Venous block: Anticoagulation

Vascular Surgery - 506

Presentation: Bluish/Reddish nodules in lymphedematous limb
Ix: Biopsy
Mx: Aggressive surgery (± Amputation)

Investigations for Quantification of Lymphedema

Gold Standard: Water plethysmography - measure amount of water displaced on limb immersion

Lymphedema Severity Levels

Level	Description	Mild	Moderate	Severe
Crude Limb Volume		< 20%	20-40%	>40%

Lymphedema Types

Type	Description	Age of onset	Gender preference	Other characteristics
Lymphedema congenita	Present at birth	0-2 years	M > F	Can involve multiple limbs, face, genitalia, often familial; Noone-Milroy syndrome
Lymphedema praecox	More common type	2-35 years; Peak at puberty	F > M	Usually unilateral, till the knee, often familial, Meig's disease
Lymphedema tarda	Rare type appearing later in life	>35 years	-	-

Causes of Secondary Lymphedema

Upper limb: Post mastectomy lymphedema
Lower limb: Filariasis

Post Mastectomy Lymphedema

Incidence 2-10%
Increased incidence due to:
- LN removal
- Radiotherapy to axilla
- LN above axillary vein resected
Onset: Weeks to months after surgery

Thoracic Aortic Aneurysm

Clinical Features:
- Most common symptom: Chest pain radiating to the back
- More common in males than females
- Patients are typically in their 50s
- Difference in blood pressure (BP) readings between upper limbs
- Difference in BP reading between the upper and lower limbs
- Mediastinal widening
Complications: Hypotension, Coronary insufficiency
Investigations:
- Initial Investigation: Chest X-ray (CXR): Mediastinal widening, Depression of the left main bronchus
- Stable: CT angiography
- Unstable: Transesophageal echocardiogram
Types:
- DeBakey Classification:
  - Type I: Commonly seen, Ascending and descending aorta
  - Type II: Only Ascending aorta
  - Type III: Only descending aorta
- Stanford Classification:
  - Type A: Involving ascending aorta
  - Type B: Limited to descending aorta
Management:
- Initial Step: Short-acting beta blocker (e.g., Esmolol or Nicardipine)
- Type I & II: Thoracotomy and graft repair
- Type III: Conservative management plus follow-up
- If the condition progresses: Surgery
- EVAR (Endovascular Aortic Repair)

Thoraco Abdominal Aortic Aneurysms

Classification: Crawford classification:
- Type 1: Left subclavian to renal artery
- Type 2: Left subclavian to aortic bifurcation (most extensive)
- Type 3: Mid descending aorta to aortic bifurcation
- Type 4: Upper abdominal aorta to infra-renal aorta
Causes:
- 2° to atherosclerosis
- Marfan's syndrome
Clinical features:
- Asymptomatic
- Pressure symptoms:
  - Ortner's syndrome: Hoarseness d/t pressure over left recurrent laryngeal nerve
  - Dysphagia
  - Dyspnea
Investigations:
- Screening: USG
- IOC: CT angiography
Management: Graft repair if symptomatic or ≥ critical diameter (5.5 cm)

Aortic Dissection

Pathology: Tear in the tunica intima → Creation of false lumen → Blood flows b/w tunica intima & media
Site: Lateral wall of ascending thoracic aorta (most common)
Risk factors: Complication of aneurysm, Triggered by Hypertension

Lymphatic System

Embryology & Development:
- Begins: 6-7 weeks of gestation
- 4 Cystic spaces: 1 on each side of neck (Jugular) & groin (Inguinal lymph sacs)
- Lower limbs + Abdominal lymphatics Via cisterna chyli
Anatomy:
- Head & Neck + Arm lymphatics Drain (Right IJV)
- Initial lymphatics (Endothelial capillaries) → Lymph trunks
- Valves partition lymphatics into segments: Lymphangions-contractile (Help movement of lymph)
  - Terminal lymphatics (Bicuspid valves)
- Thoracic duct opens into Left IJV at confluence with subclavian vein
- Involvement d/t GI/GU cancer
Mechanism of Lymph Flow:
- Muscular contraction → Pushes lymphatics
- Sequential contraction & relaxation of lymphangions
- Valves prevent reflux

Disorders of Lymphatics

Cystic Hygroma:
- Features: Sequestered lymphatic tissue
- Site:
  - Most common: Neck (Posterior triangle)
  - Others: Axillary, inguinal regions
- Note: Other transilluminant swellings:
  - Ranula (Oral cavity)
  - Hydrocele
  - Epididymal cyst
- Clinical Findings:
  - Partially compressible (vascular) swelling
  - Fluctuant
  - Brilliantly transilluminant
- Presentations:
  - Prenatal USG: Soft marker for chromosomal abnormalities
  - Obstructed labor
  - Respiratory distress
  - Infected

Brunner's Classification for Lymphedema

Grade	Interpretation
0 Subclinical (Latent)	There is excess interstitial fluid and histological abnormalities in lymphatics and lymph nodes, but no clinically apparent lymphedema.Edema pits on pressure, and swelling largely or completely disappears on elevation and bed rest.
1 Pitting Edema	Edema pits on pressure.
II Non-pitting Edema	Edema does not pit and does not significantly reduce upon elevation.Seen in long standing cases.Edema is associated with irreversible skin changes, i.e.fibrosis, papillae.

Complications of Lymphedema

Infection
Skin changes
Cancer: Stewart Treve's syndrome

Chronic Skin Changes in Lymphedema

Stage 1: Initial stage, possibly with a “Buffalo Hump"
Stage 2: More advanced stage of swelling
Stage 3: More pronounced swelling
Stage 4: Significant swelling

Stewart Treve's Syndrome

Pathology: Long standing (8-10 yrs), untreated lymphedema
Possible complication: Angiosarcoma
Other complications: Lymphedema post mastectomy, bluish/reddish nodules

Thoracic Outlet Syndrome

Risk factors:
- Cervical rib
- Weak musculature
- Trauma
Symptoms:
- Subclavian artery: Thrombus → Emboli → U/L claudication
- Subclavian/Axillary vein thrombosis: Swelling of upper limb (Paget-Schroetter)
- Brachial plexus compression: Neurological symptoms (most commonly ulnar nerve)

Tests and Results:

Test	Maneuver	Result
ADSON test	Affected arm is abducted 30° at the shoulder while maximally extended, while extending the neck and turning the head towards the ipsilateral shoulder, patient inhales deeply	Decrease or absence of ipsilateral radial pulse
Elevated Arm Stress Test (EAST) or ROOS	Arms are placed in the surrender position with shoulders abducted to 90° and in external rotation, with elbows flexed to 90°.Patient slowly opens and closes hand for 3 minutes.	Precipitates pain, paresthesias, heaviness or weakness
Upper Limb Tension Test (ULTT) or ELVEY	Position 1: Arms abducted to 90° with elbows flexed; Position 2: Active dorsiflexion of both wrists; Position 3: Head is tilted ear to shoulder, in both directions	Positions 1 and 2 elicit symptoms on the ipsilateral side while position 3 elicits symptoms on the contralateral side

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Description

This quiz covers essential features, signs, and imaging related to vascular surgery, including the management of conditions like congenital fistulas and cardiac issues. It also delves into the indications and grafts used in Coronary Artery Bypass Grafting (CABG), making it ideal for medical students and professionals. Test your knowledge on these critical surgical topics.