Podcast
Questions and Answers
What is the primary causative organism for acute lymphangitis?
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.
Surgery is the primary treatment for large cystic hygroma.
True (A)
What is the main feature of lymphedema?
What is the main feature of lymphedema?
Excessive interstitial fluid (ISF)
Acute lymphangitis is characterized by pain and a __________ streak.
Acute lymphangitis is characterized by pain and a __________ streak.
Match the types of lymphedema with their characteristics:
Match the types of lymphedema with their characteristics:
What is a common complication associated with the use of the reversed great saphenous vein graft in CABG?
What is a common complication associated with the use of the reversed great saphenous vein graft in CABG?
The Nicoladoni/Branham sign indicates an increase in pulse rate when pressing on the feeding vessel.
The Nicoladoni/Branham sign indicates an increase in pulse rate when pressing on the feeding vessel.
What type of imaging is used in vascular surgery for patients requiring angiography?
What type of imaging is used in vascular surgery for patients requiring angiography?
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 _____ .
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 _____ .
Match the following grafts with their respective uses in CABG:
Match the following grafts with their respective uses in CABG:
What is the most common cause of carotid artery aneurysm?
What is the most common cause of carotid artery aneurysm?
Popliteal aneurysms are typically bilateral in 50% of cases.
Popliteal aneurysms are typically bilateral in 50% of cases.
What is the management strategy for asymptomatic popliteal aneurysms larger than 2 cm?
What is the management strategy for asymptomatic popliteal aneurysms larger than 2 cm?
A common presentation of carotid artery aneurysm is a transient ischemic attack (TIA), which is often considered the m/c ______.
A common presentation of carotid artery aneurysm is a transient ischemic attack (TIA), which is often considered the m/c ______.
Match the aneurysm types to their management strategies:
Match the aneurysm types to their management strategies:
What is the primary management option for a symptomatic cirsoid aneurysm?
What is the primary management option for a symptomatic cirsoid aneurysm?
Congenital A-V fistulas can occur due to conditions such as Parkes Weber syndrome.
Congenital A-V fistulas can occur due to conditions such as Parkes Weber syndrome.
What is the most common cause of iatrogenic A-V fistula?
What is the most common cause of iatrogenic A-V fistula?
A cirsoid aneurysm is located in the region of the ________ temporal vessels.
A cirsoid aneurysm is located in the region of the ________ temporal vessels.
Match the following investigations to their purposes:
Match the following investigations to their purposes:
What type of aortic dissection does Type I of the DeBakey Classification involve?
What type of aortic dissection does Type I of the DeBakey Classification involve?
Most cases of vascular surgery are more common in females than males.
Most cases of vascular surgery are more common in females than males.
What is the initial investigation commonly performed for suspected aortic dissection?
What is the initial investigation commonly performed for suspected aortic dissection?
The most common symptom of vascular surgery is chest pain radiating to the __________.
The most common symptom of vascular surgery is chest pain radiating to the __________.
Match the following aortic dissection types with their corresponding features:
Match the following aortic dissection types with their corresponding features:
What is the gold standard for quantification of lymphedema?
What is the gold standard for quantification of lymphedema?
Lymphedema tarda presents at an early age, typically between 2-35 years.
Lymphedema tarda presents at an early age, typically between 2-35 years.
What is the incidence rate of post mastectomy lymphedema?
What is the incidence rate of post mastectomy lymphedema?
The ____ type of lymphedema is present at birth and can involve multiple limbs.
The ____ type of lymphedema is present at birth and can involve multiple limbs.
Match the type of lymphedema with its corresponding age of onset:
Match the type of lymphedema with its corresponding age of onset:
Which type of thoraco abdominal aortic aneurysm extends from the left subclavian to the aortic bifurcation?
Which type of thoraco abdominal aortic aneurysm extends from the left subclavian to the aortic bifurcation?
Marfan's syndrome is a known cause of thoraco abdominal aortic aneurysms.
Marfan's syndrome is a known cause of thoraco abdominal aortic aneurysms.
What is the critical diameter at which symptomatic thoraco abdominal aortic aneurysms typically require graft repair?
What is the critical diameter at which symptomatic thoraco abdominal aortic aneurysms typically require graft repair?
The common clinical feature associated with pressure symptoms in thoraco abdominal aortic aneurysms is __________.
The common clinical feature associated with pressure symptoms in thoraco abdominal aortic aneurysms is __________.
Match the following types of thoraco abdominal aortic aneurysms with their respective locations:
Match the following types of thoraco abdominal aortic aneurysms with their respective locations:
What is the primary site commonly affected by cystic hygroma?
What is the primary site commonly affected by cystic hygroma?
The thoracic duct opens into the right internal jugular vein.
The thoracic duct opens into the right internal jugular vein.
At which gestational week does the lymphatic system begin to develop?
At which gestational week does the lymphatic system begin to develop?
Cystic hygroma commonly presents as a __________ swelling that is brilliantly transilluminant.
Cystic hygroma commonly presents as a __________ swelling that is brilliantly transilluminant.
Match the following features of cystic hygroma with their descriptions:
Match the following features of cystic hygroma with their descriptions:
Which of the following is a symptom of brachial plexus compression in Thoracic Outlet Syndrome?
Which of the following is a symptom of brachial plexus compression in Thoracic Outlet Syndrome?
The ADSON test involves lowering the arm while turning the head away from the affected side.
The ADSON test involves lowering the arm while turning the head away from the affected side.
List one risk factor associated with Thoracic Outlet Syndrome.
List one risk factor associated with Thoracic Outlet Syndrome.
Subclavian artery thrombosis can lead to ______ which results in claudication.
Subclavian artery thrombosis can lead to ______ which results in claudication.
Match the test with its primary result:
Match the test with its primary result:
What is a characteristic of Grade II Non-pitting Edema?
What is a characteristic of Grade II Non-pitting Edema?
Stewart-Treves syndrome can occur after a duration of 8-10 years of untreated lymphedema.
Stewart-Treves syndrome can occur after a duration of 8-10 years of untreated lymphedema.
What are potential complications of lymphedema?
What are potential complications of lymphedema?
In the initial stage of lymphedema, the condition may present with a __________.
In the initial stage of lymphedema, the condition may present with a __________.
Match the stages of lymphedema with their descriptions:
Match the stages of lymphedema with their descriptions:
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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
- Reversed great saphenous vein (most common)
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
- Indications:
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
- Traumatic
- 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
- DeBakey Classification:
- 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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