Vascular Surgery

Clinical assessment of leg ulcer:
Features
Venous
Arterial
Neurotrophic
Traumatic
Malignant
Site
·       Gaiter area:70%
·       Lateral:20%
·       Circumferential:5%
·       Malleoli
·       Heel
·       Metatarsal heads
·       5 MT base
·       Pressure area
·       Site of trauma
·       Face
·       Lips
·       Tongue
Size/shape
·       Large shallow
·       Vertically oval
·       Small deep
·       Variable
·       Variable
·       Variable
Margin
Irregular
Regular
Regular
Edge
Sloping
Punched out
Sloping
Everted/rolled
Floor
Granulation
Slough/necrosis
Slough
Variable
Black mass

 

·       Venous Leg Ulcer:
o   Common in elderly
o   Result of chronic venous hypertension
o   Persistent inflammation
o   Hemosiderin deposits
o   Lipodermatosclerosis
·       Arterial Ulcer:
o   Reduced blood supply
o   Ischemia, necrosis
o   Little exudate
o   Atrophic skin
o   Common in diabetes
o   Pain
·       Diabetic Foot Ulcer:
o   Common in diabetes
o   Hyperglycemia
o   Micro/macro-angiopathy
o   Neuropathy
o   Infection
o   Foot deformities
·       Pressure Sore:
o   Area of tissue necrosis
o   Caused by prolonged soft tissue compression
o   Local ischemia, moisture
o   Multi-morbid and elderly
Arterial Ulcer
Sx
Pain w/ rest & elevation
PEx
·       Sharply demarcated
·       No discharge or granulation tissue
·       Distal fingers
·       Sorrounding skin shows PVD, shiny, and loss of hair
Dx
Clx
Tx
·       Wound care w/ debridement if needed
·       Re-vascularization if needed
Peripheral Vascular Dz
Screen Shot 2019-08-13 at 9.39.23 AM
Acute Limb Ischemia
Acute limb ischemia
Cause
·       Cardiac/arterial embolus (e.g., AF, LV thrombus, IE)
·       Arterial thrombosis (e.g., PVD)
·       Iatrogenic/blunt trauma
Clx
6Ps of acute limb ischemia
·       Pain
·       Pallor
·       Paresthesias
·       Pulselessness
·       Poikilothermia (cool extremity)
·       Paralysis (late)
Tx
·       Anticoagulation (e.g., heparin)
·       Thrombolysis versus surgery

Acute limb ischemia:

≈ MI of limb

  • Acute
  • Cath → cholesterol thrombus

Path:

A Fib → thrombus/embolism

PVD → thrombus

Pt:

6 Ps

  • Pain
  • Pallor
  • Paresthesias
  • Pulselessness
  • Poikilothermia (Pared-بارد) (cool extremity)
  • Paralysis (late)

Dx:

1ْ  US Doppler → 2ْ ARTERIOGRAM

Tx:

W/ 6 hours → Embolectomy OR TPA

F/u → Compartment syndrome

 

_

Compartment syndrome:

(early pain + paresthesia → S/M Sx)

Common:

  • Pain out of proportion to injury
  • Pain ⤴️  on passive stretch
  • Rapidly increasing and tense swelling
  • Paresthesia (early)

Uncommon:

  • ⤵️ sensation
  • Motor weakness (hours)
  • Paralysis (late)
  • ⤵️ distal pulses (uncommon)
Extremity Vascular Trauma
Clx
Hard signs:
·       Observed bleeding
·       Presence of bruit/thrill over injury
·       Expanding hematoma
·       Sign of distal ischemia
Soft signs ∆:
·       Diminished pulses
·       Bony injury
·       Neurologic 🆎
Tx
If (hard) signs or HD unstable:
·       Surgical exploration
Otherwise:
·       CT scan or conventional angiography
·       Duplex Doppler ultrasound
____
Aorta
AAA
Aortic Dissection
S/S
·       Pulstile abdomenal mask,
·       Smoker
·       Incidentally found on CT.
·       >65 male
·       Atherosclerotic
·       HTN
·       TEARING Chest pn radiating to back
·       Asymmetric BP in arms
·       Widened mediastinum
Dx
·       US
·       NOT CT
·       NOT ARTERIOGRAM
BEST? CT ARTERIOGRAM
NOT ARTERIOGRAM
Tx
Strategy:
If small AAA –> I will wait & screen.
If big AAA or growing fast, I shall operate.
A tender abdominal aortic aneurysm is going to rupture within a day or two, and thus immediate repair is indicated.
>3.5 cm –> screen q1 year
>4.5 cm –> screen q6 months
>5.5 / growin fast (0.5 per 6 m) –> SURGERY
Type A (Ascending): OR –> offer aortic valve replacement
Type B (Descending): IV BB

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