Oxford Medical Handbooks- Oxford Handbook of Clinical Surgery
Notes on vascular surgery based on lecture notes and covers all the content in oxford clinical handbook of surgery. Contains information about clinical features of each condition, as well as relevant diagnostic tests and investigations, risk factors, causes and management guidelines.
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Chronic Limb Ischaemia and Peripheral Vascular Disease
Peripheral vascular disease
Stenotic +/- atherosclerotic disease of peripheral arteries producing symptoms + signs of ischaemia
Peripheral infra-renal aorta to the feet
Common in elderly population but only 1-2% develop critical limb ischaemia
Mild: intermittent claudication, pain relieved by rest
Mod: short distance claudication < 100m
Severe: v. short distance claudication, nocturnal pain
Rest pain, ulceration/tissue loss critical
limb ischaemia
History: Typical CV risk factors, associated with IHD,
ischaemic stroke
- Intermittent claudication
o Claudication distance is the same
every time
o Worse up hill or walking fast
o Relieved by rest
o Calf, thigh, buttock muscle groups affected depending on level of PVD
o Unilateral/bilateral symptoms – one limb almost always worse than other
- Red flag symptoms
o Very short distance claudication < 50m
o Nocturnal foot pain
Neuro-ischaemic pain ( BP at night hydrostatic pressure)
Patient awoken by pain – needs to hang foot out of bed/get up and walk around
o Pain at rest (in foot) – typically requires opiate analgesia
o Ulceration or tissue loss
Examination
- Appearance
o Dry, shiny, thin skin
o Loss of hair
o Loss of muscle bulk
o Thickened nails
o Ulcers – toe and pressure areas
o Necrosis/tissue loss
- Pulses: femoral, popliteal, dorsalis pedis, posterior tibial
o Palpable foot pulses? Not significant PVD
o Beware of the easily palpable popliteal pulse ?popliteal artery aneurysm
- Handheld Doppler
o Monophasic signal PVD
- Ankle Brachial Pressure Index
o > 1.2 Upper limb PVD or incompressible vessles e.g. infra-popliteal Ca2+ in DM
o ? Absolute pressure
o < 0.9 PVD
o ABPI < 0.3 or absolute pressure < 40mmHg ~ critical limb ischaemia
- Buerger’s sign (a) – significant lower limb ischaemia – cold, red foot
o Elevating the foot results in significant pallor and venous guttering
, o Lowering the foot results in dependent rubor ‘redness’
o Foot becomes cyanotic ‘sunset’ foot
- Arterial ulcers (b)
o ‘Punched out’
o Occur at toes or pressure points
o Painful
o Associated with severe PVD and signs
- Necrosis/tissue loss threatened limb (c)
Differentials
1. Arthritis
a. Joint stiffness in am + symptoms worse at end of day
b. Good days and bad days
2. Spinal stenosis
a. Relieved by sitting down/leaning forwards
3. Sciatica/lumbar spine radiculopathy
a. Paraesthesia at toes in dermatomal distribution
b. Posterior thigh symptoms – not quads
c. Symptoms at rest/in bed/positional
d. Only proximal symptoms
If patient gets pain at rest it isn’t claudication
Management
1. Best medical therapy
a. Stop smoking
b. Anti-platelet (aspirin/clopidogrel)
c. ? Aspirin + low dose rivaroxaban
d. Statin
e. Diabetic glycaemic control
f. BP control
g. Exercise – 30 mins walking x3/week
Investigations
- Arterial duplex
o Non-invasive but time consuming and not available OOH
o Operator dependent
o Calcification obscures view esp in infra-popliteal disease
o Poor views of distal aorta/iliac arteries due to bowel gas
- MR angiogram – gives view of lumen of vessels but not much information about walls
o Not available OOH, contraindications with metalwork
, o Patients with eGFR < 30 may develop nephrogenic systemic fibrosis (gadolinium contrast)
which may be fatal
- CT angiogram
o Available OOH, may result in contrast induced nephropathy
o Calcification may make imaging more difficult
- Catheter angiogram – ‘gold standard’ but invasive
o Digital subtraction angiogram – only artery can be seen
Infra-popliteal disease
Typically affects diabetics – develop severe PVD and calcification below the knee
- Often co-existing peripheral neuropathy – unnoticed trauma
- Ulceration complicated by infection
- May not have claudication but may present with tissue loss/ulceration +/- infection
- O/E
o Femoral + popliteal pulses but no PT/DP
o Unreliable ABPI due to incompressible vessels from calcium
Treatment
- Angioplasty or distal bypass
o Fem-distal bypass
Bypass between common femoral a. and one of the 3 below knee arteries using
great saphenous vein
Typically ipsilateral GSV in reversed configuration
Non-reversed/insitu GSV can be used but valves must be removed
If insufficient GSV can take contralateral GSV/upper limb vein and splice the vein
Prosthetic bypass can be performed using dacron/PTFE +/- vein cuff
- Debridement or drainage of infection
Femoral-popliteal disease
Superficial femoral a./popliteal a.
- Calf claudication
- Claudication critical limb ischaemia
- Femoral pulse only, no popliteal pulse or distal pedal pulses
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