Miss Kaji Sritharan
Specialist Registrar in General Surgery
Northwest Thames, London Deanery
Dec 2009
Common History Cases:
Lower Limb PVD
AAA
Carotid Disease
Short Cases
Varicose Veins
Establish:
Whether symptoms:
Acute
Acute on chronic
Chronic
Viability of the limb
Acute Limb Ischaemia
Pain
Pale or white
Perishingly cold
Pulseless
Paraesthesiae
Paralysis Dictates
urgency
Remember:
60% ‐ thrombotic occlusion of pre‐existing stenotic arterial segment
30% ‐ embolus (80% from left atrial appendage in assoc AF)
Blood tests
ECG
CXR
Echo
Abdominal U/S
Thrombophilia
screen
Arterial Duplex
DSA
Management
Management of of
Acute
Acute Limb
Limb Ischaemia
Ischaemia
Sensation
Sensation &&
Paralysis
Paralysis &
& Paraesthesia
Paraesthesia Movement
Movement
intact
intact
1.
1. Optimise
Optimise patient
patient
1.
1. Resuscitate
Resuscitate 2.
2. IV
IV heparin
heparin
2.
2. IV
IVheparin
heparin 3.
3. Arteriogram
Arteriogram –– plan
plan for
for bypass
bypass
3.
3. Urgent
Urgentsurgery
surgery––embolectomy/
embolectomy/bypass
bypass 4.
4. Observe
Observe limb
limb for
for deterioration
deterioration
History
Claudication
(?deteriorated)
Rest pain
Tissue Loss
Pain calf, thigh or buttock,
after walking predictable distance
resolution of pain after rest
Not while standing or sitting.
Pain in the toes/forefoot at rest.
Initially only at night, relieved by
dependency
Progresses to constant pain
Can occur in areas of tissue loss
elsewhere
Dry/wet gangrene, usually painful
NB: diabetic foot wounds (not
always painful)
Ulcers – can be of mixed aetiology
Amputations
‐ when and why? Diabetic? Was
revascularisation attempted
before?
Arterial Ulcers or Gangrene
OR
Rest pain of 2 weeks or more requiring Opiate
Analgesia
AND
Absolute Ankle Pressure < 50mmHg
or Toe Pressure <30mmHg
Do you smoke or have you ever smoked? If yes,
estimate pack year history, record how long cessation.
Are you diabetic? If yes, what do you use to control
your blood sugar levels?
Do you have, or take medicine to control, high
cholesterol or high blood pressure?
Have you ever suffered angina, had a heart attack,
treatment of heart disease (angioplasty or CABG)
Have you ever suffered a stroke or ministroke ʹTIAʹ.
Have any of your close family suffered from heart
disease or PVD?
Fitness for operation
à PMH: Co-morbidity
à Anaesthetic Hx
Rehabilitation potential
General approach
Inspect
- General
- Focussed: look for evidence of adequate or
inadequate perfusion
Palpate/Auscultate the major pulses to
work out the likely level of the problem
Wash/gel
Introduce
Permission
Explain
Position
Expose
Tender?
You must listen to the examiner as the
instructions may be more or less
explicit about what is required
Even if the instruction is to examine
the lower limbs you must make a
reference to how you would usually
start your examination at the hands
Look for clues around the bed
INSPECT FOR:
Nicotine staining
Pallor
Muscle wasting
Splinter haemorrhage
Venous guttering
Scars
Fistula
Tissue loss
PALPATE FOR:
Warmth
Capillary refill
Radial pulse
(AF? R-R delay?)
Ulnar pulse
Allen’s Test
Brachial pulse
Axillary pulse
Subclavian abnormality
Carotid bruit
Look
Colour
à mottling, marbled,
pallor, venous
guttering
Trophic changes
à hair loss, thin skin,
muscle atrophy
Scars
Amputations
Ulcers + Gangrene
Scars to note:
Carotid end‐arterectomy
CABG
Thoraco‐abdominal
Midline laparotomy
Vertical groin
Above‐knee medial
Below‐knee medial
LSV distribution
Lateral calf
Foot
Scars to note:
Fasciotomy
Feel
Temperature difference
CRT <2sec
Pulses
Femorals
Popliteals
Posterior Tibial
Dorsalis pedis
Auscultate
Bruits
Buergers Test/Angle
angle foot goes white
< 20 degrees – severe ischaemia
To Finish:
Examine Neuro lower limb + Fundoscopy
Examine the remainder Peripheral Vascular
System
Examine Abdomen AAA
Measure ABPIs
Dipstick Urine
ABPI Vascular status
1.0 Normal
0.5 – 0.8 Intermittent Claudication
< 0.5 Rest pain
>1.0 Incompressible in diabetics
(calcified vessels)
Absolute ankle pressure < 50 mmHg = critical ischaemia
Simple: Blood tests: Cholesterol,
HbA1c, U&E
Duplex Ultrasound
(CTA or MRA depending on local
skills)
Angiography (like cardiac like to
perform intervention at same sitting)
Management of
PVD
Intermittent Critical
claudicant ischaemia
Medical therapies Revascularisation Revascularisation Sepsis control
Encourage exercise Angioplasty +/- stenting Angioplasty +/- stenting Antibiotics + DM control
STOP SMOKING
Bypass procedure Bypass procedure Debridement
BP control
Statins & aspirin Amputation
Diabetic control
Watch retino/nephopathy
+ Medical therapies
Definition: necrosis of
tissue with mummification
or putrefaction
Types :
1. Dry – well demarcated, auto-
amputate
2. Wet – due to trauma, acute
ischaemia & infection. Poorly
demarcated and spreading.
Vascular (thrombosis, embolus, critical
ischaemia, Buerger’s disease, Raynaud’s
disease)
Diabetes
Trauma – cold, heat, pressure
Drug induced e.g. ergot poisoning
A. C.
B.
D.
Indications:
“DEAD, DYING OR
DANGEROUS”
Vascular (80‐90%)
Infection (Osteomyelitis, Gas gangrene)
Trauma (Burns, Frostbite)
Malignancy
Definition
Break in continuity of an epithelial surface
Aetiology
y Vascular (arterial, venous or mixed)
y Neuropathic
y Traumatic
y Malignant
Site
Size
Shape
Edge
Base
Depth
Surrounding Tissue
Site: overlies lateral malleolus
Edge: punched out
Base: deep; often lacks granulation tissue;
necrotic
Minimal exudate
Painful +/- cellulitis
Gangrene
Medical
‐ Pain control
‐ Optimise risk factors
‐ ?intravenous prostaglandins
‐ Antibiotics if infection
Surgical
‐ Debridement
(surgical,dressings,maggots)/amputation
‐ Improve blood supply
(lumbar sympathectomy, angioplasty, BPG)
Site: gaiter area; lower 3rd medial aspect leg
Shape: varies – can be very large, irregular
Edge: sloping and shallow
Base: often pink granulation tissue +/-
seropurulant discharge
Surrounding skin: induration, pigmentation,
lipodermatosclerosis
Painful
NB. Examine for VVs, check ABPI’s
Exclude arterial component
If mixed – correct arterial factor
Non-Surgical – high success (80-90% at 1 year)
Rest + elevate leg
Four layer compression bandaging
Once healed – grade II compression hosiery
Surgical
Exclude malignancy
Skin grafting if clean
Treat primary varicose veins
Site: pressure areas
Edge: even wound margins; callous
around ulcer
Base: granulation tissue present (unless
co-existing PVD); low to moderate
exudate
Absence of pain
Peripheral pulses present
Common: 10-20% population
Women > men
Definition
Tortuous, dilated, elongated veins of
the superficial venous system
Superficial veins
y Long saphenous vein (LSV)
y Short saphenous vein (SSV)
Deep veins
Perforator veins
Giacomini vein
Aetiology
Congenital Acquired
Valve Muscle pump Venous return
Incompetence Immobility Pregnancy
Deep vein thrombosis Abdo/ pelvic mass
Focussed history
‘Primary LSV' +/- signs at ankle
Ulcer of unknown aetiology
(venous/arterial/mixed)
Age, Occupation
How long have you had varicose veins?
How do your veins trouble you?
y Cosmesis
y Swelling – typically end of day
y Aching
y Pruritis
y Cramps
y Ulcers +/- infection - periostitis
Age
Female
Family history (uncertain as to why!!!)
Pregnancy (impaired venous return as well as hormonal effect on vein wall)
PMH of DVT or long bone fracture
Contributing factors: HRT, OCP, obesity, sedentary lifestyles, and
professions that require prolonged standing or sitting
Listen to the examiner’s instructions
Wash/gel
Introduce
Consent
Explain
Position/Expose
Pain or tenderness anywhere?
Inspect front and back for:
Obvious varicosities and their distribution
Signs (skin changes) at the ankle/calf
Signs of previous surgery
Saphenovarix
- Assess for cough
impulse
Feel
- Tap test
- Temperature
- Tethering
Tourniquet test versus Trendelenberg test
¾ GIVE CLEAR INSTRUCTIONS
Elevate the limb, milk the veins
Apply tourniquet to upper thigh
Immediate filling of veins, release the tourniquet
and tell the examiner:
'the filling of the varicose veins is not controllable at
the level of the SFJ'
OR
Veins not immediately filled, very slow filling =
undo the tourniquet and tell the examiner:
'the filling of the varicose veins is controlled at the
level of the SFJ'
Auscultate the varicosities that do not empty
lying flat ‘machinery murmur’ of AVM
Offer to palpate lower limb pulses +/- ABPIs
Perthes test
Offer to perform Abdo/Pelvic/Scrotal/rectal
examinations
Wash hands, ensure patient re-covered
Hand held
doppler
Duplex imaging
Venography
Abdo/Pelvis
ultrasound
Please examine this patients superficial
venous system in the lower limb.
Trendelenberg
and tourniquet
test positive
How would you treat varicose veins?
Leg elevation
Regular walking to improve calf muscle
pump
Class II support stockings – above or below
knee
Skin changes require - 4 layer bandaging
(Charing cross)
Eczema – topical emolliants
Thrombophlebitis – NSAIDs
Open Surgery:
- High tie and strip – ligation of SFJ
+/- avulsions – removal of varicosities
Foam injections
Sclerotherapy:
- 1% Sodium tetradecyl sulphate
EVLT or VNUS
Accumulation fluid in interstitium
due to problem with lymphatic
drainage
Typically bilateral and non-pitting
Aetiology:
y Primary: Milroy’s disease
y Secondary:
○ Lymphadenectomy
○ Malignancy
○ Post radiotherapy
○ Infections: Filiarisis
