General Surgery
Vascular Surgery
MBBS surgery notes on vascular disease: peripheral arterial disease, acute limb ischaemia, aortic aneurysm and varicose veins, mapped to NMC codes SU27.1 to SU27.8.
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Vascular Surgery
MBBS surgery notes on vascular disease: peripheral arterial disease, acute limb ischaemia, aortic aneurysm and varicose veins, mapped to NMC codes SU27.1 to SU27.8.
This chapter covers arterial and venous surgical disease. It spans peripheral arterial disease and acute limb ischaemia, abdominal aortic aneurysm, carotid disease, varicose veins and venous thromboembolism.
High-yield: Vascular Surgery
- Peripheral arterial disease causes intermittent claudication, cramping calf or thigh pain on walking that is relieved by rest.
- Critical limb ischaemia gives rest pain, tissue loss or gangrene and threatens the limb.
- The six features of acute limb ischaemia are pain, pallor, pulselessness, paraesthesia, paralysis and perishing cold.
- Acute limb ischaemia is an emergency and the limb is at risk after about six hours of complete ischaemia.
- The ankle brachial pressure index quantifies limb perfusion; a value below 0.9 indicates arterial disease.
- A falsely high ankle brachial index can occur with calcified, incompressible vessels in diabetes.
- An abdominal aortic aneurysm is defined as an aortic diameter of 3 cm or more and is often asymptomatic until it ruptures.
- A ruptured abdominal aortic aneurysm classically presents with the triad of pain, hypotension and a pulsatile abdominal mass.
- Elective aneurysm repair is generally considered when the diameter reaches about 5.5 cm or grows rapidly.
- Carotid artery stenosis can cause a transient ischaemic attack or stroke, and symptomatic tight stenosis may need endarterectomy.
- Varicose veins result from incompetent valves and venous hypertension in the superficial venous system.
- Chronic venous insufficiency causes ankle swelling, haemosiderin pigmentation, lipodermatosclerosis and venous ulcers over the medial malleolus (the gaiter area).
- Deep vein thrombosis presents with a swollen, tender, warm calf and is diagnosed with compression ultrasound.
- The Virchow triad of stasis, endothelial injury and hypercoagulability explains the risk of venous thrombosis.
- Diabetic foot ulcers arise from a combination of neuropathy, ischaemia and infection and need multidisciplinary care.
Arterial versus venous limb disease
- **Chronic arterial:** Intermittent claudication, rest pain, cool pulseless foot; ankle brachial index below 0.9.
- **Acute limb ischaemia:** The six Ps: pain, pallor, pulselessness, paraesthesia, paralysis and perishing cold; limb-threatening emergency.
- **Chronic venous:** Ankle swelling, pigmentation and ulcers over the medial malleolus in the gaiter area.
- **Aortic aneurysm:** Diameter 3 cm or more; repair around 5.5 cm; ruptures with pain, hypotension and a pulsatile mass.
NMC competencies in this chapter
- **SU27.1:** Peripheral arterial disease and intermittent claudication
- **SU27.2:** Acute limb ischaemia and its management
- **SU27.3:** Abdominal aortic aneurysm
- **SU27.4:** Carotid artery disease and stroke prevention
- **SU27.5:** Varicose veins and chronic venous insufficiency
- **SU27.6:** Deep vein thrombosis and venous thromboembolism
- **SU27.7:** Diabetic foot and lower limb ulcers
- **SU27.8:** Investigations and principles of vascular surgery
Frequently Asked Questions
What are the six Ps of acute limb ischaemia?
Pain, pallor, pulselessness, paraesthesia, paralysis and perishing cold. Paraesthesia and paralysis are late signs, and the limb is threatened after about six hours.
What does the ankle brachial pressure index show?
It compares ankle and arm systolic pressures to quantify limb perfusion. A value below 0.9 indicates arterial disease, though it can be falsely high in calcified diabetic vessels.
When is an abdominal aortic aneurysm repaired electively?
Generally when the diameter reaches about 5.5 cm, when it grows rapidly or when it becomes symptomatic, balancing the risk of rupture against the risk of surgery.
Where do venous ulcers typically occur?
Over the medial malleolus in the gaiter area, associated with pigmentation and lipodermatosclerosis from chronic venous hypertension.
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