Vascular Surgery

• Peripheral arterial disease (PAD) refers to the narrowing of the arteries supplying the limbs and periphery, reducing the blood supply to these areas.
• Peripheral arterial disease usually refers to the lower limbs, resulting in symptoms of claudication.
• Intermittent claudication is a symptom of ischaemia in a limb, occurring during exertion and relieved by rest.
• Intermittent claudication typically causes a crampy, achy pain in the calf, thigh or buttock muscles associated with muscle fatigue when walking beyond a certain intensity.
• Critical limb ischaemia is the end-stage of peripheral arterial disease, where there is an inadequate supply of blood to a limb to allow it to function normally at rest.
• Critical limb ischaemia is characterised by pain at rest, non-healing ulcers and gangrene.
• Venous thromboembolism (VTE) is a common and potentially fatal condition that involves blood clots (thrombi) developing in the circulation, usually due to stagnation of blood and hyper-coagulable states.
• Pain in critical limb ischaemia is worse at night when the leg is raised, as gravity no longer helps pull blood into the foot.
• A thrombus that develops in the venous circulation is called a deep vein thrombosis (DVT).
• Acute limb ischaemia refers to a rapid onset of ischaemia in a limb.
• Acute limb ischaemia is typically due to a thrombus (clot) blocking the arterial supply of a distal limb, similar to a thrombus blocking a coronary artery in myocardial infarction.
• Once a thrombus has developed, it can travel (embolise) from the deep veins, through the right side of the heart and into the lungs, where it becomes lodged in the pulmonary arteries, blocking blood flow to areas of the lungs and is called a pulmonary embolism (PE).
• Ischaemia refers to an inadequate oxygen supply to the tissues due to reduced blood supply.
• If the patient has a hole in their heart (for example, an atrial septal defect), the blood clot can pass through to the left side of the heart and into the systemic circulation.
• Necrosis refers to the death of tissue.
• If the blood clot travels to the brain, it can cause a large stroke.
• Gangrene refers to the death of the tissue, specifically due to an inadequate blood supply.
• There are several factors that can put patients at higher risk of developing a DVT or PE, including immobility, recent surgery, long haul travel, pregnancy, hormone therapy with oestrogen (combined oral contraceptive pill and hormone replacement therapy), malignancy, polycythaemia, systemic lupus erythematosus, and thrombophilia.
• Thrombophilias are conditions that predispose patients to develop blood clots.
• Varicose veins are distended superficial veins measuring more than 3mm in diameter, usually affecting the legs.
• Reticular veins are dilated blood vessels in the skin measuring less than 1-3mm in diameter.
• Atherosclerosis is a combination of atheromas (fatty deposits in the artery walls) and sclerosis (the process of hardening or stiffening of the blood vessel walls).
• Atherosclerosis affects the medium and large arteries.
• Atherosclerosis is caused by chronic inflammation and activation of the immune system in the artery wall.
• Lipids are deposited in the artery wall, followed by the development of fibrous atheromatous plaques.
• Stiffening of the artery walls, leading to hypertension and strain on the heart, is a feature of atherosclerosis.
• Stenosis, leading to reduced blood flow, is another feature of atherosclerosis.
• Plaque rupture, resulting in a thrombus that can block a distal vessel and cause ischaemia, is also a feature of atherosclerosis.
• Atherosclerosis risk factors can be divided into modifiable and non-modifiable risk factors.
• Non-modifiable risk factors for atherosclerosis include older age, family history, male gender, and medical co-morbidities such as diabetes, hypertension, chronic kidney disease, inflammatory conditions, atypical antipsychotic medications, and others.
• Modifiable risk factors for atherosclerosis include smoking, alcohol consumption, poor diet, low exercise/sedentary lifestyle, obesity, poor sleep, stress, and medical co-morbidities.
• End results of atherosclerosis can include angina, myocardial infarction, transient ischaemic attack, stroke, peripheral arterial disease, chronic mesenteric ischaemia, intermittent claudication, and others.
• Peripheral arterial disease presents with intermittent claudication, characterised by a crampy pain that predictably occurs after walking a certain distance, and after stopping and resting, the pain will disappear.
• Leriche syndrome occurs with occlusion in the distal aorta or proximal common iliac artery.
• Telangiectasia refers to dilated blood vessels in the skin measuring less than 1mm in diameter.
• Varicose veins, also known as spider veins or thread veins, contain valves that only allow blood to flow in one direction, towards the heart.
• Varicose veins are often asymptomatic or can cause symptoms such as a heavy or dragging sensation in the legs, aching, itching, burning, oedema, muscle cramps, restless legs, and signs and symptoms of chronic venous insufficiency.
• Special tests for varicose veins include the tap test, cough test, Trendelenburg’s test, and Perthes test.
• Varicose veins can be managed through simple treatment measures such as weight loss, staying physically active, keeping the leg elevated when possible, compression stockings, endothermal ablation, sclerotherapy, and stripping.
• Complications of varicose veins can include prolonged and heavy bleeding after trauma, superficial thrombophlebitis, deep vein thrombosis, all issues of chronic venous insufficiency, and more.