Kingdom of Bahrain Arabian Gulf University College of Medicine and Medical Sciences

1. Kingdom of BahrainArabian Gulf UniversityCollege of Medicine and Medical Sciences Subspecialty Surgery Vascular Surgery Ali Jassim Alhashli

2. Ulcers

3. Ulcers

4. Diabetic neuropathic ulcer: • There is loss of pressure sensation which is normally carried by dorsal column. Therefore, ulcer is formed. • Pressure sensation is examined by monofilament or tuning fork (to grade pressure sensation, there are different thickness fibers which can be used). Notice that when < 10 g of monofilament is lost → patient is a candidate to develop neuropathic ulcer at any time. • Common site: base of the big toe which sustains a pressure of 70 kg/cm2 compared to 7 kg/cm2 sustained by the heel. • Shape: round • Edge: punched-out. • Depth: deep. • Floor: granulation tissue or necrotic tissue or exposure of deep structures. • Discharge: purulent. • Wound is infected when there are signs of inflammation around it (swelling, tenderness, erythema and warmth) + purulent discharge. • Wagnar grading for diabetic ulcer: • What investigations would you order for a patient presenting with diabetic neuropathic ulcer? • Swab culture. • X-ray: looking for bone involvement. • If there is osteomyelitis, the following is seen with X-ray: periosteal elevation, cortical destruction and sequestrum. • Management: • Normal wound with granulation tissue: saline irrigation and simple dressing. • Necrotic wound: debridement. Ulcers

5. Ischemic ulcer (tissue loss): • Common sites: • Tip of the toes: because small arteries are affected first when there is hypoperfusion. • Web spaces: blood supply in these areas is weak because it is shared between two arteries. • Shape: round. • Depth: deep. • Edge: vertical/ punched-out. • Floor: presence of eschar (dead tissue) which is suggesting ischemia. • Discharge: little (serous) or absent. • Surrounding area: absent pulse, cold with intact sensations (sometime even sensations might be absent due to combined neuropathy with ischemia). • Regional lymph nodes: negative. • Venous ulcer: • Site: Gaiter’s area (area extending from just above the malleolus to below the knee) and tends to occur on both lateral and medial aspect of the leg. The importance of this area is because 95% of venous ulcers occur in it. • Shape: very irregular (healing from one side and breaking from the other). • Depth: shallow. • Floor: granulation tissue. • Discharge: minimum. • Surrounding area: intact pulse and sensations but dilated veins (varicose) might be present. Ulcers

6. Ulcers Ischemic ulcer Venous ulcer

7. Atherosclerosis affects tunica intima + 1/3 of tunica media (which are supplied by the blood itself while the rest of arterial wall layers are supplied by vasavasorum). A common site for atherosclerotic plaque is in superficial femoral artery. • Normal Ankle-Brachial Index (ABI) ranges from: 0.8 – 1.2 (in non-diabetics) and > 1 (in diabetics). • Clinical Presentation of Peripheral Vascular Disease (PVD): • Claudication: cramp-like pain felt in group of muscles usually the calf, initiated by exercise and relieved by rest. Why is the pain commonly felt in calf muscles? because when there is loss of blood supply distal most muscles will suffer first. Treatment of claudication “PACE”: • P: Pentoxifylline. • A: Aspirin. • C: Cessation of smoking. • E: Exercise. • Rest pain: pain in the foot over distal metatarsals which arise at rest (classically at night). • > 2 weeks: mild. • > 2 weeks: this is called limb-threatening ischemia in which the patient has rest pain for more than 2 weeks accompanied by gangrene/ulcer. • Tissue loss/gangrene (death of a tissue with rotting-caused by saprophyticus bacteria). • Absent pulse, shiny skin, no hair, thick toe nails and presence of ulcers. • Treatment for severe PVD: • Surgical graft bypass. • Angioplasty (balloon dilation). Peripheral Vascular Disease

8. Definition: acute occlusion of an artery usually by embolization (AFib) of common femoral artery. • If this condition can be reversed within 6 hours → the affected tissue can be saved. • Features of acute arterial occlusion (6 P’s): • Pain. • Parasthesia: it occurs before paralysis (pain and light touch sensations are lost first). How would you check for neural system when a patient presents to emergency department with suspected acute arterial occlusion? • Motor function: ask the patient to dorsiflex his foot. • Sensory function: check for pain and light touch. • Paralysis. • Pallor. • Poikilothermia. • Pulslessness. • Indication for A-gram when there is acute ischemia? not needed pre-operatively (because you have to manage the patient as quick as possible) but it is needed intra-operatively (to determine the exact location and extent of the lesion). • Treatment: thrombectomy/ embolectomy (with Fagorty balloon catheter). Remember not to jump to thrombolytic therapy unless: • Patient is not a candidate for surgery or anesthesia. • Development of a thrombus in already existing graft. • When there is irreversible tissue ischemia → amputation: • Patient is stable: wait for the line of demarcation to appear. • Patient is unstable: amputation is done at highest level. • Compartment syndrome is a serious complication of acute arterial occlusion (common in the leg): • Risk of developing compartment syndrome increases when patient presents to the hospital after 6 hours -of onset of ischemia- with tissue damage. Therefore, fasciotomy is done first followed by thrombectomy. • Normal compartment pressure is 2-3 mmHg. Compartment syndrome occurs when pressure exceeds 30 mmHg. Acute Arterial Occlusion

9. Definition: it is a localized dilation of an artery ≥ 50% of its diameter. • How to differentiate –by physical examination- between an aneurysm and a solid tumor overlying the artery? by placing two fingers over the mass: • Solid tumor: transmitted pulsation (your fingers move upwards). • Aneurysm: expansile pulsation (your fingers move outwards). • What are the features detected by physical examination which make you diagnose an aneurysm? • Expansile pulsation. • Compressibility and refilling when pressure is released. • Thrill on palpation. • Bruit on auscultation. • Description of an aneurysm: • Abdominal Aortic Aneurysm (AAA): • Average diameter of abdominal aorta is 2-3 cm (notice that it is smaller in females). • Laplace law is applied on pressure in an aneurysm in which wall tension increases proportionally with increased diameter of the aneurysm. • Commonest cause: atherosclerosis; commonest site: infrarenal. Aneurysms

10. Aneurysms • Clinical presentation of AAA: • 75% of patients are ASYMPTOMATIC at time of diagnosis. • If symptomatic: pain (most common), distal embolization or features of shock if there is rupture (risk factors for rupture: diastolic HTN, initially large size at diagnosis and COPD).  • Diagnosis: • Physical examination: periumbilical, palpable, pulsatile mass. • CT-scan or MRI (providing more details than CT). • Ultrasound: used for follow-up of aneurysm size over time (not assessment of acute phase). • Angiogram. • Intervention: • Repair is indicated when abdominal aortic aneurysm is ≥ 5.5 cm (this is when the risk of surgery is equal to the risk of rupture). • Types: • Open aortic repair: with re-wrapping of native aneurysm adventitia around the prosthetic graft. • Endovascular repair: repair by femoral catheter placed stents. • Leading cause for post-operative death in elective AAA repair: MI

11. Aneurysms

12. It is classified as being: • Deep Venous Thrombosis (DVT): it occurs when a thrombus forms in one or more of the deep veins in your body, usually your legs. It can cause leg pain/swelling but can also be asymptomatic. • Superficial thrombophlebitis: it is a common inflammatory-thrombotic disorder in which a thrombus develops in a vein located near the surface of the skin.  • What is Virchow’s triad of venous thromboembolism? • Stasis of blood. • Endothelial injury (if a vein stretches > 20% of its normal diameter, cracks develop in the endothelium and this is simply what happens when there is stasis of blood). • Hypercoagulability. • Risk factors: • Congenital: • Antiphospholipid antibody syndrome. • AT-III deficiency. • Plasminogen deficiency (decreased fibrinolysis). • Factor V Leiden. • Protein C and S deficiency. • Acquired: • Congestive heart failure and MI (20-40%). • Fractures of hip, pelvis and proximal femur (35-60%). • Join replacement operation (15-30%). • Others: malignancy, obesity, pregnancy, sepsis and prolonged immobility. • Most common site of venous thrombus formation is in deep veins of lower limbs (especially soleus plexus of veins). • Clinical features (30% of patients have sub-clinical DVT!): • Calf tenderness/pain (Homan’s sign is not very reliable and not recommended to be done once there is a high suspicion of DVT because this can dislodge the thrombus). • Edema/swelling. • Erythema and warmth. • Sometimes there might be dilated veins (varicose veins). Venous Thromboembolism

13. What are your differential diagnoses for a patient presenting to the hospital with a clinical picture suggestive of DVT? • Backer’s cyst rupture. • Muscle rupture and hematoma. • Cellulitis. • What investigations are you going to request for the patient? • Duplex ultrasound (report will state the following): femoral vein is non-compressible due to presence of a thrombus.  • How are you going to manage your patient? • Anticoagulation: • Start with heparin which has an immediate action (within 3 minutes). • Start warfarin at the same time. • When INR reaches 2.5, stop heparin and continue warfarin for 6 months. • What are the indications for the use of vena cava filter: • Contraindications for anticoagulation. • Recurrence of thromboembolism despite anticoagulation. Venous Thromboembolism

14. Etiology: • It occurs when there is venous hypertension (pressure in deep vein increases) due to damaged valves. • Clinical features: • Signs: different stages of varicose veins. • Symptoms: • Aching pain (which is especially felt by the end of the day). • Venous claudication. • Edema/swelling. • Investigations: • Duplex ultrasound which is going to show the following: • Status of deep veins. • Varicose veins. • Level of communication. • Management: • Graded-compression stocking (providing maximum pressure on the foot and as you ascend pressure decreases). • Elevation of the leg at night. • For stage C6 (varicose veins with ulceration): you provide 4 layer bandage followed by surgery. • Surgical repair (open technique) is done for stages > C4. Chronic Venous Insufficiency

15. Definition: it is the accumulation of proteinaceous fluid which causes swelling/edema in arms/legs. • Causes: • Primary: lack of development of lymphatics (dysplasia). • Secondary: • Infective: filariasis and bilharzia. • Inflammatory: lymphadenitis. • Malignancy: in which lymph nodes will be removed during surgery. • Traumatic. • Clinical classification of lymphedema (according to age): • > 2 years: congenital. • Praecox: detected during puberty until the 3rd decade of life. • Tarda: detected during adult life (+ 35 years). • What are the symptoms: • Feeling as though your clothes, rings, wristwatches or bracelets are too tight. • Feeling of fullness in your arms or legs. • Less flexibility in your wrists, hands and ankles. • What are the investigations which you will request for such patients? • Lymphangiography or the modern test lymphoscintigraphy which will show the following: • Aplasia. • Hypoplasia. • Hypotrophy. Lymphedema