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Surgery Topics: Arteries, Veins & Lymphatics
🔴 ARTERIES
1. Arterial Occlusion (Acute)
Sudden occlusion of an artery is usually caused by an embolus. It may also occur when thrombosis develops on an atherosclerotic plaque, though the outcome is less dramatic because collateral vessels may have developed in chronic stenosis.
Classic presentation - The 5 Ps of Acute Limb Ischaemia (ALI):
- Pain
- Pallor
- Paraesthesia
- Paralysis
- Pulselessness
Management: Emergency embolectomy (Fogarty balloon catheter), anticoagulation with heparin, or thrombolysis. Key: differentiate embolism (sudden, no collaterals) vs. thrombosis on atheroma (prior claudication history, collaterals present).
- Bailey and Love's Short Practice of Surgery 28th Edition
2. Ischaemic Artery Disease (Chronic)
Progressive narrowing of arteries due to atherosclerosis leading to chronic limb ischaemia. Stages:
- Mild: asymptomatic
- Intermittent claudication (pain on walking, relieved by rest)
- Rest pain (Fontaine stage III)
- Tissue loss / gangrene (Fontaine stage IV)
Measured by Ankle-Brachial Pressure Index (ABPI): Normal >0.9; claudication 0.5-0.9; critical ischaemia <0.5.
3. Aneurysm
Definition: Localised dilatation of an artery with ≥50% increase in diameter (below 50% = ectatic).
Types:
- True aneurysm - contains all 3 arterial wall layers (intima, media, adventitia)
- False (pseudo) aneurysm - single layer of fibrous tissue; occurs after trauma or arterial puncture
Shapes: Fusiform (spindle-shaped, most common) vs. Saccular (outpouching on one side)
Aetiology: Atherosclerotic (most common), traumatic, mycotic (infective - caused by bacteria, not fungi), inflammatory
Common sites: Abdominal aorta (AAA - most common), popliteal, femoral, iliac, splenic arteries
Complications: Rupture (life-threatening), thrombosis, embolism, pressure on adjacent structures
Management of AAA: Elective repair when >5.5 cm; emergency surgery for rupture
- Bailey and Love's Short Practice of Surgery 28th Edition
4. Embolism
An embolus is an object carried in the bloodstream from another site that lodges in a vessel and causes obstruction.
Sources of arterial emboli:
- Left atrium in atrial fibrillation (most common)
- Left ventricular mural thrombus after myocardial infarction
- Vegetations on heart valves (infective endocarditis)
- Thrombi in aneurysms
- Atherosclerotic plaques
Sites and effects:
- Arm/leg: acute limb ischaemia (5 Ps)
- Brain: TIA or stroke (middle cerebral artery most common)
- Retina: amaurosis fugax (fleeting blindness)
- Mesenteric: bowel ischaemia/infarction
Treatment: Embolectomy, anticoagulation, thrombolysis
- Bailey and Love's Short Practice of Surgery 28th Edition
5. Thrombosis (Arterial)
Formation of a clot within an artery, usually on an atherosclerotic plaque. Unlike embolism, thrombosis is in situ - the vessel has pre-existing disease so collaterals may be present, making onset less dramatic.
Virchow's Triad (applies to all thrombosis):
- Stasis of blood flow
- Endothelial injury (vessel wall damage)
- Hypercoagulability (changes in blood constituents)
Treatment: Anticoagulation, thrombolysis, bypass surgery, or angioplasty depending on severity.
6. Atherosclerosis
The fundamental pathological process underlying most arterial disease. It involves:
- Fatty streaks → atherosclerotic plaques in the intima
- Plaque contents: lipid core, foam cells, inflammatory cells, fibrous cap
- Complications of plaque: stenosis, occlusion, ulceration, thrombosis, embolism, calcification
Risk factors (modifiable): Smoking, hypertension, diabetes, hyperlipidaemia, obesity
Risk factors (non-modifiable): Age, male sex, family history
Common sites: Aorta, coronary arteries, carotid arteries, lower limb arteries
7. Gangrene
Definition: Death of macroscopic portions of tissue, turning black due to breakdown of haemoglobin and formation of iron sulphide. Usually affects the most distal part of a limb due to arterial obstruction.
| Feature | Dry Gangrene | Wet Gangrene |
|---|---|---|
| Cause | Gradual arterial occlusion (atheromatous) | Superadded infection + putrefaction |
| Appearance | Desiccated, mummified | Swollen, oedematous, foul-smelling |
| Crepitus | Absent | Present (gas-forming organisms) |
| Urgency | Less urgent | Surgical emergency |
| Common in | Peripheral vascular disease | Diabetic foot |
Management: Dry gangrene - wait for demarcation then amputation; Wet gangrene - emergency debridement or amputation, IV antibiotics, control diabetes.
- Bailey and Love's Short Practice of Surgery 28th Edition
8. Thromboangiitis Obliterans (Buerger's Disease)
Definition: An inflammatory occlusive disease affecting small and medium-sized limb arteries AND veins, characterised by thrombosis.
Key features:
- Occurs almost exclusively in young male smokers (typically <45 years old)
- Affects upper and lower limbs
- Associated with superficial thrombophlebitis (migratory)
- Associated with Raynaud's syndrome
- Histology: inflammatory changes in arterial and venous walls leading to thrombosis
Clinical: Rest pain, finger/toe ischaemia, gangrene, ulceration
Treatment: Total abstinence from smoking (arrests but does not reverse the disease). Established occlusions treated as atheromatous disease. Amputations may be eventually required.
- Bailey and Love's Short Practice of Surgery 28th Edition
9. Raynaud's Disease
Definition: Idiopathic condition of abnormal arteriolar sensitivity to cold, usually in young women, affecting hands more than feet.
Classic triphasic colour change:
- White (pallor) - arteriolar constriction, digits go numb
- Blue (cyanosis) - capillaries dilate, fill with deoxygenated blood
- Red (rubor) - arterioles relax, oxygenated blood returns; associated with pain
Raynaud's Disease vs. Raynaud's Syndrome:
- Disease = idiopathic (no underlying cause), bilateral, young women
- Syndrome = secondary to another condition (scleroderma, SLE, Buerger's, vibration tools, cervical rib, drugs)
Treatment: Protection from cold, avoid smoking; calcium channel blockers (nifedipine); sympathectomy in severe cases
- Bailey and Love's Short Practice of Surgery 28th Edition
🔵 VEINS
10. Venous Thrombosis
Clot formation within a vein - Virchow's triad applies (stasis, endothelial injury, hypercoagulability).
11. Thrombophlebitis (Superficial Vein Thrombosis)
Thrombosis of superficial veins with inflammation.
Causes:
- External trauma (especially to varicose veins)
- IV cannula left >24-48 hours
- Hyperosmolar IV solutions
- Systemic diseases: Buerger's disease, malignancy (pancreatic cancer - "thrombophlebitis migrans" - affects different veins at different times)
- Coagulation disorders: polycythaemia, thrombocytosis, sickle cell disease
Features: Solid, tender vein on palpation; overlying skin may be erythematous then turns brown; a palpable cord
Management: NSAIDs, compression stockings, low-molecular weight heparin (LMWH) if extensive
- Bailey and Love's Short Practice of Surgery 28th Edition
12. Deep Vein Thrombosis (DVT)
Thrombosis occurring in the deep veins (commonly calf, popliteal, femoral, iliac).
Risk factors (Virchow's triad):
- Stasis: prolonged immobility, long-haul flights, bed rest, heart failure
- Hypercoagulability: malignancy, pregnancy, OCP, thrombophilia (Factor V Leiden, antiphospholipid syndrome)
- Endothelial injury: surgery, trauma
Clinical features: Calf pain, swelling, warmth, erythema; Homan's sign (unreliable)
Investigations: D-dimer, Doppler ultrasound / duplex scan
Treatment:
- LMWH (low molecular weight heparin) rapidly, then oral anticoagulation
- NOACs (Novel Oral Anticoagulants): rivaroxaban or apixaban (Factor Xa inhibitors), dabigatran (direct thrombin inhibitor) - equally effective as warfarin, less bleeding risk
- Duration: minimum 3 months (longer if recurrent or persistent risk factors)
- IVC filter if anticoagulation contraindicated
- Endovascular techniques for iliofemoral DVT to prevent post-thrombotic syndrome
Feared complication: Pulmonary embolism (PE) - treated with anticoagulation; massive PE may need thrombolysis or catheter embolectomy
- Bailey and Love's Short Practice of Surgery 28th Edition
13. Varicose Veins
Tortuous, dilated, elongated superficial veins due to incompetent valves in the saphenofemoral or saphenopopliteal junctions or perforating veins, leading to reversed venous flow.
Risk factors: Female sex, pregnancy, prolonged standing, obesity, family history, deep vein thrombosis
Complications: Thrombophlebitis, venous eczema, lipodermatosclerosis, bleeding, venous ulceration
Investigations: Duplex ultrasound (gold standard), Trendelenburg test, tourniquet test
Treatment:
- Conservative: compression stockings, leg elevation, weight loss
- Endovenous thermal ablation (laser/radiofrequency) - first-line
- Foam sclerotherapy
- Surgery: high ligation and stripping
14. Venous Ulcer
Key facts: Venous disease accounts for ~85% of chronic lower limb ulcers.
Pathophysiology: Sustained venous hypertension → leukocyte trapping in capillaries → inflammatory mediator release → tissue damage and ulceration. Pericapillary fibrin "cuffs" impede oxygen diffusion.
Location: Typically on the gaiter area (medial lower leg, above medial malleolus)
Features: Shallow, irregular borders, wet/weeping base, surrounding lipodermatosclerosis, varicose eczema, haemosiderin pigmentation
Mixed ulcers: 15-30% of venous ulcers have concomitant arterial disease - always check ABPI before applying compression.
Management: Four-layer compression bandaging (ABPI >0.8), wound dressings, treat underlying venous disease
- Bailey and Love's Short Practice of Surgery 28th Edition
🟢 LYMPHATICS
15. Lymphangiography
Definition: Radiological technique for imaging the lymphatic vessels and lymph nodes using contrast dye injected into lymphatics (usually in the web space of the foot/hand).
Indications: Investigation of lymphoedema, staging of lymphoma, evaluation of chylous fistulae
Largely superseded by: CT/MRI lymphangiography, lymphoscintigraphy, and PET-CT
16. Lymphoedema
Definition: Accumulation of protein-rich fluid in the interstitium due to inadequate lymphatic drainage.
Types:
| Type | Cause |
|---|---|
| Primary | Congenital lymphatic hypoplasia; Milroy's disease (congenital), Meige's disease (onset at puberty) |
| Secondary | Malignancy, surgical lymph node removal, radiotherapy, infection (filariasis - most common worldwide), trauma |
Features: Non-pitting oedema (in chronic stages), Stemmer's sign (inability to pinch skin at base of second toe), "buffalo hump" appearance, elephantiasis in severe cases
Complications: Recurrent cellulitis, skin changes, malignant transformation (Stewart-Treves syndrome - angiosarcoma)
Management: Conservative (complex decongestive therapy - CDT, compression garments, skin care, exercise); surgical (liposuction, lymphovenous anastomosis)
17. Lymphomas
Malignant neoplasms of lymphoid tissue. Broadly divided into Hodgkin and Non-Hodgkin lymphomas.
18. Hodgkin's Lymphoma (HL)
Hallmark: Reed-Sternberg (RS) cells - large binucleate cells with prominent "owl-eye" nucleoli; CD15+, CD30+
Age: Bimodal distribution - young adults (15-35 years) and elderly (>55 years)
Presentation:
- Painless cervical lymphadenopathy (most common)
- B symptoms: fever, night sweats, weight loss (>10%) - indicates worse prognosis
- Mediastinal mass
- Pel-Ebstein fever (cyclical fever)
- Alcohol-induced pain in lymph nodes (characteristic but rare)
Staging (Ann Arbor): Stage I-IV based on number of node regions involved and side of diaphragm
Types (WHO): Nodular sclerosis (most common, young women), mixed cellularity, lymphocyte-rich, lymphocyte-depleted
Treatment: ABVD chemotherapy (Adriamycin/doxorubicin, Bleomycin, Vinblastine, Dacarbazine) ± radiotherapy
Prognosis: Excellent - >90% cure rate in early disease
19. Non-Hodgkin's Lymphoma (NHL)
Broader group of lymphoid malignancies - B-cell or T-cell origin. No Reed-Sternberg cells.
More common than HL; more extranodal involvement
Common types:
- Diffuse Large B-Cell Lymphoma (DLBCL) - most common aggressive NHL
- Follicular lymphoma - most common indolent NHL
- Mantle cell lymphoma
- Marginal zone lymphoma
Features: Lymphadenopathy (may be widespread), B symptoms, splenomegaly, constitutional symptoms
Treatment: R-CHOP (Rituximab + Cyclophosphamide, Hydroxydaunorubicin, Oncovin/vincristine, Prednisolone) for aggressive B-cell lymphomas
20. Burkitt's Lymphoma
A highly aggressive B-cell Non-Hodgkin lymphoma.
Key associations:
- t(8;14) translocation - c-MYC oncogene overexpression (pathognomonic)
- Epstein-Barr virus (EBV) - in endemic (African) form
Types:
| Type | Feature |
|---|---|
| Endemic (African) | EBV-positive, jaw/facial bone mass in children, "starry sky" histology |
| Sporadic | Ileocaecal region (presents as abdominal mass), common in young adults |
| Immunodeficiency-associated | HIV patients |
Histology: "Starry sky" pattern - macrophages engulfing apoptotic tumour cells (tingible-body macrophages)
Treatment: High-intensity chemotherapy (aggressive multi-agent); very fast-growing (doubling time ~24 hours) but potentially curable
21. Cutaneous T-Cell Lymphoma (CTCL)
Most common type: Mycosis fungoides / Sézary syndrome
Features:
- Pruritic, scaly skin patches → plaques → tumours
- Sézary syndrome = leukaemic variant with circulating Sézary cells (atypical T-cells) in blood
Treatment: Topical steroids, phototherapy (PUVA), systemic agents (bexarotene, interferon), bone marrow transplant in advanced disease
22. Chylous Ascites
Definition: Accumulation of chyle (lymph + dietary fat = milky/turbid fluid) in the peritoneal cavity due to disruption of the thoracic duct or abdominal lymphatics.
Causes: Malignancy (lymphoma - most common in adults), surgical injury, trauma, cirrhosis, tuberculosis, filariasis
Diagnosis: Paracentesis - milky fluid; triglyceride >200 mg/dL (confirms chyle)
Management: Low-fat diet with MCT (medium-chain triglycerides) which bypass intestinal lymphatics; total parenteral nutrition (TPN); octreotide; surgical repair or TIPS (transjugular intrahepatic portosystemic shunt)
- Bailey and Love's Short Practice of Surgery 28th Edition
23. Chylothorax
Definition: Presence of chyle in the pleural space due to disruption of the thoracic duct.
Causes: Surgical (post-thoracic surgery / oesophagectomy - most common), trauma, malignancy (lymphoma), idiopathic
Diagnosis: Pleural fluid triglycerides >110 mg/dL; milky appearance; lymphocyte-predominant
Management:
- Conservative: low-fat diet / TPN + octreotide
- Thoracic duct ligation (surgical)
- VATS (video-assisted thoracoscopic surgery) ligation or pleurodesis
24. Sarcoidosis
Definition: A systemic granulomatous disease of unknown aetiology characterised by non-caseating granulomas in multiple organs, most often the lungs and lymph nodes.
Key features:
- Bilateral hilar lymphadenopathy (BHL) - classic chest X-ray finding
- Erythema nodosum (tender, red nodules on shins)
- Skin: lupus pernio (violaceous skin plaques)
- Eyes: uveitis, keratoconjunctivitis sicca
- Lofgren's syndrome (acute): BHL + erythema nodosum + arthritis (good prognosis)
- Elevated serum ACE (angiotensin-converting enzyme)
- Hypercalcaemia (granulomas produce 1,25-dihydroxyvitamin D)
Management: Steroids (prednisone) for symptomatic/organ-threatening disease; methotrexate for steroid-sparing
25. Acute Lymphangitis
Definition: Bacterial infection spreading through the lymphatic channels, presenting as red streaks tracking proximally from a wound or infection site (typically cellulitis).
Causative organisms: Streptococcus pyogenes (most common), Staphylococcus aureus
Features:
- Red linear streaks running along the lymphatics toward regional lymph nodes
- Tender regional lymphadenopathy
- Fever, malaise, leukocytosis
- The infected limb has pain, swelling and warmth
Management: IV antibiotics (penicillin / amoxicillin-clavulanate), elevation of the limb, treat the primary wound/infection
- Bailey and Love's Short Practice of Surgery 28th Edition
26. Acute Lymphadenitis
Definition: Acute inflammation of lymph nodes, usually due to bacterial or viral infection draining into those nodes.
Causes:
- Reactive: any local infection (bacterial > viral)
- Staphylococcus aureus and Streptococcus (most common bacteria causing suppurative lymphadenitis)
Features:
- Enlarged, tender, warm lymph nodes
- May progress to abscess formation (suppurative lymphadenitis) - fluctuant node
- Fever and systemic symptoms
Management:
- Antibiotics for bacterial cause
- Incision and drainage (I&D) if abscess has formed
- Biopsy if malignancy suspected (persistent, hard, non-tender nodes)
- Robbins, Cotran & Kumar Pathologic Basis of Disease
Quick Summary Table
| Topic | Category | Key Feature | Management |
|---|---|---|---|
| Arterial occlusion | Artery | 5 Ps of ALI | Embolectomy / heparin |
| Ischaemic artery disease | Artery | Claudication, ABPI | Angioplasty / bypass |
| Aneurysm | Artery | ≥50% dilatation | Repair if >5.5 cm (AAA) |
| Embolism | Artery | AF → limb ischaemia | Embolectomy |
| Thrombosis | Artery/Vein | Virchow's triad | Anticoagulation |
| Atherosclerosis | Artery | Plaque → stenosis/occlusion | Risk factor control |
| Gangrene | Artery | Black necrotic tissue | Debridement / amputation |
| Buerger's disease | Artery+Vein | Young male smoker | Stop smoking |
| Raynaud's disease | Artery | White-blue-red colour change | Nifedipine |
| Thrombophlebitis | Vein | Superficial, tender cord | NSAIDs, LMWH |
| DVT | Vein | Leg swelling, PE risk | LMWH + NOACs x 3 months |
| Varicose veins | Vein | Incompetent valves | Laser ablation / surgery |
| Venous ulcer | Vein | Gaiter area, medial malleolus | Compression bandaging |
| Lymphangiography | Lymph | Imaging lymphatics | Diagnostic/staging |
| Lymphoedema | Lymph | Non-pitting oedema | CDT, compression |
| Hodgkin's lymphoma | Lymph | Reed-Sternberg cells | ABVD chemo |
| Non-Hodgkin's lymphoma | Lymph | No RS cells, extranodal | R-CHOP |
| Burkitt's lymphoma | Lymph | t(8;14), EBV, starry sky | High-intensity chemo |
| Cutaneous T-cell lymphoma | Lymph | Skin patches/plaques | PUVA, topical steroids |
| Chylous ascites | Lymph | Milky ascites, high TG | Low-fat diet / TPN |
| Chylothorax | Lymph | Milky pleural fluid | TPN + duct ligation |
| Sarcoidosis | Lymph | Non-caseating granulomas, BHL | Steroids |
| Acute lymphangitis | Lymph | Red streaks up limb | IV antibiotics |
| Acute lymphadenitis | Lymph | Tender swollen nodes | Antibiotics / I&D |
All content sourced primarily from Bailey and Love's Short Practice of Surgery, 28th Edition, supplemented by Robbins & Kumar Pathologic Basis of Disease and Goldman-Cecil Medicine.
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