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SURGERY EXAM NOTES: VASCULAR DISEASES

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SECTION 5: ARTERIAL DISEASE

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a. Investigations in Arterial Disease

• Ankle-Brachial Index (ABI): Ratio of highest systolic BP at ankle to highest systolic BP at arm. Measured with a hand-held Doppler probe.

  • 0.90 = Normal

  • 0.71-0.90 = Mild obstruction
  • 0.41-0.70 = Moderate obstruction
  • 0.00-0.40 = Severe obstruction
• Continuous-wave Doppler: Detects flow velocity, direction and quality of signal (triphasic = normal; monophasic = severe disease)
• Treadmill exercise testing: Exposes claudication; post-exercise ABI drop confirms PAD
• Duplex ultrasonography: Combines B-mode imaging with Doppler flow analysis; maps stenosis and occlusion; identifies false aneurysms and DVT

• Digital Subtraction Angiography (DSA): Gold standard for PAD; defines anatomy, site and extent of occlusion, collateral flow and "run-off" before surgery. Needs iodinated contrast; risk of contrast nephropathy (~0.1% severe allergy)
• CT Angiography (CTA): Non-invasive, high resolution 3D reconstruction of vessels
• MR Angiography (MRA): No ionizing radiation; good for renal failure patients (gadolinium, not iodine)
• Intraoperative arteriography / flow measurement: Confirms patency after repair

• Full blood count, ESR, lipid profile, blood glucose, HbA1c, renal function, coagulation screen
• ECG and echocardiogram (assess cardiac source of emboli)
• Chest X-ray

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b. Assessment of a Case of Peripheral Vascular Disease (PVD)

• Claudication: Pain in calf, thigh, or buttock on walking; relieved by rest (< 2 min). Note: walking distance, progression
• Rest pain: Severe, burning pain in foot/toes at night; relieved by hanging foot down
• Ulceration / gangrene
• Risk factors: smoking (2-3x more likely than for CAD), diabetes, hypertension, hyperlipidaemia, age >65, family history
• Co-existing disease: cardiac, cerebrovascular, renal

• Inspect: skin - pallor, cyanosis, dependent rubor, loss of hair, trophic nail changes, ulcers, gangrene
• Palpate: temperature (cool), capillary refill, pulses (femoral, popliteal, posterior tibial, dorsalis pedis)
• Auscultate: bruits over aorta, iliacs, femorals
• Buerger's angle: limb raised - note angle at which pallor appears (<20° = severe ischaemia); dependent rubor on lowering = positive Buerger's sign
• ABPI measurement

• Lumbosacral root irritation
• Hip/knee arthritis (pain on weight-bearing, not walking distance-dependent)
• Chronic venous insufficiency
• Neurogenic claudication (spinal stenosis - walking distance variable, relieved by sitting/flexion not just rest)

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c. Embolism

• Heart (most common): Atrial fibrillation (mural thrombus in LAA), recent MI, dilated cardiomyopathy, rheumatic valve disease, prosthetic valves, infective endocarditis
• Proximal aorta/iliac: Atherosclerotic plaques, aneurysm thrombus ("cholesterol embolism")
• Paradoxical embolism: Via patent foramen ovale from venous system
• Fat/air/amniotic fluid embolism (non-thrombotic)

1. Pain - sudden, severe
2. Pallor - cold, white
3. Pulselessness - distal pulses absent
4. Paraesthesia - "pins and needles" = early neurological sign
5. Paralysis - late, indicates irreversibility (muscle necrosis)
6. Perishing cold (Poikilothermia)

• Emergency: IV heparin immediately (5000 units bolus)
• Surgical embolectomy: Fogarty balloon catheter via femoral arteriotomy (within 4-6 hours ideally)
• Thrombolysis: Intra-arterial tissue plasminogen activator (tPA) for thrombosis or emboli in poor surgical candidates
• Post-procedure: Warfarin / DOAC long-term; treat source

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d. Thromboangiitis Obliterans (Buerger Disease)

• Young males, typically <35 years
• Heavy cigarette smokers (strongly associated; direct EC toxicity or immune response to tobacco antigens)
• Increased prevalence in Israel, India, Japan; associated with certain MHC haplotypes

• Segmental, thrombosing acute and chronic inflammation of tibial and radial arteries
• Thrombus contains micro-abscesses (neutrophils surrounded by granulomatous inflammation) - pathognomonic
• Extends to contiguous veins and nerves (unique - not seen in other vasculitides)
• Eventually all three structures encased in fibrous tissue

1. Raynaud phenomenon
2. Instep claudication (foot pain on exercise)
3. Superficial migratory nodular phlebitis

• Progresses to rest pain, ulceration, and digital gangrene
• Microangiography shows "corkscrew" collateral vessels (characteristic finding)

• Clinical: young male smoker + distal ischaemia + migratory phlebitis
• Exclude atherosclerosis (lipid profile, normal in TAO)
• Arteriography: segmental occlusions in small vessels, corkscrew collaterals
• No reliable serology

• Absolute cessation of smoking - only proven effective intervention
• Sympathectomy - may provide some relief
• Prostaglandins (iloprost) - vasodilation, some evidence
• Amputation inevitable if smoking continues

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e. Arteriosclerosis

1. Atherosclerosis - most common; intimal plaques
2. Monckeberg medial calcific sclerosis: Calcium deposits in the media of muscular arteries (not intima); does not narrow lumen; vessels palpable as "pipestem"; not usually clinically significant
3. Arteriolosclerosis: Affects small arteries/arterioles; two types:
   • Hyaline arteriolosclerosis: homogeneous pink hyaline thickening of wall; associated with benign hypertension and diabetes
   • Hyperplastic arteriolosclerosis: "onion-skin" concentric laminated thickening; associated with malignant hypertension

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f. Atherosclerosis and Aneurysms

Atherosclerosis

• Non-modifiable: Age, male sex, family history
• Modifiable: Smoking, hypertension, hyperlipidaemia, diabetes mellitus, obesity, sedentary lifestyle

1. Endothelial injury (shear stress, oxidised LDL, smoking, hypertension)
2. LDL enters intima, oxidised by free radicals
3. Monocyte recruitment → macrophages → engulf ox-LDL → foam cells → fatty streak
4. Smooth muscle cell migration from media, proliferation, collagen deposition → fibrous cap
5. Lipid core + fibrous cap = atheromatous plaque

• Calcification (stable)
• Ulceration / rupture → thrombosis (acute MI, stroke, acute limb ischaemia)
• Haemorrhage into plaque
• Aneurysm formation (weakening of media)
• Embolisation of plaque fragments

• Coronary: Angina, MI
• Cerebrovascular: TIA, stroke
• Peripheral: Claudication, rest pain, gangrene
• Renal: Renovascular hypertension
• Mesenteric: Intestinal angina

Aneurysms

• True aneurysm: Involves all three layers (intima, media, adventitia) - e.g. AAA, popliteal
• False (pseudo) aneurysm: Breach in all three layers, contained by perivascular tissue - e.g. post-traumatic, anastomotic
• Dissecting aneurysm: Blood tracks between layers of media - e.g. aortic dissection

• Fusiform (symmetric, circumferential)
• Saccular (asymmetric outpouching)

• Defined as aorta >3 cm; >5.5 cm = indication for repair
• 90% are infrarenal
• Cause: Atherosclerosis + proteolytic degradation of elastin/collagen
• Risk: Rupture (5-year risk: 25% if >5 cm, 30-40% if >7 cm)
• Symptoms: Pulsatile, expansile mass; back/flank pain; rupture = "haemodynamic collapse + abdominal pain + pulsatile mass" = EMERGENCY
• Investigation: USS screening; CT for planning
• Treatment: Elective open repair or EVAR (endovascular aneurysm repair)

• Most common peripheral aneurysm
• Complications: Thrombosis, embolisation, rupture
• Treatment: Bypass (with saphenous vein or Dacron)

• Similar natural history to popliteal
• Treatment: Primary repair with vein or Dacron interposition

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g. Gangrene

• Critical limb ischaemia: Defined by rest pain + ulceration/gangrene; ABI typically <0.40
• Tissue hypoxia → cell death → liquefaction necrosis (wet) or coagulative necrosis (dry)
• Demarcation line forms between viable and non-viable tissue

• Dry gangrene: Allow to autoamputate OR elective amputation after demarcation; revascularise if possible
• Wet/gas gangrene: Emergency; IV antibiotics, debridement, possible amputation; gas gangrene requires hyperbaric oxygen + high-dose penicillin

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h. Conservative Management of an Ischaemic Limb

• Stop smoking (single most important intervention)
• Control diabetes (target HbA1c <7%)
• Control hypertension (target <130/80)
• Statin therapy (lipid-lowering; also pleiotropic benefit on plaque stability)
• Control weight, encourage physical activity

• Supervised exercise programme: 30-45 min walking 3x/week for 3-6 months
• Improves claudication distance by stimulating collateral development and muscle oxidative capacity
• First-line before revascularisation for stable claudication

• Aspirin 75-100 mg/day OR clopidogrel 75 mg/day
• Reduces MI, stroke and vascular death (not directly claudication)

• Cilostazol (phosphodiesterase-3 inhibitor): Improves walking distance; also antiplatelet (first-line drug for claudication)
• Naftidrofuryl (5HT2 antagonist): Modestly improves claudication

• Only for acute limb ischaemia (heparin) or after bypass surgery
• Not routinely for claudication

• Regular inspection, nail care, avoid tight footwear
• Early treatment of infection
• Pressure-relieving footwear

• Rest pain: Opioids (morphine) short term; gabapentin for neuropathic component
• Elevation of head of bed (dependent position of foot reduces rest pain by gravity-assisted perfusion)

• Clean wound, offload pressure, control infection (systemic antibiotics)
• Wound debridement, silver dressings; negative pressure wound therapy

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i. Surgical Management - Direct Arterial Surgery

• Critical limb ischaemia (CLI) - rest pain, gangrene, non-healing ulcers
• Severe claudication unresponsive to conservative treatment
• Acute limb ischaemia

1. Adequate imaging (arteriography/CTA/MRA) to define inflow, stenosis and outflow ("run-off")
2. Intraoperative angiography/flow measurements to confirm patency

1. Embolectomy

• Fogarty balloon catheter passed distal to embolus → balloon inflated → catheter withdrawn, extracting clot
• Done via femoral arteriotomy under local anaesthetic
• For acute embolic occlusion within 6 hours ideally
• Post-op heparin → long-term anticoagulation

2. Endarterectomy

• Surgical removal of atheromatous intima and media from within vessel
• Best for short segment stenosis, e.g. carotid (CEA) or common femoral
• Carotid Endarterectomy (CEA): For symptomatic carotid stenosis >70%; temporary shunt to maintain cerebral perfusion during clamping

3. Bypass Grafting

• A conduit is anastomosed proximal and distal to the occlusion
• Conduit options:
  • Autologous vein (long saphenous vein) - preferred; best long-term patency; reversed or in-situ
  • Synthetic grafts - Dacron or PTFE; used when vein unavailable or for large vessels
• Common operations:
  • Aorto-bifemoral bypass: For aortoiliac occlusive disease (Leriche syndrome)
  • Femoro-popliteal bypass: For superficial femoral artery occlusion (above or below knee)
  • Femoro-tibial bypass: For distal tibial disease (limb salvage)
  • Axillo-bifemoral bypass (extra-anatomical): For patients unfit for laparotomy
  • Femoro-femoral crossover: For unilateral iliac occlusion

4. Percutaneous Transluminal Angioplasty (PTA) & Stenting

• Balloon catheter expands stenotic segment; stent may be placed
• First-line for short segment aortoiliac or iliac stenosis
• Drug-eluting stents / drug-coated balloons improve long-term patency
• Increasingly preferred over open surgery (lower morbidity)

5. Sympathectomy

• Lumbar sympathectomy: Destroys sympathetic chain (L2-L3) → vasodilation in skin
• Reduces rest pain, promotes healing of minor ulcers
• Does NOT improve claudication (muscle blood flow not sympathetically mediated)
• Chemical (phenol injection) or surgical
• Used in inoperable cases with rest pain

6. Amputation

• Last resort after failed revascularisation or non-viable limb
• Levels: Digital → Ray → Transmetatarsal → Syme's → Below-knee (preferred if possible) → Knee disarticulation → Above-knee → Hip disarticulation
• Below-knee amputation preferred when possible (better prosthetic rehabilitation)
• Guillotine amputation: Emergency, for septic gangrene; formal closure later
• Indication: Gangrene (dry - elective; wet - emergency), rest pain with no revascularisation option, failed bypass, malignancy

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SECTION 6: VENOUS DISEASES

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a. Varicose Veins

• Long saphenous vein (LSV): Medial side of leg, joins femoral vein at saphenofemoral junction (SFJ) in groin
• Short saphenous vein (SSV): Posterior leg, joins popliteal vein at saphenopopliteal junction (SPJ) in popliteal fossa
• Perforating (communicating) veins: Connect superficial to deep system; valves normally direct flow superficial → deep

• Primary varicose veins: Inherited valve weakness / wall weakness
• Secondary varicose veins: DVT (destroys deep vein valves → high deep venous pressure transmitted to superficial system), pelvic tumour, pregnancy

• Unsightly dilated veins
• Aching, heaviness, cramps (worse in evening, better with elevation)
• Ankle oedema
• Complications: Superficial thrombophlebitis, varicose eczema, lipodermatosclerosis, haemorrhage, venous ulcer

• Trendelenburg test: Leg elevated to drain varices → tourniquet applied at suspected incompetent junction → patient stands up. If varices remain empty = incompetent junction correctly identified; release tourniquet → rapid filling confirms site
• Doppler: Demonstrates reflux in superficial system; identifies sites of incompetence
• Duplex USS: Maps SFJ, SPJ, perforators; confirms deep vein patency; pre-operative planning

• Graduated compression stockings (Class 2): For elderly/unfit; reduces symptoms, prevents progression

• Sclerosant (e.g. ethanolamine oleate, sodium tetradecyl sulphate - STS, foam sclerotherapy) injected into vein → thrombosis and fibrosis
• Vein immediately compressed with bandage for ≥7 days
• Does NOT address source of incompetence → higher recurrence rate than surgery
• Best for: Thread veins, residual varicosities after surgery, short SSV incompetence

• Sapheno-femoral disconnection (Trendelenburg operation): Flush ligation of LSV at SFJ with all tributaries tied
• Long saphenous vein stripping: From groin to knee (below knee - risk of saphenous nerve injury)
• Multiple stab avulsions: Residual varices removed through tiny incisions
• Sapheno-popliteal disconnection: For SSV incompetence

• EVLA (Endovenous Laser Ablation): Laser fibre inserted into vein, thermal obliteration; day-case; equivalent outcomes to surgery
• Radiofrequency ablation (RFA): Similar mechanism

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b. Superficial and Deep Vein Thrombosis

Superficial Vein Thrombosis (SVT) / Thrombophlebitis

• Tender, cord-like, red, inflamed vein
• Low risk of PE
• Treatment: NSAIDs, compression, elevation, early mobilisation; fondaparinux if extensive

Deep Vein Thrombosis (DVT)

1. Venous stasis: Immobility, surgery, long flights, cardiac failure
2. Hypercoagulability: Malignancy, OCP, pregnancy, thrombophilia (Factor V Leiden, antiphospholipid syndrome)
3. Endothelial damage: Trauma, surgery, IV catheter

• Calf pain, tenderness, swelling, pitting oedema
• Increased warmth, distended superficial veins
• Homans' sign (calf pain on dorsiflexion) - non-specific
• Phlegmasia alba dolens: Massive DVT with pale, oedematous, painful limb
• Phlegmasia cerulea dolens: Massive DVT + arterial spasm; cyanotic, extreme pain; may progress to venous gangrene

• Wells score to pre-test probability
• D-dimer: Sensitive but not specific; if low probability + negative D-dimer → DVT excluded
• Duplex ultrasonography: Investigation of choice; compressibility of vein = gold standard
• Venography (rarely used now; contrast-ascending venography)

• Pulmonary embolism (PE) - most feared
• Post-thrombotic syndrome: Chronic venous insufficiency
• Venous gangrene

• Therapeutic anticoagulation: LMWH → DOAC (rivaroxaban/apixaban) or warfarin for 3-6 months
• Minimum 3 months for provoked DVT; 6+ months for unprovoked or cancer-associated
• Compression stockings to reduce post-thrombotic syndrome
• IVC filter: If anticoagulation contraindicated + recurrent PE
• Catheter-directed thrombolysis: For massive ilio-femoral DVT / phlegmasia

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c. Chronic Venous Ulcers

• Venous valve incompetence → sustained venous hypertension → capillary leak → fibrin cuff around capillaries → tissue hypoxia → ulceration
• Site: Gaiter area (medial malleolus, medial lower 1/3 leg) - area of most perforator incompetence

• Shallow, irregular edges, sloping margins, pink granulation base
• Surrounding skin: Varicose eczema, haemosiderin pigmentation (brown), lipodermatosclerosis, atrophie blanche
• Painless (unless infected or arterial component)
• Cf. arterial ulcer: Deep, "punched-out," painful, toes/heel/pressure points, no oedema

• Exclude arterial component: Measure ABPI (>0.8 = compression safe; <0.5 = contraindication to compression)
• Ascending venogram / ambulatory venous pressure if deep vein damage suspected

• Bed rest with elevation of leg to reduce venous hypertension
• Wound care: Wound swab for culture; systemic (not topical) antibiotics for infection; debridement
• Compression bandaging: 4-layer bandage (Charing Cross technique) even ambulatory; emptying dilated veins, aiding muscle pump
• Once healed: Graduated compression stockings to prevent recurrence
• Surgical: Ligate incompetent perforating veins (once ulcer healed, demonstrated on venography); strip associated varicose veins

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SECTION 7: LYMPHATICS AND LYMPH NODES

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a. Lymphangitis and Lymphatic Obstruction (Filariasis)

Lymphangitis

• Red streaks running proximally from wound toward regional lymph nodes
• Tender, warm
• Fever, rigors, systemic toxicity
• Regional lymphadenopathy
• Can progress to septicaemia

• Rest, elevation of limb
• IV/IM penicillin (Streptococcal) or cloxacillin/flucloxacillin (Staphylococcal)
• Treat primary source of infection

Lymphoedema (Lymphatic Obstruction)

• Primary lymphoedema: Congenital abnormality of lymphatics
  • Congenital (Milroy disease): Present at birth; autosomal dominant; lower limb
  • Praecox: Onset at puberty/early adult life (most common); females > males
  • Tarda: Onset after 35 years
• Secondary lymphoedema: Damage to lymphatics by:
  • Filariasis (most common worldwide)
  • Malignancy (direct invasion or nodal metastasis)
  • Surgery (block dissection of lymph nodes, e.g. axillary clearance → arm oedema)
  • Radiotherapy (fibrosis)
  • Recurrent cellulitis / streptococcal lymphangitis

Filariasis

• Acute: Filarial fever, acute lymphangitis, epididymo-orchitis
• Chronic: Elephantiasis - massive non-pitting lymphoedema of lower limbs, scrotum, labia
• Chyluria (milky urine), hydrocele, chylous ascites Diagnosis: Night blood smear for microfilariae (W. bancrofti microfilariae are nocturnally periodic); immunochromatographic card test Treatment:
• Diethylcarbamazine (DEC) - kills microfilariae and some adult worms
• Albendazole + ivermectin (single dose, annual) - for mass drug administration
• Doxycycline (targets Wolbachia endosymbiont of filariae)
• Surgical: Excision of redundant skin/tissue; scrotal surgery; lymphovenous bypass (specialised)

• Isotope lymphography (lymphoscintigraphy): Gold standard for mapping lymphatic flow
• Lymphangiography (oil contrast): Defines lymphatic anatomy
• MRI: Differentiates lymphoedema from lipoedema

• Non-pitting oedema (early may be pitting; late = non-pitting due to fibrosis)
• Stemmer sign: Unable to pinch skin fold at base of second toe (pathognomonic)
• Hyperkeratosis, papillomatosis of skin
• Recurrent cellulitis
• Eventually skin becomes thick, tough, indurated

• Skin care + hygiene to prevent cellulitis
• Manual lymphatic drainage (MLD) - specialist physiotherapy
• Multilayer lymphoedema bandaging (MLLB)
• Compression garments (class 2-3)
• Exercise / weight loss

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b. Diseases of Lymph Nodes

i. Acute Lymphadenitis (Acute Inflammation)

• Reactive hyperplasia of lymphoid follicles
• Neutrophil infiltration
• If untreated: Abscess formation, necrosis (suppurative lymphadenitis)

• Tender, enlarged, warm, soft/fluctuant nodes
• Overlying skin: Erythema, warmth
• Systemic: Fever, leucocytosis
• May progress to abscess, pointing and spontaneous discharge

• Treat underlying infection (antibiotics)
• If abscess: Incision and drainage
• Needle aspiration for Gram stain and culture

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ii. Chronic Lymphadenitis (Chronic Inflammation)

• Chronic bacterial infection: TB (most important), syphilis, cat-scratch disease (Bartonella)
• Chronic viral infection: HIV, EBV (infectious mononucleosis), CMV
• Fungal: Histoplasma
• Parasitic: Toxoplasma

• Most common cause of chronic cervical lymphadenopathy in developing countries
• Pathology: Central caseating granulomatous necrosis with Langhans giant cells
• Features: Rubbery, firm, initially discrete nodes → matting → collar-stud abscess (extension through deep fascia; can point through skin)
• Treatment: Standard ATT (2HRZE / 4HR); surgical drainage if abscess

• Non-tender or mildly tender
• Firm/rubbery
• May mat together
• Constitutional symptoms (fever, weight loss, night sweats = "B symptoms")

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iii. The Reticuloses (Lymphomas)

1. Hodgkin Lymphoma (HL)
2. Non-Hodgkin Lymphoma (NHL)
3. Leukaemias (when circulating)
4. Myeloma (plasma cell)

Hodgkin Lymphoma

• Painless, rubbery cervical/supraclavicular lymphadenopathy (most common presentation)
• Mediastinal mass (especially nodular sclerosis)
• B symptoms: Fever (Pel-Ebstein fever - cyclical), night sweats, weight loss >10%
• Alcohol-induced lymph node pain (characteristic of HL)
• Pruritus

• I: Single lymph node region
• II: Two or more regions, same side of diaphragm
• III: Regions on both sides of diaphragm
• IV: Extranodal involvement (bone marrow, liver, lung)
• A = No B symptoms; B = B symptoms present

• Chemotherapy: ABVD (Adriamycin, Bleomycin, Vinblastine, Dacarbazine) - standard
• Radiotherapy: For early-stage disease (ISRT - involved site)
• Highly curable (>85% 5-year survival early stage)

Non-Hodgkin Lymphoma (NHL)

• B-cell lymphomas: ~85-90% (e.g. Diffuse Large B-cell Lymphoma (DLBCL), Follicular, Burkitt, Mantle cell)
• T-cell/NK lymphomas: ~10-15%
• Indolent vs aggressive

• Painless lymphadenopathy (peripheral ± central)
• Extranodal involvement more common than HL (GI tract, CNS, skin, bone marrow)
• B symptoms (less common than HL)
• NHL associated with: EBV (Burkitt, PTLD), H. pylori (gastric MALT), HIV (aggressive B-cell), HTLV-1 (T-cell)

• Excision biopsy of lymph node - essential for histological diagnosis (not just FNA)
• Immunohistochemistry (IHC): CD markers
• Flow cytometry, FISH/cytogenetics
• Staging: CT chest/abdomen/pelvis; PET scan; bone marrow trephine biopsy

• DLBCL: R-CHOP (Rituximab + Cyclophosphamide, Doxorubicin, Vincristine, Prednisolone)
• Follicular: Watch and wait (indolent) or rituximab ± chemo
• Burkitt: Intensive chemotherapy (highly aggressive but curable)

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SUMMARY TABLE: ARTERIAL vs VENOUS ULCERS

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