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Abdominal aortic aneurysms
- Omer Aziz, Sanjay Purkayastha, Paraskevas Paraskeva
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- Hospital Surgery
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- 06 July 2010
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- 16 February 2009, pp 459-463
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Summary
Introduction
Prevalence of abdominal aortic aneurysm (AAA) is 3% in those >50 years. The frequency increases steadily in men >55 yrs, reaching a peak of 5.9% at 80–85 yrs. In women, the peak is 4.5% at age > 90 years. Male: female ratio is 4:1. Abdominal aortic aneurysms are 3–7 times more common than thoracic aneurysms. Other aneurysms coexisting with abdominal are iliac (20–30%) and femoropopliteal (15%). Popliteal aneurysms are a marker of AAA. AAAs are present in 8% of patients with unilateral and in 50% with bilateral popliteal aneurysms. Cigarette smoking is associated with an increased incidence of AAA, 8:1 as compared with non-smokers. Popliteal aneurysms are the most common peripheral arterial aneurysms. Atherosclerotic in 95%, M:F 30:1, sixth to seventh decade, bilateral in 50%. Rare causes are entrapment syndrome or trauma.
Definition
An aneurysm is a permanent localized dilation of an artery with an increase in diameter of greater than 50% (1.5 times) its normal diameter. Ectasia refers to dilation of an artery that does not reach the above threshold.
Classification
True (contains all components of the arterial wall – intima, media and adventitia) or false (only adventitia). Congenital or acquired (atherosclerosis, trauma, infection, or medial cystic necrosis). Saccular (arising from one part of the arterial wall) or fusiform (generalized dilation of the arterial wall) (Figures 103 and 104). The aneurysms can also be divided into: aneurysms of the aortoiliac area, peripheral aneurysms and splanchnic aneurysms. They may present electively or in an emergency.
Diabetic foot
- Omer Aziz, Sanjay Purkayastha, Paraskevas Paraskeva
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- Hospital Surgery
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- 06 July 2010
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- 16 February 2009, pp 464-467
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Summary
Introduction
About 27% of people > 55 yrs of age have peripheral arterial disease (PAD). Diabetics are 2–4 times more likely to have PAD. Around 15% develop PAD after 10 years of diabetes and 45% after 20 years. Diabetic foot accounts for the highest number of non-traumatic lower extremity amputations.
Definition
A neuroischaemic condition leading to soft tissue loss+/- infection over pressure-bearing areas.
Incidence
84% of patients with a 20-year history of diabetes have vascular disease and 75% die of vascular disease or its complications; primarily IHD and stroke. Gangrene occurs 50 times more commonly in diabetic males and 70 times more commonly in female diabetic patients as compared with non-diabetic patients.
Pathogenesis
Arterial occlusive disease in diabetics is a different pattern compared with atherosclerosis in non-diabetics. It mainly affects the distal popliteal segment, the tibial and metatarsal vessels with sparing of inflow and peroneal artery. Microscopically: thickening of the intima, increased thickness of the basement membrane, patchy distribution – diabetic microangiopathy.
Neuropathy: segmental demyelination of both sensory and motor nerves (defect in metabolism of Schwann cells) causing delayed nerve conduction. Distal nerves are affected more than proximal. Initial night cramps and paraesthesia progress to loss of vibratory sense and perception of light touch and pain and finally deep tendon reflexes are lost.
Motor dysfunction results in malfunction of the intrinsic muscles of the foot leading to distortion of foot architecture. It consists of extensor subluxation of the toes, plantar prominences of metatarsal heads and imbalance in action of flexors and extensors. The metatarsal arch then collapses. In its extreme form, the mid foot deteriorates leading to the so-called Charcot's foot.
Carotid disease
- Omer Aziz, Sanjay Purkayastha, Paraskevas Paraskeva
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- Hospital Surgery
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- 06 July 2010
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- 16 February 2009, pp 468-472
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Summary
Introduction
The earliest link reported between carotid disease and stroke was credited to Savory in 1856. In 1954 Eastcott reported the first carotid artery reconstruction to prevent stroke at St. Mary's Hospital in London. Main diseases affecting carotid artery are occlusive, dissection, aneurysms, trauma and inflammatory.
Definition
There are three clinical presentations of carotid occlusive disease.
Asymptomatic: patients with no history of cerebral symptoms
Transient ischaemic attacks (TIA): temporary neurological deficits >24 hours with complete recovery. Crescendo TIA suggests repeated frequent embolization with complete recovery in between. The average reported rate of risk of stroke ranges from 5% within the first 2 days and 20% within the first month to 10.5% within 90 days. The benefit from intervention is greatest for patients undergoing surgery within two weeks of their last ischaemic event.
Stroke: permanent neurological deficit – defect ranging fromminimal with good recovery to massive causing death.
Pathogenesis
Up to 30% of cerebral events are caused by embolization from atherosclerotic lesions at the carotid bifurcation, or low-flow related ischaemic events. Other causes include embolization from the aortic arch, intracerebral bleeds and tumours.
Symptoms and signs
Presentation is usually in the form of discrete motor or sensory dysfunction contralateral to the side of the ischaemic event. Since the left hemisphere is dominant in 95% of the population, an ischaemic event affecting the left hemisphere may also cause receptive or expressive aphasia. It can also present as transient visual loss (amaurosis fugax) in the ipsilateral eye. Patients typically describe a curtain drawn over the eye, or field defect.
Raynaud's syndrome
- Omer Aziz, Sanjay Purkayastha, Paraskevas Paraskeva
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- Hospital Surgery
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- 06 July 2010
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- 16 February 2009, pp 473-476
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Summary
Introduction
In 1862 Maurice Raynaud described an episodic digital ischaemia due to vasospasm of the small arteries and arterioles of the extremities, precipitated by cold or emotion. It consists of intense pallor (vasoconstriction), cyanosis (spasm relaxation with a trickle of blood flow causing rapid desaturation) and rubor (increased blood flow into dilated capillaries), with full recovery in 15–45 minutes. The fingers remain normal in between the episodes.
The term ‘Raynaud's phenomenon’ is used when the cause is unknown, and if underlying cause is identifiable, it is known as Raynaud's disease. However, the syndrome is better classified into spastic and obstructive type depending on the causative factor.
Incidence
The prevalence varies with climate and probably ethnic origin. In cooler countries (UK, Scandinavian) the prevalence varies from 20 to 25%. It affects all age groups but mainly young women. Around 40–80% of Raynaud's patients have associated disease, scleroderma being the most common.
Pathogenesis
Two types: obstructive and spastic.
Obstructive arterial disease causes a decrease in resting digital arterial pressure and, in these patients, even normal vasoconstrictive response to cold or emotion is sufficient to cause symptoms. Spastic type has normal resting digital pressure and symptoms are caused due to an increased intensity of cold-induced arterial spasm. Both α2 adrenoceptors and presynaptic βreceptors are implicated in its causation.
Raynaud's disease can be associated with autoimmune diseases (SLE, RA, Sjögren's syndrome, mixed connective-tissue disorders, scleroderma), haematological diseases (mixed cryoglobulinaemia, monoclonal gammopathies, leukaemia, cold agglutinins, thrombocytosis), trauma, vibrating tools, arteriosclerosis, frostbite, Buerger's disease, hypothyroidism, thoracic outlet obstruction, and drugs.
Varicose veins
- Omer Aziz, Sanjay Purkayastha, Paraskevas Paraskeva
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- Hospital Surgery
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- 06 July 2010
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- 16 February 2009, pp 477-481
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Summary
Incidence
More than 50% of men and two-thirds of women have physically identifiable disease. The appearance of varicose veins in childhood is rare although adolescents have incompetent valves. European data indicate that up to 1.5% of adults will suffer a venous stasis ulcer at some point in their lives. Annual healthcare cost in the UK for venous ulceration is estimated at £290 million.
Definition
Varicose veins are abnormal tortuous, dilated, elongated superficial veins. These are most commonly found in the long (LSV) and short saphenous vein (SSV) distribution. Spider veins are dilated smaller cutaneous venules (Figure 105).
Classification: CEAP (clinical, etiological, anatomical, pathological)
Clinical: 0 – no signs of venous disease, 1 – reticular veins, 2 – varicose veins, 3 – oedema, 4 – skin changes (lipodermatosclerosis), 5 – skin changes with healed ulceration, 6 – active ulceration
Aetiological: congenital, primary (no cause), secondary (deep vein thrombosis, traumatic, etc.)
Anatomical: superficial, perforator or deep; location (long or short saphenous)
Pathological: reflux, obstruction, both.
Aetiology
The risk factors for varicose vein include prolonged standing, hereditary, female sex, parity and history of phlebitis. Venous ulcers on the other hand have different risk factors and include old age, obesity, hypertension, trauma, history of venous thrombosis, and low socioeconomic status.
Symptoms
Symptoms range from cosmetic to intractable pain. A burning sensation over the varicose veins is caused by local pressure on cutaneous sensory nerves. In early stages, it causes mild swelling, heaviness and easy fatigability. Dull pain and aching usually starts in the afternoon after long standing and is relieved with leg elevation. Itching is a manifestation of local cutaneous stasis and precedes the onset of dermatitis.
Chronic limb ischaemia
- Omer Aziz, Sanjay Purkayastha, Paraskevas Paraskeva
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- Hospital Surgery
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- 06 July 2010
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- 16 February 2009, pp 453-458
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