Miss Kaji Sritharan

Specialist Registrar in General Surgery 
Northwest Thames, London Deanery 
Dec 2009
Š Common History Cases:
ƒ Lower Limb PVD
ƒ AAA
Carotid Disease
Š Short Cases
Š Varicose Veins
Establish:
Š Whether symptoms: 
ƒ Acute
ƒ Acute on chronic
ƒ Chronic

Š Viability of the limb
Š Acute Limb Ischaemia
ƒ Pain
ƒ Pale or white
ƒ Perishingly cold
ƒ Pulseless
ƒ Paraesthesiae
ƒ Paralysis Dictates
urgency
Remember:
60% ‐ thrombotic occlusion of pre‐existing stenotic arterial segment
30% ‐ embolus (80% from left atrial appendage in assoc AF)
Š Blood tests
Š ECG
Š CXR
Š Echo
Š Abdominal U/S
Š Thrombophilia 
screen
Š Arterial Duplex
Š DSA
 Management
Management of of
Acute
Acute Limb
Limb Ischaemia
Ischaemia

Sensation
Sensation &&
Paralysis
Paralysis &
& Paraesthesia
Paraesthesia Movement
Movement
intact
intact

1.
1. Optimise
Optimise patient
patient
1.
1. Resuscitate
Resuscitate 2.
2. IV
IV heparin
heparin
2.
2. IV
IVheparin
heparin 3.
3. Arteriogram
Arteriogram –– plan
plan for
for bypass
bypass
3.
3. Urgent
Urgentsurgery
surgery––embolectomy/
embolectomy/bypass
bypass 4.
4. Observe
Observe limb
limb for
for deterioration
deterioration
Š History
ƒ Claudication 
(?deteriorated) 
ƒ Rest pain
ƒ Tissue Loss
 Pain calf, thigh or buttock,

after walking predictable distance

resolution of pain after rest

Not while standing or sitting.

Pain in the toes/forefoot at rest.

Initially only at night, relieved by

dependency

Progresses to constant pain

Can occur in areas of tissue loss

elsewhere
Dry/wet gangrene, usually painful 

NB: diabetic foot wounds (not 
always painful)

Ulcers – can be of mixed aetiology

Amputations
‐ when and why? Diabetic? Was 
revascularisation attempted 
before?
 Arterial Ulcers or Gangrene
OR
Rest pain of 2 weeks or more requiring Opiate 
Analgesia
AND 
Absolute Ankle Pressure < 50mmHg 
or Toe Pressure <30mmHg
Do you smoke or have you ever smoked? If yes, 
estimate pack year history, record how long cessation. 

Are you diabetic? If yes, what do you use to control 
your blood sugar levels? 

Do you have, or take medicine to control, high 
cholesterol or high blood pressure? 

Have you ever suffered angina, had a heart attack, 
treatment of heart disease (angioplasty or CABG)

Have you ever suffered a stroke or ministroke ʹTIAʹ. 

Have any of your close family suffered from heart 
disease or PVD?
ƒ Fitness for operation
à PMH: Co-morbidity
à Anaesthetic Hx

Rehabilitation potential
General approach

Inspect
- General
- Focussed: look for evidence of adequate or
inadequate perfusion

Palpate/Auscultate the major pulses to

work out the likely level of the problem
Wash/gel
Introduce
Permission
Explain

Position
Expose
Tender?
You must listen to the examiner as the
instructions may be more or less
explicit about what is required

Even if the instruction is to examine

the lower limbs you must make a
reference to how you would usually
start your examination at the hands
Look for clues around the bed
INSPECT FOR:
Nicotine staining
Pallor
Muscle wasting
Splinter haemorrhage
Venous guttering
Scars
Fistula
Tissue loss
PALPATE FOR:
Warmth
Capillary refill
Radial pulse
(AF? R-R delay?)
Ulnar pulse
Allen’s Test
Brachial pulse

Axillary pulse

Subclavian abnormality

Carotid bruit
Š Look
ƒ Colour 
à mottling, marbled, 
pallor, venous 
guttering
ƒ Trophic changes
à hair loss, thin skin, 
muscle atrophy
ƒ Scars 
ƒ Amputations
ƒ Ulcers + Gangrene
Scars to note:

Carotid end‐arterectomy
CABG
Thoraco‐abdominal
Midline laparotomy
Vertical groin
Above‐knee medial
Below‐knee medial
LSV distribution
Lateral calf
Foot
Scars to note:

Fasciotomy
Š Feel
ƒ Temperature difference
ƒ CRT <2sec
ƒ Pulses 
Femorals
Popliteals
Posterior Tibial
Dorsalis pedis
Š Auscultate
ƒ Bruits

Š Buergers Test/Angle 
ƒ angle foot goes white
ƒ < 20 degrees – severe ischaemia
To Finish:
Š Examine Neuro lower limb + Fundoscopy

Š Examine the remainder Peripheral Vascular 
System
Š Examine Abdomen AAA

Š Measure ABPIs

Š Dipstick Urine
 ABPI Vascular status

1.0 Normal

0.5 – 0.8 Intermittent Claudication

< 0.5 Rest pain

>1.0 Incompressible in diabetics

(calcified vessels)

Absolute ankle pressure < 50 mmHg = critical ischaemia

 Simple: Blood tests: Cholesterol,
HbA1c, U&E

Duplex Ultrasound
(CTA or MRA depending on local
skills)

Angiography (like cardiac like to

perform intervention at same sitting)
 Management of
PVD

Intermittent Critical
claudicant ischaemia

Medical therapies Revascularisation Revascularisation Sepsis control

Encourage exercise Angioplasty +/- stenting Angioplasty +/- stenting Antibiotics + DM control
STOP SMOKING
Bypass procedure Bypass procedure Debridement
BP control
Statins & aspirin Amputation
Diabetic control
Watch retino/nephopathy
+ Medical therapies
Š Definition: necrosis of
tissue with mummification
or putrefaction
Š Types :
1. Dry – well demarcated, auto-
amputate
2. Wet – due to trauma, acute
ischaemia & infection. Poorly
demarcated and spreading.
Š Vascular (thrombosis, embolus, critical 
ischaemia, Buerger’s disease, Raynaud’s 
disease)
Š Diabetes
Š Trauma – cold, heat, pressure
Š Drug induced e.g. ergot poisoning
A. C.

B.
D.
Indications: 
“DEAD, DYING OR 
DANGEROUS”
Š Vascular (80‐90%)
Š Infection (Osteomyelitis, Gas gangrene)
Š Trauma (Burns, Frostbite)
Š Malignancy
€ Definition
Break in continuity of an epithelial surface

€ Aetiology
y Vascular (arterial, venous or mixed)
y Neuropathic
y Traumatic
y Malignant
€ Site
€ Size
€ Shape
€ Edge
€ Base
€ Depth
€ Surrounding Tissue
Š Site: overlies lateral malleolus
Š Edge: punched out
Š Base: deep; often lacks granulation tissue;
necrotic
Š Minimal exudate
Š Painful +/- cellulitis
Š Gangrene
€ Medical
‐ Pain control
‐ Optimise risk factors 
‐ ?intravenous prostaglandins
‐ Antibiotics if infection

€ Surgical
‐ Debridement       
(surgical,dressings,maggots)/amputation
‐ Improve blood supply 
(lumbar sympathectomy, angioplasty, BPG) 
Š Site: gaiter area; lower 3rd medial aspect leg
Š Shape: varies – can be very large, irregular
Š Edge: sloping and shallow
Š Base: often pink granulation tissue +/-
seropurulant discharge
Š Surrounding skin: induration, pigmentation,
lipodermatosclerosis
Š Painful

NB. Examine for VVs, check ABPI’s

Š Exclude arterial component
Š If mixed – correct arterial factor

Non-Surgical – high success (80-90% at 1 year)

Š Rest + elevate leg
Š Four layer compression bandaging
Š Once healed – grade II compression hosiery

Surgical
Š Exclude malignancy
Š Skin grafting if clean
Š Treat primary varicose veins
Š Site: pressure areas
Š Edge: even wound margins; callous
around ulcer
Š Base: granulation tissue present (unless
co-existing PVD); low to moderate
exudate
Š Absence of pain
Š Peripheral pulses present
€ Common: 10-20% population
€ Women > men

Definition
Tortuous, dilated, elongated veins of
the superficial venous system
€ Superficial veins
y Long saphenous vein (LSV)
y Short saphenous vein (SSV)

€ Deep veins
€ Perforator veins
€ Giacomini vein
 Aetiology

Congenital Acquired

Valve Muscle pump Venous return

Incompetence Immobility Pregnancy

Deep vein thrombosis Abdo/ pelvic mass
€ Focussed history

€ ‘Primary LSV' +/- signs at ankle

€ Ulcer of unknown aetiology

(venous/arterial/mixed)
€ Age, Occupation
€ How long have you had varicose veins?
€ How do your veins trouble you?
y Cosmesis
y Swelling – typically end of day
y Aching
y Pruritis
y Cramps
y Ulcers +/- infection - periostitis
€ Age
€ Female
€ Family history (uncertain as to why!!!)
€ Pregnancy (impaired venous return as well as hormonal effect on vein wall)
€ PMH of DVT or long bone fracture
€ Contributing factors: HRT, OCP, obesity, sedentary lifestyles, and
professions that require prolonged standing or sitting
€ Listen to the examiner’s instructions

€ Wash/gel
€ Introduce
€ Consent
€ Explain
€ Position/Expose
€ Pain or tenderness anywhere?
Inspect front and back for:

€ Obvious varicosities and their distribution

€ Signs (skin changes) at the ankle/calf

€ Signs of previous surgery

Saphenovarix
- Assess for cough
impulse

Feel
- Tap test

- Temperature

- Tethering
Tourniquet test versus Trendelenberg test
¾ GIVE CLEAR INSTRUCTIONS

€ Elevate the limb, milk the veins

€ Apply tourniquet to upper thigh

€ Immediate filling of veins, release the tourniquet
and tell the examiner:
'the filling of the varicose veins is not controllable at
the level of the SFJ'

OR

€ Veins not immediately filled, very slow filling =

undo the tourniquet and tell the examiner:
'the filling of the varicose veins is controlled at the
level of the SFJ'
€ Auscultate the varicosities that do not empty
lying flat ‘machinery murmur’ of AVM

€ Offer to palpate lower limb pulses +/- ABPIs

€ Perthes test

€ Offer to perform Abdo/Pelvic/Scrotal/rectal

examinations

€ Wash hands, ensure patient re-covered

€ Hand held
doppler

€ Duplex imaging

€ Venography

€ Abdo/Pelvis
ultrasound
 € Please examine this patients superficial
venous system in the lower limb.

Trendelenberg
and tourniquet
test positive

How would you treat varicose veins?

€ Leg elevation
€ Regular walking to improve calf muscle
pump
€ Class II support stockings – above or below
knee
€ Skin changes require - 4 layer bandaging
(Charing cross)
€ Eczema – topical emolliants
€ Thrombophlebitis – NSAIDs
€ Open Surgery:
- High tie and strip – ligation of SFJ
+/- avulsions – removal of varicosities

€ Foam injections

€ Sclerotherapy:
- 1% Sodium tetradecyl sulphate

€ EVLT or VNUS
€ Accumulation fluid in interstitium
due to problem with lymphatic
drainage
€ Typically bilateral and non-pitting
€ Aetiology:
y Primary: Milroy’s disease
y Secondary:
○ Lymphadenectomy
○ Malignancy
○ Post radiotherapy
○ Infections: Filiarisis