GCC Nursing Guide — Advanced Vascular Surgery

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AAA — Definition & Thresholds

An abdominal aortic aneurysm (AAA) is a permanent dilatation of the aorta ≥3 cm (≥1.5× the expected normal diameter). The infrarenal aorta is the most common site.

Definition threshold≥3 cm maximum diameter

Repair threshold — Men≥5.5 cm

Repair threshold — Women≥5.0 cm

Annual growth rate (average)~2–3 mm/yr (if <4 cm)

Rapid expansion>1 cm/yr — expedite review

Risk of Rupture by Size

<4 cm<1% per year

4–5 cm~1–3% per year

5–6 cm~5–10% per year

>6 cm>10–25% per year

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AAA Surveillance Programme (NICE)

ℹ️

NHS AAA Screening: One-off abdominal USS offered to all men aged ≥65 years. Single-scan programme — if normal (<3 cm) no further surveillance required.

Surveillance intervals by diameter

Small AAA <4.0 cm5-yearly USS

Medium AAA 4.0–4.9 cmAnnual USS

Large AAA 5.0–5.4 cm3-monthly USS

≥5.5 cm (men) / ≥5.0 cm (women)Refer vascular — repair assessment

Women are not routinely included in NHS AAA screening but have a lower repair threshold due to higher relative rupture risk at smaller diameters.

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Open AAA Repair vs EVAR — Comparison

Parameter	Open Repair	EVAR
Access	Laparotomy / retroperitoneal	Percutaneous / bilateral groin cut-downs
Aortic cross-clamp	Yes — bowel / renal ischaemia risk	No aortic cross-clamp
Anaesthetic	General (+ epidural)	GA or regional / local
Blood loss	Significant — major transfusion risk	Minimal
ICU admission	Routine — 1–3 days minimum	Often avoidable — HDU/ward
Length of stay	7–10 days typical	1–2 days
30-day mortality (elective)	~3–5%	~1%
Long-term re-intervention	Low — durable repair	Higher — endoleak surveillance lifelong
Key post-op concerns	Bowel ischaemia, AKI, ileus, wound	Endoleak, graft migration, access site

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Post-Open AAA ICU Nursing

Haemodynamic monitoring: Arterial line, CVP, urine output hourly. MAP target ≥65 mmHg. Watch for third-space losses.
Renal function: Suprarenal clamp → AKI risk. Monitor creatinine, eGFR, urine output ≥0.5 mL/kg/hr. Avoid nephrotoxins.
Bowel assessment: Aortic cross-clamp → bowel ischaemia. Listen for bowel sounds. Watch for bloody diarrhoea — sigmoid ischaemia sign.
Pain management: Epidural analgesia preferred. Assess pain score ≤4/10. Adequate analgesia improves respiratory effort.
Respiratory: Incentive spirometry, physiotherapy, early mobilisation. Ileus/splinting risk post-laparotomy.
Graft surveillance: No palpable mass, abdominal bruit, limb perfusion checks bilaterally — detect early graft thrombosis.

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Post-EVAR Nursing

Access Site Monitoring (Bilateral Groin)

Hourly groin wound inspection — haematoma, haemorrhage, pseudoaneurysm
Pedal pulses bilateral — Doppler if uncertain
Groin closure — percutaneous closure device (ProGlide/Angio-Seal) or surgical cut-down
Immobility of affected limb first 4–6 hours if closure device used

Contrast Nephropathy Prevention

Pre and post-procedural IV crystalloid hydration (per local protocol)
Avoid NSAIDs post-procedure
Renal function check at 24–48 hrs
Contrast volume documented — alert if >3× eGFR

EVAR Complications — Endoleak Types

Type IFixation site leak — proximal/distal attachment

Type IIBranch vessel backflow (IMA, lumbar)

Type IIIGraft junction / modular disconnection

Type IVGraft porosity (rare with modern grafts)

Type VEndotension — sac expansion, no flow detected

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Ruptured AAA — Emergency Protocol

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Ruptured AAA = Catastrophic Haemorrhage — Mortality without intervention ~80–90%

Classic triad: sudden severe abdominal/back pain, pulsatile abdominal mass, haemodynamic instability. One or more features may be absent.

Immediate Actions

ACTIVATE massive transfusion protocol (MTP) immediately
2 large-bore IV access — send bloods: FBC, coag, U&E, G&S (crossmatch 6+ units)
Permissive hypotension: target SBP 70–80 mmHg (avoid over-resuscitation — worsens bleeding)
Prep operating theatre — emergency OR or hybrid suite
Urgent vascular surgery and anaesthetic review
Transfer to CT only if haemodynamically stable — do NOT delay OR for imaging

Permissive Hypotension Rationale

Aggressive fluid resuscitation increases aortic wall tension and dislodges clot. Target SBP 70–80 mmHg until aortic control achieved in OR. Use 1:1:1 ratio (pRBC:FFP:Platelets) via MTP.

REVAR / Emergency EVAR

Where anatomy permits, emergency EVAR (REVAR) preferred — lower mortality than emergency open repair. Requires EVAR-capable hybrid theatre and on-call endovascular team.

⚠️

Do not leave patient unattended. Continuous BP monitoring. Alert blood bank, theatres, porters simultaneously.

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Carotid Artery Disease — Pathophysiology

Atherosclerosis at the carotid bifurcation causes plaque formation → stenosis → embolism → TIA or ischaemic stroke. The internal carotid artery (ICA) is the primary site.

Symptomatic vs Asymptomatic Stenosis

Symptomatic >50%CEA within 2 weeks of TIA/stroke

Symptomatic 50–69%Benefit from CEA (NASCET trial)

Symptomatic >70%Greatest benefit from CEA

Asymptomatic >70%Consider CEA — weaker evidence (ACAS/ACST)

Symptoms of Carotid TIA/Stroke

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Pre-CEA Nursing Assessment

Neurological Baseline (mandatory pre-op)

NIHSS (National Institutes of Health Stroke Scale) baseline score
GCS, orientation, speech assessment, facial symmetry
Motor strength bilateral UL and LL — document carefully
Visual fields — document amaurosis fugax history
Swallowing baseline — prior dysphagia noted

Pre-operative Checklist

Antiplatelet continuation confirmed (clopidogrel 75mg or aspirin 75mg — do NOT stop)
Carotid Doppler/duplex findings reviewed and documented
CT angiography or MRA findings available for surgeon
BP target pre-op: avoid hypo- or hypertension (MAP 70–90 mmHg)
Statin therapy confirmed (plaque stabilisation)

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Post-CEA Neurological Monitoring Schedule

ℹ️

Neurological obs are the priority post-CEA. Any new neurological deficit = immediate vascular surgery review. Time to re-exploration is critical.

First Hour

Every 15 minutes

GCS
Motor power (grip, plantarflexion)
Speech — dysphasia / dysarthria
Facial symmetry
BP (bilateral arm — note difference)
Wound inspection — haematoma

Hours 2–5

Every 30 minutes

Neuro obs as above
Continue wound checks
BP control maintained
Swallowing assessment before oral fluids
Cranial nerve assessment (see below)

Hours 6+

Hourly

Neuro obs continued until stable
Mobilisation when safe
Antiplatelet medication given post-op
Follow-up carotid duplex arranged

Post-CEA Cranial Nerve Injuries — Know These

Nerve	Number	Clinical Sign	Significance
Hypoglossal	XII	Tongue deviation to ipsilateral side on protrusion	Usually temporary — nerve retraction injury
Vagus (recurrent laryngeal)	X	Hoarse voice, bovine cough, dysphagia	Unilateral vocal cord palsy — aspiration risk
Glossopharyngeal	IX	Dysphagia, loss of gag reflex ipsilateral	Aspiration risk — swallow assess before eating
Marginal mandibular (facial VII)	VII branch	Ipsilateral drooping of corner of mouth	Usually temporary — cosmetic concern
Greater auricular nerve	Sensory	Numbness/tingling of earlobe and cheek	Very common — sensory only, not motor

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Post-CEA Complications

Carotid Haematoma — Airway Emergency ▼

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Expanding neck haematoma = airway emergency. Tracheal deviation and stridor indicate imminent obstruction.

Call vascular surgeon and anaesthetist immediately
Sit patient upright — maintain airway position
High-flow O₂ via non-rebreathe mask
Do NOT delay — open wound at bedside if airway compromised and theatre not immediately available
Prep emergency re-exploration — scrub team on standby
Fibreoptic intubation preferred if airway distorted — alert anaesthetics early

Hyperperfusion Syndrome ▼

Occurs in ~1–3% post-CEA. After removal of high-grade stenosis, sudden increase in cerebral blood flow to previously ischaemic territory.

Signs

Ipsilateral headache (often throbbing, unilateral)
Seizures
Focal neurological deficits
Intracerebral haemorrhage (severe cases)

Management

Strict BP control: target SBP <140 mmHg post-CEA in high-risk patients
IV labetalol or GTN infusion if indicated
Urgent CT head if seizure or focal deficit
Neurosurgical liaison if haemorrhage confirmed

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TCAR — Transcarotid Artery Revascularisation

TCAR is a hybrid endovascular technique for high-surgical-risk patients. Flow reversal during stent deployment reduces embolic risk compared to conventional carotid artery stenting (CAS).

Technique Overview

Direct carotid access via small neck incision (vs femoral in CAS)
Reversed flow to femoral vein during stent deployment traps emboli
Carotid stent deployed under neuroprotection
Less invasive than open CEA — suitable for contralateral laryngeal nerve palsy, re-stenosis, hostile neck

Access Site Nursing (Neck + Groin)

Neck wound inspection q1h first 4 hours — haematoma / bleeding
Femoral venous access site: check for VTE, haematoma
Dual antiplatelet therapy (aspirin + clopidogrel) post-procedure
Neurological obs same schedule as post-CEA
No high-flow O₂ unless clinically indicated

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Bypass Indications & Graft Selection

Indications for Bypass Surgery

Chronic Limb-threatening Ischaemia (CLTI) — rest pain (Rutherford 4), tissue loss (Rutherford 5–6)
Failed or unsuitable angioplasty/stenting
Long-segment occlusions not amenable to endovascular treatment
Acute limb ischaemia when embolectomy insufficient

Graft Types

Autologous Vein

Great Saphenous Vein (GSV) — gold standard. Best long-term patency. Reversed or in-situ. Resistant to infection.

Synthetic Grafts

PTFE or Dacron — used when GSV unavailable or inadequate. Lower patency especially below knee. Higher infection risk.

Patency by Configuration

Fem-pop above knee (vein)~75% at 5 years

Fem-pop below knee (vein)~60% at 5 years

Fem-pop above knee (PTFE)~50% at 5 years

Fem-distal (tibial) vein~40–50% at 5 years

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Intraoperative Nursing Considerations

Anaesthetic & Positioning

GA or regional (spinal/epidural) — regional preferred in high cardiac-risk patients
Supine position — groin access requires slight leg abduction and external rotation
Below-knee bypass: leg elevated — frog-leg position for popliteal/tibial access
Pressure area care — heel pad protection essential (the affected limb is already ischaemic)

Heparinisation

Systemic heparin given before vessel clamping — typically 5,000 IU IV
ACT (activated clotting time) monitoring intraoperatively in some centres
Reversal with protamine at end of procedure in some protocols

Scrub Nurse Key Responsibilities

Tunnelling instruments available for anatomical bypass route
Vein preparation: harvest, distension, valve lysis (in-situ bypass)
Anastomosis: 5-0 or 6-0 polypropylene sutures available
Intraoperative completion arteriogram or Duplex confirmation

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Post-Bypass Limb Perfusion Monitoring

ℹ️

Hourly limb perfusion checks are mandatory. Early graft thrombosis (within first 24 hours) is salvageable only if detected quickly. Time to re-exploration is critical.

Doppler Signal

Handheld Doppler to pedal vessels (dorsalis pedis + posterior tibial) — document biphasic/triphasic vs monophasic vs absent. Loss of signal = emergency.

Temperature & Colour

Compare with contralateral limb. Warm pink = perfused. Cool, pale, mottled = ischaemia. Mark temperature line on leg if concern — document change in boundary level.

Sensation & Movement

Dermatome sensory testing and toe/ankle movement. Loss of sensation or motor function = late sign of critical ischaemia — act immediately.

Graft Pulse Palpation

In some configurations the graft is palpable in groin or thigh. Document graft pulse presence each hour. If graft pulse lost and Doppler deteriorating — immediate vascular surgical review.

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Graft Thrombosis: Loss of Doppler signal + cooler, pale limb = emergency. Call vascular surgery immediately. Prepare for return to OR — thromboembolectomy or revision bypass.

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Wound & Groin Complications

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Groin wound infection after bypass = high-risk complication. Deep groin infection can erode the bypass graft — potential catastrophic haemorrhage and graft loss.

Groin Wound Care

Daily wound inspection — erythema, warmth, purulent discharge, dehiscence
Keep incision dry — no bath/immersion until healed
Obesity increases risk — skin-fold management, barrier creams
MRSA screen pre-op and treat colonisation
Wound swab if signs of infection — culture-guided antibiotics

Groin Haematoma

Post-operative anticoagulation increases haematoma risk
Avoid pressure dressings directly over anastomosis
Large haematoma → risk of graft compression → limb ischaemia
Expanding haematoma → return to theatre for exploration

Lymphocoele

Clear fluid discharge or swelling — not blood/pus
Aspirate under USS guidance if large — strict aseptic technique
Avoid repeated aspiration → infection risk

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Chronic Venous Insufficiency (CVI)

CVI results from venous hypertension due to valve incompetence and/or venous obstruction. Prolonged venous hypertension → lipodermatosclerosis → skin changes → venous ulceration.

Pathophysiology Sequence

Valve incompetence / obstruction → venous reflux
Venous hypertension → capillary leak → oedema
Fibrin cuff formation → tissue hypoxia
Lipodermatosclerosis — indurated, hyperpigmented skin (gaiter area)
Haemosiderin deposition — brown pigmentation
Atrophie blanche → venous ulcer formation (C6)

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CEAP Classification

CEAP = Clinical, Aetiological, Anatomical, Pathophysiological — international standard for venous disease classification.

C0No visible/palpable signs of venous disease

C1Telangiectasias or reticular veins

C2Varicose veins

C3Oedema

C4aPigmentation or eczema

C4bLipodermatosclerosis or atrophie blanche

C5Healed venous ulcer

C6Active venous ulcer

Treatment	Mechanism	Post-procedure Care	Complications
EVLA Endovenous Laser Ablation	Laser energy → thermal damage → GSV occlusion	Compression stocking 2 weeks, walk immediately, avoid swimming 2 weeks	Bruising, haematoma, DVT, skin burns (rare), paraesthesia
RFA Radiofrequency Ablation	RF energy → heat → collagen contraction → vein closure	Same as EVLA — compression, early ambulation	Similar to EVLA — slightly less bruising reported
Foam Sclerotherapy	Sclerosant foam displaces blood → endothelial injury → fibrosis	Compression 5–7 days, avoid air travel 48h	Visual disturbance, stroke (rare — PFO), skin staining, DVT
Surgical Ligation Trendelenburg + stripping	Sapheno-femoral junction ligation + GSV stripping	Compression, regular mobilisation, wound care	Nerve injury (saphenous), haematoma, wound infection

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Venous Leg Ulcer Nursing

Wound Characteristics

Location: medial gaiter area (above medial malleolus) — most common
Irregular margins, shallow, moderate–high exudate
Haemosiderin-stained surrounding skin
Lipodermatosclerosis — "inverted champagne bottle" leg appearance
Painful (worse on dependency, better on elevation)

Wound Bed Preparation (TIME)

T — Tissue: debridement if necrotic/sloughy tissue present
I — Infection/Inflammation: wound swab, treat clinical infection
M — Moisture balance: appropriate absorbent dressing
E — Epithelial edge: non-advancing edge = re-assess (biopsy if malignant change suspected)

Four-Layer Compression Bandaging

40mmHg at ankle, graduated compression up the leg. Apply over moist wound dressing. ABI (ankle-brachial index) must be ≥0.8 before compression — risk of arterial compromise if lower.

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Never apply compression bandaging without ABPI assessment — arterial insufficiency + compression = limb-threatening ischaemia.

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May-Thurner Syndrome & Deep Vein Reconstruction

May-Thurner Syndrome

Left common iliac vein compressed by the overlying right common iliac artery → chronic venous obstruction → left iliac DVT (iliac vein thrombosis / Phlegmasia).

PresentationLeft-sided DVT in young women, oedema, chronic venous hypertension

DiagnosisDuplex USS, CT venogram, IVUS (gold standard)

TreatmentCatheter-directed thrombolysis + iliac vein stenting

Post-Iliac Vein Stenting Nursing

Anticoagulation — LMWH bridge to warfarin or DOAC (per protocol)
Compression stocking — Class II or III, full leg
Limb elevation when at rest
Access site (femoral/popliteal vein) observation — haematoma
Follow-up duplex at 1 month — stent patency assessment

Deep Vein Reconstruction / Valvuloplasty

Reserved for severe post-thrombotic syndrome with documented deep valve incompetence. Rare, specialist centres only (Kistner valvuloplasty, vein segment transfer). Long-term anticoagulation mandatory.

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Acute Limb Ischaemia Post-Bypass

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The 6 Ps of Acute Limb Ischaemia: Pain, Pallor, Pulselessness, Paraesthesia, Paralysis, Perishing Cold. Paralysis and paraesthesia = irreversible ischaemia imminent.

Immediate Nursing Actions

Document Doppler signals — bilateral comparison
Call vascular surgery immediately — do NOT delay
Nil by mouth — prepare for emergency theatre
IV heparin — bolus as directed by surgeon (anticoagulation bridges to embolectomy)
IV access × 2, bloods: FBC, coag, U&E, group & save
Document sensory and motor function — grade of ischaemia

Rutherford Classification — Acute Limb Ischaemia

Class I — ViableNo sensory/motor loss, Doppler present

Class IIa — ThreatenedMinimal sensory loss, no motor loss

Class IIb — Immediately threatenedSensory + motor deficit — emergency revascularisation

Class III — IrreversibleProfound loss — primary amputation considered

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Graft Infection

Microbiology

Signs of Graft Infection

Wound erythema, warmth, swelling over graft course
Sinus tract formation or purulent discharge
Systemic sepsis — fever, raised WBC, CRP
Haemorrhage (graft erosion — catastrophic)
False aneurysm formation at anastomosis

Management Principles

Blood cultures × 3 before antibiotics
CT angiogram — graft perigraft gas/fluid, false aneurysm
MRSA screen and isolate if MRSA positive
IV antibiotics (broad-spectrum, then guided by cultures)
Surgical: graft excision ± extra-anatomical bypass (axillo-femoral or obturator bypass)
Rifampicin-soaked gelatin-sealed grafts may be used for re-implantation

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Reperfusion Injury & Compartment Syndrome

Reperfusion Injury

After revascularisation of acutely ischaemic limb: restoration of blood flow → oxygen free-radical generation → cell injury → massive oedema → compartment syndrome risk.

Rhabdomyolysis

Muscle necrosis → myoglobin release → AKI
Dark "tea-coloured" urine = myoglobinuria
Monitor CK (creatine kinase) — levels >5,000 indicate significant muscle injury
Aggressive IV fluid resuscitation — maintain urine output ≥100 mL/hr
Urinary alkalinisation (sodium bicarbonate) — prevents myoglobin tubular precipitation

Compartment Syndrome — 4-Compartment Fasciotomy

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Compartment pressure >30 mmHg (or within 30 mmHg of diastolic) = immediate fasciotomy.

Fasciotomy wound care — large open wounds, plan for delayed primary closure or SSG
Dressing change in theatre × 48–72h
Monitor for compartment recurrence — ongoing neuro/limb obs
Myonecrosis extent determines amputation risk — specialist centre decision

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AKI After Vascular Surgery

Risk Factors

Suprarenal aortic cross-clamp — renal artery ischaemia
Contrast nephropathy (post-EVAR, post-angiogram)
Perioperative hypotension — renal hypoperfusion
Pre-existing CKD (common in vascular patients — atherosclerotic renovascular disease)
Nephrotoxic drugs: NSAIDs, aminoglycosides, ACE inhibitors perioperatively

Monitoring & Management

Hourly urine output ≥0.5 mL/kg/hr — catheterise all major vascular cases
Creatinine, eGFR, electrolytes daily post-op
Avoid nephrotoxins — review all medications
Renal team liaison if oliguria persists or creatinine rising
Haemofiltration/dialysis if KDIGO Stage 3 AKI with complications

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Spinal Cord Ischaemia & CSF Drainage

Spinal cord ischaemia is a rare but devastating complication of thoracoabdominal aortic repair (TAAA). Anterior spinal artery perfusion depends on intercostal arteries sacrificed during repair.

Prevention — CSF Drainage

Lumbar CSF drain inserted pre-operatively or intraoperatively
Target CSF pressure: keep ≤10 mmHg (drain off as needed)
CSF drainage reduces spinal cord pressure → improves anterior spinal artery perfusion

CSF Drain Nursing (Specialist Skill)

Document CSF pressure continuously (transducer attached)
Drain ≤10–15 mL/hour — avoid rapid large-volume drainage (subdural haematoma risk)
Check drain site for leakage, infection, CSF clarity
Neurological obs hourly — lower limb power, proprioception
Any new lower limb weakness = raise MAP, reduce drainage, alert team immediately
Drain removed when neurologically stable, usually 48–72h post-op

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New paraplegia post-TAAA: Raise MAP to ≥90 mmHg, drain CSF to pressure <10 mmHg, urgent spinal cord MRI. Irreversible if not treated within hours.

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Ileus After Open Aortic Surgery

Causes

Prolonged bowel exposure and manipulation intraoperatively
Bowel ischaemia (inferior mesenteric artery ligation)
Opiate analgesia
Electrolyte imbalance (hypokalaemia, hypomagnesaemia)
Retroperitoneal haematoma — mass effect

Sigmoid Ischaemia Warning Signs

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Bloody diarrhoea post-aortic surgery = sigmoid ischaemia until proven otherwise. Flexible sigmoidoscopy urgently.

Nursing Management of Ileus

NG tube insertion for decompression — document drainage output
Bowel sounds documented q4–8h
IV fluid maintenance — correct electrolytes
Early mobilisation — walking promotes peristalsis
Minimise opiates where possible — consider epidural or PCA with ketamine adjunct
Cautious oral introduction when bowel sounds return and NG drainage reduces
Dietitian referral if nil by mouth >5 days — consider PN

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AAA — Exam Table (Surveillance & Repair Thresholds)

AAA Diameter	Category	Action (Men)	Action (Women)
<3.0 cm	Normal	No further action after screening	No further action
3.0–3.9 cm	Small AAA	5-yearly USS	5-yearly USS
4.0–4.9 cm	Medium AAA	Annual USS	Annual USS
5.0–5.4 cm	Large AAA	3-monthly USS	Refer for repair assessment
≥5.5 cm	Repair threshold	Refer vascular — repair assessment	Refer vascular — repair assessment
Symptomatic / Ruptured	Emergency	Emergency surgery — activate MTP — OR immediately

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Endoleak Types — Quick Reference

Type	Source	Significance	Management
Type I	Fixation site (proximal or distal attachment zone)	High pressure — sac pressurisation — repair urgently	Balloon moulding, cuff/extension, open conversion
Type II	Branch backflow (IMA, lumbar arteries)	Most common — usually benign — watch if sac expanding	Embolisation of feeding vessel if sac grows
Type III	Graft junction / modular disconnection / fabric tear	High pressure — urgent re-intervention	Relining endograft, open conversion
Type IV	Graft porosity (early post-implant)	Benign — self-limiting — anticoagulation effect	Usually resolves spontaneously
Type V	Endotension — sac expansion without detectable flow	Sac at risk despite no visible endoleak	Surveillance — relining if sac expanding significantly

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Graft Infection — Signs & Management Summary

Clinical Signs

Management Steps

Blood cultures × 3 — before antibiotics
CT angiogram — perigraft gas/fluid, false aneurysm mapping
MRSA screen and isolate (contact precautions)
Broad-spectrum IV antibiotics → culture-guided
Surgical: graft excision + extra-anatomical bypass (ax-fem / obturator)
Rifampicin-soaked graft for in-situ reconstruction in selected cases
Long-term suppressive antibiotics often required

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DHA / DOH / SCFHS / QCHP High-Yield Questions

AAA & EVAR High-Yield Points ▼

AAA screening is for men ≥65 — ONE-OFF USS (not repeated if normal)
Repair threshold: men ≥5.5 cm, women ≥5.0 cm
Ruptured AAA: permissive hypotension — target SBP 70–80, NOT normal BP
Most common endoleak: Type II (branch vessel backflow)
Most dangerous endoleak: Type I and III (high pressure, sac pressurisation)
EVAR advantage: lower 30-day mortality; disadvantage: lifelong surveillance
Post-EVAR: bilateral groin access, contrast nephropathy prevention, endoleak surveillance

Carotid / CEA High-Yield Points ▼

CEA indicated in symptomatic stenosis >50% within 2 weeks of TIA/stroke
Post-CEA neuro obs: q15 min first hour, q30 min for 4h, then q1h
Do NOT stop antiplatelet therapy pre-CEA
Cranial nerve most commonly injured: hypoglossal (XII) — tongue deviates to side of operation
Hoarse voice post-CEA = vagus/RLN injury — check swallowing before oral fluids
Expanding neck haematoma = airway emergency — call anaesthetics urgently
Hyperperfusion syndrome: headache + seizures post-CEA — strict BP control

Bypass & Limb Ischaemia High-Yield Points ▼

Best patency graft: autologous GSV (great saphenous vein)
6 Ps of acute limb ischaemia: Pain, Pallor, Pulselessness, Paraesthesia, Paralysis, Perishing cold
Paralysis + paraesthesia = irreversible ischaemia approaching — emergency revascularisation
Compartment syndrome: pressure >30 mmHg = fasciotomy
Rhabdomyolysis: dark urine (myoglobinuria), high CK, AKI — aggressive IV fluids
Groin wound infection after bypass = graft erosion risk — catastrophic haemorrhage

Venous / CEAP High-Yield Points ▼

CEAP C6 = active venous ulcer (highest clinical grade)
ABPI <0.8 = do NOT apply compression bandaging
Four-layer compression: 40 mmHg at ankle — graduated upward
May-Thurner: LEFT iliac vein compressed by RIGHT iliac artery — left-sided DVT
Foam sclerotherapy risk: stroke (rare) if patent foramen ovale (PFO) present
Venous ulcer location: medial gaiter area (above medial malleolus)

Post-Vascular Complications High-Yield Points ▼

CSF drainage: target pressure ≤10 mmHg — max 10–15 mL/hr drainage
New lower limb weakness post-TAAA: raise MAP ≥90, drain CSF — immediate action
Sigmoid ischaemia after aortic surgery: bloody diarrhoea → urgent sigmoidoscopy
Ileus post-laparotomy: NG decompression, electrolyte correction, early mobilisation
AKI after suprarenal clamp: monitor urine output, creatinine, avoid nephrotoxins
Graft infection: most common organisms — Staphylococcus aureus and MRSA

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AAA Surveillance & Repair Decision Tool

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AAA Maximum Diameter (cm)

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