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Surgery > Chapter 20, part 2 > Flashcards

Chapter 20, part 2 Flashcards

1
Q

Etiology of acute lower extremity ischemia

A

either embolism of a clot or plaque from a proximal source or local development of thrombus

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2
Q

What are the six Ps of acute lower extremity ischemia?

A 
Pain
Pallor
Paresthesias
Pulselessness
Poikilothermia
Paralysis
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3
Q

What is the most common presenting symptom of acute lower extremity ischemia?

A

Pain

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4
Q

Paralysis in acute LE ischemia?

A

A late finding and is indicative of advanced ischemia

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5
Q

Systemic effects of tissue necrosis

A 
Acidosis
Hyperkalemia
Myoglobinuria
Renal failure
Sepsis
Death
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6
Q

What should occur once the clinical dx has been made?

A

It is more advantageous to proceed directly to arteriography and definitive management to maximize the likelihood of limb salvage

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7
Q

Management of acute lower extremity ischemia

A

Systemic anticoagulation with heparin should be instituted immediately
First step in dx and intervention is arteriography

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8
Q

Complications of acute lower extremity ischemia

A

Compartment syndrome- 2%
Minor catheter-related bleeding
Bleeding requiring transfusion
Hemorrhagic stroke

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9
Q

Characteristics of compartment syndrome

A

Pain with passive stretch of the muscles and increased compartment pressures (>20 to 30 mm Hg)

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10
Q

Dx of compartment syndrome

A

Made by hx, PE, and a high index of suspicion

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11
Q

Tx of compartment syndrome

A

Four-compartment fasciotomy of the leg

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12
Q

Most common sx of chronic lower extremity ischemia

A

Intermittent claudication
Rest pain
Ischemic ulcers
Frank gangrene

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13
Q

What will most pts report in chronic lower extremity ischemia?

A

Heart dz
DM
Kidney dz
HTN

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14
Q

PE of chronic lower extremity ischemia

A 
Diminished peripheral pulses
Hair loss
Skin atrophy
Nail hypertrophy
Elevation pallor
Dependent rubor
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15
Q

What is typically the initial symptom of chronic lower extremity ischemia?

A

Intermittent claudication

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16
Q

Claudication

A

Extremity discomfort, pain or weakness consistently produced by exercise and promptly relieved by rest.
Sx generally occur one level below the area of disease

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17
Q

What are the most common conflicting diagnoses of claudication?

A

Neurogenic leg pain caused by spinal stenosis, nerve compression, and diabetic neuropathy.

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18
Q

Critical limb ischemia

A

The presence of ischemic rest pain, the presence of tissue loss, or gangrene secondary to arterial insufficiency

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19
Q

Ischemic ulcers

A

Usually result from minor traumatic injuries, which fail to heal because of lack of adequate blood supply
They are most common in areas of focal pressure on the foot are usually dry and punctate

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20
Q

Ulcers of venous insufficiency

A

Mostly located superior to the medial malleolus and are often moist, superficial, and diffuse
Also associated with hemosiderin skin pigmentation and venous varicosities

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21
Q

Gangrene

A

Characterized by cyanotic, anesthetic tissue associated with necrosis d/t inability of the arterial blood supply to meet minimal metabolic requirements

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22
Q

Classification of gangrene

A

Can be classified as dry or wet
Dry is more common in pts with atherosclerotic dz and frequently results from embolization to the toes or forefoot
Elective amputation is required
Wet gangrene is more common in diabetic pts who sustain unrecognized trauma to the foot
Mandates either complete debridement of infected, nonviable tissue or guillotine amputation

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23
Q

Diagnostic tests for chronic lower extremity ischemia

A

Measurement of segmental systolic blood pressures
ABI
Pulse volume recordings (PVRs)

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24
Q

What ABI is considered nl?

A

> 1.0

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25
Q

Difference in management between PAD and chronic limb ischemia

A

PAD warrant medical therapy
-Initial management is antiplatelet therapy and risk factor modification
-Exercise therapy
Revascularization is indicated for all functional pts

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26
Q

Tx of aortoiliac occlusive dz

A

Endovascular therapy for single stenoses of the common iliac artery or external iliac artery shorter than 3 cm
Surgical revascularization for more complex lesions

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27
Q

In pts with hostile abdomen or high surgical risk who cannot be revascularized with an endovascular approach for aortoiliac occlusive dz, what is the tx?

A

Axillobifemoral bypass grafting

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28
Q

For pts with unilateral iliac dz not amenable to endovascular therapy, what is the tx?

A

Unilateral aortofemoral grafting

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29
Q

How is endovascular therapy for infrainguinal dz different from aortoiliac dz?

A

The patency rates are lower
No more than two focal stenoses less than 3 cm in length should be treated
The role of primary stenting is unclear
Bypass grafting is indicated when endovascular therapy is inappropriate or inadequate

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30
Q

What is the option of choice for tibial-peroneal dz?

A

Femoral-distal bypass

31
Q

What are the three common time points that bypass grafts fail?

A

Early: <30 days
Intermediate (30 days to 2 yrs)
Late (>2 yrs)

32
Q

Causes of early bypass graft failure

A

Assumed to be related to a technical or judgement error, though infection and hypercoagulability are also possible

33
Q

Causes of intermediate bypass graft failure

A

Most often caused by neointimal hyperplasia within a vein graft or at anastomotic sites

34
Q

Causes of late bypass graft failure

A

Natural progression of atherosclerotic dz

35
Q

Exam of bypass graft

A

Perioperatively
6 wks
3-mo intervals
for 2 yrs and every 6 mos after

36
Q

Complications of interventions for chronic lower extremity ischemia

A

Two categories: those related to concomitant systemic illnesses and those related to surgery
First category examples: MI and renal failure
Surgical complications: pseudoaneurysm resulting from arterial puncture, compartment syndrome, and graft infection

37
Q

RFs for AAA

A 
Advanced age
Atherosclerosis
HTN
Smoking hx
Men
First-degree FHx
38
Q

Sx of AAA

A

Usually asymptomatic

Presence of sx such as abdominal or back pain signifies impending or active rupture

39
Q

Presentation of rupture of AAA

A

Severe abdominal or back pain with associated hypotension, tachycardia, and shock

40
Q

PE of AAA

A

May reveal a pulsatile abdominal mass, but only 30-40% of aneurysms are noted on PE

41
Q

Dx of AAA

A

Often dxed accidentally by u/s or abd CT

CT is preferred

42
Q

How to decide whether to operate in pts with asymptomatic AAA

A

Decision is largely driven by diameter criterion

Aneurysms greater than or equal to 5.5 cm should be electively repaired

43
Q

What are the most common early complications of open AAA repair?

A 
Paralytic ileus
Coronary ischemia
Cardiac arrhythmias
Renal dysfunction
PNA
44
Q

What are the less common early complications of open AAA repair?

A 
Ischemic colitis
Impotence
Paralysis
Graft infection
Pseudoaneurysm
45
Q

Late complications of AAA open repair

A 
Incisional hernia
Pseudoaneurysm development
Atherosclerotic graft occlusion
Graft thrombosis
Aortoenteric fistula
46
Q

Device-related complications of endovascular aneurysm repair

A

Kinking
Occlusion
Thrombosis
Endoleak

47
Q

Non-device related complications of endovascular aneurysm repair

A

Dissection or thrombosis of the access vessels
Contrast-induced nephropathy
Wound complications

48
Q

Origin of aneurysmal disease that occurs in the renal, hepatic, and splenic arteries

A

Usually not of atherosclerotic etiology and tend to occur in younger pts

49
Q

Tx of visceral aneurysms

A

Renal and hepatic aneurysms should be repaired when discovered
Closely monitor splenic aneurysms
-Those in pregnant women or women who may become pregnant and those larger than 2 cm in diameter should be repaired
Renal, hepatic and splenic aneurysms are treated with exclusion and bypass grafting

50
Q

Tx of iliac artery aneurysms

A

Should be repaired if they are symptomatic, larger than 3 cm, or mycotic either endovascularly with a covered stenth or through open surgical bypass graft with exclusion of the aneurysm

51
Q

Tx of femoral artery aneurysms

A

Should be repaired if they are symptomatic, larger than 2.5 cm, or mycotic
Exclusion of the aneurysm and bypass graft

52
Q

Tx of popliteal artery aneurysms

A

Repaired if they are symptomatic, larger than 2 cm, or mycotic
Exclusion and bypass with saphenous vein graft, although recently stent grafting has gained support, especially in high-risk pts

53
Q

Where are most upper extremity vascular dz lesions?

A

Proximal

54
Q

What is the most commonly affected vessel of upper extremity vascular dz?

A

The subclavian artery

55
Q

Subclavian steal syndrome

A

Occurs in the presence of a proximal stenosis or occlusion of the subclavian artery
The delivery of arterial blood to the ipsilateral extremity thus depends on reversed flow through the ipsilateral vertebral artery via the circle of Willis

56
Q

Thoracic outlet syndrome

A

A constellation of vascular and/or neurologic sx, often without any physical findings and most commonly without an anatomic correlate
Caused by compression of the subclavian artery, vein, or branches of the brachial plexus

57
Q

Pt complaints in thoracic outlet syndrome

A 
Weakness
Numbness
Paresthesias
Pain
Swelling of the extremity
58
Q

Where do the brachial plexus and subclavian artery pass through?

A

Through the narrow triangle formed by the anterior scalene muscle, the middle scalene muscle and the first rib (the scalene triangle)

59
Q

What can cause compression of the brachial plexus, subclavian artery, and/or subclavian vein?

A

Presence of an anomalous cervical rib or hypertrophy of the anterior scalene muscle

60
Q

Complaints of neurologic thoracic outlet syndrome

A

Weakness
Paresthesias and numbness typically occur in the hand and medial forearm
Pain in the subscapular, scapular and cervical regions

61
Q

Physical findings of neurologic thoracic outlet syndrome

A

Weakness and atrophy of the triceps muscle, the intrinsic muscles of the hand, and the wrist flexors

62
Q

Dx of neurologic thoracic outlet syndrome

A

Often based on hx, PE, and exclusion of other conditions

63
Q

What is the mainstay of tx of neurologic thoracic outlet syndrome?

A

Conservative, with exercise and physical therapy providing symptomatic relief
Surgical tx of neurologic TOS should be reserved for refractory cases because major neurovascular complications are not uncommon

64
Q

What does subclavian artery compression usually result from?

A

Hypertrophy of the anterior scalene muscle in athletes but may also be caused by the presence of a cervical rib.

65
Q

Surgery for subclavian artery compression

A

Involves release of the scalene muscles and resection of bony abnormalities

66
Q

Presentation of compression of subclavian vein in TOS

A

Presents as effort-induced thrombosis (Paget-von Schrotter disease)
Common in young men with a hx of strenuous upper extremity activity, with painful swelling of the affected arm

67
Q

Dx of compression of subclavian vein

A

Venous duplex studies and venography

68
Q

Tx of compression of subclavian vein

A

Recanalizing the subclavian vein with thombolytics and anticoagulation

69
Q

What does acute embolic occlusion usually affect

A

The SMA and the embolus is typically from a cardiac source

70
Q

What is the most common site for an embolus to lodge

A

At the origin of the middle colic artery, distal to the first jejunal branches

71
Q

Classic finding of mesenteric ischemia

A

Pain out of proportion to physical examination

72
Q

Common sx of mesenteric ischemia

A

Sudden onset of periumbilical pain
Diarrhea
vomiting
GI bleeding

73
Q

Diagnostic test for mesenteric ischemia

A

If dx suspected before onset of peritoneal signs, mesenteric angiography is the procedure of choice
If embolism present, laparotomy should be performed immediately, with embolectomy of the SMA and resection of nonviable bowel

Surgery (30 decks)

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