Vascular Surgery

Question 1

What is atherosclerosis?

Answer 1

Systemic disease that has multiple manifestations (stroke, TIA, CAD, MI, mesenteric ischemia, AAA, PVD); presence of any one of these should raise suspicion for the others

Question 2

How do you manage a stroke?

Answer 2

Carotid duplex study, observation for improvement, CEA is not indicated until patient has stabilized

Question 3

What is a TIA?

Answer 3

Brief neurological deficit that fully resolves within 24 hours; due to thromboembolus from internal carotid arteries

Question 4

How do you manage a TIA?

Answer 4

Physical exam and carotid duplex
TIA + amaurosis fugax: emboli from carotid travels to retina causing transient blindness. Dx by fundoscopic exam reveals Hollenhorst plaque (a bright shiny spot in a retinal artery)
TIA + aphasia: emboli from left carotid travels to speech center located in the left hemisphere

Question 5

When do you do a CEA?

Answer 5

Indicated for >70% carotid stenosis with either neurologic symptoms or asymptomatic bruits; complications include 1-3% risk of perioperative stroke, or injury to facial, vagus, or hypoglossal nerve

Question 6

What is subclavian steal syndrome?

Answer 6

Presents as nothing at rest, but arm claudication and CNS sx with arm activity due to subclavian artery atherosclerosis
Dx: arteriogram
Tx: bypass surgery

Question 7

How does an arterial embolus present?

Answer 7

6 P’s: pain, pallor, paresthesias, poikilothermia, pulselessness, paralysis, clot source is usually Afib or recent MI

Question 8

How do you treat an arterial embolus?

Answer 8

Requires urgent revascularization within six hours; give heparin and go to OR for balloon catheter embolectomy +/- fasciotomy

Question 9

What is compartment syndrome?

Answer 9

Revascularization of acutely ischemic limb results in ischemia-reperfusion injury, causing muscle edema within fascial compartment and the 6 P’s. Treated with a fasciotomy

Question 10

What is the ankle-brachial index?

Answer 10

Ratio of BP in arm vs. leg; ABI >1.0 is normal, ischemic ABI is 0.6-0.8 (claudication) or 0.3-0.5 (rest pain)

Question 11

How do you manage claudications?

Answer 11

Exercise-induced ischemia that causes reversible calf pain, MCC is an atherosclerotic SFA
If mild, not indicated for surgery, so exercise and lifestyle changes are recommended
If severe, get Doppler tracing, then arteriogram to localize

Question 12

What is aortoiliac stenosis and how do you treat it?

Answer 12

Presents as triad of claudication + absent femoral pulse + impotence
Treatment depends on case;bilateral loss of femoral pulse –> aortofemoral bypass graft, single segment iliac stenosis–> angioplasty, high risk pt –> lifestyle changes

Question 13

What is a severe claudication?

Answer 13

Presents as claudication + rest pain or foot ulcers, common in diabetics; get a vascular workup and arteriogram to determine level of occlusion, and assess general medical status

Question 14

SFA treatment:

Answer 14

SFA stenosis: reverse GSV to SFA graft
Iliac stenosis: surgical revascularization or balloon dilation
SFA + iliac stenosis: both of the above
SFA + popliteal stenosis: femoropopliteal bypass to the best artery continues with the foot
Multiple obstruction: reconstruction may not be possible, limb amputation indicated

Question 15

What is post-op management of a bypass?

Answer 15

Daily duplex studies to check for graft stenosis, give aspirin, educate on lipid control and foot care, MCC death is CAD

Question 16

What is trash foot?

Answer 16

Post-op embolization of atherosclerotic debris following bypass results in cyanotic toe
tx is heparinization of clot and long-term aspirin use

Question 17

How does an AAA present?

Answer 17

Presents as painless pulsatile abdominal mass; management is getting ultrasound and CT scan, then elective graft repair if aorta is >5 cm

Question 18

What are the risks of AAA post-op?

Answer 18

Major fluid shifts (third-space loss on POD1/2, third-space mobilization on POD 3), cardiac problems due to aortic clamping, and impotence due to damage of hypogastric circulation or autonomic nerves around IMA

Question 19

How does a ruptured AAA present?

Answer 19

Presents as pulsatile mass, back and abdominal pain, and hypotension. If unstable, OR
If stable, get CT scan or US then OR

Question 20

What are the risks of ruptured AAA repair?

Answer 20

AAA repair + bloody diarrhea: indicates ischemic colitis due to interrupted IMA; dx sigmoidoscopy
tx is bowel rest if limited to mucosa, colectomy and colostomy if full-thickness involvement
AAA repair + delayed fever: indicates vascular graft infection via S. aureus or S. epidermidis. Dx by CT scan, Tx graft removal, debridement, antibiotics
AAA repair + UGI bleed: indicates aortoduodenal fistula, usually a small bleed followed by 1-2 days later by massive bleeding; Dx CT scan, tx graft removal and GI repair

Question 21

What is mesenteric ischemia and how do you manage it?

Answer 21

Presents as postprandial abd pain, weight loss, and multiple abd bruits due to atherosclerosis of celiac trunk or SMA
Management: Dx by mesenteric angiogram, tx is revascularization, follow-up with aspirin and evaluation for other atherosclerotic diseases

Question 22

How does aortic dissection present and how do you manage it?

Answer 22

Presents as acute onset tearing chest/back pain due to severe HTN (200/140), CXR shows widened mediastinum
Dx: MRI, spiral CT, transesophageal echo, or arteriography; if ascending aorta–> go to OR for surgical repair
if descending aorta–> beta blockers

Question 23

How does a DVT present?

Answer 23

Presents as acute onset dull leg pain, unilateral swelling, and Homan’s sign

Question 24

How do you manage a DVT?

Answer 24

Dx duplex ultrasound, tx therapeutic heparin or LMWH, followed by long-term warfarin therapy

Question 25

What is post-thrombotic syndrome?

Answer 25

Occurs in 10% of DVT patients, presents as severe leg edema and ulceration around ankle area due to chronic venous HTN
Management: prevention via chronic use of support hose, heal ulcers

Question 26

What is DVT prophylaxis for hip fx?

Answer 26

Fondaparinux and leg compression devices

Question 27

How does a PE present?

Answer 27

Presents as acute onset chest pain,dyspnea, and hyperventilation (decreased PCO2) due to DVT embolization into lung –> wedge-shaped area of lung infarction, S1Q3T3 on EKG

Question 28

What are the side effects of heparin and wafarin?

Answer 28

anticoagulation + HIT: rare heparin side effects include thrombocytopenia and paradoxical arterial clots
anticoagulation and skin necroses: rare side-effect of warfarin therapy

Question 29

What is phlegmasia cerulea dolens?

Answer 29

Presents as acute onset leg edema with pain and cyanosis due to venous outflow obstruction, high risk of nerve damage and venous gangrene
Manage by elevating leg and immediate anticoagulation, then order duplex ultrasound and pelvic CT scan to confirm the dx

Question 30

How does temporal arteritis present?

Answer 30

Presents as severe, unilateral headache, visual changes, and nodularity of the temporal artery; give high dose steroids right away to prevent blindness