Barash Vascular

Question 1

Generalized inflammatory disorder of the arterial tree with associated endothelial dysfunction

Answer 1

Atherosclerosis

Question 2

With a coronary stent, continue mono therapy with ASA,

you can discontinue plavix for as short a time interval as possible for pts with bare mental stents 1 year

Answer 2

…

Question 3

What are vascular surgery patients at HIGH risk for postoperatively?

Answer 3

postop nervous system disease, delirium, stroke, spinal cord ischemia

Question 4

Which treatment modality is best for a large AAA depends on what 3 variables?

Answer 4

AAA size, AAA morphology, patient preoperative risk

Question 5

EVAR is considered for pts with smaller AAAs.

Answer 5

…

Question 6

EVAR has a lower perioperative risk than OAR but similar

Answer 6

2 year mortality

Question 7

What is the most common cause of emergency aortic repair?

Answer 7

Leaking or ruptured aortic aneurysm.

Ruptured aortic aneurysm carry an associated mortality roughly 10 times greater than elective repair.

Question 8

EVAR stands for

Answer 8

endovascular abdominal aneurysm repair

Question 9

PAD

Answer 9

peripheral arterial disease (atherosclerosis affecting the limb and can develop into claudication or critical limb ischemia

Question 10

PAD affecting the lower limb can be detected by the

Answer 10

ANKLE BRACHIAL INDEX: The ratio of the highest systolic ankle bp to the highest sys arm bp. It is the single best initial screening test to perform in a pt suspected of having PAD. Ratio <0.4 is associated with limb threatening ischemia.

Question 11

What is the standard method for diagnosis the PAD?

Answer 11

catheter based angiography

Question 12

AAA: risk of rupture

Answer 12

</- 4cm in diameter = very low

AAA between 4 and 5 cm in diameter should be followed every 6-12 months to determine whether they are increasing in size

Question 13

Medical therapy for atherosclerosis: the use of statins may reduce progression or even cause regression of atherosclerotic plaques, improve endothelial function and reduce cardiovascular events in high risk pts. It is associated with improved graft latency, limb salvage and decorated amputation rate in pts undergoing infrainguinal bypass for AVD.

Answer 13

..

Question 14

First __ wks after coronary stent placement, non cardiac survey carries considerable risks.

Answer 14

6 wks

Question 15

What ar ethe two basic types of stents?

Answer 15

bare metal stents and drug eluting stents

Question 16

Tell me about drug eluting stents?

Answer 16

They have a reduced incidence of restenosis, slow to endothelialize, and the exposed stent material remains thrombogenic far longer than bare metal stents

Question 17

what is dual anti platelet therapy?

Answer 17

aspirin 325mg/day and clopidogrel 75mg/day

Question 18

What is the duration of dual antipaltelet therapy for bare metal stent and drug eluting stent?

Answer 18

bare metal stent: 1 month
drug eluting stent: 365 days (12 months (1year))
*aspirin is rec for an indefinite period

Question 19

If plavix can’t be used for a year, recommendations for DOT are as follows: _ months for sirolimus eluting stents and _ months for paclitaxel eluting stents

Answer 19

3 months for sirolimus eluting stents

6 months for paclitaxel eluting stnets

Question 20

what are the two types of PMI (preoperative myocardial infarction)?

Answer 20

early and delayed

Question 21

Early PMI resembles …

Answer 21

acute nonsurgical MI and is probably due to acute coronary occlusion resulting from plaque rupture and thrombosis .

Question 22

Delayed PMI is associated with.. .

Answer 22

SUSTAINED ELEVATION of HR, ABSENCE of CP, prolonged premonitory episodes of ST segment depression before over MI

Question 23

New definition of MI

Answer 23

requires the rise and fall of biochemical marker of myocardial necrosis together with one of the following clinical or ECG criteria: ischemic symptoms, development of pathologic Q waves, ischemic EKG changes, or a coronary intervention

Question 24

AHA/ACC claffified the clinical predictors of increased preoperative cardiovascular risk (MI, CHF, death) as major, intermediate, minor

Answer 24

Major: “active cardiac conditions” are acute MI (70years, abnormal ECG, rhythm other than sinus, uncontrolled systemic HTN,

*Aortic and Peripheral vascular surgery are placed in the High-risk surgery category with an estimated cardiac risk (MI or cardiac related death) exceeding 5%.
CEA/EVAR are regarded as intermediate risk category

Question 25

Preoperative Coronary Revascularization: CARP trial

Answer 25

randomized pts with coronary disease (except Left Main stem disease or EF80% of pts on beta blockers, >70% on ASA and >50% statins they could find no benefit to coronary revascularization. Thus preoperative coronary revascularization surgical or interventional may be of no value in preventing cardiac events except in those pts in whom revascularizations is independently indicated for acute coronary syndrome. High risk pts should have surveillance or Myocardial ischemia (troponin I or T) and risk reducing strategies (including HR control).

Question 26

Should coronary revascularization be required before vascular surgery then surgical revascularization is a suitable option compared with PCI. The safe time interval between surgical revascularization and vascular surgery is _ wks for surgical coronary revascularization and _ wks for coronary angioplasty

Answer 26

4-6 wks for surgical coronary revascularization and 2 wks for coronary angioplasty.

Question 27

The DECREASE trials evaluated the value of preoperative testing before major vascular surgery.

Answer 27

..

Question 28

Heparin induced thrombocytompenia and thrombosis can occur (immunogloblin g mediated after several days of exposure to heparin. What is the treatment?

Answer 28

cessation of all heparin, full anticoagulation with a direct thrombin inhibitor {direct thrombin inhibitors are a class of medication that act as anticoagulants by directly inhibiting the enzyme thrombin-Argatroban, Bivalirudin, Lepirudin} and 3 wks of warfarin therapy to prevent arterial thrombosis.

Question 29

IRI (ischemia reperfusion injury) is an active biphasic process (ischemia and reperfusion) in which both process contribute to injury

Answer 29

...

Question 30

Several intraoperative factors including ____ can predict postoperative kidney injury.

Answer 30

hemodynamic instability, the need for inotropic support, and the transfusion of greater than fiver units of packet cells or autologous blood can predict postoperative kidney injury

Question 31

In aortic surgery, the level of aortic clamping is correlated with postop kidney dysfunction, With Suprarenal cross-clamping of the aorta placing the kidneys at ...

Answer 31

highest risk. With suprarenal occlusion, renal blood flow decreases by 80%. Even with infrarenal aortic clamping, renal blood flow is still reduced by 45%.

Question 32

Intraoperative urine output is not predictive of postoperative renal function.

Answer 32

..

Question 33

What does mannitol do?

Answer 33

induces osmotic diuresis, decreases epithelial and endothelial cell swelling, acts as a hydroxyl free radical scavenger and increases synthesis of prostaglandin resulting in renal vasodilation.

Question 34

DOPamine infusion of 0.5 to 2 mcg/kg body weight per minute increase renal plasma flow, sodium excretion, and GFR.

Answer 34

...

Question 35

Prevention of pulmonary complications: Abdominal surgery, surgery lasting longer than 3 hours, emergency surgery, preoperative CHF and preoperative chronic lung disease as significant risk factors for pulmonary complications.

Answer 35

..

Question 36

the most effective preventive measure is postoperative lung expansion either ... or ...

Answer 36

CPAP OR INCENTIVE SPIROMETRY.

Question 37

2000 ARDSNET trial = reported a mortality benefit of low tidal volumes (6-8mL/kg) in pts with ARDS.

Answer 37

..

Question 38

aortic clamp site influences the risk of postoperative pulmonary complication (suprarenal vs infrarenal 25% vs 12%)

Answer 38

...

Question 39

Vascular surgey patents are at high risk for poster operative nervous system disease including...

Answer 39

delerium, stroke, and spinal cord ischemia.

Question 40

Prevention of preoperative delirium aka "central nervous system failure":

Answer 40

...

Question 41

The spinal cord is supplied by two posterior arteries which are ...

Answer 41

Anterior spinal artery which supplies 75% of spinal cord blood flow and is the primary supply to the anterolateral cord and is fed by a series of radicular arteries arising from the aorta and collateralization is POOR. The blood supply to the thoracolumbar cord is served from the radicular artery of Adamkiewicz. In 75% of cases, it joins th anterior spinal artery between T8-T12. and in 10% it joins between L1-L2. Much of the blood flow in the anterior spinal artery depends on the artery of Adamkiewicz.

Question 42

What is a GOTT shunt?

Answer 42

a heparin zed tube that can decompress the heart and also provide distal perfusion. It is most commonly placed proximally into the ascending aorta (the most common site) and inserted distally into the descending aorta (most commonly).

Question 43

Carotid Endarterectomy

Answer 43

Most common noninvasive test is the carotid duplex ultrasonography. Positive tests are usually followed by confirmatory angiography

Question 44

Preoperative Evaluation and Preparation for CEA: Most pts presenting for CA will be taking aspirin which should be continued throughout the preoperative period.

Answer 44

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