cardiac, thoracic and vascular Flashcards
(125 cards)
1
Q
thoracic anatomy
1) where does the azygous vein run
2) where does the thoracic duct run
3) where does the phrenic nerve run
4) where does the vagus nerve run
5) what are the volumes of each lung and and lobes
6) what muscles are responsible for quiet inspiration
7) what are accessory muscles?
8) role of type I and II pneumocytes
9) role of pores of Kahn
A
1) runs along the right side and dumps into superior vena cava
2) runs along the right side, crosses midline at T4-5 and dumps into left subclavian vein at junction with internal jugular vein
3) runs anterior to hilum
4) runs posterior to hilum
5) right lung, 3 lobes is 55% volume and left (2 lobes + lingula) is 45%
6) diaphragm (80%), intercostals (20%)
7)sternocleidomastoid muscle, levators, serratus posterior, scalenes
8) Type I pneumocytes-gas exchange
Type II pneumocytes- surfactant production
9) direct air exchange bw alveoli
2
Q
Pulmonary Function tests
1) what predicted postop FEV1 do you need to be able to resect?
- what if it is close, what diagnostic test should you get
2) What is DLCO, what does it measure/represent and what does the value depend on
3) what predicted postop DLCO is needed for lung resection
4) what preop pCO2, pO2 and VO2max are contraindications for lung resection
A
1) predicted postop FEV1>0.8 needed for resection
- -if close, get qualitative V/Q scan to see contribution of that portion of lung to overall FEV1. if low may still be able to resect.
2) Diffusion capacity of lung for CO-measures carbon monoxide diffusion and represents O2 exchange capacity
- value is dependent on capillary surface area, hemoglobin content and alveolar architecture
3) >10mL/min/mm HgCO (or >40% predicted postop value)
4) pCO2>50, PO2
3
Q
What is the most common lung surgery that causes
1) persistent air leak
2) atelectasis
3) Arrhythmias
A
1) wedge/secmentectomy
2) lobectomy
3) pneumonectomy
4
Q
Lung Cancer
1) T/F: MCC of cancer-related death in US
2) what factor has strongest influence on survival
3) what is MC site of metastasis (and other met sites)
4) T/F: recurrence usually appears as single metastasis
5) what disease stages are resectable
6) possible surgeries
7) prognosis
8) MC type of lung CA
9) Most malignant Lung CA
A
1) True
2) node involvement
3) Brain (liver, other lung, supraclavicular nodes, adrenals)
4) False- usually disseminated metastases
5) Stage I and II are resectable, T3N1M0 (stage IIIa) may be resectable
6) lobectomy or pneumonectomy MC, sample suspicious nodes
7) poor. 10% 5-year overall survival. 30% with resection for cure
8) non-small cell carcinoma, adenocarcinoma is MC overall type
9) mesothelioma
5
Q
Non-small cell carcinoma of lung
1) what % of all lung CA
2) what type is more centrally located
3) what type is more peripherally located
4) chemo- when to use and which drugs
A
1) 80%
2) squamous cell CA
3) adenocarcinoma (MC)
4) Stage II or higher- carboplatin, Taxol (can also do XRT)
6
Q
Small cell lung CA
1) what % of lung CA
2) prognosis
3) 5-year survival rate for T1N0M0
4) rx
5) cell origin
A
1) 20%
2) poor, <5% 5-year survival
3) 50%
4) most just get chemo-XRT (cisplatin, etoposide)
5) neuroendocrine
7
Q
TNM staging for lung CA
1) difference bw T1-T4
2) difference bw N1-N3 and significance for treatment
3) difference bw stage 1-IV
4) single best test to determine T and N status
5) single best test to determine M status
A
1) T1 is 3cm but >2cm from carina; T3-invades chest wall, pericardium, diaphragm or
8
Q
Paraneoplastic syndromes associated with
1) squamous cell CA
2) small cell lung CA
3) which paraneoplastic syndrome is MC
A
1) PTH-related peptide
2) ACTH and ADH
3) ACTH
9
Q
Mesothelioma
1) prognosis
2) risk factor
A
1) most malignant lung CA–> aggressive local invasion, nodal invasion and distant mets common at diagnosis
2) asbestos exposure
10
Q
Mediastinoscopy 1) what lung tumors should you use it for? 2) what does it not assess 3) where are you looking with it? a-right-side structures b- left-side structures c-anterior structures
A
1) centrally located tumors and pts with suspicious adenopathy
2) aorto-pulmonary window nodes (L-lung drainage)
3) middle mediastinum
a-azygous vein and SVC
b- Recurent laryngeal nerve, esophagus, aorta, main pulmonary artery
c-innominate artery and vein, right pulm artery
11
Q
What is the Chamberlain procedure and what does it assess
A
goes through left 2nd rib cartilage (anterior thoracotomy or parasternal mediastinotomy) to assess the AP window nodes (L-lung drainage)
12
Q
What is Bronchoscopy used to assess for lung CA
A
needed for centrally located tumors to check for airway invasion
13
Q
2 criteria needed for operative resection of lung CA
A
pts must be
1) operable (appropriate FEV1 and DLCO values)
2) resectable (no T4, N2, N3 or M disease)
14
Q
Pancoast tumor
1) where is it?
2) related symptoms/syndromes
A
1) invades apex of chest wall–>
2) Horner’s syndrome (invasion of sympathetic chain-> ptosis, miosis, anhidrosis) or ulnar nerve compression
15
Q
Coin lesion on CXR
1) how many are malignant overall and by age
2) what findings suggest benign disease
3) If suspicious what is next step
A
1) 10% malignant overall (<5% in pts younger than 50yo but 50% in pts older than 50yo)
2) no growth in 2 years, smooth contour
3) guided bx or wedge resection
16
Q
1) Asbestos exposure increases lung CA risk by what %
2) appearance of bronchoalveolar CA
3) treatment of lung metastasis from other primary
A
1) 90%
2) can look like pneumonia, grows along alveolar walls, multifocal
3) can resect if isolated and not associated with any other systemic disease for colon, renal cell, sarcoma, melanoma, ovarian and endometrial CA
17
Q
Carcinoids of lung
1) cell type and location
2) % with mets, % with symptoms
3) pronosis for typical and atypical carcinoid
4) rx
5) tumor characteristics that result in increased recurrence
A
1) Neuroendocrine tumor, centrally located usually
2) 5% have mets and 50% have sx at time of dx
3) typical has 90% 5-yr survival, atypical is only 60%
4) resection, treat like CA
5) recurrence increased with positive nodes or tumors>3cm (outcome closely linked to histology)
18
Q
Bronchial Adenomas
1) types and malignant potential
2) which types are slow growing and don’t metastasize
3) which types spread along perineural lymphatics
4) which types are very XRT sensitive
5) rx for each type
6) which type can have 10-yr survival with unresectable disease
A
1) mucoepidermoid adenoma, mucous gland adenoma and adenoid cystic adenoma (all are malignant)
2, 5) Mucoepidermoid adenoma and mucous gland adenoma (rx-resection)
3, 4, 5) Adenoid cystic adenoma-slow growing (rx- resection, if unresectable, XRT is good palliation). Can get 10-yr survival with unresectable disease
19
Q
Hamartomas
1) malignant potential
2) CT appearance
3) dx and rx
A
1) benign (MC benign adult lung tumor)
2) calcifications and appear as popcorn lesion
3) dx made with CT- repeat chest CT in 6 months to confirm, no resection needed
20
Q
Mediastinal tumors in adults
1) MC presentation/sx
2) MC type in adults and children
3) what % of symptomatic mediastinal masses are malignant
4) what % of asymptomatic mediastinal masses are benign
5) MC site for mediastinal tumor
6) Anterior tumors
7) Middle mediastinal tumors
8) posterior tumors
A
1) asx. however, can have CP, cough, dyspnea
2) neurogenic tumors (usually posterior)
3) 50%; 4) 90%
5) thymus (anterior)
6) Thymus- thymoma (#1 anterior mediastinal mass in adults), thyroid CA and goiters, T-cell lymphoma, Teratoma (and other germ-cell tumors), paraThyroid adenomas
7) heart, trachea, ascending aorta- bronchogenic, paricardial and enteric cysts, lymphoma
8) esophagus and descending aorta-enteric cysts, neurogenic tumors, lymphoma
21
Q
Thymoma
1) rx
2) 50% rule
3) what % of pts with Myasthenia gravis have thymoma
A
1) resect (also resect thymus if too big or refractory M.G.)
2) 50% have symptoms, 50% have M.G., 50% are malignant
3) 10%
22
Q
Myasthenia Gravis
1) sx and cause
2) rx
A
1) fatigue, weakness, diplopia, ptosis, caused by antibodies to acetylcholine receptors
2) anticholinesterase inhibitors (neostigmine), steroids, plasmapheresis. 80% get improvement with thymectomy (including those who don’t have a thymoma)
23
Q
Mediastinal Germ Cell Tumors
1) how to dx
2) MC one in mediastinum
3) MC malignant one in mediastinum
4) Teratoma-
a) benign or malignant?
b) rx
5) Seminoma
a) tumor markers
b) rx
6) Non-seminoma
a) tumor markers
b) rx
A
1) biopsy (often with mediastinoscopy)
2) Teratoma
3) Seminoma
4) a- can be either
b- resection, possible chemo
5) a-10% are beta-HCG positive. should NOT have AFP
b-XRT (extremely sensitive) , chemo only if mets or bulky nodal disease, surgery for residual dz after that
6)a-90% have AFP and beta-HCG elevation
b-chemo (cisplatin, bleomycin, VP-16), surgery for residual disease
24
Q
Mediastinal cysts 1) Bronchiogenic a-location b-rx 2) Pericardial a-location b-rx
A
1) a-posterior to carina; b-resect
2) a-right costophrenic angle; b-leave alone (benign)
25
Neurogenic Mediastinal tumors
1) sx
2) rx
3) what % have intraspinal involvement requiring simultaneous spinal surgery
4) what type is MC
5) what type produces catecholamines and is associated with von Recklinghausen's disease
6) 2 other types of tumors
1) pain, neurologic deficit
2) resection
3) 10%
4) Schwannoma (Neurolemmoma)
5) Paraglanglioma
6) Neurofibroma, neuroblastoma
26
Trachea
1) benign tumor in adults
2) benign tumor in children
3) malignant tumor
4) MC early complication after tracheal surgery and rx
5) MC late complication after tracheal surgery
1) papilloma
2) hemangioma
3) squamous cell carcinoma
4) laryngeal edema. rx- intubate, recemic epi and steroids
5) granulation tissue formation
27
```
Trachea
1) post-intubation stenosis
a- where does it occur with tracheostomy and ET tube
b- rx
2) Tracheo-innominate artery fistula-
a-when does it occur
b- rx
c- how to avoid this complication
3) Tracheoesophageal fistula
a-when does it occur
b- temporary treatment
c- permanent treatment
```
1) a-at stoma site with tracheostomy and at cuff site with ET tube
b- if minor- serial dilation, bronchoscopic resection or laser ablation
if severe or recurring- tracheal resection with end-to-end anastamosis
2) a- with tracheostomy-> can have rapid exsanguination
b-place finger in trach hole and hold pressure--> median sternotomy with ligation and resection of innominate artery
c- keep tracheostomy above 3rd tracheal ring
3) a-with prolonged intubation
b- place large-volume cuff endotracheal tube below fistula, attempt repair after vent wean
c-tracheal resection and reanastamosis; close hole in esophagus; sternohyoid flap between esophagus and trachea
28
Lung Abscess
1) MC cause and location
2) rx
3) how to differentiate from empyema
1) aspiration, superior segment of RLL
2) abx alone (95% success); if that fails- CT-guided drainage. Surgery if above fails or can't r/o CA (>6cm, doesn't resolve within 6month)
3) can get CT scan
29
Empyema
1) MC cause
2) symptoms
3) characteristics of pleural fluid labs
4) empyema phases- time when it is seen and rx
a) exudative phase
b) Fibro-proliferative phase
c) organized phase
1) pneumonia and subsequent paraneumonic effusion (staph or strep) is MC. but also can be 2/2 esophageal, pulm or mediastinal surgery
2) pleuritic CP, fever, cough, SOB
3) WBCs >500cells/cc, bacteria and + gm stain
4) a)1st week. rx- abx, CT
b) 2nd week. rx- CT, abx; possible VATS deloculation (=video-assisted thoracoscopic surgery)
c) 3rd week. rx- decrotication (fibrous peel occurs around lung). some use intra-pleural tPA to dissolve the peel. May need Eloesser flap (open thoracic windo direct to external environment) to frail/elderly
30
Chylothorax
1) fluid appearance and lab findings and special stain
2) infection risk
3) MC causes
4) causes of L-sided chylothorax vs right-sided chylothorax
5) rx
1) white, milky fluid. has inc lymphocytes and TAGs (triglycerides >110ml/uL). Sudan red stains fat
2) resistant to infection= no risk
3) trauma or iatrogenic injury 50%
malignancy (ie-lymphoma 2/2 tumor burden in lymphatics) 50%
4) Injury above T5/6-> left-sided chylothorax
Injury below-> right sided chylothorax
5) 2-3 wks conservative rx (Chest tube, octreotide, low-fat diet/TPN)
-if fails and cause is trauma-> ligation of thoracic duct on right side in low mediastinum
-if fails and cause is malignant-> need talc pleurodesis and possible chemo &/or XRT
31
Massive Hemoptysis
1) quantity that defines it
2) MC site of bleed
3) MC cause
4) MCC of death
5) rx
1) >600cc/24hr
2) high pressure bronchial arteries
3) 2/2 infection
4) asphyxiation
5) place bleeding side down; mainstem intubation to opposite side of bleed. rigid bronchoscopy to identify site and possible control of beed. May need lobectomy/pneumonectomy or bronchial artery embolization if not suitable for surgery
32
Spontaneous pneumothorax
1) classic patient description
2) MC side
3) recurrence risk
4) rx for all
5) when to operate and what operation
1) thin, tall, healthy young male
2) right side MC
3) after 1st pneumo-20%, after 2nd-60%, after 3rd-80%
4) Chest tube
5) if recurrence, air leak >7 days, non-reexpansion, high-risk profession (airline pilot, diver, mountain climber) or pt living in remote area
- - do thoracoscopy, apical blebectomy and mechanical pleurodesis
33
Other lung conditions
1) MCC of arrest after blunt trauma
2) occurs in temporal relation to menstruation 2/2 to endometrial implants in visceral lung pleura
3) rx of residual hemothorax despite 2 good chest tubes
4) when to surgically drain clotted pneumothorax
5) cause of broncholiths
6) MCC of mediastinitis
1) tension pneumo 2/2 impaired venous return
2) Catamenial pneumothorax
3) OR for thorascopic drainage
4) if >25% of lung, air-fluid levels or signs of infection (fever, inc WBCs). do surgery in 1st week to avoid peel
5) infection
6) usually occurs after cardiac surgery
34
Management of whiteout on CXR if
1) midline shift toward whiteout
2) midline shift away from whiteout
3) no shift
1) most likely collapse-> need bronchoscopy to remove plug
2) most likely effusion-> place CT
3) CT scan to figure out
35
Bronchiectasis
1) causes
2) surgical management
1) acquired from infection, tumor or cystic fibrosis
| 2) too diffuse for surgery
36
TB
1) MC location in lungs
2) typical pathology
3) what is a Ghon complex
4) Rx
5) difference between path in sarcoidosis and TB
1) apical
2) calcifications and caseating granulomas
3) parenchymal lesion + enlarged hilar LNs
4) INH, rifampin, pyrazinamide
5) has non-caseating granulomas
37
1) Rx of recurrent pleural effusions
2) rx of airway fires
3) MC benign Chest wall tumor
4) MC malignant chest wall tumor
1) mechanical pleurodesis (Talc powder for malignancies)
2) usually from laser.
3) osteochondroma
4) chondrosarcoma
38
Lung AVMS
1) vasculature involved
2) MC location
3) what syndrome can they occur with
4) rx
5) sx
1) cnxn bw pulm artery and veins
2) lower lobes
3) osler-Weber-rendu disease
4) embolization
5) hemoptysis, SOB, neurologic events
39
Congenital Heart disease
1) a)what kind of shunt results in cyanosis
b) why does squatting relive symptoms in these pts
c) what is Eisenmenger's syndrome and why does it occur
d) complications of cyanosis
2) what kind of shunt causes CHF
3) 3 causes of L-> R shunts and how do they present
4) 1 cause of R->L shunt
1) a) R->L shunt
b) squatting-> increased SVR and decrease R->L shunt
c) shift from L-> R to R->L shunt. 2/2 increased pulmonary vascular resistance (PVR) and pulmonary HTN, generally irreversible
d) polycythemia, strokes, brain abscess, endocarditis
2) L-> R shunt
3) VSD, ASD, PDA. manifest as failure to thrive, inc HR, tachypnea, hepatomegaly (1st sign of CHF in children)
4) tetralogy of fallot
40
Congenital Heart disease
1) what is the ductus arterios
2) What is the ductus venosum
3) what provides fetal circulation to placenta (supply deoxygenated blood from fetus to placenta)
4) what provides fetal circulation away from placenta (supplies oxygenated blood to fetus)
5) MC congenital heart defect
6) MC congenital heart defect that results in cyanosis
1) connection bw left PA and descending aorta (blood shunted away from lungs in utero)
2) Cnxn bw portal vein and IVC (blood shunted away from liver in utero)
3) 2 x umbilical arteries
4) umbilical vein (only 1 vein, but 2 arteries)
5) VSD
6) tetrology of fallot
41
Ventricular Septal Defect
1) direction of shunt
2) what % close spontaneously and by what age
3) when do they cause symptoms and physiology of why
4) consequent symptoms/effects
5) Medical rx
6) when to repair
a) large VSD (Shunt >2.5)
b) medium VSD (Shunt 2-2.5)
c) what is MC reason for earlier repair
1) L->R
2) 80% spontaneously close by 6mo
3) large VSDs cause symptoms at 4-6weeks bc of PVR decreasing and shunt increasing
4) CHF (tachypnea, tachycardia) and failure to thrive
5) diuretics and digoxin
6) a- at 1 year old; b-at 5 years old; c- failure to thrive
42
Atrial Septal Defect
1) shunt direction
2) what is MC type and location
3) what type can have mitral valve and tricuspid valve problems and what syndrome do you see this type with
4) when do symptoms occur and what are they
5) medical rx
6) when to repair
1) L->R
2) Ostium secundum, centrally located, 80%
3) ostium primum (or Atrioventricular defects or endocardial cushion defects) seen with DOwn's syndrome
4) when shunt >2-> CHF (SOB, recurrent infections). In adults can get paradoxical emboli
5) diuretics and digoxin
6) 1-2years of age. If canal defects 3-6mo.
43
Tetrology of Fallot
1) shunt direction
2) what defects are part of this
3) medical rx
4) usual timing of repair
5) how is repair done
1) R->L
2) anterior superior displacement of infundibular septim->pulm artery stenosis and VSD, over-riding aorta, and RV hypertrophy (secondary occurance)
3) B-blockers
4) 3-6months
5) removal of RV outflow tract obstruction (RVOT) and RVOT enlargement + VSD repair
44
Patent Ductus Arteriosus
1) direction of shunt
2) what drug causes the PDA to close, and during what timeframe is this successful
3) repair of persistent PDA through what type of incision
1) L-> R
2) indomethacin, rarely effective beyond the neonatal period
3) requires surgical repair through left thoracotomy
45
Adult Cardiac Disease: Coronary Artery disease
1) risk factors
2) medical treatment
3) branches of Left Main coronary artery
4) where are most stherosclerotic lesions
5) what is the restenosis rate of drug-eluting stent at 1 year
6) what is saphenous vein graft 5-year patency rate
7) what is the best conduit for CABG- name the artery, where it branches off of and what it collateralizes with
8) Indictions for CABG
9) high mortality risk factors for CABG
1) smoking, HTN, male, family hx, hyperlipidemia, diabetes
2) nitrates, smoking cessation, weight loss, statins, ASA
3) Left anterior descending and Left circumflex arteries
4) proximal
5) 20% restenosis at 1-year
6) 80% patency at 5-years
7) internal mammary (branch of subclavian artery) collateralizes with superior epigastric artery
8) >70% stenosis for most areas except >50% stenosis for Left main disease is considered significant.
CABG for:
-Left main >50% stenosis
-3-vessel disease (LAD, Cx, and Right Coronary Artery)
-2-vessel disease involving LAD
-lesions not amenable to stenting
9) pre-op cardiogenic shock is #1 risk factor, emergency operations, age, low EF
46
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Complications of MI
1) Ventricular Septal Rupture
a-symptoms
b-timeframe in which occurs
c- shunt direction and consequent O2 content effect
d-how to dx
e- rx
2) Papillary muscle rupture
a- syptoms
b-when it occurs
c-dx
d-rx
```
1)a- hypotension, pansystolic murmur
b-usually 3-7d after MI
c- L-> R shunt-> increase in pulmonary artery and right atrium O2 content
d- echo
e- temporize with intra-aortic balloon pump, patch over septum
2) a- hypotension and severe mitral regurg
b- 3-7 days after MI
c-echo
d- temporize with IABP, valve replacement
47
Adult Cardiac disease
1) what is MC cause of death in US
2) MC valve lesion
3) MC benign tumor of the heart and where are they located
4) MC malignant heart tumor
5) MC metastatic tumor to the heart
6) which veins have lowest O2 tension of any tissue in the body and why
7) what is the treatment for coming off cardiopulmonary bypass and aortic root vent when blood is dark and aortic perfusion cannula blood is red
8) with mediastinal bleeding after a cardiac procedure when do you need to re-explore
9) risk-factors for mediastinitis and rx
1) Coronary Artery disease
2) aortic stenosis
3) myxoma- 75% in LA
4) Angiosarcoma
5) lung CA
6) coronary veins 2/2 O2 extraction by myocardium
7) ventilate the lungs
8) >500cc for 1st hour, or >250cc/h for 4 hours-> need to re-explore
9) obesity, use of bilateral internal mammary arteries, DM. rx- debridement with pectoralis flaps (can also use omentum)
48
Superior Vena Cava symdrome
1) sx
2) MC cause and rx
1) upper extremity and face swelling
| 2) MC 2/2 to lung CA invading SVC-> emergent XRT
49
Post-pericardiotomy syndrome
1) sx
2) EKG findings
3) rx
1) pericardial friction rub, fever, chest pain, SOB
2) diffuse ST-segment elevation in mult leads
3) NSAIDS, steroids
* basically like pericarditis
50
Endocarditis
1) sx
2) MC site of prosthetic valve infections
3) MC site of native valve infections
4) MC organism responsible
5) what is MC side except for in which pts
6) MC organism in IVDA
7) Rx and indications for surgery (how often is medical rx successful)
1) fever, chills, sweats
2) Aortic valve
3) Mitral Valve
4) staph aureus responsible for 50%
5) Left side MC (mitral valve) except in IVDA (tricuspid valve)
6) pseudomonas
7) medical therapy 1st- sucessful in 75%, sterilizes valve in 50%
surgery if- failure of abx, severe valve failure or perivalvular abscesses, pericarditis
51
Cardiac Valve disease
1) MC valve to become stenosed and cause
2) what type of valves don't require anticoagulation
3) Bioprosthetic tissue valves
a-how long to give AC
b-when to use
c-life of tissue valves
d-what pts is it c/i in
4) Aortic Stenois
a- cardinal symptoms and mean survival for each (Dyspnea, Angina, Syncope)
b- indications for operation and peak gradient/valve area at the time
5) Mitral regurge
a-key index of disease progression in pts with MR
b- common associated arrhythmia
c- indications for surgery
6) Mitral stenosis
a- MC cause
b-symptoms
c- indications for surgery and 1st operation to try
1) Aorta (degenerative calcification)
2) bioprosthetic tissue valves
3) a- not needed
b- pts who want pregnancy, C/I to anticoagulation, >65yo and unlikely to require another valve, or frequent falls
c- last 10-15 years (not as durable as mechanical valves)
d- children and young pts bc of rapid calcification
4) a) dyspnea on exertion (mean survival 5yr), angina (4years), syncope (3 years)
b) symptomatic (usually peak gradient >50mmHg and valve area LV function key index of dz progression
b- a-fib. In end-stage dz pulmonary congestion occurs
c- symptoms or severe mitral regurge
6)a- rare- MC cause rheumatic fever
b- dyspnea and pulmonary edema
c- symptoms (usually valve area
52
Vascular
1) MC congenital hypercoagulable disorder
2) MC acquired hypercoagulable disorder
1) resistance to activated protein C (Leiden factor)= factor 5 leiden d/o
2) smoking
53
Stages of atherosclerosis
1) 1st stage- cells that are present
2) 2nd stage- proliferation of what cells? and what is it mediated by and what is the result
3) 3rd phase- what happens and result
4) risk factors
5) vessel layers from inside to out
1) foam cells= macrophages that have absorbed fats and lipids in the vessel wall
2) smooth muscle cell proliferation caused by growth factors released from macrophages-> wall injury
3) intimal disruption (From SM cell proliferation)-> exposure of collagen in vessel wall-> thrombus formation-> fibrous plaques form in these areas with underlying atheromas
4) smoking, HTN, hypercholesterolemia, DM, hereditary factors
5) Endothelium-> Intima-> media-> adventitia
54
Cerbrovascular disease
1) Most important risk factor for stroke?
2) where does stroke rank in MC causes of death in US?
3) what artery supplies 85% of blood flow to brain
4) MC site of stenosis
5) Type of flow in normal internal carotid artery? and 1st branch of internal carotid artery?
6) Type of flow in normal external carotid artery and first branch?
7) how does communication bw ICA and ECA occur
8) MC diseased intracranial artery
9) MC cause of cerebral ischemic events
1) HTN
2) 3rd MC cause of death
3) carotid artery (vertebral artery supplies the rest)
4) at carotid bifurcation
5) continuous forward flow. Ophthalmic artery is 1st branch
6) triphasic flow, superior thyroid artery is 1st branch
7) ophthalmic artery (off ICA) and internal maxillary artery (off ECA)
8) middle cerebral artery
9) arterial embolization from ICA (not thrombosis), heart is 2nd MC source of emboli. Can also occur via low-flow state through severely stenotic lesion
55
Cerebrovascular disease
1) symptoms of
a- anterior cerebral artery events
b-middle cerebral artery events
c- posterior cerebral artery events
2) what is amaurosis fugax (cause and sx) and what do you see on ophthalmologic exam
3) what allows for antergrade perfusion when proximal occlusion develops in carotid or vertebral arteries
4) what allows for retrograde flow through the ophthalmic artery to internal carotid artery in presence of cervical internal carotid artery occlusion.
1) a- slowing, AMS
b- contralateral motor and speech (if dominant side), contralateral facial droop
c- vertigo, tinnitus, drop attacks, incoordination
2) occlusion of the ophthalmic branch of the ICA (visual changes like shade coming down over eyes)- changes are transient. See Hollenhorst plaques on ophthalamic exam
3) extensive collaterals bw vertebral and carotids
4) periorbital collaterals
56
Cerebraovascular disease
1) Carotid traumatic Injury with major fixed deficit- when do you repair and why don't you always repair it
2) Carotid endarterectomy
a- indications for surgery
b- what if recent completed stroke, when to operate
c- when is emergent CEA of benefit
d- when to use a shunt during CEA
e-which side do you repair first
3) when should you do carotid stenting instead of CEA
1) repair if not occluded with carotid stent or open procedure. Don't repair if occluded bc can exacerbate injury with bleeding
2) a- syptomatic and >70% stenosis or asymptomatic and >80% stenosis.
b- wait 4-6 weeks, then perform CEA if meets criteria (earlier operation has bleeding risk)
c-with fluctuating neuro symptoms or crescendo/evolving TIAs
d- for stump pressures
57
Complications from carotid endarterectomy
1) MC cranial nerve injury with CEA, sx and cause
2) hypoglossal nerve injury- exam findings and sx
3) glossopharyngeal nerve injury- when does it occur and sx
4) Ansa cervicalis injury- what does it innervate and sx from damage
5) Mandibular branch of facial nerve injury effects
6) management of acute event immediately after CEA
7) symptoms and management of pseudoaneurysm after CEA
8) HTN after CEA- % that have it, cause and rx
9) MC cause of non-stroke morbidity and mortality following CEA
10) restonisis rate
1) Vagus nerve injury-secondary to vascular clamping during endarterectomy. Pts get hoarseness (recurrent laryngeal comes off vagus)
2) tongue deviates to the side of injury-> speech and mastication difficulty
3) difficulty swallowing. seen with really high carotid dissection
4) strap muscles- no sx
5) corner of mouth (smile)
6) back to OR to check for flap or thrombus
7) pulsatile bleeding mass after CEA. drape and prep before intubation, intubate, then repair.
8) 20% have it caused by injury to carotid body. rx- nipride to avoid bleeding
9) MI
10) 15%
58
Vertebrobasilar artery disease
1) what do vertebral arteries arise from?
2) what do they combine to form?
3) what does the basilar artery split into
4) T/F: usually need basilar artery or bilateral vertebral artery disease to have symptoms
5) causes of vertebrobasilar insufficiency
6) symptoms of vertebrobasilar insufficiency
7) rx
1) subclavian arteries-> 2 vertebral arteries
2) 2 vertebral arteries -> basilar artery
3) basilary artery-> 2 posterior cerebral arteries
4) True
5) atherosclerosis, spurs, bands
6) diplopia, vertigo, tinnitus, drop attacks, incoordination
7) Percutaneous transluminal angioplasty (PTA) with stent
59
Carotid body tumors
1) presentation (sx)
2) where are they MC
3) Cell type
4) rx
1) painless neck mass.
2) near bifurcation
3) neural crest cells, extremely vascular
4) resection
60
Thoracic Aortic disease
1) anatomy
a- what are the aortic arch vessels and branches
2) ascending aortic aneurysm
a- symptoms and dx
b- indications for repair (how does this change in pts with Marfan's)
3) descending aortic aneurysm
a-indications for repair
b-risk of mortality or paraplegia with endovascular vs open repair
c- where should you reimplant intercostal arteries with an open repair and why?
1) a- innominate (branches into right subclavian and right common carotid arteries), left common carotid artery and left subclavian artery
2) a-often asx and found via CXR. Other possible sx include- compression of: vertebra-> back pain, RLN-> voice changes, bronchi-> dyspnea or PNA, esophagus-> dysphagia
b-repair if acutely symptomatic or 5.5+cm (5cm or more in Marfans) or rapid increase in size (>0.5cm/year)
3)a- if endovascular repair possible- >5.5cm, if open repair needed- >6.5cm
b- risk is 2-3% with endovascular and 20% with open repair
c-below T8 to help prevent paraplegia with open repair
61
Aortic dissections
1) What is stanford classification based on? describe class A and B
2) What is DeBakey classification based on? Describe Types I-III
3) where do most dissections start
4) sx
5) what % of pts have severe HTN at presentation
6) risk factors
7) dx
8) what layer of the blood vessel wall does the dissection occur in?
9) what % have aortic inssufficiency and cause?
1) based on presence or absence of involvement of ascending aorta.
Stanford Class A= any ascending aorta involvement
Class B= descending aorta involvement only
2) based on site of tear and extent of dissection
DeBakey Class I= ascending and descending
Class II= ascending only
Class III=descending only
3) in the ascending aorta
4) tearing chest pain, unequal pulses or BP in upper extremitiy
5) 95%
6) Marfan's, previous aneurysm, atherosclerosis
7) Chest CT with contrast (CXR may be normal or may have wide mediastinum)
8) medial layer
9) 70% 2/2 annular dilatation or when valve cuff is sheared off
62
Thoracic Aortic Dissections
1) what arteries can become occluded?
2) MC causes of death after dissection
3) Initial medical rx
4) definitive rx- when to operate and how to repair
5) followup post-dissection
6) postop complications for thoracic aortic surgery
7) cause of paraplegia with descending thoracic aortic surgery
1) coronary arteries and major aortic branches
2) Cardiac failure from aortic insufficiency, cardiac tamponade, or rupture
3) BP control with b-blockers (ie- esmolol) and Nipride
4) Operate on ALL ASCENDING aortic dissections- need open repair with graft placed to eliminate flow to false luman
ONLY operate on descending aortic dissections with visceral or extremity ischemia, or if contained rupture- rx- endograft or open repair or can just place fenestrations in the dissection flap to restore blood flow to viscera or extremity if ischemia is the prbm
5) pts need lifetime serial scans (MRI to decrease radiation exposure) bc 30% get aneurysm formation and need surgery
6) MI, renal failure, paraplegia (descending thoracic aortic surgery)
7) spinal cord ischemia 2/2 occlusion of intercostal arteries and artery of Adamkiewicz that occurs with descending thoracic aortic surgery
63
```
Abdominal Aortic Disease
1) AAA
a- normal size of aorta
b- what layer degenerates
c- risk factors
d- MC presentation
e-leading cause of death
2) branches of aorta in order from cephalad down
```
1) a- 2-3cm
b- medial layer degeneration
c- smoking, male, age, family hx
d- incidental finding. Other presentations include rupture, distal embolization or compression of adjacent organs
e- rupture without operation
2) 1st- celiac trunk (branches to splenic and common hepatic and left gastric). Common hepatic branches include Right Gastric, gastroduodenal and proper hepatic. Gastroepiploics come off of R and L gastric. Superior Pancreaticoduodenal artery comes from Right gastric
2nd- L and R renal artery
3rd- SMA
4th- IMA
5th- splits into 2 common iliacs which -> internal and external iliac (external iliac-> common femoral which branches into superficial and deep femorals)
64
```
Abdominal Aortic Disease
1) AAA rupture
a- sx
b- dx
c- most likely site of rupture
d- comorbidities that increase risk of rupture
e- mortality
2) AAA treatment
a- when to repair
b- type of graft to use
c- when do you need to reimplant the IMA
d- what should you do for bleeding lumbar arteries
e- what must your check if you are doing an aorto-bifemoral repair instead of a straight graft and why
```
1) a- back or abdominal pain, profound hypotension
b- US or CT (showes fluid in retroperitoneal space and extraluminal contrast with rupture)
c- left posterolateral wall, 2-4cm below renals
d- COPD and HTN (predictors of expansion)
e- 50% mortality if reach hospital alive
2) a- if symptomatic, >5.5cm or growth >0.5cm/yr
b- if backpressure
65
Abdominal Aortic Aneurysm
1) Complications of surgery for AAA repair
a- what is the major vein injury with proximal cross-clamp
b- cause of impotence
c- mortality of elective repair
d- MCC of acute death after surgery
e- MCC of late death after surgery
f- Risk factors for mortality
2) Graft infection rate
3) rate of pseudoaneurysm after graft placement
4) MC Late complication after aortic graft placement
5) what should you worry about if pt presents with diarrhea (esp if bloody) after AAA repair and why
a- how to dx and what parts of rectum are spared?
b- rx
1) a- retro-aortic left renal vein
b- 1/3 get 2/2 disruption of autonomic nerves and blood flow to the pelvis
c-5%
d-MI
e- renal failure
f-Cr>1.8 is #1 RF. Others are CHF, EKG ischemia, pulmonary dysfunction, older age, females
2) 1%
3) 1%
4) atherosclerotic occlusion
5) ischemic colitis bc IMA often sacrificed with AAA repair and can cause ischemia of L colon
a- dx- endoscopy or abdominal CT. middle and distal rectum are spared from ischemia (supplied by middle and inferior rectal arteries which are branches of internal iliac artery)
b-if peritoneal signs, mucosa is black on endoscopy or part of colon looks dead on CT-> OR for colectomy and colostomy placement.
66
Criteria for AAA endovascular repair
1) Neck length > than?
2) neck diameter
3) neck angulation than?
5) common iliac artery diameter
6) other criteria that must be met
1) >15mm
2) 20-30mm
3) 10mm
5) 8-18mm
6) non-tortuous, noncalcified iliac arteries, lack of neck thrombus
67
Treatment for AAA endovascualr repair leak type for the following failure sites:
1) Type 1- proximal or distal graft attachment sites
2) Type II- collaterals (patent lumbar, IMA, intercostals, accessory renal)
3) Type III- overlap sites when using multiple grafts or fabric tear
4) Type IV- Graft wall porosity or suture holes
5) Type V- Expansion of aneurysm without evidence of leak
1) Extension cuffs
2) Observe most. Perc coil embolization if pressurizing aneurysm
3) secondary endograft to cover overlap site or tear
4) observe. nonporous stent if that fails.
5) repeat EVAR or open repair.
68
```
AAA
1) inflammatory aneurysms
a- % of AAA
b-T/F- secondary to infection
c-where can it cause adhesions?
d- what can become entrapped?
e-symptoms and lab and CT findings
f- when does inflammatory process resolve
2) Mycotic aneurysms
a- top 2 causes
b- pathophysiology
c- sx and lab results
d-rx
```
1) a- 10%
b- false
c- 3rd and 4th parts of duodenum
d- ureteral entrapment in 25%
e- weight loss, inc ESR, thickened rim above calcifications on CT
f- after aortic graft placement (may need to place preoperative ureteral stents
2) a-Salmonella is #1, Staph is #2
b- bacteria infect atherosclerotic plaque, can cause aneurysm
c- pain, fever, 50% have positive blood cultures, periarotic fluid, gas, retroperitoneal soft tissue edema, lymphadenopathy
d- extra-anatomic bypass (axillary-femoral with femoral-to-femoral crossover) and resection of infrarenal abdominal aorta to clear infection
69
Aortic graft infection
1) MC causes
2) CT findings
3) T/F- many pts have negative blood cx
4) rx
5) what graft site is infected most
1) Staph #1, E. Coli #2
2) fluid, gas, thickening around graft
3) true
4) bypass through non-contaminated field (ie- axillary femoral bypass with femoral-to-femoral crossover) and then resect infected graft
5) groin grafts (aorto-bifemoral grafts)
70
Aortoenteric fistulas
1) time frame for occurance after abdominal aortic surgery
2) sx
3) MC site of fistula
4) rx
1) >6mo after abdominal aortic surgery
2) herald bleed with hematemesis, then blood per rectum.
3) graft erodes into 3rd or 4th portion of duodenum near proximal suture line
4) bypass through non-communicating field (axillary-femoral bypass with femoral-to-femoral crossover), resect graft and close hole in duodenum
71
```
Peripheral Arterial Disease (PAD)
1) anatomy- branches of external iliac artery from cephalad down
2) Leg compartments- name the nerves (and what they innervate) and arteries for each compartment
a- Anterior compartment
b- Lateral
c- deep posterior
d- superficial posterior
3) symptoms and MC cause of PAD
```
1) external iliac-> common femoral-> deep femoral (perforator arteries branch off) and superficial femoral artery-> popliteal artery (branches include anterior tibial, peroneal then posterial tibial artery. Dorsal pedis artery comes from anterior tibial.
2) a- anterior-deep peroneal nerve (dorsiflexion, sensation bw 1st and 2nd toes) and anterior tibial artery
b-lateral-superficial peroneal nerve (eversion, lateral foot sensation
c- deep posterior- tibital nerve (plantar flexion), posterior tibial artery and peroneal artery
d-superficial posterior- sural nerve
3) pallor, dependent rubor, hair loss, slow capillary refill. MC 2/2 atherosclerosis
72
Atherosclerosis
1) #1 preventative agent
2) effect of homocystinuria on atherosclerosis and rx
1) statins
| 2) increased risk of atherosclerosis rx- Folate and B12
73
```
Peripheral Arterial disease
1) Claudication treatment
2) symptoms- where do they occur
3) name the level of occlusion for the following symptoms
a- buttock claudiation
b- mid-thigh claudication
c- calf claudication
d- Foot claudication
4) what disease can mimic claudication
5) what disease can mimic rest pain
```
1) medical rx first-> ASA, smoking cessation, exercise until pain occurs to improve collaterals
2) at one level below occlusion
a- aortoiliac disease
b- external iliac disease
c- common femoral artery or proximal superficial femoral disease
d- popliteal disease or superficial femoral artery
3) lumbar stenosis
4) diabetic neuropathy
74
Leriche syndrome
1- signs/sx
2- level of lesion
3- rx
1) no femoral pulses, buttock or thigh claudication, impotence (from decreased flow in the internal iliacs
2) level of aortic bifurcation or above
3) aorto-bifemoral bypass graft
75
Peripheral artery disease (PAD)
1) MC atherosclerotic occlusion in lower extremities- location and muscle that covers it
2) what causes collateral artery formation and where do collaterals form
3) ABI- at what ankle-brachial index do you
a- start to get claudication
b- start to get rest pain
c- start to get ulcers
d- see gangrene
4) in what pts can ABIs be inaccurate and why
5) T/F: in pts with claudication ABI drops with exercise
1) Hunter's Canal (distal superficial femoral artery exits here); the sartorius muscle covers hunter's canal
2) abdominal pressure gradients->
- circumflex iliacs to subcostals
- circumflex femoral arteries to gluteal arteries
- Geniculate arteries around knees
3) a- ABI
76
Peripheral Arterial Disease
1) Postnatal angiogenesis- what is it and what stimulates it
2) Pulse Volume Recordings- what are they used for
3) When is arteriogram indicated
1) budding from preexisting vessels. Angiogenin involved
2) used to find significant occlusion and at what level
3) indicated if pulse-volume recordings suggest significant disease, Also used to treat pt with percutaneous intervention. Gold standard for vascular imaging.
77
Surgical Indications for PAD (Periph. arterial dz)
1) indications
2) when to use PTFE (polytetrafloroethylene)= Gortex grafts. Otherwise what should you use.
3) when to use Dacron grafts
4) repair of aortoiliac occlusive disease and how to prevent vasculogenic impotence/pelvic ischemia
5) rx of isolated iliac lesion
6) Femoropopliteal grafts
a- 5-yr patency
b-what are the muscles surrounding the popliteal artery in the knee that you must identify for exposure
1) rest pain, ulceration or gangrene, lifestyle limitation, atheromatous embolization
2) only for bypasses above the knee. Need to use saphenous vein for below the knee bypasses
3) good for aorta and large vessels
4) aorto-bifemoral repair MC. ensure flow to at least 1 internal iliac artery (hypogastric with good back-bleeding) to prevent vasculogenic impotence and pelvic ischemia, otherwise need bypass to internal iliac.
5) PTA (percutaneous transluminal angioplasty) with stent 1st choice. if that fails, consider femoral-femoral crossover
6) a- 75%
b- gastrocnemius is posterior and popliteus is anterior
78
Surgery for PAD (periph art dz)
1) Femoral-Distal grafts (peroneal, anterior tibial or posterior tibial artery
a-5-yr patency
b- T/F- patency influenced by level of distal anastamosis
c- T/F- distal lesions more limb threatening bc of lack of collaterals
d- when are bypasses to distal vessels used and what is needed for them to be successful
2) when to use extra-anatomic grafts
3) complication of femoral-to-femoral crossover graft
1) a- 50%
b-false. not influenced by level
c- true
d- for limb-salvage only. bypass vessel needs to have run-off below the ankle for it to be successful
2) to avoid hostile conditions in the abdomen (multiple previous operations in a frail patient
3) doubles blood flow to donor artery-> can get vascular steal in donor leg.
79
Lower extremity bypass complications
1) Swelling
a- if early causes and complications and rx
b- if late cause
2) complications of reperfusion of ischemic tissue
3) #1 cause of early failure of reversed saphenous vein graft
4) #1 cause of late failure
1) a- reperfusion injury and compartment syndrome. rx- fasciotomy
b- DVTs- dx- US, rx- heparin, coumadin
2) compartment syndrome, lactic acidosis, hyperkalemia, myoglobinuria
3) technical prbm
4) atherosclerosis
80
```
Peripheral Arterial Disease
1) rx of heal ulceration to bone
2) What is difference bw dry and wet gangrene
3) rx of dry gangrene
4) rx of wet gangrene
5) Mal perforans ulcer
a- location
b- risk factor
c- what may be present at time of dx at site of ulcer
d-rx
```
1) amputation
2) wet gangrene is infectious nd need to remove infected necrotic matl and give abx. Dry gangrene is noninfectious and can allow to autoamputate if small or just toes
3) amputate large lesions, see if pt has correctable vascular lesion
4) can be surgical emergency if extensive infection or systemic complications (ie- sepsis). May need emergency amputation. Otherwise debridement and abx
5) a- at metatarsal heads- 2nd MTP joint MC
b-DM. c- osteomyelitis. d-non-weightbearing, debridement of metatarsal head (remove cartilage), abx. assess need for revascularization
81
Percutaneous Transluminal angioplasty (PTA)
1) when to use
2) how it works
1) use for short stenoses. excellent for common iliac artery stenosis
2) intima usually ruptured and media stretched, pushes the plaque out (requires passage of a wire first)
82
Compartment syndrome
1) caused by what after PAD intervention
2) cell type responsible
3) which compartment is it most likely to occur in and sx
4) rx
1) reperfusion injury-> swelling-> compartment syndrome
2) PMNs
3) anterior compartment-> foot drop
4) fasciotomies (get all 4 compartements in lower leg) and leave open 5-10days
83
Popliteal entrapment syndrome
1) presentation/ what pts and sx
2) anatomic abnormality
3) rx
1) men, 40s, loss of pulses with plantar flexion, present with mild intermittent claudication
2) medial deviation of artery around medial head of gastrocnemius
3) resection of medial head of gastrocnemius muscle. may need arterial reconstruction
84
Adventitial Cystic Disease
1) who gets it
2) where is MC area to have it
3) sx
4) dx
5) rx
1) Men, 40s
2) popliteal fossa, often bilateral (gnaglia originate from adjacent joint capsule or tendon sheath)
3) intermittent claudication, change in sx with knee flexion/extension.
4) angiogram
5) cyst resection. vein graft if vessel is occluded
85
WHat are the arterial autografts used in CABG
radial artery grafts and IMA
86
```
Amputations
1) indications
2) Mortality for leg amputation
3) How many heal, walk again, mortality for
a-BKA
b-AKA
4) when to do emergency amputation
```
1) gangrene, large non-healing ulcers or unrelenting rest pain not amenable to surgery
2) 50% in 3 years
3) a- 80% heal/70% walk/ 5% mortality
b- 90% heal/ 30% walk again/ 10% mortality
4) systemic complication or extensive infection
87
```
Acute arterial emboli
1) clinical distinction bw acute arterial embolism and acute arterial thrombosis-which is associated with
a-arrhythmia
b- claudication or rest pain
c- absence of contralateral pulses
d-no physical findings of chronic limb ischemia
e- collaterals
2) symptoms
3) MCC
4) MC site of peripheral obstruction
5) rx
```
1) a and d-emboli, b, c and e-thrombosis
2) Pain, pallor, poikliothermia, pulselessness, parasthesia, paralysis
leg goes from white (pallor)-> cyanotic-> marbling
3) a-fib #1. Others- recent MI with LV thrombus, myxoma, aorto-iliac disease
4) common femoral artery
5) embolectomy, need to get pulses back, postop angiogram
-consider fasciotomy if ischemia>4-6hr
-aortoiliac emboli can be treated with bilateral femoral artery cutdowns and bilateral embolectomies
88
Atheroma embolism
1) cause
2) MC site of atheroma embolization
3) Blue toe syndrome- source of emboli, PE findings
4) dx
5) rx
1) cholesterol clefts that can lodge in small arteries
2) renals
3) flaking atherosclerotic emboli off abdominal aorta or branches. pts typically have good distal pulses. Aortoiliac dz MC source
4) chest/abd/pelvis CT to look for aneurysma source and echo to look for clot or myxoma in heart
5) may need aneurysm repair or arterial exclusion with bypass
89
Acute arterial Thrombosis treatment
```
#for threatened limb (loss of sensation or motor fnc)-> give heparin and go to OR for thrombectomy
#if limb not threatened->angiography for thrombolytics
#if thrombosis of PTFE (Gortex) graft-> thrombolytics and AC. if limb threatened go to OR for thrombectomy
```
90
Renal vascular disease
1) where does right renal artery run
2) % of pts with accessory renal arteries
3) signs of renovascular HTN (renal artery stenosis)
4) Renal atherosclerosis- location and sex affected
5) fibromuscular dysplasia- location and sex
6) Dx
7) rx
8) indications for nephrectomy with renal HTN
1) posterior to IVC
2) 25%
3) bruits, diastolic BP>115, HTN, in kids or premenoausal women HTN resistant to drug rx
4) left side, proximal 1/3, men
5) right side, distal 1/3, women
6) angiogram
7) PTA with stent placement if due to atheroscerotic disease
8) atrophic kidney
91
```
Upper extremity vascular disease
1) Occlusive disease
a- why are proximal lesions usually asymptomatic
b- MC site of UE stenosis
c-rx
2) Subclavian steal syndrome
a- what is it/cause
b-when to operate
c-rx
3) Thoracic outlet syndrome
a- where does the subclavian vein run
b- where do the brachial plexus and subclavian artery run
c-symptoms
d-dx
e- MCC of anatomic abnormality
f- MCC of pain
```
1) a- collaterals; b-subclavian artery
c-PTA with stent. common carotid to subclavian bypass if that fails
2) a-proximal subclavian artery stenosis-> reversal of flow through ipsilateral vertebral artery into the subclavian artery
b- if limb or neuro sx (vertebrobasilar symptoms)
c- PTA with stent to subclavian artery. common carotid to subclavian bypass if that fails
3) a- over the 1st rib anterior to anterior scalene muscle, then behind the clavical
b- over the 1st rib, posterior to anterior scalene and anterior to middle scalene
c- back, neck and/or arm pain/weakness/tingling (often worse with palpation/manipulation
d- cervical spine and chest MRI, duplex US (vascular etiology), electromyelogram (EMG, neurologic etiology). Neuro involvement MC than vascular
e- cervical rib
f- brachial plexus irritation
92
```
THoracic outlet syndrome
1) If brachial plexus irritation cause
a-how to reproduce symptoms
b-MC nerve distribution and effects
c-rx
2) if subclavian vein cuase
a- presentation
b-is venous or arterial thrombus MC
c- dx
d-rx
3) if subclavian artery cause of sx
a- MCC of compression
b-sx
c-what is Adson's test
d- dx
e-rx
```
1) a- tapping (tinsel's test)
b- ulnar nerve-> tricep muscle weakness and atrophy, weakness of intrinsic muscles of hand, weak risk flexion
c- cervical rib and 1st rib resection, divide anterior scalene muscle
2) a- effort-induced thrombosis of subclavian vein (Paget-Von-Schrotter disease, baseball pitchers)- acutely painful, swollen, blue limb
b- venous MC
c- venography gold standard, but Duplex US fine
d- thrombolytics initially, repair at that admission (cervical rib and 1st rib resection, divide anterior scalene)
3)a- compression 2/2 anterior scalene hypertrophy. lease common cause of TOS.
b-hand pain from ischemia
c- absent radial pulses with head turned to ipsilateral side
d-duplex US or angiography
e-surgery- cervical rib and 1st rib resection, divide anterior scalene muscle. possible bypass graft if artery damaged or aneurysmal
93
Why can motor fnc remain in digits after prolonged hand ischemia
bc motor groups are in proximal forearm
94
Mesenteric ischemia
1) mortality
2) MC artery involved
3) CT findings
4) MC causes of visceral ischemia
1) 60%; 2) SMA; 3) bowel wall thickening, vascular occlusion, intramural gas, portal venous gas
4) embolic- 50%, thrombotic-25%, non-occlusive-15%, venous thrombosis- 5%
95
```
Mesneteric ischemia 2/2
1) SMA embolism
a- MC location; b- MC source; c- sx
d-PMH/risk factors; e-dx; f-rx
g- how to get SMA exposure
2) SMA thrombosis
a- sx
b-dx
c-rx
3) mesenteric vein thrombosis
a- presentation/ PMH
b-dx
c- rx
```
1) a-near origin of SMA; b- heart (a-fib); c-pain out of proportion to exam, sudden onset, hematochezia and peritoneal signs are late findings
d- a-fib/endocarditis/recent MI, recent angiography
e- angiogram or CT abd with IV contrast
f-embolectomy, resect infarcted bowel if present
g-divide ligament of treitz, SMA is to the right of this near the base of the transverse colon mesentery
2) a-h/o food fear, weight loss, vasculitis or hypercoaguable state. sx similar to embolism
b- angiogram or CT abd with IV contrast
c- thrombectomy. May need PTA with stent or open bypass. Resection of infarcted bowel
3) a- short segments of intestine involved-> bloody diarrhea, crampy abdominal pain, PMH- vasculitis, hypercoagulable state, portal HTN
b- abd CT or angio with venous phase
c- heparin + resection of infarcted bowel if present
96
Non-occlusive mesenteric ischemia
1) causes
2) risk factors
3) sx
4) what areas are most vulnerable
5) rx
1) spasm, low-flow, hypovolemia, hemoconcentration, digoxin-> final common pathway is low cardiac output to visceral vessels
2) prolonged shock, CHF, prolonged cardiopulmonary bypass
3) blood diarrhea, pain
4) watershed areas (Griffith's - splenic flexure; Sudak's- upper rectom
5) volume resuscitation, catheter directed nitroglycerin can inc visceral blood flow. may also need to inc cardiac output (dobutamine). also resect infarcted bowel.
97
Median arcuate ligament syndrome
1) what does it cause
2) symptoms/signs
3) rx
1) celiac artery compression
2) bruit near epigastrium, chronic pain, weight loss, diarrhea
3) transect median arcuate ligament; may need arterial recon
98
Chronic Mesenteric angina
1) sx
2) dx
3) rx
1) weight loss 2/2 food fear (visceral angina 30min after meals)
2) lateral visceral vessel aortography to see origins of celiac and SMA
3) PTA and stent. Bypass if that fails
99
What is Arc of Riolan
collateral bw SMA and celiac
100
Visceral and peripheral aneurysms
1) MC complication of aneurysms above inguinal ligament
2) MC complication of aneurysms below inguinal ligament
3) Visceral artery aneurysms
a- risk factors
b-MC visceral aneurysm
c- rx- when to repair splanchnic aneurysms, what about splenic and type of repair
1) rupture
2) thrombosis/emboli
3) a-medial fibrodysplasia, portal HTN, arterial disruption 2/2 inflammation (ie- pancreatitis)
b-splenic artery aneurysm (women, 2% risk of rupture)
c- Repair all splanchnic artery aneurysms >2cm when diagnosed (50% rupture risk) except splenic
-Repair splenic after aneurysms if sx, pregnant (high rate of pregnancy-related rupture MC in 3rd trimester), childbearing age or >3-4 cm
rx- PTA and stent. bypass if fails. Splenic artery aneurysms can be ligated bc good collaterals
101
Visceral and peripheral aneurysms
1) Renal artery aneurysm- size to rx and rx
2) Iliac and femoral artery aneurysms- size to rx and rx
3) MC peripheral aneurysm
4) Most likely type to get thrombosis or emboli with limb ischemia
1) >1.5cm. rx- covered stent
2) Iliac >3cm or femoral >2.5 cm. rx- covered stent
3) Popliteal artery aneurysm
4) Popliteal artery aneurysm
102
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Visceral and peripheral aneurysms
1) Popliteal artery aneurysm
a-findings on leg exam
b- what % are BL or have another aneurysm elsewhere
c-dx
d-indications for surgery
e-rx
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1) a- prominent popliteal pulses
b-50%; c-ultrasound; d-sx, >2cm or mycotic
e- exclusion and bypass, 25% have complication that requires amputation if not treated. DO NOT USE covered stent for these
103
visceral and peripheral Pseudoaneurysm
1) MC location
2) cause
3) rx
4) what does a pseudoaneurysm that occurs at a suture line late (months to years) after surgery imply
1) femoral artery
2) percutaneous interventions or disruption of a suture line bw graft and artery
3) if sp percutaneous intervention-> US-guided compression with thrombin injection
if at suture line early after surgery-> surgical repair
4) suggests graft infection
104
Fibromuscular dyspasia
1) who gets it and sx
2) MC involved vessel
3) MC variant
4) Rx
1) women, HTN if renal involved. HA or stroke if carotids involved
2) renal artery, then carotid and iliac
3) medial fibrodysplasia (85%)
4) PTA (best), bypass if that fails
105
Buerger's Disease
1) who gets it/risk factors
2) sx
3) angiogram findings
4) rx
1) young men, smokers
2) severe rest pain with B/L ulceration, gangrene of digits esp fingers
3) corkscrew collaterals and severe distal disease. normal arteries proximal to popliteal and brachial vessels (it's a SMALL VESSEL DISEASE)
4) quit smoking. otherwise will require serial amputations
106
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Cystic Medial Necrosis syndromes
1) Marfan's disease
a- defect
b- sx
2) Ehlers-Danlos syndrome
a-defect
b-sx
c-can you do angiogram
d-rx
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1) a- fibrillin (connective tissue elastic fibers)
b- marfinoid habitus, retinal detachment, aortic root dilatation
2) a- collagen defects
b- easy bruising, hypermobile joints, tendacy for arterial rupture (esp abdominal vessels)
c- NO!-> risk of vessel laceration
d- repair too difficult. must ligate vessels to control hemorrhage
107
immune arteritis
1) Temporal arteritis
a-size of artery affected; b- sx and who gets it;
c) dx; d)- path; e-rx
2) Polyarteritis nodosa
a-size of artery affected
b- what does it cause; c- MC artery involved; d-rx
3) Kawasaki's disease
a-size of artery affected; b- who gets it and sx
c- MC cause of death; d-rx
4) hypersensitivity angiitis
a-size of artery affected; b- cause; c- sx; d-rx
1) a- large artery; b-women >55yo. HA, fever, blurred vision (risk of blindness); c-temporal artery bx; d- giant cell arteritis, granulomas, inflammation of large vessels, long segments of smooth stenosis alternating with segments of large diameter;
e- steroids, bypass of large vessel if needed.
2) a- medium sized; b- aneurysms that thrombose or rupture; c-renal; d-steroids
3) a- medium; b) kids, febrile viral illness with erythematous mucosa and epidermis, get aneurysms of coronary arteries and brachiocephalic vessels; c-arrhythmia; d- steroids, possible CABG
4) a- small artery dz; b- 2/2 drug/tumor antigens; c- rash (palpable purpura), fever, symptoms of end-organ dysfnc. d-Ca-channel blockers, pentoxifylline, stop offending agent
108
Radiation arteritis
1) Early changes
2) Late changes (1-10yr)
3) Late late (3-30yr)
1) sloghing and thrombosis (Obliterative endarteritis)
2) fibrosis, scar, stenosis
3) advanced atherosclerosis
109
Raynaud's disease
1) who gets it and sx
2) rx
1) young women, pallor-> cyabosis-> rubor
| 2) Ca-channel blockers and warmth
110
Venous Disease
1) what vein does greater saphenous vein drain to and where does it run
2) can you clamp the IVC
3) which renal vein can be ligated near the IVC in emergencies bc of collaterals
1) runs medially and joins femoral vein near groin
2) NO-> it will tear
3) the left renal vein can be ligated near the IVC bc of collaterals (L gonadal vein and L adrenal vein). The R renal vein doesn't have these collaterals
111
Dialysis access grafts
1) MC reason of failure of AV grafts for dialysis
2) Crimino graft- artery and vein used. when can you start to use for dialysis
3) Interposition graft- vein involved and when you can use
1) venous obstruction 2/2 intimal hyperplasia
2) radial artery to cephalic vein. Wait 6wks to use to allow the vein to mature
3) brachiocephalic loop graft. wait 6 wk to allow fibrous scar to form
112
Aquired AV fistula
1) MC cause
2) symptoms
3) how to repair
1) trauma
2) peripheral arterial insuffciency, CHF, aneurysm, limb-length discrepancy
3) lateral venous suture arterial side may need a patch or bypass graft, interpose tissue so it doesn't recur
113
Varicose veins
1) risk factors
2) rx
1) smoking, obesity, low activity
| 2) sclerotherapy
114
Venous ulcers
1) cause
2) where do they occur
3) what size ulcers will heal without surgery
4) rx
1) venous valve incompetence
2) above and posterior to malleoli
3) t need surgery
4) Unna boot compression cures 90%, may need to ligate perforators or have vein stripping of greater saphenous vein
115
Venous insufficiency
1) sx
2) rx
1) aching, swelling, night cramps, brawny edema, venous ulcers. edema 2/2 to incompetent perforators and/or valves
2) elevate, leg wrap, ambulation with avoidance of long standing
- greater saphenous vein stripping for saphenofemoral valve incompetence or removal of perforators if just perforator valves invompetent (stab avulsion technique) if sx are severe or recurrent ulceration despite medical rx
116
Superficial thrombophlebitis
1) cause
2) rx
1) nonbacterial inflammation
| 2) NSAIDs, warm packs, ambulation
117
Suppurative thrombophlepitis
1) signs/sx
2) rx
1) pus fills vein; fever, inc WBC, erythema, fluctuance, usually associated with infection following peripheral IV
2) resect entire vein
118
Migrating thrombophelbitis- what is this a sign of
pancreatic cancer
119
what is seen on a normal venous doppler US
augmentation of flow with distal compression or release of proximal compression
120
how do SCDs work
decrease venous stasis and increase tPA release
121
DVTs
1) which leg is MC involved and why
2) Virchow's Triad
3) IVC filter indications
4) how does a pt get a PE with IVC filter in place
5) Phlegmasia cerulea dolens- sx and rx
1) Left 2x more than right bc longer left iliac vein compressed by right iliac artery
2) venous stasis, hypercoagulability, venous wall injury
3) C/I to anticoagulation; PE while on coumadin, free-floating ileofemoral thrombi; after pulmonary embolectomy
4) comes from ovarian veins, inferior vena cava superior to filter, or from upper extremity via SVC
5) tenderness, cyanosis, massive edema. rx- heparin, rarely need surgery
122
Management of venous thrombosis with central line
pull out central line if not needed, then heparin. can try to rx with systemic heparin or TPA down line if access site is important
123
Lymphatics
1) T/F: do not contain basement membrane
2) T/F: are found in bone, muscle, tendon, cartilage, brain and cornea
3) MC infection in Lymphedema
4) rx of lymphedema
5) MC side for congenital lymphedema
1) true
2) false- not found in these
3) strep
4) leg elevation, compression, abx for infection
5) L>R
124
Lymphangiosarcoma
1) symptoms
2) early mets to where
3) what is Stewart-Treves syndrome
1) raised blue/red coloring
2) lung
3) lymphangiosarcoma associated with breast axillary dissection and chronic lymphedema
125
Lymphocele following surgery
1) usually after what type of operation
2) signs
3) dx and rx
1) groin dissection
2) leakage of clear fluid
3) perc drain. resection if that fails- can inject isosulfan blue dye into foot to identify the lymphatic channels supplying the lymphocele
