Flashcards in Chap 108-109 Aorto-iliac Dz Deck (108):
What are symptoms of AI dz?
Claudication (calf, thigh, butt)
embolism (saddle or blue toe syndrome)
What collateral network supplies distal to AI dz?
why are the collaterals important?
lumbar and hypogastric feeding vessles connect to circumflex iliac, hypogastric, femoral and profunda recipients
in extreme, IMA to inferior epigastric and
SMA to IMA and
hemorrhoidal artery via arc of Riolan and meadering mesenteric artery
prevent CLI, main presentation in claudication
What are signs and symptoms of blue toe syndrome?
palpable pulses with patchy ischemia (livedo) but distal gangrene can occur
What is Leriche syndrome?
Terminal aortic occlusion
Thigh, hip, buttock claudication, atrophy of leg muscles, impotence, decreased femoral pulses
What is small aortic syndrome or hypoplastic aortic syndrome?
What is life expectancy?
Where is plaque?
Isolated AI in usually younger females, usually smokers
posterior plaque prox or at bifurcation
What are pullback pressure in AI?
Pull back pressure 5-10mmhg at rest or change in systolic pressure greater then 15% indicates dz warranting revasc
What are indications for surgery?
ischemic rest pain
What is natural history of claudicants in AI?
1%/year limb loss
20-30% require OR in 5 years
What % of AI have CAD?
What are repair techniques for AI?
throaci/supra-celiac- fem bypass
When is endarterectomy best suited?
Want to avoid prosthetic graft
Erectile dysfunction as may improved hypogastric perfusion
Best for focal stenosis otherwise not usually done
Advantages to End-end in aortobifem?
Possible better hemodynamics, less flow turbulence
Less rate of pseudoaneurysm
Close peritoneum over graft
With concomitant aneurismal disease should to end-end
Advantages to end-side in aortobifem?
Preserve flow hypogastrics
Less erectile dysfunction, paraplegia secondary to cauda equina syndrome
Good if heavily calcified aorta
What is cauda equina?
what are symptoms?
damage to the cauda equina causes acute loss of function of the lumbar plexus, (nerve roots) of the spinal canal below the termination of the spinal cord. CES is a lower motor neuron lesion.
decreased anal tone and consequent fecal incontinence;
bilateral (or unilateral) sciatic leg pain and weakness;
and absence of ankle reflex.
What dose of heparin do you give before clamping?
Is there benefit of adjunctive profundoplasty in aortobifem?
May Improve long-term patency in AI bypasses
5year patency 88%
Advantages/disadvantages for external iliac anastomosis in AI bypass?
Good for hostile groin, obese, DM with intertriginous rash
More technically difficult and possible lower patency rates then to fem
when to consider inflow and outflow bypass?
tissue loss (appears no increase m&m)
how many patients have improvement of symptoms after ABF for AI?
2/3 still have symptoms
When do you do concomittant SMA or Renal bypass?
what is mortality with ABF and ABF with SMA/renal recons?
what is symptom response rate?
If associated with the lesion repair
If thought to have reaversible on refractory hypertension or ischemic nephropathy
mortality 1-2% 5-6%(renal/SMA).
Favorable response to HTN 60-70%,
improvement in renal function 30%
what is 5 year patency for endart and ABFG in AI?
10 year patency?
95% and 85-90%
85-90% and 75-85% (older 95%, but <50yo 66%)
isolated normal life expectency, multilevel disease 50%
patency difference between trans vs retro approach ABF?
PTFE vs Dacron
What are early complications and percentages ABF?
Sexual dysfunction <5%
bowl ischemia 2%
where is bowel ischemia usually found after Bypass for AI?
how to avoid?
preserve IMA, keep up perfusion
what are features of neurogenic claudication?
diffues deep aching,burning possible paresthesias from buttock to feet. relieved by sitting or beding over while walking. occurs with walking
What are common causes of IC?
SFA stenosis, athersclerosis, pop entrapment, ACD, chronic compartement syndrom, arteriris, thrombosis, FMD, coarctation
what are RF for claudication?
HTN, DM, metabolic syndrome, smoking, male, age, DLP, hyperhomocystenemia
What is natural history of IC?
10% deteriorate within one year then 2-3% per year to CLI
1% risk of major amputation per year
2-5% risk of cardiac death per year
70% angioplasty rates for 5 years
What is the natural history for CLI patients?
30% will lose leg in one year
if unconstructable 40% limb loss at 6 months
25% dead in one year
25% CLI resolved
What is included in hypercoag workup?
activated partial thromboplastin time
protein S, protein C assays
factove V leidan asay
lupus anticoagulant assay
heparin induced plt antibodies
fibrinogen, plasminogen levels
anticardiolipin antibody assay
How does hyperhomocysteine cause athero?
high level toxic to endothelium and reduce NO release, promote mSMC proliferation and arterial wall inflammation leading to athero
What is risk of surgery for PAD?
5% risk MI, CHF, death
What test to perfomr if has IC but palpable pulses?
exercise stress test
ABI at rest then walks 3.5km/hr on treadmill with 12% incline
if >20% decrease in ankle pressure for >3 minutes indicates vascular dz
What is the rutherford classification?
0 asympto normal
1 mild claudication completes treadmill test, but ankle pressure >50mmhg but at least 20mmhg lower then resting value
2 moderate caludication b/w catergories 1 and 3
3 severe claudication cannot complete standard teradmill exercise. AP after exercise <30
4 rest pain
5 ulcerations not exceeding digits
6 major tissue loss
what are features of a walking exercise for PAD?
treadmill or track walking, 35 mins porgressing to 50mins 35 times per week. treadmill incline should elicits IC within 3-5 mins
What drugs have evidence in IC?
statin (supporting evidence)
what is cilastozol?
what is the evidence
RCT, 50% increase in walking distance
CI in CHF
What is the evidence for pentoxifylline?
MA questionable benefit
What was the BASIL trial?
what were findings of the trial?
RCT, angio vs open for severe limb ischemia
AFS primary end point
at 2 years surivival and AFS better in surgical arm, no difference at six months
if patient life expectancy >2 years then open
if attempt endo first then durability of subsequent open worse
What is the mortality with LE bypass?
wha are some complications?
graft stenosis 20% in 1 year
major amp 5-10%
graft infection 1-3%
What are some scoring models for survival with LE intervention?
What are some indications for extra-anatomic bypass?
When is axem or fem-fem best suited?
when is obturator bypass best suited?
no endo option, high risk lap, hostile abdo or acute presentation
what is better unilat ilio fem or fem-fem for patency?
what about aorta-fem vs ilio fem?
unilat ilio-fem at ten years
no difference at ten years
where is fem-fem tunneled?
pre-peritoneal if thin or too fat, previsou surgery, radiation damage to skin
What is the mortality periop, 3 yr survival, 5 yr patency for fem-fem?
What features on duplex are concerning for graft failure?
peak systolic >300cm/sec inflow or <60cm/sec midgraft
What size better for fem-fem? what amterial?
what % have steal with fem-fem
45% exercise induced
Which side axillary artery to choose for ax-fem?
if will need future left chest surgery
if 10mmhg discrepency
what is 3 year survival for ax-fem?
5 year patency?
3 yr limb salvage
75% better in claudicants then CLI
What is normal resting flow in ax fem?
what flow indicates impending graft failure?
300-400 ml.min each limb
<240ml.min in 6mm
describe obturator bypass?
donor artery exposed retroperitoneal via oblique lower quadrant incision (or trasnperitoneal)
dissect medial to external iliac vein and posterior to pubic ramus
obturator nerve (may injure) and artery perforate postolaterally
membrane must be opened sharply
What are the 3 and 5 yr patency for obturator bypass?
75 and 60%
What does the obturator nerve innervate?
sensory to medial thigh
motor of adductor muscles of LE
What are features of throaco-fem surgery?
7-8th rib incision
tunnel graft retroperitoneally behind or anterior to kidney
What are TASC A lesions for AI?
uni/bilat short <3cm EIA
Waht are TASC B lesions for AI?
short infrarenal aorta
uni CIA occlusion
single or multiple (3-10 cm) isolated EIA
uni isolated EIA occlusion
What are TASC C lesions for AI?
bilat CIA occlusion
bilat isolated EIA stenosis (3-10cm)
unilat EIA stenosis into CFA
unilat EIA occlusion origin of CFA or iliac
heavily calcified uni EIA
What are type D TASC lesions for AI?
infrarenal aortic occlusion
diffuse aort-iliac dz
diffuse stenosis of uni CIA, EIA, and CFA
bilat occlusion of EIA
iliac leasion in AAA that requires open surgery
When should you consider preventative measure for constrast enduced nephropathy? what are they?
GFR <45ml/min if IV
bicarb to alkalinize urine (MA shows benefit)
metformin can increase risk of AKI
What is a significant pullback gradient?
>15% with papaverine
what are re-entry devices?
What are mechanical properties of balloon expandable vs self-expanding stents?
high hoop strength
less flexible, premanently defromed, can become dislodged from balloon
what is the difference between selective stenting and angioplasty in AI?
RCT no difference with selective placement
20% will get stent reintervention and 20% in plasty alone will get reintervention
better patency with primary stenting
reduces long term failure by 40% then plasty alone
What are patency rates for TASC lesions for endo in AI dz?
10 yr A or B 70%
5 yr C or D 70%
5 yr 80% patency with 30% comps
What are predictors of endovascular failure for AI dz?
what can improve patency?
EI dz (PPR 1 year 50%)
What is the definition of CLI?
persistent, recurring ischemic rest pain requiring opiate >2 weeks
What size vein for LE bypass?
whats a linton patch?
when bypass comes of CFA endart anastomoses
what is the patency of isolated popliteal target?
situational perfusion enhancement
5 yr patency 50%, secondary 75%
What are graft options for LE bypass?
endarterectomized seg of SFA
What % of contra vein is used for future surgery?
What is the advantage of a vein cuff for LE bypass
may improve patency by 2-3 years
with cuff and PTFE 2 yr patency 50% vs 30%
What is the difference between miller, taylor, st marys boot?
miller---rim of vein circum, then ptfe sewed to rim
taylor patch--patch on toe of anastomosis (half artery, half ptfe)
sta mary boot--rim of vei nthat folds around on itself vein then comes off the top
What are correction rates for intra-op imaging for LE bypass?
arteriography 27%--may not see incomplete valve lysis
DUS 12% (psv >250)
What are patency rates of dacron vs ptfe for AK bypass?
HUV vs PTFE for AK?
PTFE cuff vs no cuff?
AK pop vein vs prothetic?
BK pop vein vs prosthetic?
infrapop vein vs prothetic?
1 yr 70% for both, 5 yr 50%
5 year 70 vs 40 (but some studies show not difference)
AK no diff, 1 yr 80%
BK 80 vs 65% 1 yr
60 vs 40% no signif
75 vs 55
70 vs 15%
What is the benefit of warfarin therapy for infr-inguinal bypass?
insitu vs reversed?
warfarin benefited prothetic graft patency but at double bleeding complications
what is a schedule for post-op graft surveillance?
what is the benefit of graft surveillance
3 month x 1 year
6month x 2 yr
improves patency by 15%
what are duplex criteria for impending infrainguinal graft failure?
velocity ratio >3.5-4
drop in ABI 0.15
what are causes of early graft failure?
anastomotic, clamp defect, valve defect, poor quality conduit, inadequate outflow
What are techniques for treating stenosis or late occlusion?
patch, interposition, valve excision, plasty, anastomotic translocation
thrombectomy, lysis, redo with vein or prosthetic
What are TASC A lesion for fempop?
single O <5cm
single s <10
What are TASC B for fempop?
multiple stenosis or collusion each <5cm
SS/O SFA <15
S/M lesions with no continuous runoff
Heavily calcified occlusion <5
single pop stenosis
What are TASC C lesions for fempop?
multiple stenosis or occlusions total >15cm
recurrent stenosis or occlusion after 2 endo attempts
what are Tasc D lesions for fem pop?
CTO of CFA/SFA
CTO of pop and prox trifurcation
What are TASC A lesion for infrapop?
singel stenosis <1cm in tibials
What are TASC B lesions for infrapop?
multiple stenosis of tibials each <1cm at trifurcation
short tibial stenosis with fempop PTA
What are TASC C lesions for infrapop?
occlusions 1.2 cm of tibials
extensive stenosis of trifurcation
What are TASC D lesions for infrapop?
tibial occlusion >2cm
diffusely dz tibials
What are determinants of succes in endovascular?
improvement in at leas one rutherford and ABI increase >0.15
absence of stenosis <200
What are favorable characteristics for endovascular therapy?
short stenosis length
single level dz
no residual stenosis or dissection
robust hemodyn response
What is patency difference for lesion > or < then 2 cm?
focal vs multifocal?
good vs poor runoff?
5 yr 75% vs 50%
70% vs 20%
50 vs 30%
What are 1,2,3 year success rates for endo in LE for endo vs open?
40, 20, 10 endo
85, 70, 70 open
How successful is angioplasty for fempop dz?
angio vs bypass?
angio vs stenting?
DCB vs POBA?
3 yr PP for stenosis in IC 60%
occlusion in IC 50%
stenosis in CLI 45%
occlusion in CLI 30%
BASIL, if lives >2 years open better
lesion greater then 5cm benefit from primary stenting
sirocco II failed to show improvement with DES for restenosis
DCB better at 6 months
What is patency of angio for infrapop?
difference in angio vs stenting?
wha is patency for laser atherrectomy?
1 yr 75%
What is benefit of DES in infrapop endo?
3 yrs everolimus had higher PP then BMS 30 vs 20
What is plasty/stenting surveillance?
ABI, PVR, Duplex
1,3,6,9,12 months then yearly
what is patency of CFA steting?
3 yr patency 80%, surgery recommended
What is endo not indicated for PFA?
usually not suitable because of ostial, bifurcation and diffuse
What are cholesterol targets for PAD?
sympto/asympto PAd LDL 100mg/dL
PAD and vascular dz in other beds 70mg/dL
What medications should PAD patients be on, TASC?
cilostazol first line for relief of claudication
What is an alternative way to test for IC if ABI unreliable?
active pedal flexion
inflate cuff for 3-5 minutes, this produces reactive hyperaemia, measure pressure 30sec after deflating cuff
What is critical TcPO2 level?
What are the principles of ulcer management?
restoration of perfusion
local ulcer and pressure relief
treatment of infection
What are the treatment of choice for different TASC lesions for AI or fempop?
TASC A endo
TASC D open
TASC B endo preferred
TASC C open preferred if good risk