Chap 63-65 SVC Reconstruction and Venous Tumors Flashcards Preview

Vascular Surgery > Chap 63-65 SVC Reconstruction and Venous Tumors > Flashcards

Flashcards in Chap 63-65 SVC Reconstruction and Venous Tumors Deck (38):
1

What are most common cause of SVC obstruction?

Non small cell
aortic aneurysm

2

What are most common symptoms of SCV obstruction?

feelingo f fullness in head and neck
dyspnea
orthopnea
H/A
syncope visual disturbances

3

What are some less frequent symptoms?

mental confusion
hemoptysis
dysphagia
WL

4

What are signs on exam?

dilated neck veins
swelling of face, neck, eyelids
chest wall colaterals
arm swelling

5

What is pemberton's sign?

elevation of arms until the touch side of face
facial congestion and cyanosis after one minute
indicates increase intrathoracic venous P

6

What are findings on CXR of SVC syndrome?

Mediastinal widening
Right hilar mass
Pleural effusion
Infiltrates
Dilated veins may be visible
May be normal

7

What are findings on US for SVC obstruction?

Loss of normal variation in respiratory flow in subclavian
No change in diameter or flow with valsalva
Collaterals

8

What are findings on CT/MR?

location of obstruction
mass/tumor
collaterals

9

How do you do a venography for SVC obstruction?

bilat simultaneous injections of arm vein

10

What are important collaterals in SVC syndrome?

1. azygos-hemiazygos (intercostals)
2. internal mammary (inf and superios epigastric)
3. lateral thoracoepigastric
4. vertebral and small mediastinal veins(femoral to vertebral)

11

What are the type of SVC obstruction? Which is the most common?

Type I partial
Type II complet or nearly complete with flow in the azygos vein remaining antegrade
Type III is 90-100% obstruction of the SVC with reversed azygos flow
Type IV extensive mediastinal central occlusion with venous return through IVC

Type III

12

What are initial treatments?

conservative
elevation of HOB
diuresis
steroids/chemo/rad (if cancer
anticoag if cancer

13

What are invasive treatments?

endovascular first line
stent with/out CDT
surgical

14

How many patients resolve with chemo/rad?

80% in 4 weeks

15

what are indications for intervention for SVC obstruction?

indication incapacitating symptoms that cannot be alleviated by conservative measures

III and IV usually not candidates for endovascular

failure of endovascular

16

What is surgical option for SVC obstruction?

jugular/innominate to femoral vein/RA bypass with
SVG
femoral vein
spiral saphenous
ePTFE

17

What are surgical approaches?

Mediastinal reconstruction if life expectancy > 1year
Extra-anatomic if <1year

18

What conditions lead to SVC obstruction via intraluminal fibrosis?

indwelling catheters
PM
hypercoag state

19

What ar emost commonly used stents for IVC?

gianturco-Z
palmaz
SMART
wall stent

20

What is primary latency of stenting?

malignant 65% at 1 year
benign 75% at 1 year

21

how are venous tumours classified?

Infrarenal
Suprarenal (retrohepatic, infrahepatic—to RV)
Suprahepatic

22

How are intracaval thrombus classified?

Level I extends within 2 cm of RV
Level II extends into suprarenal IVC but below hepatic veins
Level III thrombus is to hepatic veins but below diaphragm
Level IV extends into right side of heart

23

What are primary venous CA?

primary leiomyosarcoma

24

What are secondary inferrer vena cava tumours that have thrombus

RCC most common
pheo
sarcoma
germ cell

25

What are symptoms of venous tumour?

abdo pain most common
palpable mass
lower limb edema
WL
Budd-chiari
Fever weakness, anorexaia, night sweats (less often)

26

What is most useful diagnostic test for venous tumour?

CT/MR

27

What incision to use for infrarenal or infra hepatic tumour?

midline

28

What incision to sue for retrohepatic IVC replacement, or infra hepatic with wide costal margin?

bilateral subcostal

29

What incision for retrohepatic IVC replacement and liver resection?

right retro peritoneal (8-9)

30

When can you resect IVC without replacing?

if well collateralized

31

What adjuncts to perform when infra hepatic IVC thrombus?

divide caudate lobe veins
consider total vascular isolation (minimize blood loss)
consider venovenous bypass

32

When to embolize RA?

inoperable
can consider pre-op but may not shrink tumor and may increase peri-op comps

33

When to replace IVC?

when majority of IVC need replacement for tumor margins

34

what to patch IVC?

if going to be greater then 50% stenosis

35

How do you do retrohepatic vena cava replacement?

Total vascular isolation
Selective use of veno venous bypass for hemodynamics
Ligation of afferent and efferent lobar vasculature before prenchymal Division

36

What is the sequence of clamping for total vascular occlusion

Infrahepatic
Hepatic artery
Portal vein in gastrohepatic ligament
Suprahepatic

37

When to consider veno venou bypass?

when using total vascular occlusion to improve hemodynamics

lower complication rates

38

When to consider circa arrest?

thrombus level III or IV
retrohepatic
intrahepatic
suprahepatic dz
extensive reconstruction

benefit is cold schema time