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Flashcards in Chapter 27: Vascular Deck (394):
1

Most common congenital hyper coagulable disorder

Resistance to activated protein C (Leiden factor)

2

Most common acquired hyper coagulable disorder

Smoking

3

Atherosclerotic stages
- 1st
- 2nd
- 3rd

1) Foam cells (macrophages have absorbed fat and lipids in the vessel wall)
2) Smooth muscle cell proliferation (caused by growth factors released from macrophages; results in wall injury)
3) Intimal disruption (from smooth muscle cell proliferation)

4

What stage of athersclerosis causes thrombus formation?

Third - intimal disruption: leads to exposure of collagen in vessel wall and eventual thrombus formation -> fibrous plaques then form in these areas with underlying atheromas

5

Risk factors for atherosclerosis

Smoking, HTN, hypercholesterolemia, DM, hereditary factors

6

3rd most common cause of death in the United States

Stroke

7

Most important risk factor for stroke

HTN

8

Supple 85% of blood supply to the brain

Carotids

9

Most common site of stenosis in cerebrovascular disease

Carotid bifurcation

10

Type of flow from normal internal carotid artery

Continuous forward flow

11

1st branch off the internal carotid artery

Ophthalmic artery

12

Type of flow from external carotid artery

Triphasic flow

13

1st branch of the external carotid artery

Superior thyroid artery

14

Communication between the ICA and ECA

Ophthalmic artery (off ICA) and internal maxillary artery (off ECA)

15

Most commonly diseased intracranial artery

Middle cerebral artery

16

Most commonly from arterial embolization from the ICA (not thrombosis)
- Can also occur from a low-flow state through a severely stenotic lesion

Cerebral ischemic events

17

2nd most common source of cerebral emboli

Heart

18

Lesion: mental status changes, release, slowing

Anterior cerebral artery events

19

Lesion: contralateral motor and speech (if dominant side); contralateral facial droop

Middle cerebral artery events

20

Lesion: vertigo, tinnitus, drop attacks, incoordination

Posterior cerebral artery events

21

Occlusion of the ophthalmic branch of the ICA (visual changes -> shade coming down over eyes); visual changes are transient

Amaurosis fugax

22

What do you see on ophthalmologic exam in amaurosis fugax?

Hollenhorst plaques

23

Treatment: carotid traumatic injury with major fixed deficit:
- Occlusion
- Nonocclusion

- If occluded, do not repair -> can exacerbate injury with bleeding
- If not occluded -> repair with carotid stent or open procedure

24

Indications for CEA

Symptomatic > 70%, asymptomatic > 80%

25

When do you consider CEA in a recent completed stroke?

Wait 4-6 weeks and then perform CEA if it meets criteria (bleeding risk if performed earlier)

26

Indications for emergenct CEA

May be of benefit with fluctuating neurologic symptoms or crescendo / evolving TIAs

27

When do you use a shunt during CEA?

Use a shunt during CEA from stump pressures > 50 or if contralateral side is tight

28

What side do you repair in bilateral stenosis during CEA?

Repair the tightest side first if the patient has bilateral stenosis

29

What side do you repair if the patient has equally tight carotid stenosis bilaterally during CEA?

Repair the dominant side first if the patient has equally tight carotid stenosis bilaterally

30

Complications from repair during CEA

- Vagus nerve injury
- Hypoglossal nerve injury
- Glossopharyngeal nerve injury
- Ansa cervicalis
- Mandibular branch of facial nerve

31

Most common cranial nerve injury with CEA

Vagus nerve: secondary to vascular clamping during endarterectomy; patients get hoarseness (recurrent laryngeal nerve comes off vagus)

32

CEA complication: tongue deviates to the side of injury-> speech and mastication difficulty

Hypoglossal nerve injury

33

CEA complication: rare, occurs with really high carotid dissection -> causes difficulty swallowing

Glossopharyngeal nerve injury

34

CEA complication: innervation to strap muscles; no serious deficits

Ansa cervicalis

35

CEA complication: affects corner of mouth (smile)

Mandibular branch of facial nerve

36

Treatment: acute event immediately after CEA

Back to OR to check for flap or thrombosis

37

Pulsatile, bleeding mass after CEA
- Treatment?

Pseudoaneurysm

Tx: drape and prep before intubation, intubate, then repair

38

Why do 20% have hypertension following CEA?

Caused by injury to the carotid body

39

Tx: HTN following CEA

Nipride to avoid bleeding

40

Most common cause of non-stroke morbidity and mortality following CEA

Myocardial infarction

41

Restonosis rate after CEA

15%

42

Indications for carotid stenting

For high-risk patients (e.g. patients with previous CEA and restenosis, multiple medical comorbidities, previous neck XRT)

43

Pathway of the vertebrobasilar artery

Two vertebral arteries arise from the subclavian arteries and combine to form a single basilar artery; the basilar then splits into two posterior cerebral arteries

44

When do you see symptoms in vertebrobasilar artery disease?

Usually need basilar artery or bilateral vertebral artery disease to have symptoms

45

Tx: vertebrobasilar artery disease

PTA with stent

46

What causes vertebrobasilar artery disease?

Caused by atherosclerosis, spurs, band; get vertebrobasilar insufficiency

47

Symptoms: diplopia, vertigo, tinnitus, drop attacks, incoordination

Vertebrobasilar artery disease

48

Tx: vertebrobasilar artery disease

PTA with stent

49

Present as a painless neck mass, usually near bifurcation, neural crest cells; are extremely vascular

Carotid body tumors

Tx: resection

50

What are the aortic arch vessels?

Innominate artery (which branches into the right subclavian and right common carotid arteries), the left common carotid artery, and the left subclavian artery

51

- Often asymptotic and picked up on routine CXR
- Can get compression of vertebra (back pain), RLN (voice changes), bronchi (dyspnea or PNA), or esophagus (dysphagia)

Ascending aortic aneurysm

52

Indications for repair in ascending aortic aneurysm

Acutely symptomatic, > 5.5 cm (with Marfan's > 5.0cm), or rapid increase in size ( > 0.5 cm/yr)

53

Indications for repair of descending aortic aneurysm (also thoracoabdominal aneurysms)

If endovascular repair possible > 5.5 cm.

If open repair needed > 6.5cm

54

Risk of mortality or paraplegia endovascular repair vs open repair

Less with endovascular repair (2-3%) compared to open repair (20%)

55

How can you help prevent paraplegia with open repair?

Reimplant intercostal arteries below T8 to help prevent paraplegia with open repair

56

Classifications of Aortic Dissection

Stanford classification
DeBakey classification

57

What is the difference between the Stanford classification and the DeBakey Classification?

- Stanford: based on presence or absence of involvement of ascending aorta
- DeBakey: based on the site of tear and extent of dissection

58

Stanford classification: Class A

any ascending aortic involvement

59

Stanford classification: class B

Descending aortic involvement only

60

Type I DeBakey

Ascending and descending

61

Type II DeBakey

Ascending only

62

Type III DeBakey

Descending only

63

Where do most dissections start?

In the ascending aorta

64

What can aortic dissection mimic?

Myocardial infarction

65

Symptoms: tearing like chest pain, can have unequal pulses (or BP) in upper extremities

Aortic dissection

66

What is present in 95% of patients with aortic dissection?

95% of patients have severe HTN at presentation

67

Risk factors for aortic dissection

Marfan's syndrome, previous aneurysm, atherosclerosis

68

Dx: aortic dissection

Chest CT with contrast

69

Where does aortic dissection occur?

Dissection occurs in the medial layer of blood vessel wall

70

Incidence of aortic insufficiency in aortic dissection

Aortic insufficiency: occurs in 70%, caused by annular dilatation or when aortic valve cusp is sheared off

71

What arteries are at risk in aortic dissection?

Can also have occlusion of the coronary arteries and major aortic branches

72

What is usually the cause of death in aortic dissection?

Death with ascending aortic dissections usually secondary to cardiac failure form aortic insufficiency, cardiac tamponade or rupture

73

Medical treatment initially for aortic dissections

Control BP with IV beta-blockers (e.g. esmolol) and Nipride

74

When to operate on ascending aortic dissections?

Operate on all ascending aortic dissections.
- Tx: need open repair; graft is placed to eliminate flow to the false lumen

75

When to operate on descending aortic dissections?

Only operate on descending aortic dissections with visceral or extremity ischemia or if contained rupture
- Tx: Endograft or open repair; can also just place fenestrations in the dissection flap to restore blood flow to viscera or extremity if ischemia is the problem.

76

Follow up for surgery for aortic dissection

Follow these patients with lifetime serial scans (MRI to decrease radiation exposure)

77

Why do people status post aortic dissection repair need lifetime follow up?

30% eventually get aneurysm formation requiring surgery

78

Post op complications for thoracic aortic surgery

MI, renal failure, paraplegia (descending thoracic aortic surgery)

79

Why is paraplegia a risk in aortic dissection repair?

Paraplegia is caused by spinal cord ischemia due to occlusion of intercostal arteries and artery of Adamkiewicz that occurs with descending thoracic aortic surgery

80

Normal aorta size

2-3cm

81

What causes AAA?

Results from degeneration of the medial layer

82

Risk factors for AAA

males, age, smoking, family history

83

How do AAA usually present?

- Usually found incidentally.
- Can present with rupture, distal embolization, or compression of adjacent organs

84

Leading cause of death in AAA

Rupture: leading cause of death without an operation

85

Symptoms: back or abdominal pain, can have profound hypotension

Rupture

86

Dx: Ruptured AAA

Ultrasound or abdominal CT

87

CT findings in ruptured AAA

CT shows fluid in the retroperitoneal space and extraluminal contrast with rupture

88

Where is AAA most likely to rupture?

Most likely to rupture on left posterolateral wall, 2-4 cm below renals

89

When is AAA more likely to rupture?

More likely to rupture in the presence of diastolic HTN or COPD (thought to be predictors of expansion)

90

Rate of mortality with rupture of AAA if patient reaches hospital alive

50% mortality rate with rupture if patient reaches hospital alive

91

Indications for surgical repair of AAA

Repair if symptomatic, > 5.5 cm, or growth > 0.5 cm/yr

92

When do you reimplant the inferior mesenteric artery in surgical repair of ruptured AAA?

Reimplant IMA if back pressures

93

What arteries need ligation in ruptured AAA repair?

Ligate bleeding lumbar arteries

94

What artery needs ensured flow in aorto-bifemoral repair instead of straight tube graft in ruptured AAA repair?

If performing an aorto-bifemoral repair: ensure flow to at least one internal iliac artery (hypogastric artery) to avoid vasculogenic impotence

95

Graft used for repair of AAAs

Usually use a straight tube Dacron graft for repair of AAAs

96

Complications of AAA repair

Major vein injury with proximal cross-clamp. Impotence. MI. Renal failure. Graft infection. Pseudo aneurysm. Atherosclerotic occlusion. Diarrhea.

97

AAA complication: major vein injury with proximal cross-clamp

Retro-aortic left renal vein

98

AAA complication: impotence

In 1/3 secondary to disruption of autonomic nerves and blood flow to the pelvis

99

Rate of mortality with elective AAA repair

5% mortality with elective repair

100

#1 cause of acute death after surgery

MI

101

#1 cause of late death after surgery

Renal failure

102

Risk factors for mortality in AAA repair

Creatinine > 1.8 (#1), CHF, EKG ischemia, pulmonary dysfunction, older age, females

103

#1 risk factor for mortality after AAA repair

Creatinine > 1.8

104

Graft infection rate s/p AAA repair

1%

105

Pseudoaneurysm formation s/p graft placement for AAA repair

1%

106

Most common later complication after aortic graft placement

Atherosclerotic occlusion

107

What is diarrhea (especially bloody) worrisome for after AAA repair?

Ischemic colitis

108

Why is ischemic colitis a possible complication in AAA repair?

Inferior mesenteric artery is often sacrificed with AAA repair and can cause ischemia (most commonly left colon)

109

Dx: ischemic colitis s/p AAA repair

Endoscopy or abdominal CT: middle and distal rectum are spared from ischemia (middle and inferior rectal arteries are branches off the internal iliac artery)

110

When do you go to OR for ischemic colitis s/p AAA repair?

If patient has peritoneal signs, mucosa is black on endoscopy, or part of the colon looks dead on CT scan -> take to OR for colectomy and colostomy placement

111

AAA: ideal criteria for endovascular repair:
- Neck length
- Neck diameter
- Neck angulation
- Common iliac artery length
- Common iliac artery diameter
- Other

- Neck length: > 15mm
- Neck diameter: 20-30mm
- Neck angulation: 10mm
- Common iliac artery diameter: 8-18mm
- Other: non-tortuous, noncalcified iliac arteries, lack of neck thrombus

112

AAA repair: failure site -> Type 1 endoleak

Proximal or distal graft attachment sites

Tx: extension cuffs

113

AAA repair: failure site -> Type 2 endoleak

Collaterals (eg patent lumbar, IMA, intercostals, accessory renal)

Tx: observe most, percutaneous coil embolization if pressurizing aneurysm

114

AAA repair: failure site -> Type 3 endoleak

Overlap sites when using multiple grafts or fabric tear

Tx: Secondary endograft to cover overlap site or tear

115

AAA repair: failure site -> Type 4 endoleak

Graft wall porosity or suture holes

Tx: Observe, can place nonporous stent if that fails

116

AAA repair: failure site -> Type 5 endoleak (endotension)

Expansion of aneurysm without evidence of leak

Tx: repeat EVAR or open repair

117

- Occurs in 10% of patients with AAA; males
- Weight loss, increased ESR, thickened rim above calcifications on CT scan

Inflammatory aneurysms

- Not secondary to infection: just an inflammatory process

118

Anatomical problems to consider in inflammatory aneurysms

- Can get adhesions to the 3rd and 4th portion of the duodenum
- Ureteral entrapment in 25%

119

How do you prevent ureteral injury (25%) in repair of inflammatory aneurysms?

May need to place preoperative ureteral stents to help avoid injury.

120

Treatment: inflammatory aneurysm

Inflammatory process resolves after aortic graft placement

121

Cause of mycotic aneurysms

#1 Salmonella
#2 Staphylococcus

122

How do bacteria cause mycotic aneurysms?

Bacteria infect atherosclerotic plaque, cause aneurysm

123

- Pain, fevers, positive blood cultures in 50%
- Periaortic fluid, gas, retroperitoneal soft tissue edema, lymphadenopathy

Mycotic aneurysms

124

Treatment: mycotic aneurysms

Usually need extra-anatomic bypass (axillary-femoral with femoral-to-femoral crossover) and resection of infrarenal abdominal aorta to clear infection

125

Causes of aortic graft infections

#1 Staphylococcus
#2 E. coli

126

- Cause: 1) Staph 2) Ecoli
- See fluid, gas, thickening around graft
- Blood cultures negative in many patients

Aortic graft infections

127

What are aortic graft infections most common in?

More common with grafts going to the groin (e.g., aorto-bifemoral grafts)

128

Treatment: aortic graft infections

Bypass thru non-contaminated field (e.g. axillary-femoral bypass with femoral-to-femoral crossover) and then resect the infected graft

129

- Usually occurs > 6 months after abdominal aortic surgery
- Herald bleed with hematemesis, then blood per rectum

Aortoenteric fistula

130

Where does the graft erode in aortoenteric fistula?

Graft erodes into 3rd or 4th portion of duodenum near proximal suture line

131

Treatment: aortoenteric fistula

Bypass through non-contaminated field (e.g. axillary-femoral bypass with femoral-to-femoral crossover), resect graft, and then close hole in the duodenum

132

Standard treatment for an infected aortic valvular prosthesis

An axillobifemoral bypass is performed first. This is followed a few days later by removal of the infected aortic prosthesis and careful oversewing of the aortic stump as illustrated

133

Components of leg compartments

Anterior: deep peroneal nerve (dorsiflexion, sensation between 1st and 2nd toes), anterior tibial artery
- Lateral: superficial peroneal nerve (eversion, lateral foot sensation)
- Deep posterior: tibial nerve (plantar flexion), posterior tibial artery, peroneal artery
- Superficial posterior: sural nerve

134

Components of anterior leg compartment

Deep peroneal nerve (dorsiflexion, sensation between 1st and 2nd toes), anterior tibial artery

135

Components of lateral leg compartment

Superficial peroneal nerve (eversion, lateral foot sensation)

136

Components of deep posterior leg compartment

Tibial nerve (plantar flexion), posterior tibial artery, peroneal artery

137

Components of superficial posterior leg compartment

Sural nerve

138

Signs of PAD

Pallor, dependent rubor, hair loss, slow capillary refill

139

MCC PAD

Atherosclerosis

140

#1 preventative agent for atherosclerosis

Statin drugs (lovastatin)

141

Can increase risk of atherosclerosis.
- Tx: folate and B12

Homocystinuria

142

Treatment of claudication

Medical therapy first: ASA, smoking cessation, exercise until pain occurs to improve collaterals

143

Level of occlusion: buttock claudication

Aortoiliac disease

144

Level of occlusion: mid-thigh claudication

External iliac

145

Level of occlusion: calf claudication

Common femoral artery or proximal superficial femoral artery disease

146

Level of occlusion: foot claudication

Distal superficial artery or popliteal disease

147

How can you remember the symptoms associated with the level of occlusion in PAD?

Symptoms occur one level below occlusion

148

What can mimic claudication?

Lumbar stenosis

149

What can mimic rest pain in PAD?

Diabetic neuropathy

150

- No femoral pulses
- Buttock or thigh claudication
- Impotence (from decreased flow in the internal iliacs)

Leriche syndrome

151

Where is the lesion in Leriche syndrome?

Lesion at aortic bifurcation or above

152

Treatment: Leriche syndrome

Aorto-bifemoral bypass graft

153

Most common atherosclerotic occlusion in the lower extremities

Hunter's canal (distal superficial femoral artery exits here)

154

What muscle covers Hunter's canal?

Sartorius muscle

155

What forms collateral circulation?

Forms form abnormal pressure gradients

156

Collateral circulation of circumflex iliacs

Circumflex iliacs to subcostals

157

Collateral circulation of circumflex femoral arteries

Circumflex femoral arteries to gluteal arteries

158

Collateral circulation around the knee

Geniculate arteries

159

Budding from preexisting vessels; angiogenin involved

Postnatal angiogenesis

160

ABI

Start to get claudication (typically occurs at same distance each time)

161

ABI

Start to get rest pain (usually across the distal arch and foot)

162

ABI

Ulcers (Usually starts in toes)

163

ABI

Gangrene

164

Why can ABIs be very inaccurate in patients with diabetes?

Secondary to incompressibility of vessels; often have to go off Doppler waveforms in these patients

165

How does walking affect the ABI?

In patients with claudication, the ABI in the extremity drops with walking (i.e. resting ABI may be 0.9 but can drop to

166

Used to find significant occlusion and at what level

Pulse volume recordings (PVRs)

167

When is arteriogram indicated in PAD?

If PVRs suggest significant disease - can also at times treat the patient with percutaneous intervention; gold standard for vascular imaging.

168

Gold standard for vascular imaging

Arteriogram

169

Surgical indications for PAD

Rest pain, ulceration or gangrene, lifestyle limitation, atheromatous embolization

170

Only for bypasses above the knee; need to use vein for below the knee bypasses

PTFE (Gortex)

171

Good for aorta and large vessels

Dacron

172

Most get aorto-bifemoral repair

Aortoiliac occlusive disease

173

How do you prevent vasculogenic impotence and pelvic ischemia during repair of aortoiliac occlusive disease?

Need to ensure flow to at least 1 internal iliac artery (hypogastric artery; want to see good back-bleeding from at least 1 of the arteries, otherwise need a bypass to an internal iliac artery) when performing aorto-bifemoral repair

174

Treatment for isolated iliac lesions

PTA with stent 1st choice; if that fails, consider femoral-to-femoral crossover

175

- 75% 5-year potency
- improved patency with surgery for claudication as opposed to limb salvage

Femoropopliteal grafts

176

Popliteal artery exposure below the knee:
- Posterior muscle
- Anterior muscle

Posterior muscle: gastrocnemius

Anterior muscle: popliteus

177

Arteries useful in femoral-distal grafts

Peroneal, anterior tibial, or posterior tibial artery

178

Rate of potency of femoral-distal grafts

50% 5-year potency; potency not influenced by level of distal anastomosis

179

Why are distal lesions more limb threatening?

Because of lack of collaterals

180

When are bypasses to distal vessels usually performed?

Usually used only for limb salvage

181

If you are going to perform distal bypass on the leg, what do you need to ensure?

Bypassed vessel needs to have run-off below the ankle for this to be successful

182

Why use saphenous vein for bypass below the knee?

Synethetic grafts have decreased patency below the knee -> need to use saphenous vein.

183

When to consider extra-anatomic grafts?

Can be used to avoid hostile conditions in the abdomen (multiple previous operations in a frail patients_

184

Doubles blood flow to donor artery; can get vascular steal in donor leg

Femoral-to-femoral crossover graft

185

Dx: early swelling following lower extremity bypass

Reperfusion injury and compartment syndrome

Tx: fasciotomies

186

Dx: late swelling following lower extremity bypass

DVT

Dx: US
Tx: heparin, coumadin

187

Complications of reperfusion of ischemic tissue

Compartment syndrome, lactic acidosis, hyperkalemia, myoglobinuria

188

#1 cause of early failure of reversed saphenous vein grafts

Technical problem

189

#1 cause of late failure of reversed saphenous vein grafts

Atherosclerosis

190

Noninfectious, can allow to autoamputate if small or just toes.

Dry gangrene

191

Management of dry gangrene

- Large lesions should be amputated
- See if patient has a correctable vascular lesion

192

Infectious, need to remove infected necrotic material ; antibiotics

Wet gangrene

193

When is wet gangrene considered a surgical emergency?

If extensive infection (Eg swollen red toe with pus coming out and red streaks up leg) or systemic complication occur (e.g. septic) -> may need emergency amputation

194

- At metatarsal heads
- Diabetics, can have osteomyelitis

Mal perforans ulcer

195

MC'ly involved joint in mal performs ulcer

2nd MTP joint most common

196

Tx: mal perforans ulcer

Non-weightbearing, debridement of metatarsal head (need to remove cartilage), antibiotics; assess need for revascularization

197

- Excellent for common iliac artery stenosis
- Best for short stenoses

Percutaneous transluminal angioplasty (PTA)

198

How does percutaneous transluminal angioplasty (PTA) work?

Intimal usually ruptured and media stretched, pushes the plaque out.
- Requires passage of wire first.

199

What causes compartment syndrome?

Is caused by repercussion injury to the extremity (mediated by PMNs; occurs with cessation of blood flow to extremity and repercussion > 4-6 hours later).

200

What causes increased compartment pressures in compartment syndrome?

Reperfusion injury leads to swelling of the muscle compartments -> raising compartment pressures, which can lead to ischemia

201

Symptoms of compartment syndrome

Pain with passive motion; extremity feels tight and swollen

202

Where is compartment syndrome most likely to occur?

Most likely to occur in the anterior compartment of leg (get foot drop)

203

Dx / Tx: compartment syndrome

Dx: often based on clinical suspicion; compartment pressure > 20 - 30 mmHg abnormal

Tx: fasciotomies (get all 4 compartments if in lower leg) -> leave open 5-10 days

204

- Most present with mild intermittent claudication
- Men, 40s, loss of pulses with plantar flexion

Popliteal entrapment syndrome

205

What leads to popliteal entrapment syndrome?

Have medial deviation of artery around medial head of gastrocnemius muscle

206

Tx: popliteal entrapment syndrome

Resection of medial head of gastrocnemius muscle; may need arterial reconstruction

207

- Men, 40s, popliteral fossa most common area
- Symptoms: intermittent claudication, changes in symptoms with knee flexion / extension

Adventitial cystic disease

208

Why is adventitial cystic disease most often bilateral?

Ganglia originate from adjacent joint capsule or tendon sheath

209

Dx / Tx: adventitial cystic disease

Dx: angiogram

Tx: resection of cyst; vein graft if the vessel is occluded

210

What are arterial autografts?

Radial artery grafts for CABG, IMA from CABG

211

When do you amputate?

For gangrene, large non-healing ulcers or unrelenting rest pain not amenable to surgery.

212

Rate of mortality within 3 years for leg amputation

50% mortality

213

BKA:
- ___% heal
- ___% walk again
- ___% mortality

80% heal
70% walk again
5% mortality

214

AKA:
- ___% heal
- ___% walk again
- ___% mortality

90% heal
30% walk again
10% mortality

215

Indications for emergency amputation

Systemic complications or extensive infection

216

Embolism or Thrombosis?
- Arrhythmia
- No prior claudication or rest pain
- Normal contralateral pulses
- No physical findings of chronic limb ischemia

Embolism

217

Embolism or thrombosis?
- No arrhythmia
- History of claudication or rest pain
- Contralateral pulses absent
- Physical findings of chronic limb ischemia

Thrombosis

218

- Usually do not have collaterals, signs of chronic limb ischemia, or history of claudication with emboli (do have collaterals with thrombosis)

Acute arterial emboli

219

Contralateral leg in acute arterial emboli

Contralateral leg usually has no chronic signs of ischemia and pulses are usually normal

220

Symptoms: pain, paresthesia, poikilothermia, paralysis

Acute arterial emboli

221

Extremity ischemia evolution in acute arterial emboli

Pallor (white) -> cyanosis (blue) -> marbling

222

MCC acute arterial emboli

Atrial fibrillaiton

223

Common causes of acute arterial emboli

A fib (MCC), recent MI with LV thrombus, myxoma, aorto-iliac disease

224

MC site of peripheral obstruction from emboli

Common femoral artery

225

Tx: acute arterial emboli

Embolectomy usual; need to get pulses back; post op angiogram
- Consider fasciotomy is ischemia > 4-6 hours

226

When do you consider fasciotomy in acute arterial emboli?

If ischemia > 4-6 hours

227

Treatment possibility in aortoiliac emboli (loss of both femoral pulses)

Can be treated with bilateral femoral artery cutdown and bilateral embolectomies

228

Cholesterol clefts that can lodge in small arteries

Atheroma embolism

229

Most common site of atheroma embolization

Renals

230

Flaking atherosclerotic emboli off abdominal aorta or branches
- Patients typically have good distal pules

Blue toe syndrome

231

MC source of blue toe syndrome

Aortoiliac disease

232

Dx: atheroma embolism

Chest/abdomen/pelvis CT scan (look for aneurysmal source) and ECHO (clot or myxoma in heart)

233

Tx: atheroma embolism

May need aneurysm repair or arterial exclusion with bypass

234

Do patients with acute arterial thrombosis usually have arrhythmia?

No. These patients usually do not have arrhythmias.

235

What is the usually history in acute arterial thrombosis?

Do have a history of claudication and have signs of chronic limb ischemia and poor pulses in the contralateral leg.

236

Tx: acute arterial thrombosis

Threatened limb (loss of sensation or motor function) -> give heparin and go to OR for thrombectomy

If limb is not threatened: angiography for thrombolytics

237

Treatment: thrombosis of PTFE graft

Thrombolytics and anticoagulation; if limb threatened -> OR for thrombectomy

238

Where does the right renal artery run?

Posterior to IVC

239

Rate of accessory renal arteries in humans

Accessory renal arteries in 25%

240

Bruits. Diastolic blood pressure > 115, HTN, in children or premenopausal women, HTN resistant to drug therapy.

Renovascular HTN (renal artery stenosis)

241

Renovascular HTN:
- Left side
- Proximal 1/3
- Men

Renal atherosclerosis

242

Renovascular HTN:
- Right side
- Distal 1/3
- Women

Fibromuscular dysplasia

243

Dx: renovascular HTN (renal atherosclerosis, fibromuscular dysplasia)

Angiogram

244

Tx: renovascular HTN (renal atherosclerosis, fibromuscular dysplasia)

PTA (percutaneous transluminal angioplasty); place stent if due to atherosclerotic disease

245

Indications for nephrectomy with renal HTN

Atrophic kidney

246

Occlusive disease in the upper extremity: why are proximal lesions usually asymptomatic?

Secondary to increased collaterals

247

Most common site of upper extremity stenosis

Subclavian artery

248

Tx: occlusive disease of the upper extremity

PTA with stent; common carotid to subclavian artery bypass if that fails.

249

Proximal subclavian artery stenosis resulting in reversal of flow through ipsilateral vertebral artery into the subclavian artery

Subclavian steal syndrome

250

When do you operate in subclavian steal syndrome?

Operate with limb or neurologic symptoms (usually vertebrabasilar symptoms)

251

Tx: subclavian steal syndrome

PTA with stent to subclavian artery, common carotid to subclavian artery bypass if that fails.

252

Passes over the first rib anterior to the anterior scalene muscle, then behind clavicle

Subclavian vein

253

Passes over the first rib posterior to the anterior scalene muscle and anterior to the middle scalene muscle

Brachial plexus and subclavian artery

254

General symptoms: back, neck, and/or arm pain / weakness / tingling (often worse with palpation / manipulation)

Thoracic outlet syndrome

255

Dx: thoracic outlet syndrome

Cervical spine and chest MRI, duplex US (vascular etiology), electromyelogram (EMG; neurologic etiology)

256

If neurologic or vascular involvement more common in thoracic outlet syndrome?

Neurologic involvement - much more common than vascular

257

#1 anatomic abnormality in thoracic outlet syndrome

Cervical rib

258

#1 cause of pain in thoracic outlet syndrome

Brachial plexus irritation

259

How does the exam look in thoracic outlet syndrome?

Usually have normal neurologic exam; tapping can reproduce symptoms (Tinsel's test)

260

Most common nerve distribution causing pain in thoracic outlet syndrome

Ulnar nerve distribution (C8-T1) - inferior portion of brachial plexus

261

Symptoms of ulnar nerve distribution involvement in thoracic outlet syndrome

Tricep muscle weakness and atrophy, weakness of intrinsic muscles of hand, weak wrist flexion.

262

Tx: thoracic outlet syndrome

Cervical rib and 1st rib resection, divide anterior scalene muscle

263

Usually presents as effort-induced thrombosis of subclavian vein (Paget-von Schrotter disease; baseball pitchers) - acutely painful, swollen, blue limb

Subclavian vein TOS

264

What type of thrombosis is involved in subclavian vein TOS

Venous thrombosis is much more common than arterial

265

Dx: subclavian vein causing TOS

Venography is the gold standard for diagnosis, but duplex US makes the diagnosis and is quicker to get.

266

Rate of thoracic outlet problem in subclavian vein problem causing TOS

80% have associated thoracic outlet problem.

267

Tx: subclavian vein TOS

Thrombolytics initially; repair at that admission (Cervical rib and 1st rib resection, divide anterior scalene)

268

Least common cause of TOS

Subclavian artery

269

What is the cause of subclavian artery involvement in TOS?

Compression usually secondary to anterior scalene hypertrophy (weight lifters)

270

Symptoms: subclavian artery TOS

Hand pain from ischemia

271

Test used to confirm subclavian artery TOS

Adson's test: absent radial pulse with head turned to ipsilateral side

272

Dx / Tx: subclavian artery TOS

Dx: duplex US or angiogram (gold standard)

Tx: surgery -> cervical rib and 1st rib resection, divide anterior scalene muscle; possible bypass graft if artery is too damaged or aneursymal

273

Why can motor function be preserved in digits after prolonged hand ischemia?

Motor function can remain in digits after prolonged hand ischemia because motor groups are in the proximal forearm.

274

- Overall mortality 60%
- Usually involve SMA
- CT findings: vascular occlusion, bowel wall thickening, intramural gas, portal venous gas

Mesenteric ischemia

275

MCC of visceral ischemia

- Embolic occlusion: 50%
- Thrombotic occlusion: 25%
- Nonocclusive: 15%
- Venous thrombosis: 5%

276

MC location of SMA embolism

Most commonly occurs near origin of SMA

277

#1 source of SMA embolism

Heart (atrial fibrillation)

278

- Pain out of proportion to exam; pain usually of sudden onset; hematochezia and peritoneal signs are late findings
- May have h/o a fib, endocarditis, recent MI, recent angiography

SMA embolism

279

Dx / Tx: SMA embolism

Dx: angiogram or abdominal CT with IV contrast

Tx: embolectomy, resect infarcted bowel if present

280

How do you expose the SMA?

Divide ligament of Treitz, SMA is to the right of this near the base of the transverse colon mesentery

281

- Often history of chronic problems (food fear, weight loss)
- Possible history of vasculitis or hyper coagulable state
- Symptoms: similar to embolism, may have developed some collaterals

SMA thrombosis

282

Dx / Tx SMA thrombosis

Dx: angiogram or abdominal CT with IV contrast

Tx: thrombectomy (open or catheter directed; thrombolytics may have a role) ; may need PTA with stent or open bypass after the vessel is opened for any residual stenosis; resection of infarcted bowel

283

Dx: SMA thrombosis

Angiogram or abdominal CT with IV contrast

284

Tx: SMA thrombosis

thrombectomy (open or catheter directed; thrombolytics may have a role) ; may need PTA with stent or open bypass after the vessel is opened for any residual stenosis; resection of infarcted bowel

285

- Usually short segments of intestine involved; bloody diarrhea, crampy abdominal pain
- May have a history of vasculitis, hyper coagulable state, portal HTN

Mesenteric vein thrombosis

286

Dx: mesenteric vein thrombosis

Abdominal CT scan or angiogram with venous phase

287

Tx: mesenteric vein thrombosis

Heparin usual; resection of infarcted bowel if present

288

Dx / Tx: mesenteric vein thrombosis

Dx: abdominal CT scan or angiogram with venous phase

Tx: heparin usual; resection of infarcted bowel if present

289

- Spasm, low-flow states, hypovolemia, hemoconcentration, digoxin -> final common pathway is low cardiac output to visceral vessels
- Symptoms: bloody diarrhea, pain

Nonocclusive mesenteric ischemia

290

Final common pathway of nonocclusive mesenteric ischemia

Low cardiac output to visceral vessels

291

Risk factors of nonocclusive mesenteric ischemia

Prolonged shock, CHF, prolonged cardiopulmonary bypass

292

What areas are most vulnerable to nonocclusive mesenteric ischemia?

Watershed areas (Griffith's - splenic flexure and Sudak's - upper rectum)

293

Watershed area: splenic flexure

Griffith's

294

Watershed area: upper rectum

Sudak's

295

Tx: nonocclusive mesenteric ischemia

Volume resuscitation, catheter-directed nitroglycerin can increase visceral blood flow; also need to increase cardiac output (dobutamine); resection of infarcted bowel if present

296

- Causes celiac artery compression
- Bruit near epigastrium, chronic pain, weight loss, diarrhea

Median arcuate ligament syndrome

297

Tx: median arcuate ligament syndrome

Transect median arcuate ligament; may need arterial reconstruction

298

Weight loss secondary to food fear (visceral angina 30 minutes after meals)

Chronic mesenteric ischemia

299

Dx: chronic mesenteric ischemia

Get lateral visceral vessel aortography to see origins of celiac and SMA

300

Tx: chronic mesenteric ischemia

PTA and stent; bypass if that fails

301

Important collateral between the SMA and celiac

Arc of Riolan

302

Most common complication of aneurysms above the inguinal ligament

Rupture

303

Most common complications of aneurysms below inguinal ligament

Thrombosis and emoli

304

Risk factors for visceral artery aneurysms

Medial fibrodysplasia, portal HTN, arterial disruption secondary to inflammatory disease (eg, pancreatitis)

305

Repair guidelines for visceral artery aneursyms

Repair all splanchnic artery aneurysms (>2cm) when diagnosed (50% risk for rupture) except splenic

306

MC visceral aneurysm
- More common in women
- 2% risk of rupture

Splenic artery aneurysm

307

When do you repair splenic artery aneurysms?

If symptomatic, if patient is pregnant, if occurs in women of childbearing age, or is > 3-4 cm

308

Splenic artery aneurysm: what is concerning in pregnants?

High rate of pregnancy-related rupture -> usually in 3rd trimester

309

Tx: visceral artery aneurysm

Covered stent (best); exclusion with bypass if that fails

310

Treatment splenic artery aneurysms

Splenic artery aneurysms can just be ligated if open procedure is required (have good collaterals)

311

When do you treat renal artery aneurysms?

> 1.5 cm

Tx: covered stent

312

When do you treat iliac and femoral artery aneurysms?

Iliac: > 3.0 cm
Femoral: > 2.5 cm

Tx: covered stent

313

Most common peripheral aneurysm

Popliteal artery aneurysm

314

- Leg exam reveals prominent popliteal pulses
- 1/2 are bilateral
- 1/2 have another aneurysm elsewhere (AAA, femoral, etc)
- Most likely to get thrombosis or emboli with limb ischemia
- Can also get leg pain from compression of adjacent structures

Popliteal artery aneurysm

315

Dx: popliteal artery aneurysm

Ultrasound

316

Surgical indications for repair of popliteal artery aneurysm

Symptomatic, > 2cm, or mycotic

317

TX: popliteal artery aneurysm

Exclusion and bypass of all popliteal aneurysms; 25% have complication that requires amputation if not treated; covered stent not recommended for these

318

Collection of blood in continuity with the arterial system but not enclosed by all 3 layers of the arterial wall

Pseudoaneurysm

319

Most common location of pseudoaneurysm

Femoral artery

320

What can cause pseudo aneurysm?

Can result from percutaneous interventions or from disruption of a suture line between graft and artery

321

Treatment pseudo aneurysm if it occurs after percutaneous intervention

Ultrasound-guided compression with thrombin injection (surgical repair if flow remains in the pseudo aneurysm after thrombin injection)

322

Treatment pseudo aneurysm if it occurs at a suture line early after surgery

Need surgical repair

323

What do pseudo aneurysms that occur at suture lines late after surgery (months to years) suggest?

Suggests graft infection

324

- Young women; HTN if renal involved; headaches or stroke if carotids involved
- String of beads appearance

Fibromuscular dysplasia

325

Most commonly involved vessel in fibromuscular dysplasia

Renal artery, followed by carotid and iliac

326

Most common variant of fibromuscular dysplasia

Medial fibrodysplasia

327

- young men, smokers
- severe rest pain with bilateral ulceration; gangrene of digits, especially fingers

Buerger's disease

328

What do you see on arteriogram of Buerger's disease?

Corkscrew collaterals on angiogram and severe distal disease; normal arterial tree proximal to popliteal and brachial vessels (i.e., a small vessel disease)

329

Treatment: Buerger's disease

Stop smoking of will require continued amputations

330

Cystic medial necrosis syndromes

Marfan's, Ehlers-Danlos syndrome

331

Fibrillin defect (connective tissue elastic fibers); marfanoid habitus, retinal detachment, aortic root dilatation

Marfan's disease

332

- Many types of collagen defects are identified
- Easy bruising, hypermobile joints; tendency for arterial rupture, especially abdominal vessels
- Get aneurysms and dissections

Ehlers-Danlos syndrome

333

Angiogram protocol for Ehlers Danlos syndrome

No angiograms -> risk of laceration to vessel

334

What is important to consider in Ehlers Danlos syndrome cystic medial necrosis?

Often too difficult to repair and need ligation of vessels to control hemorrhage

335

- Women, age > 55, headache, fever, blurred vision (risk of blindness)
- Inflammation of large vessels (aorta and branches)
- Long segments of smooth stenosis alternating with segments of larger diameter

Temporal arteritis (large artery)

336

What do you see on temporal artery biopsy in temporal arteritis?

Giant cell arteritis, granuloma

337

What do you see on temporal artery biopsy in temporal arteritis?

Giant cell arteritis, granuloma

338

Tx: temporal arteritis (large artery)

Steroids, bypass of large vessels if needed; no endarterectomy

339

- Weight loss, rash, arthralgias, HTN, kidney dysfunction
- Get aneurysms that thromboses or rupture
- Renals most commonly involved

Polarteritis nodosa (medium artery)

340

What organ is most commonly involved in polyarteritis nods?

Renals

341

Tx: polyarteritis nodosa (medium artery)

Steroids

342

- Children; febrile viral illness with erythematous mucosa and epidermis
- Get aneurysms of coronary arteries and brachiocephalic vessels
- Die from arrhythmias

Kawasaki's disease (medium artery)

343

What do peeps with Kawasaki's die from?

Arrhythmias

344

Tx: kawasaki disease

Steroids, possible CABG

345

- Often secondary to drug / tumor antigens
- Symptoms: rash (palpable purpura), fever, symptoms of end-organ dysfunction

Hypersensitivity angiitis (small artery)

346

Tx: hypersensitivity angiitis (small artery)

Calcium channel blockers, pentoxifylline, stop offending agent

347

Radiation arteritis:
- Early
- Late
- Late late

- Early: sloughing and thrombosis (obliterative endarteritis)
- Late: (1-10 years) - fibrosis, scar, stenosis
- Late late (3-30 years) - advanced atherosclerosis

348

- Young women
- Pallor -> cyanosis -> rubor

Raynaud's disease

349

Tx: raynaud's disease

Calcium channel blockers, warmth

350

Joins femoral vein near groin; runs medially

Greater saphenous vein

351

Why no clamps on the IVC?

Will tear

352

Can be ligated near the IVC in emergencies because of collaterals (left gonadal vein, left adrenal vein); right renal vein does not have these collaterals

Left renal vein

353

Most common failure of AV grafts for dialysis

Venous obstruction secondary to intimal hyperplasia

354

Dialysis access grafts:
- Radial artery to cephalic vein
- Wait 6 weeks to use -> allows vein to mature

Cimino

355

Dialysis access grafts
- eg brachiocephalic loop graft
- wait 6 weeks to allow fibrous scar to form

Interposition graft

356

Two types of dialysis access graft

Cimino, interposition graft

357

- Usually secondary to trauma; can get peripheral arterial insufficiency, CHF, aneurysm, limb-length discrepancy
- Most need repair -> lateral venous suture; arterial side may need patch or bypass graft; try to place interposing tissue so it does not recure

Acquired AV fistula

358

- Causes: smoking, obesity, low activity
- Tx: sclerotherapy

Varicose veins

359

- Secondary to venous valve incompetence (90%)
- Ulceration occurs above and posterior to malleoli

Venous ulcers

360

Venous ulcers: size that often heal without surgery

Ulcers > 3cm often heal without surgery

361

Tx: venous ulcers

Unna boot compression cures 90%

362

What do you need to consider in the treatment of venous ulcers?

May need to ligate perforators or have vein stripping of greater saphenous vein

363

- Aching, swelling, night cramps, brawny edema, venous ulcers
- Elevation brings relief

Venous insufficiency

364

What causes edema in venous insufficiency?

Secondary to incompetent perforators and/or valves

365

Tx: venous insufficiency

Leg wraps, ambulation with avoidance of long standing

366

Treatment of venous ulcers: for severe symptoms or recurrent ulceration despite medical treatment

Greater saphenous vein stripping (for saphenofemoral valve incompetence) or removal or perforators (if just perforator valves are incompetent; stab avulsion technique)

367

Nonbacterial inflammation
- Tx: NSAIDs, warm packs, ambulation

Superficial thrombophlebitis

368

- Pus fills vein; fever, increased WBCs, erythema, fluctuant; usually associated with infection following a peripheral IV
- Tx: resect entire vein

Suppurative thrombophlebitis

369

What is associated with migrating thrombophlebitis?

Pancreatic CA

370

Augmentation of flow with distal compression or release of proximal compression

Normal venous Doppler ultrasound

371

Help prevent blood clots by decreasing venous stasis and increasing tPA release

Sequential compression devices (SCDs)

372

- Most common in calf
- Pain, tenderness, calf swelling
- Risk factors: Virchow's triad (venous stasis, hypercoaguability, venous wall injury)

DVT

373

Why is the left leg 2x more involved than right in DVT?

Longer left iliac vein compressed by right iliac artery

374

DVT: minimal swelling

Calf DVT

375

DVT: ankle and calf swelling

Femoral DVT

376

DVT: leg swelling

Iliofemoral DVT

377

Tenderness, pallor (whiteness), edema
- Tx: heparin

Phlegmasia alba dolens

378

Tenderness, cyanosis (blueness), massive edema
- Tx: heparin, rarely need surgery

Phlegmasia alba dolens

379

DVT treatment

Heparin, coumadin

380

IVC filter indications

Contraindication to anticoagulation; PE while on coumadin; free-floating ileofemoral thrombi; after pulmonary embolectomy

381

Etiology of pulmonary embolism with filter in place

Comes from ovarian veins, inferior vena cava superior to filter, or from upper extremity via the superior vena cava

382

Treatment: venous thrombosis with central line

Pull out central line if not needed, then heparin; can try to treat with systemic heparin or TPA down line if the access site is important

383

- Do not contain a basement membrane
- Not found in bone, muscle, tendon, cartilage, brain, or cornea

Lymphatics

384

Are lymphatics valveless?

Deep lymphatics have valves

385

- Occurs when lymphatics are obstructed, too few in number, or nonfunctional
- Leads to woody edema secondary to fibrosis in subcutaneous tissue (toes, feet, ankle, leg)

Lymphedema

386

What are big problems in lymphedema?

Cellulitis and lymphangitis secondary to minor trauma are big problems

387

Most common infection in lymphedema

Strep

388

Laterality of congenital lymphedema

L > R

389

Tx: lymphedema

Leg elevation, compression, antibiotics for infections

390

Raised blue/red coloring; early metastases to lung

Lymphangiosarcoma

391

Lymphangiosarcoma associated with breast axillary dissection and chronic lymphedema

Stewart-Treves syndrome

392

- Usually after dissection in the groin (e.g. after femoral to popliteal bypass)
- Leakage of clear fluid

Lymphocele

393

Tx: lymphocele

Percutaneous drainage (can try a couple of times); resection if that fails

394

How can you identify the lymphatic channels supplying a lymphocele?

Can inject isosulfan blue dye into foot to identify the lymphatic channels supplying the lymphocele if having trouble locating.