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Flashcards in Fiser Chapter 27 VASCULAR Deck (233):
1

Lymphedema tx

Leg elevation, compression, antibiotics for infection

2

How do you expose the SMA?

Divide the LOT. SMA is to the right of this near the base of the transverse colon mesentery.

3

Swollen red toe with pus coming out and red streaks up leg, sepsis

Wet gangrene, surgical emergency, may need amputation

4

Inflammatory aneurysms complications

Just inflammation (not infection), occurs in 10% of AAA patients; weight loss, high ESR, thickened rim above calcifications on CT; resolves after aortic graft placement

-Adhesions to 3rd and 4th duodenum
-Ureteral entrapment

5

Watershed areas

Griffith's: splenic flexure

Sudak's: upper rectum

6

Mal perforans ulcer

Metatarsal heads
2nd MTP joint most common
Possible OM (Diabetics)

7

Leakage of clear fluid after groin surgery

Lymphocele

Tx: percutaneous drainage; resection of that fails

Can inject isosulfan blue dye into foot to identify lymphatic channels supplying lymphocele

8

Indication for repair of descending aortic aneurysms

> 5.5 cm if endovascular repair possible
> 6.5cm if open repair needed

9

Risk factors for visceral artery aneurysms

Medial fibrodysplasia
Portal HTN
Inflammation (pancreatitis causing arterial disruption)

10

Swelling right after lower extremity bypass

Reperfusion injury
can lead to compartment syndrome, lactic acidosis, hyperkalemia, myoglobinuria

11

Tx of acute arterial embolism

Embolectomy
Fasciotomy if ischemia > 4-6 hours
Aortoiliac emboli (loss of both femoral pulses): bilateral femoral artery cutdowns and bilateral embolectomies

12

Atheroma embolism diagnosis and treatment

Dx: CT CAP (look for aneurysmal source) and ECHO

Tx: aneurysm repair or arterial exclusion with bypass

13

Most common congenital hypercoagulable disorder

Leiden factor: resistance to activated protein C

14

Indication for repair of ascending aortic aneurysm

Acutely symptomatic
>/= 5.5 cm (> 5cm with Marfan's)
Rapid increase in size (>0.5 cm/yr)

15

Most common cause of acute death after AAA repair

MI

16

Major vein injured with prximal cross-clamp in AAA repair

Retro-aortic left renal vein

17

Most common visceral aneurysm, and indication for repair

Splenic artery aneurysm

High rate of rupture in 3rd trim pregnancy

Repair if symptomatic, if pregnant, if childbearing age, or is >3-4cm

18

Indications for shunt during CEA

Stump pressures < 50, or
Contralateral side is tight

19

Signs of PAD

-Pallor
-Dependent rubor
-Hair loss
-Slow capillary refill

20

Most common location of pseudoaneurysm

femoral artery

21

Risk factors for AAA

Males
Age
Smoking
Family history

22

Atherosclerosis risk factors

-Smoking
-HTN
-Hypercholesterolemia
-DM
0Hereditary factors

23

Femoropopliteal graft 5-year patency

75%
Improved if for claudication rather than limb salvage

24

Carotid endarterectomy indications

> 70% stenosis and symptoms, or
> 80% stenosis

25

HTN in young women, string of beads appearance

FMD: Most commonly renal artery followed by carotid and iliac
If carotids involved, HA or stroke

Tx: PTA best, bypass if fails

26

Postnatal angiogenesis mechanism

Budding from preexisting vessels
Involved angiogenin

27

Most complication of aneurysms above versus below inguinal ligament

Rupture above

Thrombosis and emboli below

28

Dacron graft use

Aorta and large vessels

29

Treatment of pseudoaneurysm after percutaneous interention

US-guided compression with thrombin injection
Surgical repair if flow remains afterward

30

Pain, paresthesia, poikilothermia, paralysis

acute arterial embolus

pallor -> cyanosis -> marbling

31

Popliteal artery exposure below knee

Gastrocnemius is posterior
Popliteus muscle is anterior

32

TOS most common cause of pain

brachial plexus irritation

33

Blood flow to brain

Carotids supply 85%

34

Thoracic aortic surgery complications

MI
Renal failure
Paraplegia (descending thoracic aortic surgery)

35

Patient with AAA develops back or abdominal pain and has hypotension

AAA rupture

Dx: US or abdominal CT

36

Postop aortic dissection repair monitoring

Lifetime MRIs
30% eventually get aneurysm formation requiring surgery

37

TOS most common anatomic abnormality

cervical rib

38

Wet gangrene management

Need to remove infected necrotic material, antibiotics

Can be surgical emergency if extensive infection

39

What layer of vessel wall does aortic dissection occur in?

Medial layer

40

Early and late swelling following lower extremity bypass

Early: reperfusion injury and compartment syndrome (fasciotomy)

Late: DVT

41

Raised red/blue scarring where prior lymphedema was

Lymphangiosarcoma
Early mets to lung

42

Mid-thigh claudication means occlusion is where

External iliac

43

Pseudoaneurysm definition

Collection of blood in continuity with artery but not enclosed by all 3 layers of wall

44

Patient with heel ulceration to bone: treatment?

Amputation

45

most common peripheral aneurysm

popliteal
prominent pop pulses on exam
50% have aneurysm elsewhere

46

TOS tx

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

47

Problems with smiling/corner of mouth after CEA

Mandibular branch of facial nerve injury

48

BKA versus AKA prognosis

BKA: 80% heal, 70% walk again, 5% mortality
AKA: 90% heal, 30% walk again, 10% mortality

49

Mycotic aneurysm treatment

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

50

Risk factors for aortic dissection

Marfan's
Previous aneurysm
Atherosclerosis

51

Communication between ICA and ECA

Ophthalmic artery and internal maxillary artery

52

Dx compartment syndrome

Clinical
Compt pressure >20-30 mm Hg

53

Leg amputation 3 year mortality

50%

54

Aortic graft infection organisms

1. Staphylococcus
2. E coli

55

Emergent CEA indications

Fluctuating neurologic symptoms or crescendo/evolving TIAs

56

Most common cause of non-stroke M&M after CEA

MI

57

Type III endoleak

OVERLAP sites failure when using multiple grafts or fabric tear
Tx: Secondary endograft to cover overlap site or tear

58

Superficial posterior leg compartment nerve

Sural nerve

59

Older woman with headache, fever, blurred vision

Temporal arteritis
Risk of blindness

Dx: Temproal artery bx shows giant cell arteritis, granulomas. Long segments of smooth stenosis

Tx: Steroids, bypass of large vessels if needed; NO endarterectomy

60

Where do most dissections start?

Ascending aorta

61

Greater saphenous vein stripping

tx for saphenofemoral valve incompetence

62

Isolated iliac disease tx

1. PTA with stent
2. Consider fem-fem crossover

63

MCC early failure of RSVG

Technical problem

64

Lymphatics

No basement membrane
Not in bone/muscle/tendon/cartilage/brain/cornea

65

Radiation arteritis early/late/very late

Early: obliterative endarteritis (sloughing and thrombosis)

Late 1-10 years: fibrosis, scar, stenosis

Very late 3-30 years: advanced atherosclerosis

66

MCC of PAD

Atherosclerosis

67

Treatment of Mal perforans ulcer

Non-weightbearing, metatarsal head debridement (remove cartilage), antibiotics, assess need for revasc

68

Percutaneous transluminal angioplasty indication

Common iliac artery stenosis, best for short stenosis

Mech: intima usually rupture, media stretched, plaque pushed out, requires passage of wire first

69

Patient with tearing-like chest pain, unequal pulses or BP in upper extremities

Aortic dissection

95% have HTN at presentation

70

Most common cause of cerebral ischemic events

-Arterial embolization from the ICA (not thrombosis)
-Can also occur from low-flow state through stenotic lesion
-Heart is 2nd most common source of cerebral emboli

71

Anterior cerebral artery events symptoms

AMS, release, slowing

72

Most common atherosclerotic occlusion in lower extremities

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

73

What causes death in aortic dissection?

Cardiac failure from aortic insufficiency, cardiac tamponade, or rupture

74

Popliteal artery aneurysm dx and tx

Dx: US

Tx: exclusion and bypass (not stent)

75

Lateral leg compartment nerve

Superficial peroneal nerve: eversion, lateral foot sensation

76

Rate or restenosis after CEA

15%

77

Leg compartments

1. Anterior: deep peroneal nerve (dorsiflexion and web sensation), AT artery
2. Lateral: superficial peroneal nerve (eversion, lateral foot sensation)
3. Deep posterior: tibial nerve (plantar flexion), PT artery, peroneal artery
4. Superficial posterior: sural nerve

78

Tenderness, cyanosis, massive edema

Phlegmasia cerulean dolens

Tx: heparin, rarely surgery

79

Venous ulcer cause and location

-venous valve incompetence 90%

-above and posterior to malleoli

80

Lymphedema mechanism

Obstructed, too few, or nonfunctional lymphatics

-> fibrosis in subcutaneous tissue -> woody edema

-> cellulitis and lymphangitis after minor trauma

81

#1 preventive agent for atherosclerosis

Statins

82

Next step if pulse volume recordings suggest significant disease

Arteriogram

83

Buttock or thigh claudication, impotence, no femoral pulses

Leriche syndrome: lesion at aortic bifurcation or above

Tx: Aorto-bifemoral bypass graft

84

Surgical repair of aortic dissections

Ascending: open repair with graft

Descending: endograft or open or fenestrations

85

Posterior cerebral artery events symptoms

Vertigo, tinnitus, drop attacks, incoordination

86

Tongue deviates to L after CEA, speech and mastication difficult

Left hypoglossal nerve injury

87

Premenopausal woman with resistant HTN, DBP > 115, bruits

Renal artery stenosis
FMD: R side, distal 1/3, women
Renal atherosclerosis: L side, proximal 1/3, men

88

TOS diagnosis

cervical spine and chest MRI
duplex US
EMG

89

Most common acquired hypercoagulable disorder

Smoking

90

Acute arterial thrombosis treatment

Threatened limb (loss of motor or neuro): heparin and OR for thrombectomy

Otherwise: angiography for thrombolytics

91

Virchow's triad

Venous stasis
Hypercoagulability
Venous wall injury

92

Type IV endoleak

graft WALL porosity or suture holes
Tx: observe; can place nonporous stent if that fails

93

Indications for IVC filter

AC contraindication
PE while on Coumadin
Free-floating ileofemoral thrombi
After pulmonary embolectomy

94

Mortality after elective AAA repair

5%

95

Aortic graft infection treatment

Bypass through non-contaminated field (eg axillary-femoral bypass with fem-fem crossover) and then resect infected graft

96

Most likely leg compartment to get compartment syndrome

Anterior compartment, get foot drop

97

Acute arterial embolism versus acute arterial thrombosis

Embolism: Arrhythmia, no prior claudication or rest pain, normal contralateral pulses, no physical findings of chronic limb ischemia; no collaterals

Thrombosis: No arrhythmia; history of claudication or rest pain, contralateral pulses absent, physical findings of chronic limb ischemia; collaterals present

98

Suppurative thrombophlebitis

Pus fills vein; fever, leukocytosis, erythema, fluctuance, usually associated with infection after PIV

Tx: resect entire vein

99

Collateral circulation

Circumflex iliacs to subcostals
Circumflex femoral to gluteals
Geniculate around the knee

100

Most common cause of AV graft failure

Intimal hyperplasia -> venous obstruction

101

Indications for operative repair of aortic dissections

-All ascending (class A or type I/II)
Open repair, graft to eliminate flow to false lumen

-Descending aortic dissection (class B or type III) if visceral or extremity ischemia, or if contained rupture
Endograft or open repair; or just place fenestrations in dissection flap to restore blood flow to viscera or extremity

102

Painless neck mass

Carotid body tumor: painless neck mass, usually near bifurcation, neural crest cells, EXTREMELY VASCULAR
Tx: resection

103

Type II endoleak

COLLATERALS failure (eg patent lymbar, IMA, intercostals, accessory renal)
Tx: Observe; percutaneous coil embolization if pressurizing aneurysm

104

Claudication management

ASA, stop smoking, exercise until pain occurs to improve collaterals

105

Diagnosis of AAA rupture

CT: fluid in retroperitoneal space and extraluminal contrast with rupture
-Most likely in Left posterolateral wall, 203 cm below renals

106

Aortic dissection Stanford classification

A: any ascending aortic involvement

B: descending aortic involvement only

107

Rest pain mimicker

DM neuropathy

108

Cimino fistula

Radial artery to cephalic vein

Wait 6 weeks for vein to mature

109

Type I endoleak

Proximal or distal ATTACHMENT SITES of graft failure
Tx: extension cuffs

110

Young male smoker with severe rest pain and bilateral ulceration, gangrene of digits especially fingers

Buerger's disease

Corkscrew collaterals on angiogram and severe distal disease; normal

111

Abdominal pain out of proportion, sudden onset, hematochezia and peritonitis

Mesenteric ischemia from SMA embolism

112

Vertebrobasilar symptoms and subclavian artery stenosis

Subclavian steal syndrome: proximal subclavian artery stenosis resulting in reversal of flow through ipsilateral vertebral artery into subclavian artery

Operate if limb or neuro symtpms
Tx: PTA with stent to subclavian artery; common carotid to subclavian artery bypass if fails

113

Effort-induced thrombosis of subclavian vein with acutely painful, swollen, blue limb

Paget-von-Schrotter disease, baseball pitchers

Venous thrombosis much more common than arterial

Dx: venography gold standard; also duplex US quicker

80% have associated thoracic outlet problem

Tx: Thrombolytics initially, repair at that admission (cervical rib and 1st rib resection, divide anterior scalene muscle)

114

Gold standard for vascular imaging

Arteriogram

115

CEA complications

1. Vagus nerve injury is most common cranial nerve injury, and is secondary to vascular clamping, manifests as hoarseness (d/t RLN branch)

2. Hypoglossal nerve injury: tongue deviates toward injury, speech and mastication difficult

3. Glossopharyngeal nerve injury: rare, with really high carotid dissection, difficulty swallowing

4. Ansa cervicalis: innervation to strap muscles, no serious deficits

5. Mandibular branch of facial nerve: affects corner of mouth, smile

6. Stroke: OR to check for flap or thrombosis

7. Pseudoaneurysm: pulsatile, bleeding mass; tx drape and prep, intubate, repair

8. HTN: in 20%, caused by carotid body injury, tx Nipride to avoid bleeding

9. MI: MCC of non-stroke m & m after CEA

10. Restenosis: 15 % rate

116

ECA branches

1. Superior thyroid artery
2. Ascending pharyngeal
3. Lingual
4. Facial
5. Occipital
6. Postauricular
7. Maxillary
8. Superficial temporal

Some Anatomists Like Freaking Out Poor Medical Students

117

History of food fear, weight loss, vasculitis, hypercoagulable state, presents with abdominal pain

Mesenteric ischemia from SMA thrombosis

118

Prolonged hand ischemia, why does motor function remain in digits?

Motor groups are in proximal forearm

119

Stewart-Treves syndrome

Lymphangiosarcoma associated with breast axillary dissection and chronic lymphedema

120

Graft infection rate after AAA repair

1%

121

Claudication mimicker

Lumbar stenosis

122

Foot claudication means occlusion is where

Distal superficial femoral or popliteal

123

Most common site of upper extremity stenosis

subclavian artery

tx: Perc transluminal angioplasty with stent; common carotid to subclavian artery bypass if fails

124

Atheroma embolism mechanism

Cholesterol clefts that can lodge in small arteries

125

Child with fever, viral illness with erythematous mucosa and epidermis

Kawasaki's disease (medium artery): aneurysms of coronary arteries and brachiocephalic vessels, die from arrhythmias

Tx: Steroids, possible CABG

126

DVT most common where

Calf
Left leg 2x more common (longer left iliac vein compressed by right iliac artery)

127

Varicose vein risk factors and tx

Smoking, obesity, sedentary
Tx: Sclerotherapy

128

Aortic insufficiency incidence in aortic dissection

70%
-Caused by annular dilatation or when aortic valve cusp is sheared off
-Can also have occlusion of coronary arteries and major aortic branches

129

PAD surgical indications

-Rest pain
-Ulceration or gangrene
-Lifestyle limitation
-Atheromatous embolization

130

40yo man with mild intermittent claudication, loss of pulses with plantar flexion

Popliteal entrapment syndrome: medial deviation of artery around medial head of gastrocnemius muscle

Tx: resect medial head of gastroc, may need arterial reconstruction

131

Pulse volume recordings use

To find significant occlusion and at what level

132

Diarrhea after AAA repair

Concern for ischemic colitis, especially if bloody

-IMA often sacrificed -> left colon ischemia
-Dx: endoscopy or abdominal CT; middle and distal rectum spared (middle and inferior rectal arteries come off internal iliac artery)
-If peritonitis or black mucosa on endoscopy or dead colon on CT -> OR for colectomy and colostomy

133

PTFE graft thrombosis tx

Thrombolytics and AC
If limb threatened (loss of motor or neuro): OR for thrombectomy

134

Amputation indications

Gangrene, Large non-healing ulcers, Unrelenting rest pain not amenable to surgery

Emergency amp for systemic complication or extensive infection

135

Weight loss, visceral angina 30 min after meals

Chronic mesenteric angina

Dx: Lateral visceral vessel aortography to see celiac and SMA origins

Tx: PTA and stent, bypass if fails

136

Anterior leg compartment nerve

Deep peroneal nerve: dorsiflexion and web sensation, also AT artery

137

Indications to reimplant the IMA after AAA repair?

-Backpressure < 40 (poor backbleeding)
-Previous colonic surgery
-Stenosis at SMA
-Flow to left colon appears inadequate

138

Most common site of peripheral obstruction from emboli

Common femoral artery

139

Treatment of pseudoaneurysm early after surgery at a suture line

Surgical repair

140

HTN after CEA

Carotid body injury, occurs in 20%, tx Nipride to avoid bleeding

141

Superficial thrombophlebitis

Nonbacterial inflammation

Tx: NSAIDs, warm packs, ambulation

142

AAA definition and mechanism

Degeneration of medial layer -> AAA
Normal aorta 2-3 cm

143

Hoarseness after CEA

Vagus nerve injury (RLN branch too)

144

Indication for carotid stent instead of CEA

High-risk patients (previous CEA and restenosis, multiple comorbidities, prior neck XRT)

145

Type V endoleak

Endotension: expansion of aneurysm without e/o leak
Tx: Repeat EVAR or open repair

146

Increased risk of atherosclerosis

Homocystinuria (tx folate and B12)

147

Palpable purpura rash, fever, end-organ dysfunction

Hypersensitivity angiitis (small artery) 2/2 drug or tumor antigens

Tx: CCB, pentoxifylline, stop offending agent

148

Atherosclerosis stages

1. Foam cells: macrophages with absorbed fat and lipids in vessel wall
2. Smooth muscle cell proliferation: from growth factors released by macrophages, causing wall injury
3. Intimal disruption: exposure of collagen in vessel wall and eventual thrombus formation -> fibrous plaques in areas with underlying atheromas

149

Ideal criteria for AAA endovascular repair

-Neck length > 15 mm
-Neck diameter 20-30 mm
-Neck angulation < 60 degrees
-Common iliac artery length > 10 mm
-Common iliac artery diameter 8-18 mm
-Non-tortuous, non-calcified iliac arteries
-Lack of neck thrombus

150

Tenderness, pallor, edema

Phlegmasia alba dolens

Tx: heparin

151

Upper extremity occlusive disease symptoms

Proximal lesions usually asymptomatic d/t collaterals

152

SCDs mech

Decrease venous stasis and increase tPA release

153

Below knee graft type

Saphenous vein, as synthetic grafts have decreased patency below the knee

154

How do you prevent vasculogenic impotence and pelvic ischemia in aorto-bifemoral repair?

Ensure flow to at least 1 internal iliac (hypogastric) artery, by seeing good back-bleeding, otherwise need bypass to an internal iliac artery

155

PE with IVC filter in place comes from where?

Ovarian veins,
IVC superior to filter, or
Upper extremity via SVC

156

Stroke risk factors

HTN most important

157

Middle cerebral artery events symptoms

Contralateral motor, speech (if dominant side), contralateral facial droop sparing forehead

158

Vertebrobasilar artery disease mechanism

Need either bilateral vertebral artery or basilar artery disease to have symptoms

Symptoms: Diplopia, vertigo, tinnitus, drop attacks, incoordination
Tx: PTA with stent

159

Risk factors for mortality after AAA repair

-Cr > 1.8

-CHF
-ECG ischemia
-Pulmonary dysfunction
-Older age
-Females

160

Renal artery stenosis dx and tx

Angiogram

Tx: Percutaneous transluminal angioplasty; place stent if due to atherosclerotic disease

Nephrectomy if atrophic kidney with persistently high renin levels

161

Migrating thrombophlebitis

Pancreatic Ca

162

Most common late complication after aortic graft placement

Atherosclerotic occlusion

163

Normal venous Doppler US

Augmented flow with distal compression or proximal release

164

Chronic pain, weight loss, diarrhea, bruit near epigastrium

Median arcuate ligament syndrome: celiac artery compression

Tx: Transect median arcuate ligament, may need arterial reconstruction

165

Can IVC be clamped?

No, will tear

166

6 months after AAA repair, herald bleed with hematemesis and then blood per rectum

Aortoenteric fistula

Graft erodes into 3rd or 4th duodenum near proximal suture line
Tx: bypass through noncontaminated field (ax-fem bypass with fem-fem crossover), resect graft, then close hole in duodenum

167

Stroke after CEA

OR to check for flap or thrombosis

168

Which side do you repair first in bilateral carotid stenosis?

Tighter side first
If equal, dominant side first

169

Tinsel's test positive and ulnar nerve (C8-T1) symptoms (tricep weakness, intrinsic hand weakness, wrist flexion weakness)

Brachial plexus irritation from TOS

170

ABI levels and symptoms

< 0.9 claudication
< 0.5 rest pain (distal arch and foot)
< 0.4 ulcers (toes first)
< 0.3 gangrene

171

Venous thrombosis with central line, management

Pull central line
Heparin
If need line, try heparin or tPA down line

172

ABI inaccurate in who?

DM patients 2/2 incompressiblity of vessels
Go off Doppler waveforms instead

173

Most common site of stenosis causing stroke

Carotid bifurcation

174

Deep posterior leg compartment nerve

Tibial nerve: plantar flexion
also PT artery and peroneal artery

175

Stroke with diplopia, vertigo, tinnitus, drop attacks, incoordination. What vessels cut off?

Vertebrobasilar
Tx: PTA with stent

176

Mechanism of paraplegia after descending thoracic aortic surgery

Occlusion of intercostal arteries and artery of Adamkiewicz -> spinal cord ischemia

Less risk with endovascular repair

Less risk when reimplant intercostal arteries below T8 in open repair

177

SMA embolism dx and tx

Angiogram or CTAP with IV contrast

Embolectomy, resect infarcted bowel

178

Mycotic aneurysm organisms

1. Salmonella
2. Staphylococcus

179

Aortic graft infection presentation

Fluid, gas, thickening around graft

Often cultures are negative

More common with grafts going to groin (aorto-bifem grafts)

180

Treatment of aortic dissection

Medical initially: BP control with esmolol and nipride

181

Leading cause of death in AAA without surgery

Rupture, 50% mortality if patient reaches hospital alive

182

Pseudoaneurysm rate after AAA repair

1%

183

Mesenteric ischemia cause

SMA disease
Embolic 50% (heart a fib most common source)
Thrombotic 25%
Nonocclusive 15%
Venous thrombosis 5%
60% mortality

184

Aortic dissection DeBakey classification

"DeBakey is BAD (both, ascending, descending)

based on site of tear and extent of dissection

Type I: Ascending and descending
Type II: Ascending only
Type III: Descending only

185

Splenic, renal, iliac, femoral artery aneurysm tx

covered stent

186

Fem-fem crossover graft effects on blood flow in donor leg

Doubles blood flow to donor artery
Can get vascular steal in donor leg

187

Aching, swelling, night cramps, brawny edema, venous ulcers

Venous insufficiency

Tx: leg wraps, ambulation with avoidance of long standing

188

Carotid traumatic injury with major fixed deficit, treatment

If occluded, do not repair as can exacerbate injury with bleeding

If not occluded, repair with carotid stent or open procedure

189

Young woman with hand pallor -> cyanosis -> rubor

Reynaud's disease

Tx: CCB, warmth

190

Most commonly diseased intracranial artery

Middle cerebral artery

191

Tall, retinal detachment, aortic root dilatation

Marfan's (fibrillin defect), a cystic medial necrosis syndrome

192

Nonocclusive mesenteric ischemia dx and tx

Recent prolonged shock/CHF/Cardiopulm bypass -> low cardiac output to visceral vessels -> watershed areas ischemia

Tx: volume resuscitation, catheter-directed nitroglycerin can increase visceral blood flow; also need to increased CO (dobutamine); resect infarcted bowel if present

193

Venous ulcer tx

Unna booth compression cures 90%
May need to ligate perforators or have vein stripping of greater saphenous vein

194

Femoral-distal graft 5-year patency (peroneal, AT, PT)

50%
-Usually used only for limb salvage
-Bypassed vessel needs to have run-off below ankle to be successful
-Not influenced by level of distal anastomosis
-Distal lesions more limb threatening because lack of collaterals

195

SMA thrombosis dx and tx

Angiogram or CTAP with IV contrast

Thrombectomy (open or catheter; thrombolytics), possible PTA with stent, possible open bypass, resection of infarcted bowel

196

Dry gangrene management

Can allow autoamputation if small or just toes

But large lesions should be amputated

See if patient has correctable vascular lesion

197

CT findings of intestinal ischemia

-Vascular occlusion
-Bowel wall thickening
-Intramural gas
-Portal venous gas

198

Easy bruising, mobile joints, arterial rupture especially abdominal vessels

Ehler-Danlos syndrome, collagen problems, a cystic medial necrosis: aneurysms, dissections
No angiograms (risk of lac to vessel)
Often too difficult to repair and must ligate to control hemorrhage

199

PTFE Gortex use

Bypasses above knee ONLY

200

Endoleak types

ACOWE, observe 2&4

Type I: Attachment sites

Type II: Collaterals

Type III: Overlap sites

Type IV: graft Wall porosity

Type V: Expansion or aneurysm without leak

201

Pseudoaneurysms that occur at suture lines months-years after surgery, worrisome for what?

Graft infection

202

Back, neck, arm pain/weakness/tingling, worse with palpation or manipulation

Thoracic outlet syndrome
Subclavian vein passes over 1st rib ANTERIOR to anterior scalene muscle, then behind clavicle
Brachial plexus and subclavian artery pass over 1st rib POSTERIOR to anterior scalene muscle and anterior to middle scalene muscle (traverse narrow triangle formed by anterior and middle scalene muscles and first rib)

Dx: cervical spine and chest MRI, duplex US, EMG

Neuro involvement much more common than vascular

203

Pulsatile, bleeding mass after CEA

Pseudoaneurysm: drape and prep, intubate, repair

204

Symptoms of PAD occur at what level relative to occlusion

One level below

205

Indications for repair of splanchnic artery aneurysm (>2 cm)

Repair all when diagnosed, as there is 50% risk of rupture, except splenic

206

Amaurosis fugax

Occlusion of ophthalmic branch of ICA -> shade coming down over eyes; transient

-Hollenhorst plaques on ophthalmic exam

207

Endovascular versus open repair of descending aortic aneurysms

-Less mortality, less paraplegia (2-3% versus 20%)

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

208

Most common cause of LATE death after AAA repair

Renal failure

209

40yo man with intermittent claudication, changes in symptoms with knee flexion/extension

Adventitial cystic disease: often bilateral ganglia originating from adjacent joint capsule or tendon sheath, most commonly in popliteal fossa

Dx: angiogram
Tx: Cyst resection, vein graft if vessel occluded

210

Complications of AAA

Rupture
Distal embolization
Compression of adjacent organs

211

Hand pain from ischemia in a weight lifter, absent radial pulse with head turned to ipsilateral side (Adson's test)

Anterior scalene hypertrophy causing compression and TOS

Dx: angiogram gold standard or duplex US

Tx: cervical rib and 1st rib resection, divide anterior scalene muscle, possible bypass graft if artery too damaged or aneurysmal

212

Tx compartment syndrome

Fasciotomy of all 4 compartments if in lower leg
Leave open 5-10 days

213

Mycotic aneurysm mechanism and presentation

Bacteria infect atherosclerotic plaque and cause aneurysm (Salmonella, staphylococcus)

-Pain, fevers, bacteremia
-Periaortic fluid, gas, retroperitoneal soft tissue edema, lymphadenopathy

214

Predictors of AAA rupture

diastolic HTN
COPD

215

Calf claudication means occlusion is where

Common femoral or proximal superficial femoral artery

216

Aorto-bifemoral repair complication

Vasculogenic impotence
-Ensure flow to at least one internal iliac artery (hypogastric) to avoid this

-Impotence in 1/3 d/t disruption of autonomic nerves and blood flow

217

CEA contraindications

Recent completed stroke: wait 4-6 weeks, otherwise bleeding risk

218

Swelling location and DVT location

Calf DVT - minimal swelling
Femoral DVT - ankle and calf swelling
Iliofemoral DVT - leg swelling

219

Can renal veins by ligated?

Left can, has collaterals (gonadal, adrenal)

220

MCC late failure of RSVG

Atherosclerosis

221

SMA and celiac collateral

Arc of Riolan

222

Indications for AAA repair

Symptomatic
Size > 5.5 cm
Growth > 0.5 cm/yr

223

Diagnosis of aortic dissection

Chest CT with contrast
(CXR normal or widened mediastinum)

224

Buttock claudication means occlusion is where

Aortoiliac disease

225

Traumatic AV fistula management

Most need repair: lateral venous suture

Can get peripheral arterial insufficiency, CHF, aneurysm, limb-length discrepancy

226

Most common site of atheroma embolization

Renal arteries

227

ICA first branch

Ophthalmic artery

228

Difficulty swallowing after CEA

Glossopharyngeal nerve injury (high carotid dissections)

229

MCC acute arterial embolus

A fib
Recent MI with LV thrombus
Myxoma
Aorto-iliac disease

230

Flaking atherosclerotic emboli off abdominal aorta or branches

Blue toe syndrome
Typically good distal pulses
Aortoiliac disease most common source

231

Pain with passive motion, extremity feels tigh and swollen

Compartment syndrome from reperfusion injury (PMNs mediate it, occurs after > 4-6 hours of cessation of blood flow and then reperfusion)

232

Weight loss, rash, arthralgias, HTN, kidney dysfunction

Polyarteritis nodosa (medium artery): aneurysms that thrombose or rupture, renals most commonly involved

Tx: steroids

233

Mesenteric vein thrombosis dx and tx

CTAP or angiogram with venous phase. Usually short segments of intestinve involved.

Tx: heparin usual, resection of infarcted bowel if present