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Flashcards in NMS Vascular Deck (106):
1

definition of TIA, how do you manage it

transient neuro findings < 24 h usually 2/2 embolus from carotid bifurcation;
mgmt: need to do duplex u/s of carotids, followed by carotid endarterectomy if >70% stenosis; may need echo if heart murmur

2

when is Carotid endarterectomy indicated

if > 70% stenosis in symptomatic patient; in asymptomatic patient, less well-defined; definitely carotid endarterectomy if >80% stenosis, maybe if >60% stenosis

3

what precautions needed to prevent stroke during carotid endarterectomy procedure

intraop EEG monitoring , bp control

4

what possible complications with carotid endarterectomy (3)

1) hypoglossal nerve injury
2) mandibular branch of facial nerve injury
3) vagus nerve injury

5

tx of amaurosis fugax

same as carotid endarterectomy: carotid duplex --> carotid endarterectomy if >70% stenosis

6

what to do if amaurosis fugax or TIA with PERSISTENT neuro findings (ie, stroke)

OBSERVE for 2-4 wks, then carotid endarterectomy when stable

7

what are 6 P's of acute arterial occlusion

Pain
Pallor
Pulselessness
Poikilothermia
Paralysis*
Paresthesias*
(these last 2 steps happen first; nerves most sensitive to anoxia)

8

how does acute arterial occlusion happen? how do you tx it

embolus from heart (70%) or artery/aneurysm (30%); treatment is revascularization in OR for balloon catheter embolectomy

9

what is dangerous finding postop with balloon catheter embolectomy for acute arterial occlusion

COMPARTMENT SYNDROME resulting from ischemia-reperfusion injury --> edema

10

what are 3 classifications of acute arterial occlusion? how do you know if limb is not salvagable

1) viable
2) threatened
3) irreversible (no dopplerable venous pulses, paralyzed, insensate)

11

what is most common site of acute arterial occlusion

lower extremity, specifically common femoral artery

12

how do you work up intermittent claudication

look for ulcers, skin changes, neuro deficits; TESTS include ABI (ankle brachial index, determines severity) and DOPPLER waveforms (normally triphasic)

13

most common site and findings with intermittent claudication

superficial femoral artery at adductor hiatus --> loss of popliteal and pedal pulses

14

when to do angiogram in claudication

ONLY as preop test (ie if you dont plan to operate, dont do an angiogram)

15

what is normal ABI

>1 ( i saw >0.9, but >1.2 can be pathologic/sign of severe hardened arteries 2/2 atherosclerosis)

16

how to treat patients with intermittent claudication

operate only if grossly disturbing patients lifestyle; if with activity and mildly aggravating, treatment is EXERCISE + lifestyle modification

17

what does claudication + absent femoral pulses suggest? how does that change mgmt

suggests AORTOILIAC DISEASE; more progressive than distal disease, so SURGERY should be considered if symptoms progress

18

what are the tx options for aortoiliac dz? when do you pursue each (2)

1) BYPASS: if multiple or long segments of disease
2) PTA (angioplasty): if single, short segment

19

how do you work up pt with PVD and ULCER? when to tx? what options

key is adequacy of blood supply; if SBP > 65 (or 90 in DM), supply should be adequate for healing; if NOT, tx surgically; ANGIOGRAM to define anatomy (remember this is preop test) --> graft vs. angioplasty/stent

20

what longterm tx do most pts with PVD receive

ASA

21

what is a "trash foot" (complication of PVD repair)? how is it managed

ischemic digit 2/2 atheroembolization --> blue, painful toe; TREATMENT is heparin and long term antiplatelet therapy

22

what major risk associated with surgery in pt with vascular disease? how to work up preop

CARDIAC dz often a/w vascular dz (MI risk during op) --> need CARDIAC WORKUP: stress test/thallium --> angiogram if positive treat with CABG/PTCA if dz; if testing negative, do operation with intraop monitoring if pt has other risk factors (sick, old)

23

mgmt of AAA

elective repair if > 5 cm; observe if < 5 cm

24

three big complications associated with AAA repair

1) ISCHEMIC BOWEL: presents with diarrhea +/- blood in first 3d, 2/2 sigmoid ischemia from IMA occlusion
2) VASCULAR GRAFT INFECTION: from graft seeding with skin flora, but may not present for months-years
3) AORTOENTERIC FISTULA: grossly bloody stool, usually from fistula between aorta and duodenum

25

treatment of three big complications of AAA repair

1) ISCHEMIC BOWEL: need sigmoidoscopy to determine depth of ischemia; if superficial treat with bowel rest; full thickness, resect + colostomy
2) VASCULAR GRAFT REPAIR: remove graft, debride tissue, extra anatomic bypass, long-term abx
3) AORTOENTERIC FISTULA: 3 steps:
I) remove graft
II) repair GI
III) extra anatomic aortic graft

26

Presentation, workup and tx of chronic mesenteric ischemia

PRESENTS: with post-prandial pain and resultant weight loss; WORKUP: with angiogram (b/c of intent to operate); TREAT: with surgical bypass (aorta --> vessel)

27

types of aortic dissection and management (3)

TYPE 1: ascending only (OPERATE)
TYPE 2: ascending + descending (OPERATE)
TYPE 3: descending only (MED MGMT); control htn with all types

28

tx for DVT? how long

anticoagulation (heparin --> warfarin) x 3-6 m

29

what is low dose heparin (LDH) therapy

prophylactic heparin for high risk pts: 5000 U subq heparin q8-12 hrs post-op

30

ABG findings in PE

decreased PCO2 due to hyperventilation

31

what is tx of PE

SAME AS DVT (anticoagulation x 3-6m)

32

what is phlegmasia cerulea dolens? how to tx

acute obstruction of venous outflow --> DANGEROUS (can cause sensorimotor loss and eventually gangrene) --> URGENT TX (anticoagulation, leg elevation); VENOUS THROMBECTOMY RARELY INDICATED

33

if TIA untreated what are chances of recurrences

40% chance of another TIA or stroke in 2 yrs

34

tests to eval TIA

carotid bruits, neuro exam, murmurs, echocardiogram, Duplex ultrasound of carotids

35

what % stenosis of carotids does better with surgery

70% stenosis 3x more effective than aspirin in preventing strokes

36

additional preop for carotid endarterectomy

bp control, cardiac eval

37

perioperative risk for major stroke for carotid endarterectomy

1-3%

38

nerves to avoid during carotid endarterectomy

hypoglossal, vagus, marginal branch of facial nerve

39

what imaging do you do to make sure carotid endarterectomy is perfect

on table angiogram or duplex ultrasound

40

what is risk % for carotid narrowing on operated side

13% over 5 years

41

what drug to take post op for carotid endarterectomy

asa

42

what are carotid endarterectomy pts most likely to die from

MI bc TIA is a sign of atherosclerosis. should take up exercise regimen, lifestyle changes, lipid control

43

name of ophthalmic finding with amaurosis fugax

Hollenhorst Plaque

44

what eval do you do if a person has a stroke and it's not a TIA

carotid duplex, observation for improvement, operate after patient stable; usually 2-4 weeks post stroke or when neuro status stabilizes

45

at what % carotid stenosis should asymptomatic pts get surgery ?

65%; in a 2 yr period, 2.5% of pts had stroke compared to 11% of ASA pts.

46

6 Ps for acute arterial occlusion of extremity

pain, pallor, paresthesia, paralysis, pulselessness, poikilothermia

47

when do you operate on acute occlusion of leg? what do you give them immediately

ASAP. within 6 hrs. give heparin

48

what is surgical procedure for acute occlusion

Fogarty catheter embolectomy (balloon catheter)

49

complications of acute reperfusion

compartment syndrome

50

at what pressure can compartment syndrome get dangerous

20-40 mm Hg: ischemic injury of muscles and nerves

51

3 most common sites for lower limb embolus

femoral, then iliac, then aortic saddle, then popliteal

52

long term care for post fasciotomy

coumadin, ECHO, CT to search for embolic source

53

2 common causes for acute arterial ischemia

1. femoral arterial puncture: raise intimal flaps, dislodge emboli, cause local thrombosis
2. aortic dissection where false lumen extends to femoral artery

54

workup for claudication

pulses, bruits, thrills, skin exam for ulcerations, sensory and motor function exam, dependent rubor, history of DM, cardiovascular dz

55

where in superficial femoral artery is there most likely to be occlusion

at adductor hiatus

56

if you dont get pulses in some places, what test do you do

ABI with Doppler tracing

57

what are worrisome signs with claudication

rest pain, ischemic ulceration

58

what are ranges of normal and abnormal ABI values

normal: 0.9-1.1
mild claudication: 0.6-0.8
severe claudication: < 0.3

59

in what type of patients can ABI be artificially high

diabetics (bc they have calcified vessels)

60

what happens to Doppler waveforms with claudication

triphasic --> biphasic --> monophasic

61

why wouldn't you operate on claudication

risk-benefit. dangers of arteriogram, possibility of thrombosis, infection, amputation, unfavorable medical condition such as CAD. exercise seems to help

62

how many claudicators get better

1/3 get better, 1/3 same, 1/3 deteriorate

63

why would you operate quicker on aortoiliac dz than just a plain old claudication

progresses faster!

64

how can you tell if a diabetic foot ulcer is likely to heal or not

ankle systolic BPs in torr; nondiabetics probable healing 55-65. diabetics probable healing 80-90.

65

why would we do non-preop arteriogram for diabetics with claudication

bc it changes our strategy for operation or not

66

which arteries are given preference when doing femorodistal bypass

popliteal, anterior and posterior tibial, then peroneal (fibular artery)

67

what f/u procedures after a bypass

frequent duplex of graft for patency, ASA, lipid control, foot care

68

what is Leriche syndrome

aortoiliac dz; claudication + atrophy + impotence (occlusion of internal iliac that gives rise to pudendal)

69

treatment for short segment iliac stenosis

percutaneous transluminal angioplasty

70

surgery for b/l aortoiliac dz

aortobifemoral bypass. if at risk for complications or poor general health, ax-fem-fem may be better

--> i dont fully know what this is?

71

surgery for unilateral aortoiliac dz

fem-fem

72

what part of aortobifem bypass graft surgery has greatest risk?

anesthesia induction and during hemorrhage/stress; during clamping: high afterload, must manage bp; during unclamping sudden decrease of afterload possible hypotension and decreased CO.

Unclamping flushes blood from lower body that could have become acidotic and hyperkalemic, causing arrhythmia

73

what is trash foot

microvessel occlusion following revascularization from fibrin, platelets, atherosclerotic debris that travels down to toes. with good pulses, it should heal!

74

post op for aortoiliac dz

heparin bridge to coumadin, assess toes for necrosis, watch for evidence of infection, ASA

75

cardiac morbidity perioperatively in major vessel reconstruction

up to 10%

76

cardiac mortality post operatively in major vessel reconsturction

2-3%

77

substance used for stress echo

regadenosone or dobutamine

78

how to use Eagle's criteria

for prediction of perioperative cardiac morbidity:

age>70, angina, diabetes, DTS redistribution, ventricular arrhythmia, Q waves on EKG.

0 risk factors: 3% risk of MI. operate
1-2 risk factors: 15% risk of MI. do DTS testing.
3 risk factors: 50% risk of MI. do coronary angiography and revascularize heart if necessary.

DTS= dipyrimadole thallium scanning (scintigraphy; imaging with radioisotopes)

79

AAA imaging modalities

US or CT

80

AAA more common in who

4:1 males, 11x first degree relatives, 50% pts with popliteal aneurysms

81

When should AAA be repaired

> 0.5 cm growth per year or > 5 cm in size

82

Post-op complications of AAA

1. third spacing of fluids. increase fluid requirements
2. third day mobilization of fluids, need diuresis and fluid restriction or else pulmonary edema

83

why might a AAA pt get impotence after surgery

damage to hypogastric circulation or autonomic nerves on anterior surface of aorta near IMA

84

what % ruptured AAA die

more than half

85

What are 5 yr rupture rates for AAA

7 cm: 95%

86

should the ER resuscitate fluids in ruptured AAA

no, do it after you've clamped the aorta in the OR

87

complications of aortic replacement

- ischemic colitis in rectosigmoid due to interruption of IMA flow: do sigmoidoscopy, bowel rest, NPO, GI decompression, abx, frequent reexamination, fill thickness involvement requires resection and colostomy;

- vascular graft infection due to S.epidermidis or S.aureus; remove, debride, do extra anatomic bypass, long term abx

- upper GI bleed from aortoenteric fistula in 3rd or 4th part of duodenum. remove, repair, GI tract, extraanatomic bypass

88

how to manage mesenteric ischemia

mesenteric angiogram, bypass graft from aorta to distal obstruction, could be obstruction of celiac axis or SMA (usually)

89

symptoms of aortic dissection

tearing chest pain, back pain, severe htn, tachycardia, diaphoresis

90

imaging for aortic dissection

TEE, MRI, CT, arteriography

91

Types of dissections and treatments

Type A: ascending involvement. operate
Type B: descending only. BP control with beta blockers.

92

sx of lower extremity DVT

pain with movement esp dorsiflexion (Homan's sign), leg swelling, palpable cord (thrombosed superficial vein)

93

how to dx a DVT

Duplex ultrasound

94

how to treat DVT

Heparin 70-100 U/kg bolus then maintenance of 15-25 U/kg/hr for 5-7 days. bridge to warfarin within first few days, continue 3-6 months.

95

heparin mxn

activates antithrombin which inactivates II, VII, IX, X

96

goals of heparin tx for DVT

PTT 1.5 to 2x normal and INR 2-3, follow platelet counts for HIT

97

why do we bridge to coumadin

because warfarin inhibits protein C and S synthesis, a relatively hypercoagulable state. gotta wait till the effects kick in.

98

what is post-thrombotic syndrome and how do we treat

after DVT treatment: 10% get edema, skin ulceration, venous claudication for chronic venous HTN. treat with support hose

99

Virchow triad

venous stasis, hypercoagulable state, endothelial injury

100

some dvt risk factors

over 40, recent surgery, obesity, smoking, previous hx, cancer, PV, MM, MI, CHF, COPD, pregnancy, DIC, HIT, SLE

101

what is preventive heparin

5000 U subQ preop and every 8-12 hours postop until ambulatory. dont forget to raise legs and give pneumatic compression devices.

102

workup for suspected PE

abg, ekg, cxr, pulse ox, v/q scan, CT if necessary (CTA), DVT hx

103

how to treat PE

same as treating DVT. heparin bolus and drip and bridge to coumadin

104

how to treat recurrent PE

IVC filter with heparin failure or complications such as HIT

105

what to do if someone has GI bleeding with heparin

d/c, put in IVC (greefield) filter, antiulcer tx

106

suspected dx with severe DVT and advanced pelvic ca? tx?

Phlegmasia Cerulea Dolens.
acute interruption of venous outflow due to malignancy. anticoagulate and elevate leg. duplex and CT afterward