ORAL BOARDS Flashcards

Question

Pre-op work-up for EVAR

Answer 1

Hx surgery (abdominal surgery*** right hemicolectomy, IMA patent=bad- left colon relies on IMA--> high risk of colonic ischemia 50%, open surgery with IMA reimplantation , left hemicolectomy=fine) cardiac clearance basic labs Counsel Risk modification- tobacco cessation Counsel risks and benefits Size aorta for endograft repair (diameter at and 1cm below renals, iliacs, length of aneurysm to bifurcation, length from lowest renal to iliac bifurcation)

Answer 2

After induction of general anesthesia, position the patient supine Prep and drape the patient from nipples to knees Perform Timeout Access the bilateral CFA with pre-close technique under US guidance with 8Fr sheaths Systemically heparinize the patient with 80-100u/kg heparin Exchange starter wires for stiff wires positioned in the proximal aorta Exchange for appropriately sized large bore sheaths Advance bifurcated endograft to L1-L2 Perform angiogram to mark renals through pigtail in contralateral groin Deploy endograft to contralateral gate Cannulate contralateral gate, Confirm true lumen by spinning pigtail in graft main body and repeat angiogram to confirm appropriate graft positioning Reinsert stiff wire, perform retrograde angiogram to mark iliac bifurcation, use marker pig to size contra limb length Advance sheath with introducer into contra gate Position contra limb, retract sheath and deploy Complete deployment of main body Select and deploy ipsi limb extension in similar fashion to contra limb Balloon proximal, distal and overlap of stents Completion angiogram Satisficed, I would close the groin with pre placed suture and reverse heparin, and use manual pressure until hemostasis Complete extremity exam following completion

Answer 3

After induction of general anesthesia, position the patient supine Prep and drape the patient from nipples to knees Perform Timeout- discuss allergies, antibiotics, surgical plan Perform midline incision from xiphoid to pubis The peritioneal cavity is entered Omni Retractor is placed (self retaining retractor) The grater omentum and transverse colon are reflected cephalad with moistened towels THe small bowel is retracted to the patients right and packed The ligament of trietz is identified and divided- retractors are adjusted THe RP is incised exposing the aorta the aorta is isolated to renal veins proximally and bifurcation distally The neck of the aneurysm is isolated and circumferential control obtained with umbilical tape Distal control obtained (iliacs or distal aorta), IMA isolated and controlled Systemically heparinized Clamps applied Distally then proximal- alerting anesthesia The aneurysm sac is incised, and extended with mayo scissors Clot is evacuated Backbleeding lumbars oversewn Tube graft sewn in proximally with 3-0 prolene Clamps moved down to graft, anastamosis evaluated Distal graft sew in with 3-0 prolene- flushing maneuvers prior to completion Clamps released one leg at a time Hemostasis evaluated, Doppler interrogation of distal flow IMA evaluated for re-implantation Aneurysm sac closed RP closed Midline closed

Answer 4

After induction of general anesthesia, position the patient in the lateral position with the left side up at 60 degree angle, both arms on armboards and supported. Bed flexed at patients flank. Prep and drape in the standard fashion Perform Timeout- discuss allergies, antibiotics, surgical plan *Standard - incision made over the 11th rib incision carried from posterior border axillary line to abdominal midline 5cm below umbilicus Incision carried down through subQ External oblique muscle, aponeurosis, Left anterior rectus sheath divided. left rectus divided Divide internal oblique and transversus abdominus divide transversalis fascia and enter RP space down to but not violating Gerotas fascia (accidentally entered peritoneal cavity? - running 3-0 vicryl repair I would approach the aorta from a retro-renal plane (unless retroaortic renal vein) Ureter identified and swept towards midline Identify renal artery ( should be cephalad to vein) and used to follow back to aorta Renal lumbar vein identified and ligated Aorta exposed from renals to bifurcation Plan to control Left iliac with clamp and Right iliac with a balloon from within IMA isolated and controlled

Answer 5

Incision made 2cm above and parallel to the inguinal ligament Extending from lateral rectus sheath to a point 2cm cephalad to ASIS Superficial epigastric and Circumflex iliacs ligated in subcutaneous layer External and Internal aponeurosis are divided, internal oblique muscle fibers are split Transversus muscle and transversalis fascia are opened in the lateral wound Entry to RP is gained laterally by stripping peritoneum from anterior abdominal wall PEritoneal cavity retracted superiorly External iliac exposed in center of wound Care to avoid injury to deep circumflex iliac and inferior epigastric

Answer 6

After induction of general anesthesia, position the patient in the supine position with ipsilateral hip elevated 10 degrees on rolled sheet. Entire abdomen and flank prepped and draped Perform Timeout- discuss allergies, antibiotics, surgical plan oblique skin incision is begun at lateral border of the rectus muscle 3cm above the inguinal ligament and extended to midaxillary line halfway between subcostal margin and iliac crest wound carried down through subcutaneous tissue superficial epigastric and circumflex iliac arteries is performed Aponeuroses of external and internal oblique muscles are divided muscle fibers of internal oblique are split parallel to wound axis transversus abdominus and transversalis fascia are opened in lateral half of wound gaining access to the RP RP space is entered in wounds lateral aspect (peritoneum may be fused to tranversalis fascia in midline) peritoneum stripped from lateral pelvic wall and retracted medially to expose the psoas muscle and iliac vessels on the medial side of the muscle ureter left attached to posterior peritoneal surface and retracted into medial wound EIA identified in lower wound and traced proximally to identify common and internal iliac arteries Proximal exposure can be gained to the terminal aorta

Answer 7

after entering the peritoneum... left colon mobilized by incising its lateral peritoneal attachements and developing plane between left colon mesentary and the anterior surface of gerotas fascia after the colon has been reflected to the level of the splenic flexure the spleen is mobilized by incising spleno phrenic and splenorenal ligaments plane between pancreas and gerotas fascia developed allowing the spleen and distal pancreas to be developed anteriorly and medially splenic artery identified near superior border of pancreas central portion of splenic artery dissected and mobilized (to avoid kinking) pancreatic branches divideed with silk suture sufficient length of the splenic artery is isolated and mobilized distal end divided and ligated (sufficient blood supply from short gastric and gastroepiploic arteries) spatulated end-end anastomosis with L renal

Answer 8

area of hepatoduodenal ligament exposed by retracting right lobe of liver superiorly and packing intestines and right colon inferiorly hepatoduodenal ligament incised transversely near the superior wall of the duodenum hepatic artery located on the left side of the common duct artery mobilized and encircled with vessel loops on both sides of the GDA bypasses can be anastomosed to side of hepatic artery or proximal to, distal, using the GDA.v

Answer 9

ES preferred: to preserve flow through hypos, accessory renal, patent IMA

Answer 10

After induction of general anesthesia, position the patient supine Prep and drape the patient from nipples to knees Perform Timeout- discuss allergies, antibiotics, surgical plan Perform bilateral CFA cutdowns, obtain proximal and distal control Perform midline incision from xiphoid to pubis The peritoneal cavity is entered Omni Retractor is placed (self retaining retractor) The grater omentum and transverse colon are reflected cephalad with moistened towels THe small bowel is retracted to the patients right and packed The ligament of trietz is identified and divided- retractors are adjusted THe RP is incised exposing the aorta the aorta is isolated to renal veins proximally and bifurcation distally Bilateral infrainguinal tunnels are created The aorta is isolated Distal control obtained (iliacs or distal aorta), IMA isolated and controlled Systemically heparinized Clamps applied Distally then proximal- alerting anesthesia The aorta is transected Distal aorta stump oversewn in 2 layers Bifurcated graft sewn in proximally with 3-0 prolene Clamps moved down to graft, anastamosis evaluated Limbs tunneled End-side anastamosis CFA 5-0 prolene (less ischemic leg first) Clamps released one leg at a time Hemostasis evaluated, Doppler interrogation of distal flow IMA evaluated for re-implantation Aneurysm sac closed RP closed Midline closed

Answer 11

flex sig bowel necrosis --> sigmoidectomy, diverting colostomy

Answer 12

make sure graft is on medial aspect of ascending aorta resect posterior aspect of sternoclavicular joint remove subclavian bypass limb?

Answer 13

heart cath (see if cabg needed)

Answer 14

consult cardiology to see if can treat native vessels

Answer 15

Beveled proximal anastamosis

Answer 16

TEVAR from normal aorta proximal to Celiac distally single lung ventilation Left heart bypass diaphragm incised laterally resect rib if needed CTD- need individual bypasses to viscerals

Answer 17

initial 24h: drain open, no more than 10cc/h, MAP >90, ICP < 12 24-48h post-op: clamp trial 4h, monitor for neuro changes, if stable--> liberalize MAP goals > 70, wean pressors as able >48H postop: if stable neuro exam >24 from cap, remove drain antiplatelets started 7 days after LD anticoagulation 3 days after

Answer 18

lateral supra-geniculate pop exposure - leg internally rotated, flexed at knee - longitudinal incision made in distal 1/3 of thigh between bicep femoris and IT tract - fascia lata incised posterior to junction of IT tract and lateral intermuscular septum - space between short head of biceps femoris and lateral femoral condyle is opened - vessels found posterior to femur - popliteal vein retracted posterior with tibial and peroneal nerves - pop artery is isolated

Answer 19

Lateral Approach to the profunda - vertical incision along lateral border of the sartorious - incicion carried through fascia lata - sartorius is mobilized along lateral border and reflected medially - inciison carried through fascia between vastus medialis and adductor longus - rectus femoris reflected laterally - exposes lateral femoral circumflex - identifya nd protect branches of fem nerve - ligate circumflex vein to isolate profunda

Answer 20

RP Approach Curvilinear transverse incision made 4cam above and parallel to the inguinal ligament Muscles of anterior abdominl wall divided EO split in direction of fibers IO, transversus abdominaus, transversalis fascia divided up to teh edge of the rectus sheath Access to RP space gained through lateral wound by separating peritoneum from transversalis fascia Peritoneum and contents retracted medially with ureter Iliac vessels found along medial border of psoas grafts usually lie anterior to EIA Obturator foramen is palpated under superior ramus of pubic bone bypass created centrally to avoid neuro bundle medial portion of obturator memebrane found by incising endopelvic fascia and bluntly separating underlying obturator internus and levator ani muscle fibers opening made on medial aspect of obturator membrane curved tunneler passed through the opening and routed behind the pectineus and adductor muscles into the thigh btought through adductor magnus muscle, through adductor hiatus to reach Ak-pop

Answer 21

PTFE Rifampin soaked dacron NAIS Cryograft

Answer 22

2 layer closure Anterior Spinal ligament reinforcement omental pedicle flap: passed in a retrocolic manner through an avascular section of the mesocolon to cover the aortic stump. A large sump drain is placed in the retropperitoneal space.

Answer 23

If the aortic stump tissues are friable, they may be reinforced with autogenous tissue consisting of strips or pledgets of abdominal wall or prevertebral fascia, if available. Other autogenous materials, such as endarterectomized occluded aortoiliac or hypogastric arterial segments or saphenous vein pledgets, can be used to prevent the sutures from tearing through friable aortic tissue.

Answer 24

neurovascular bundle lie superolaterally anteromedially

Answer 25

Three specific indications have evolved. The first indication is the rare situation of a hostile abdomen, usually after either extensive previous operations or radiation in the periaortic region. Circumstances including inflammatory bowel disease or abdominal wall deficiencies can enter into this decision. In such patients, aortic inflow from the left chest may be less traumatic than an abdominal exploration. The second indication is for repeated failure of abdominal aortic grafting. As a general rule, failure after a single aortofemoral bypass is appropriately managed with another intraabdominal aortic graft. After two failures, one may reasonably consider moving to the thoracic aorta for inflow. Finally, the thoracofemoral bypass has been useful for patients with multiple failed extra-anatomic bypasses. They include patients with axillopopliteal and axillofemoral grafts having had multiple graft thrombectomy operations. The patient is positioned to maintain adequate surgical access to both femoral arteries. The pelvis is left reasonably flat, with a rotation of the thorax to about 30 degrees. A thoracotomy incision is made in the sixth or seventh intercostal space and brought across the costal cartilage for several centimeters onto the abdominal wall. Remove 1 or 2 centimeters of costal cartilage with the curved Mayo scissors for a less painful closure. After the thoracic cavity is entered, the diaphragm is incised for several centimeters in a radial fashion. Later, the bypass graft will pass through this short incision. Left lung retraction with either conventional retractors or selective deflation with a double-lumen endotracheal tube is followed by incision of the inferior pulmonary ligament to expose the aorta. The aorta is circumferentially dissected above the diaphragm to allow placement of a bypass graft several centimeters above the diaphragmatic hiatus. Avoid placing the anastomosis too close to the diaphragm to prevent kinking. A nasogastric tube allows identification of the esophagus by palpation during this dissection, and an silicone elastic sling is left around the aorta for control should the side-biting aortic clamp be dislodged. Tunnels are formed from the retroperitoneum just beneath the costal cartilage incision to the left groin. This process is aided by transecting the left inguinal ligament and is achieved with blunt bimanual index finger dissection. Remarkably, finger dissection with both hands usually provides enough length for this tunnel (Figure 2). The tunnel is beneath the lateral abdominal musculature but extraperitoneally along the anterior or midaxillary line (Figure 3). After systemic anticoagulation with heparin, the proximal aortic anastomosis is performed after partial occlusion of the aorta. Selection of just the right J-shaped clamp from the instrument tray can require some experimentation. Patients are well served with a ring-supported 10-mm graft, but 8- or 12-mm ringed grafts may be used, depending upon patient size. Suture with 3–0 or 4–0 polypropylene or polytetrafluoroethylene is appropriate. Chest tube drainage for 1 or 2 days is instituted after standard closure of the thoracotomy.

Answer 26

60 mg/ml solution (1200 mg rifampin powder in 20 ml sterile saline) x 15min

Answer 27

saphenous jugular cryo bovine carotid hypogastric artery SFA with in-situ replacement with PTFE

Answer 28

Base of the Mesentery - after peritoneal cavity is entered, the peritoneal contents are rapidly evaluated, noting the extent of bowel necrosis - frankly necrotic bowel is resected - the transverse colon and omentum are elevated, intestines wrapped in moist towels and retracted to the patients right - a horizontal incision is made in the peritoneum at the base of the transverse mesocolon, extending from the the duodenal-jejunal junction towards the patients right - middle colic artery is identified in the transverse mesocolon and traced proximally to locate its origin from the SMA - Sma between middle and right colic is readily identified and isolated, careful to preserve jejunal branches - (pancreas retracted superiorly to expose more proximal artery) - proximal and distal control - heparinze if not alreaady - transverse arteriotomy - fogarty balloon embolectomy proximally and distally - close arteriotmy with interrupted prolene - doppler interrogation - inspect bowel - consider 2nd look (close with abthera)

Answer 29

Exposure of the Aorta or Common Iliac Artery The proximal anastomosis can be positioned on the proximal right common iliac artery, the infrarenal aorta, or the proximal left common iliac artery. The preference is to position the heel of the graft on the distal aorta and the toe on the right common iliac artery. However, the choice is contingent on the anatomic course of the graft and the degree of atherosclerotic involvement in the vessels. The inflow vessels are exposed by incising the retroperitoneal tissue over the midinfrarenal aorta and extending the incision over the course of the designated common iliac artery. The inflow vessels are dissected to allow clamp application, and it is not necessary to circumferentially dissect the aorta or common iliac vessels. Although the proximal anastomosis is performed in an end-to-side fashion, it may not be possible to use a partial occluding vascular clamp. Exposure of the Superior Mesenteric Artery The superior mesenteric artery is exposed by incising the ligament of Treitz and the other peritoneal attachments and then retracting the duodenum to the patient’s right side (see Fig. 40-1, C). As the base of the mesentery is dissected laterally from left to right, the superior mesenteric artery is the first structure to be encountered and is a sizable vessel. Tunneling the Bypass Graft and Anastomoses Either a 6- or a 7-mm-diameter Dacron graft is a suitable conduit, although a comparable externally supported ePTFE graft is a reasonable alternative to minimize the risk of kinking. The proximal anastomosis is usually performed first, although some surgeons have proposed the opposite to simplify the process of tunneling the graft and to obtain the optimal configuration. The distal anastomosis can be performed in either an end-to-end or end-to-side fashion, but the anatomic course of the graft may be more favorable if distal anastomosis is performed in an end-to-end manner. The graft should be tunneled so that it forms a gentle curve or C loop between the two anastomoses as it traverses caudal to cephalad and posterior to anterior. It is imperative that the graft does not kink and that the anastomoses are tension free. Closure The retroperitoneal tissue over the aorta, the ligament of Treitz, and the peritoneum over the superior mesenteric artery are reapproximated to exclude the graft from contact with the intestine. In addition, a segment of the omentum can be mobilized to cover the graft.

Answer 30

Operative Technique for Antegrade Bypass Position For antegrade aortoceliac or aortosuperior mesenteric artery bypass, the patient is positioned supine. The distal pulses are interrogated with continuous wave Doppler, and the operative field, including the chest, abdomen, groin and both lower extremities, is prepared in the standard fashion. Incision Either a midline or a bilateral subcostal incision can be used, because the anatomic structures that need to be exposed during the procedure are all along the axial skeleton. The major advantage of the midline incision is that it is somewhat easier and faster to close. The major advantage of the bilateral subcostal incision is that it provides the most optimal exposure to the upper abdomen and is helpful in larger individuals. Exposure of the Aorta The supraceliac aorta is exposed by incising the left triangular ligament of the liver (Fig. 40-2). Care should be exercised during this step to avoid injuring the vena cava or hepatic veins that serve as the lateral extent of the dissection. The left lateral segment of the liver is then folded back and retracted to the patient’s right. Exposure is facilitated by using a self-retaining Bookwalter retractor with a large round ring and by positioning four medium or deep right-angled retractor blades throughout the length of the bilateral subcostal incision. Placing the patient in a significant amount of reverse Trendelenburg also facilitates exposure by allowing the visceral structures to “fall away” from the operative field. The gastrohepatic ligament is then incised. Care should be exercised, because a replaced left hepatic artery from the left gastric artery may course through the ligament. The esophagus and stomach are then retracted to the patient’s left with the assistance of a retractor blade. The esophagus can usually be identified by the presence of a nasogastric tube or transesophageal echocardiography probe. The median arcuate ligament is subsequently incised along the longitudinal axis of the aorta, and both lateral crus of the diaphragm are incised horizontally. The pleural cavity is occasionally entered, which necessitates a chest radiograph in the immediate postoperative period to confirm that the lungs are fully expanded. The posterior peritoneum is then incised, and the supraceliac aorta exposed. Approximately 6 cm of the supraceliac aorta should be dissected free to facilitate aortic clamping. It is not necessary to dissect the aorta circumferentially. The celiac axis is exposed by dissecting caudal along the anterior surface of the aorta (Fig. 40-2). This requires incising the remaining fibers of the diaphragm and the dense, fibrous neural tissue know as the celiac ganglion that surrounds the proximal celiac artery. This is facilitated by incising the fibers with electrocautery between the jaws of a right-angled clamp. The stomach and viscera can be retracted inferiorly either manually or with a malleable retractor. The preferred technique is to dissect the origin of the celiac axis and its proximal branches circumferentially. Approximately 3 cm of the celiac artery along with its proximal branches should be exposed to facilitate constructing an end-to-end anastomosis and oversewing the proximal remnant, after the vessel is transected. The proximal branches of the celiac artery, including the splenic and left gastric arteries, occasionally need to be sacrificed to facilitate the anastomosis. This is rarely of clinical significance since the orifice of the celiac artery was already occluded or severely stenotic, and because the stomach and spleen have a rich collateral network. Alternatively, the distal anastomosis can be performed to the common hepatic artery in an end-to-side manner. This is facilitated by dissecting the common hepatic, proper hepatic, and gastroduodenal arteries circumferentially along the lesser curve of the stomach in the proximal porta hepatis. Although the dissection is somewhat easier, it is more difficult to properly orient the graft. Exposure of the Superior Mesenteric Artery A suitable segment of the superior mesenteric artery can be exposed using a variety of techniques, as detailed previously. In a preferred approach, the artery is dissected immediately caudal to the inferior border of the pancreas (see Fig. 40-1, A). The vessel is approached either through the lesser sac by incising the gastrocolic ligament or through the gastrohepatic ligament by retracting the lesser curve of the stomach inferiorly. A longitudinal incision is made in the retroperitoneum immediately below the inferior border of the pancreas to expose the artery. This can be facilitated by retracting the stomach superiorly and the small bowel and transverse colon inferiorly using the malleable retractor blades. The retroperitoneal tissue overlying the superior mesenteric artery and vein can be retracted with two Weitlander self-retaining retractors oriented at 90 degrees relative to each other. It can be somewhat challenging to find the superior mesenteric artery in patients with a significant amount of retroperitoneal fat. Identifying the adjacent superior mesenteric vein or tracing the middle colic artery retrograde can be helpful. Approximately 2 cm of the artery should be exposed to facilitate construction of the anastomosis, but caution should be exercised because multiple branches of the artery at this level are easily injured. Alternatively, the superior mesenteric artery can be exposed at the root of the transverse mesocolon (see Fig. 40-1, B). The transverse colon is elevated, and the proximal mesentery incised horizontally. Finally, the superior mesenteric artery can be approached along its left lateral surface. The ligament of Treitz and other peritoneal attachments are incised (see Fig. 40-1, C), followed by completely mobilization of the duodenum’s fourth portion. The superior mesenteric artery is surrounded by fatty tissue at this level. Arterial or venous branches will rarely be encountered when the artery is approached along its left lateral surface. Tunneling The Bypass Graft After the superior mesenteric artery is exposed, a retropancreatic tunnel is created using gentle, bimanual finger dissection between the exposed supraceliac aorta and the superior mesenteric artery. This step should be performed with caution, because the tunnel courses adjacent to the superior mesenteric vein, deep to the splenic vein, and near their confluence with the portal vein. A straight aortic clamp or red rubber catheter can be passed through the tunnel and left in place until it is necessary to pass the limb. Proximal Aortic Anastomosis The proximal anastomosis to the supraceliac aorta is performed as the next step (Fig. 40-3). Before occluding the aorta, the patient is systemically heparinized (100 units per kilogram of body weight) and given 25 g of mannitol as both an antioxidant and a diuretic. A bifurcated Dacron graft with a body diameter of 12 mm and limb diameters of 7 mm may be used. However, grafts of this size are not universally available and can be substituted with those measuring 12 × 6 or 14 × 7 mm. Both ePTFE and autogenous femoral vein are acceptable substitutes. Aortic control can usually be achieved with a partial occluding clamp, such as a Lambert-Kay clamp that has been modified with a locking device that secures the tips. When it is not possible to partially occlude the aorta because of calcification or atherosclerotic involvement, two straight aortic clamps can be used. Completely occluding the aorta is less optimal, although the time to complete the anastomosis is usually less than 15 minutes. An arteriotomy is made along the longitudinal axis of the aorta, and the graft is spatulated so that the limbs of the graft are oriented on top of each other, in contrast to the case of an aortobifemoral graft in which the limbs are oriented side by side. The anastomosis is performed with a 3-0 nonabsorbable, monofilament suture, and 5-0 sutures with felt pledgets are used as necessary for suture line bleeding. The body of the graft should be as short as possible, with the heel of the anastomosis essentially being the start of the inferior limb to the superior mesenteric artery. A short graft body is necessary because the distance between the aortic anastomosis and the celiac anastomosis is quite short. A limited endarterectomy of the aorta is occasionally necessary, but creating an aorta that is thin and will not hold sutures should be avoided. The proximal anastomosis can be challenging in large patients. Exposure of a large segment of aorta is helpful, as is the placement of retracting stay sutures in the aortotomy, parachuting the anastomosis or placing interrupted sutures. Distal Anastomoses The anastomoses to the celiac artery and the superior mesenteric artery are performed in sequence. The cephalad limb of the graft is used for the celiac anastomosis, whereas the caudal limb is tunneled deep to the pancreas. Vascular control of the branches of the celiac artery is obtained with microvascular clamps or vessel loops, whereas proximal control of the celiac artery is obtained with a right-angled clamp. The celiac artery is transected, and the stump is oversewn with a 4-0 nonabsorbable, monofilament suture. The distal celiac artery is spatulated to account for any size discrepancy between the native artery and graft, and the anastomosis performed using a 5-0 suture. The anastomosis to the superior mesenteric artery is configured in an end-to-side manner using a 5-0 suture. Upon completion of the anastomoses, the target arteries and their branches are interrogated with continuous wave Doppler to confirm adequacy of visceral perfusion. Closure The retroperitoneal tissue over the superior mesenteric artery anastomosis is closed with interrupted 3-0 absorbable sutures, whereas the proximal aortic anastomosis is not covered. The bilateral subcostal or midline incision is then closed using standard technique.

Answer 31

Upon entry into the abdominal cavity, dissection is performed with blunt and sharp technique and with the surgeon's hand following the convex surface of the organ, leading to identification of the peritoneal attachments. The spleen is gently grasped and displaced medially toward the incision. The avascular peritoneal attachments and ligaments are incised with an electrocautery or Metzenbaum scissors. These suspensory ligaments are avascular except for the gastrosplenic ligament, which contains the short gastric vessels. In patients with portal hypertension, any ligaments may have vessels that should be ligated. Attention is then turned to the hilum, where the splenic artery and veins are identified, carefully dissected, doubly ligated with 0 nonabsorbable suture (eg, silk), and transfixed with 2-0 silk suture ligatures. To avoid injury to the pancreas, the dissection is carried out at the hilum in close proximity to the spleen. Next, the short gastric vessels are identified and ligated. In hypotensive patients, the short gastric vessels usually do not bleed, nor does the splenic bed. In the case of elective splenectomy, the first step is transection of the ligamentous attachments, including the splenophrenic ligament at the superior pole and the splenocolic and splenorenal ligaments at the inferior pole. This may be accomplished with blunt dissection, an electrocautery, or, in conditions where the ligaments are thickened, Metzenbaum scissors. After the ligamentous attachments are transected, the gastric vessels that run from the spleen to the greater curvature of the stomach are ligated and divided. A Lembert suture is placed in the gastric wall in a seromuscular fashion to avoid the complication of gastric fistulization when one is unable to identify the source of bleeding from the stomach. After these maneuvers are completed, the spleen is delivered into the wound with blunt dissection of the posterior attachments. To keep from entering the splenic vein, care should be taken not to divide the posterior attachments too far medially. It is also important to avoid axial rotation of the spleen before securing the splenic vessels with vascular loop or clamps; such rotation may lead to disruption of the splenic artery or vein. Dissection is carried out at the hilum in close proximity to the spleen to avoid injury to the pancreas. Individual ligation of the splenic artery or arterial branches and the splenic vein or venous branches is generally preferable. This is accomplished by means of double ligation and transfixation with nonabsorbable suture ligatures. In the case of a markedly enlarged spleen (severe splenomegaly), it is often preferable to place a vascular loop or vascular clamp on the splenic vessels (see the image below) and double-ligate the vessels with heavy nonabsorbable suture. One may then proceed with suture ligation using a transfixed technique. This approach avoids slipped-off sutures and helps prevent postoperative bleeding. After removal of the spleen, hemostasis is obtained and confirmed in a systematic fashion through careful inspection of the left subphrenic area, the greater curvature of the stomach, and the short gastric vessel area, as well as the splenic hilum. Inspection of these areas is facilitated by proper retraction of the stomach and small bowel to allow clear visualization of the left upper quadrant and surgical bed. Attention is then turned to the surgical field to check for active bleeding. Any active bleeding is identified and hemostasis achieved.

Answer 32

left gastric (courses through gastrohepatic ligament)

Answer 33

food fear, weight loss, postprandial abdominal pain Celiac: PSV >200cm/s = >70% stenosis, EDV > 55cm/s = >50% OR: retrograde hepatic artery flow specific for significant celiac dz SMA: PSV >275cm/s = >70% stenosis, EDV > 45cm/s = >50%

Answer 34

endovascular (femoral approach, tour guide sheath)

Answer 35

Divide triangular ligament to mobilize left lobe of liver Divide gastrohepatic ligament to enter the lesser sac Retract liver to right with a self-retaining retractor Push esophagus left (use NGT to assist with identification) Divide peritoneum overlying crura to identify celiac vessels Typically trace common hepatic artery backwards to identify celiac artery Watch out for the left gastric vein as it crosses the celiac artery as it drains the lesser curve of the stomach into the portal vein. About half of the time, the phrenic artery takes an origin from the celiac artery and must be controlled during exposure. To expose the supraceliac aorta, divide the median arcuate ligament and separate the left and right crura from each other. You can trace most of the proximal celiac distribution right at the origin, and through this exposure you get access to the origin of the SMA if you mobilize the superior border of the pancreas. The neck of the pancreas and the splenic vein cross the anterior of the SMA, obscuring the rest of the mid and distal SMA from the superior approach.

Answer 36

Resect frankly necrotic bowel and contain gross spillage. Once you revascularize the bowel, compromised-appearing bowel may improve and not need immediate resection. Thus the first step is only damage control, to remove anything completely unsalvageable that is making the patient sick, or anything causing gross contamination of the operative field. The key is you’re not doing anything definitive with the bowel as your first step. Revascularization. SMA embolectomy is the initial management of choice for embolic disease. Thrombotic disease, on the other hand, may be more challenging to treat by embolectomy alone, and frequently are treated with a bypass. (More to come on these procedures). Re-assess bowel viability. Clinical status permitting, 20-30 minutes should be taken to fully assess the results of the revascularization before proceeding with resection. Perfusion can be assessed by many methods, including clinically, by Doppler, pulse oximetry (a.k.a. photoplethysmography), fluorescein fluorescence, etc. The take home is to give the bowel enough time to be perfused before going ahead with resection. Proceed with temporizing or definitive bowel repair. Resection, leaving in discontinuity, primary anastomosis, diversion, etc. All of these are options on the table, but the key here is that all of the previous steps occur before addressing the bowel. Consider second-look laparotomy. Many times, bowel may look questionable even after revascularization and thorough re-assessment. To preserve the most bowel length, it may be reasonable to leave borderline bowel alone at the index operation and do a “second look” to fully reassess the bowel, especially after the patient has benefited from aggressive resuscitation in the ICU. Endovascular approaches to acute mesenteric ischemia have been described but data is limited. Exploratory laparotomy and embolectomy should be preferred management

Answer 37

And what are some of my options for constructing a bypass? Short retrograde aorto-SMA bypass: This bypass takes is origin off of the aorta just below the SMA, anastomosing typically end-side onto the SMA just below its origin in order to bypass ostial or very proximal disease. This is a relatively quick bypass, with only one field of dissection directly from the aorta below the SMA onto the proximal-mid SMA. The length of the bypass is very short, limiting concerns with kinking or twisting of the bypass. However, this may not always be feasible, as SMA disease often coexists with significant aortic disease. Additionally, the other bypasses described have better reported patency.(Scali et al. 2019) Long retrograde R iliac-SMA bypass (“C-loop”): This bypass originates from the right common iliac artery, which presents a number of distinct advantages over an aorto-mesenteric bypass. First, using the iliacs avoids the hemodynamic consequences of an aortic cross-clamp, which may be contraindicated depending on your patient’s medical condition. Second, you can avoid showering, causing dissection, or otherwise injuring your clamp sites if you have significant disease in the mesenteric segment of the aorta, which is common in patients with chronic mesenteric ischemia. The graft should be tunneled in a gentle C-loop towards the SMA to avoid kinking or twisting. The proximal anastomosis is performed end-side on the iliac artery, and the distal can be performed either end-end or end-side depending on the anatomy of the disease. Especially when using prosthetic in a contaminated field, you can consider taking an omental flap to wrap or cover the prosthetic. Antegrade supraceliac aorta-SMA bypass: This bypass originates from the supraceliac aorta. If revascularization of both celiac and SMA is planned, a bifurcated graft can be selected. A side-biting aortic clamp can be used to mitigate the hemodynamic effect of an aortic cross-clamp. The tunnel to the SMA is created with gentle finger dissection in a retropancreatic plane, taking care to avoid injury to the SMV. Also: ROMS, endo

Answer 38

- mobilize the 4th portion of the duodenum by dividing the ligament of Trietz - SMA is isolated in the tissues cephalad to the duodenum - proximal exposure enhanced by retracted the inferior border of the pancreas to the level of the left renal vein

Answer 39

In most cases access to the superior mesenteric artery can be gained through a retrograde femoral approach. Antegrade left brachial artery access is favored for an acutely angulated mesenteric artery, an excessively narrow or tortuous distal aorta or iliac arteries, or occlusive and long segment lesions of the visceral vessels (Figs. 41-7 and 41-8). Some studies have reported more frequent stent dislodgement21 and mortality22 through a femoral approach because of greater catheter manipulation. A 5-Fr introducer sheath is first placed in the access artery, and a pigtail catheter is used to perform an aortogram. A lateral view demonstrates the origins of the celiac artery and the superior mesenteric artery and the presence and extent of stenosis. Anteroposterior views are used to assess the collateral circulation, as well as the origin of the inferior mesenteric artery. Selective magnified views complete the initial angiogram. If endovascular treatment is selected, the 5-Fr sheath is exchanged for a long guiding 6-Fr sheath to allow better support and pushability to catheterize and cross the lesion. A brachial artery cutdown can be performed if a larger sheath is required to prevent access site complications. Systemic heparin (80-100 units per kilogram of body weight) is given, and an activated clotting time greater than 240 sec is maintained during the procedure. From a femoral approach the target vessel may be accessed using a hydrophilic 0.035-inch angled wire and a preshaped catheter such as a Cobra 2 or Sos II. At times a simple angled glide catheter will suffice. If the lesion is difficult to cross, 0.018- or 0.014-inch wires should be considered. After the wire placement has crossed the lesion, the catheter is advanced beyond the lesion and its position within the lumen is confirmed by an angiogram performed through the catheter. The extent of the lesion is assessed, and distal embolization and arterial dissection are excluded. When the severity of stenosis is uncertain, a mean pressure gradient can be measured across the lesion to confirm a hemodynamically significant lesion (>10 mm Hg). If the lesion is occlusive or nearly occlusive, predilation should be performed with a 1.5- to 2.5-mm coronary balloon. In severely calcified or eccentric lesions with thrombus, a distal embolic protection device can be deployed. A stiff wire, such as an Amplatz wire (Cook Medical, Bloomington, Ind.) is then placed across the lesion to track larger balloons or stents. Severely calcified, eccentric, occlusive, or dissected lesions are primarily stented. Ostial lesions should be stented using a balloon-expandable stent (5- to 7-mm diameter) with 1 to 2 mm extending into the aorta. A simple angioplasty can be performed on straightforward atherosclerotic lesions, and a stent can be placed for residual stenosis (>30%) or a residual pressure gradient. Completion angiography in lateral and anteroposterior views is performed. Occasionally, because of wire or catheter manipulation, vasospasm may be present, and selective intraarterial infusion of nitroglycerin (200 mcg) or papaverine (30 mg) is used to reverse the spasm. The presence of dissection or embolization is also assessed, and if present, an attempt to retrieve the embolic particles can be made using a suction export catheter. If unsuccessful, focal thrombolytic therapy should be pursued. Emergent open revascularization should be pursued if ischemic bowel is suspected. Delay in treatment results in propagation of a clot and progressive intestinal infarction. Vessel rupture can also occur, particularly if the vessel is severely calcified. A covered stent, such as the iCast, can be used to seal the rupture site. Dislodged or fractured stents should be removed using a snare or grasping forceps, followed by an angiogram to rule out traumatic vessel dissection or perforation. Postoperative Care * Procedure-related complications range from 0% to 29%.23 Therefore all patients should be admitted for 24-hour observation and hydration after angioplasty and stenting of the superior mesenteric or celiac artery. * Clopidogrel should be initiated at an oral loading dose of 300 mg and continued at 75 mg daily for 1 month. Daily aspirin (81 or 325 mg) should be initiated and continued indefinitely. * Complaint of abdominal pain or tenderness should be assessed with duplex or computed tomography imaging. * Urine output and creatinine should be monitored, because renal embolization can occur during the procedure. * Patients can be fed the day after the procedure. * A baseline duplex of the treated vessel should be obtained before discharge, every 6 months for 1 year, and annually thereafter. Complications * Morbidity and mortality. Over the last 10 years, numerous reports have documented excellent technical results (82%-100%) with low morbidity and 30-day mortality rates of less than 5%.23 * Access site complications. Most common early complications are related to the access site, including a hematoma or pseudoaneurysm, brachial sheath hematoma, access artery thrombosis, or retroperitoneal hematoma. A recent report of local complications of percutaneous brachial access noted a local complication rate of 6.5%, although complications occurred more frequently in females (11.5% vs 2.7%).24,25 Aspirin lowered the risk, whereas oral anticoagulation was associated with an increased risk of hematoma. * Embolization. Wire and catheter manipulation during the procedure can result in particle embolization into the renal arteries or lower extremities, and splenic infarction has been reported after celiac artery intervention.26 * Acute superior mesenteric artery thrombosis. Early complications can result in acute mesenteric ischemia, including symptomatic thrombotic occlusion because of unrecognized arterial dissection or arterial injury and stent thrombosis.27 Reperfusion hemorrhage is rare.28 * Long-term patency. Cumulative patency over 3 years is reported between 44% and 88%. Sarac and associates reported a 1-year patency, a primary assisted patency, and a secondary patency of 65%, 97%, and 99%, respectively.22 Atkins and colleagues reported a primary patency of 58% and a primary assisted patency of 65% at 1 year.29 The most recent report of midterm patency notes a 3-year primary patency of 57% and a secondary patency of 92%.24 * Recurrent stenosis. Patients with recurrent stenosis may be treated with repeat angioplasty and stenting. The use of cutting balloons has not been shown to be superior in the treatment of restenosis. Although longitudinal follow-up is necessary, the use of covered stents provides an alternate treatment strategy (see Fig. 41-6). Omnilink stent

Answer 40

GSV >12mm width raises concern for incomplete obliteration Superficial GSV unlikely to be pushed down with tumescence - could cause staining or thermal injury to the skin GSV tortuosity may limit the ability to pass a catheter and sufficiently ablate the vein Acute superficial vein thrombosis. after failure of conservative therapy with 3months compression 30-40mmHg

Answer 41

EHIT Grade Description Treatment 1 Extension to SFJ None 2 Extension into deep system <50% of lumen diameter Close observation (repeat US 1 weeek) vs anticoagulation 3 Extension into the deep system >50% of lumen diameter Anticoagulation x 3 months 4 Occlusion of the femoral or popliteal vein Anticoagulation x 3 months

Answer 42

EHIT Bruising Thermal Injury Nerve injury Fistula (GSV- External pudendal)

Answer 43

Hyperpigmentation is probably the most common complication (11-80%), but only a small percentage persist up to a year (1-2%). Incision and drainage of the thrombus 2-4 weeks after treatment may reduce hyperpigmentation. New appearance of fine red telangiectasias (AKA telangiectatic matting) is related to underlying vessel injury in 5-57% of patients and can persist up to 1 year (1%). Cutaneous necrosis is rare (<1%) and results from extravasation of sclerosing agent, injection into dermal arteriole, reactive vasospasm or excessive cutaneous pressure. DVT and cutaneous nerve injury are also rare. 1 in 5000 neurological event (Superficial-->Deep-->PFO--> Brain) Allergy to sclerosant Acute cellulitis

Answer 44

The clinical criteria most often used to as an indication for treatment is >350ms of deep to superficial reflux, diameter greater than 3.5mm and near a healed or active ulcer.

Answer 45

venous stasis hypercoaguable state endothelial injury

Answer 46

Prior DVT Surgery Trauma Travel Immobility Malignancy OCPs

Answer 47

Dabigitran - Idarucizumab.(Glund et al. 2019) Edoxaban, apixiban and rivaroxaban - andexanet alfa.(Connolly et al. 2019) Nonspecific with some effect on other DOACs - PPC, Factor 7, and activated PPC.(Cuker et al. 2019; Kearon et al. 2016)

Answer 48

This occurs shortly after initiating warfarin and presents with purple, cool, painful toes and punctate areas of necrosis and petechiae. Treatment includes immediate cessation of warfarin and transition to LMWH, normalization of INR with Vit K and FFP.

Answer 49

Age >75 Intracranial neoplasm Intracranial/spinal surgery or trauma with the last 2 months History of hemorrhagic stroke Active bleeding or known bleeding disorder Non-hemorrhagic stroke within the past 3 months.

Answer 50

people get swelling, heaviness, pain. There is a very unique symptom, which is venous claudication, which is almost pathonogmonic of post-thrombotic syndrome with venous outflow obstruction. It’s this pain which has a bursting tense quality in the calf on exertion, which does settle on stopping, but it takes a lot longer than arterial claudication. So sometimes people will take half an hour to get better and the leg has to be elevated. So that’s venous claudication and that’s often the most disabling symptom. But of course, people can develop the same clinical complications than you can with any venous disease—skin changes, lipodermatosclerosis, venous leg ulceration, et cetera. Those are the summery of symptoms for PTS, seen in up to 50% but probably closer to 25% of proximal DVT.

Answer 51

A rather challenging and unique patient would be a pregnant patient with a DVT and placenta previa. Anticoagulation is contraindicated in placenta previa and in addition, an infrarenal IVC filter is also contraindicated, so she would require a suprarenal IVC filter.

Answer 52

The reason it happens is almost certainly a profound obstruction of venous outflow. So the venous blood in the leg cannot escape. You get this cycle of worsening pressure, leaking of fluid from the capillaries, increasing pressure on the soft tissues. Then that starts to threaten tissue perfusion and potentially if it’s bad enough this will threaten the actual arterial profusion of the leg as well. Presentation often includes iliofemoral DVT with non-palpable pulses and loss of sensation with out improvement on anticoagulation and elevation. Endovascular early thrombus removal is the first line with fasciotomies, with open thrombectomy as back up for salvage

Answer 53

Angioplasty and stenting are first line treatment for benign etiology.(Rizvi et al. 2008; Sheikh et al. 2005) Angioplasty alone may be sufficient, but stenosis refractory to angioplasty may require stenting. SVC syndrome with failed endovascular management in reasonable operative candidates can undergo open reconstruction with large diameter prosthetic graft or spiral vein graft.(Doty, Flores, and Doty 1999) However, restenosis in open repair can be as high as 15%.(Kalra, Sen, and Gloviczki 2018; Sfyroeras et al. 2017) SVC syndrome secondary to malignancy, bronchogenic or lymphoma, is often most effectively treated with palliative radiotherapy with good response.(Talapatra et al. 2016) Endovascular or open recannalization is often reserved only for those with severe symptoms refractory to radiation or chemotherapy.

Answer 54

primary dysfunction of the lymphatic channels or the secondary result of a disease that results in the destruction of lymphatic flow. Causes of secondary lymphedema include filariasis, which is endemic to parts of South America.

Answer 55

The management of lymphedema is determined primarily on its clinical stage at presentation.(Grada and Phillips 2017) The staging for lymphedema is as follows: Lymphedema Stage Description Symptoms 0 Sub-clinical No swelling, heaviness or discomfort 1 Spontaneous Reversible Swelling improved with limb elevation 2 Spontaneous Irreversible Pitting and swelling, not improved with elevation 3 Lymphostatic elephantiasis Skin hardening, non-pitting edema, verrucas changes, recurrent infection

Answer 56

On physical exam, a classic finding is Stemmer’s sign, which is a thickened skin fold at the based of the second toe/finger. The sign is positive when the tissue is hardened and cannot be lifted.(S. G. Rockson et al. 1998; Stanley G. Rockson 2019) Lymphedema is most often diagnosed based on clinical presentation and physical exam. Lymphoscintography can be used to confirm the diagnosis in complex presentations and would demonstrate dermal back flow, absent or delayed transport, crossover filling, absent or delayed visualization of lymph beds.

Answer 57

Treatment is best initially managed with combined decongestive therapy (CDT) which includes an intensive reductive phase (4-8wks), followed by life long maintenance, often with specific compression garments.(Grada and Phillips 2017) CDT in the setting of heart failure has been reported to lead to volume overload.(Lawenda, Mondry, and Johnstone 2009) In extreme cases, after CDT therapy has been instituted for at least 6 months and the patient has persistent refractory symptoms, surgery may be used for reconstruction or debulking

Answer 58

Leg prepped and draped in sterile fashion Under ultrasound guidance administer local anesthesia to the skin overlying the GSV Access the vein with a micro Advance laser through a point 2cm distal to SFJ Administer tumescent anesthesia along the vein (1cm deep to skin surface) Withdraw laser while activated 1-2mm/sec Withdraw laser and sheath Apply compression bandage Obtain duplex in 72h to evaluate for successful ablation

Answer 59

heat sink compresses vein local anesthesia 40ml 1% lidocaine with epi 10ml sodium bicarb 450ml normal saline safe amount: 35mg/kg

Answer 60

SVT Acute DVT Venous aneurysm ABI < 0.9 Vein <2mm or >20mm, tortuous proximal segment

Answer 61

lower rate of recurrent venous ulcerations with EVLT + compression EVRA showed improved rate of healing

Answer 62

fondaparinux: 2.5mg BID SVT > 5cm length or <5cm from SFJ

Answer 63

Supporative Thrombophlebitis (purulence in vein) Persistent thrombophlebitis

Answer 64

>1sec >.5sec >.35sec

Answer 65

CBC, renal, transferrin, pre-albumin, A1C biopsy if prolonged for no underlying malignancy skin subs, skin graft Unna boot arterial and venous duplex treat superficial reflux

Answer 66

Unna boot is a compression bandage; it consists of a zinc oxide-impregnated gauze wrap that is applied from the toes to the knee, covered with a layer of cotton, and wrapped with an elastic compression dressing.

Answer 67

pelvic and gonadal venous incompetence --> venous reflux and varicosities in uterine and ovarian veins (left more common than right due to likely to not have valves)

Answer 68

Micronized purified flavonoid fraction

Answer 69

treat superficial first--> often leads to symptom improvement indications to treat deep (perssitent recurrent symptoms following superficial treatment) symptomatic isolated deep reflux (can do synthetic valve)

Answer 70

Duplex- transabdominal then transvaginal does not rely on reflux diagnosed is ovarian vein dilated >6mm with valsalva CT/MRV Venography- retention of contrast in ovarian vein

Answer 71

Medical- trial medroxy progesterone Ovarian vein coiling - access R CFV under ultrasound guidance with micro - upsize to an 8fr sheath - perform venogram to identify LRV - cannulate the LRV with glidewire and angled catheter - perform venogram to identify ovarian and vein and evaluate for reflux, cross pelvic collateral, pelvic varicosities - cannulate the ovarian vein and advance catheter - deploy appropriately sized coils

Answer 72

Start hep gtt obtain CXR, EKG, stat Echo, cbc, trop, renal, ABG, CTPE

Answer 73

US guided access to R CFV with micro upsize to 8Fr sheath Heparinize infracardiac angiogram to identify R heart outflow and pulmonary arteries angled pigtail catheter to select pulmonary arteries exchange for stiff wire advance (interventional) 12fr sheath into main pulmonary artery perform aspiration thrombectomy with penumbra and attempt to macerate thrombus completion angiogram remove device and sheath purestring suture and manual pressure for hemostasis consider- IVC filter deployment ECMO if unsucessful Open thrombectomy with CTS

Answer 74

Prep the patient prone access popliteal vein under US guidance with micro upsize to 8fr sheath heparinize perform ascending venography exchange for stiff wire upsize to 16F sheath mechanical thrombectomy with penumbra repeat venogram (if residual thrombus, plan to lyse) IVUS to assess for CIV compression If >50% area reduction compared to normal caliber adjacent vein plan for venous stenting

Answer 75

Fibrinogen < 100 or 50% drop administer cryo

Answer 76

Screen Hitt antibody (ELISA) Confirm SRA Immediately stop heparin and start argatroban

Answer 77

argatroban hepatically cleared give lepirudin

Answer 78

place patient supline induction of general anesthesia mark CFV with ultrasound longitudinal incision over CFV, obtain proximal and distal control make transverse venotomy use esmark bandage to expel clot from distal extremity if unable to retrieve clot, expose PTV in distal leg, pass ebolectomy catheter antegrade from the lower leg thrombectomy of iliac vein segments close venotomy and confirm phasic flow with doppler check for return of arterial pulses fasciotomies for ischemia >4 hrs ascending venogram and IVUS of L CIV to assess need for stenting

Answer 79

After general anesthesia and draping expose L CFV through a longitudinal incision Harvest R GSV from the knee to the SFJ Create suprapubic tunnel from the Left to right CFV Heparinize with 80-100u/kg for ACT > 250 Mark and disconnect GSV distally, tunnel to left groin perfrom R GSV to L CFV anastamosis Create AVF between branch of the SFA and left femoral vein check bypass patency and distal pulses

Answer 80

The patient is placed supine on the operating table. Multiple large-bore intravenous access and radial arterial access are established. An anterior incision is then created, extending from the knee to the ankle and continued down to the level of the anterior tibial fascia. Great care is taken not to violate the fascia. However, in the event of subcutaneous tissue that is adherent to fascia, a small margin of fascia can be taken. This can lead to a degree of muscle bulging and a suboptimal cosmetic result but that is of lower priority than completing the subcutaneous excision. In some cases, a second-stage excision at the same location will be performed if the amount of tissue requiring excision is too great or the operative time becomes too long. Once the fascia is reached through the anterior incision, dissection is continued along the fascia both medially and laterally along the circumference of the leg (Fig 5). The proximal extent of this circumferential dissection is distal to the knee joint at the level of the tibial tuberosity. The dissection is intentionally beveled to allow for a gradual transition from the level of the skin superiorly to the depth of the fascia distally. This avoids the knee joint and prevents the creation of sharp angles, which would otherwise need to be traversed by future skin grafting. Once an adequate dissection plane has been achieved, the leg can be suspended with the candy cane stirrups already in place. The weight of the (now pendulous) tissue is converted from a hindrance to an aid by serving as its own retraction as it falls away from the fascia Once the circumferential dissection is complete, the specimen is placed in a large basin, and hemostasis is achieved. Voluminous fluid losses can be expected from both the specimen and the dissection (Fig 7). Close communication with anesthesia providers throughout the course of the procedure is essential, because these morbidly obese patients are susceptible to massive fluid shifts across a large volume of distribution. Wound vac applied Delayed skin grafting with plastics

Answer 81

For right retroperitoneal exposure, the flank is elevated to 15 to 20 degrees with the patient positioned in the supine position. A transverse incision can then be made extending from the rectus abdominis to the tip of the 11th or 12th rib. The external oblique, internal oblique, transversus abdominis muscles, and transversalis fascia are divided to create the retroperitoneal plane via blunt dissection. With judiciously placed self-retaining retractors, a 6-cm segment of the right lateral aspect of the pararenal and infrarenal vena cava may be easily exposed

Answer 82

For a transperitoneal exposure, either a midline laparotomy or bilateral subcostal incision will facilitate adequate exposure. Once the peritoneal space is entered, the small bowel is retracted to the left and the lateral peritoneal attachments of the right colon are divided. This facilitates medial mobilization of the right colon and mesentery and provides access to the retroperitoneal attachments of the second and third portions of the duodenum. Once these attachments are divided, the underlying vena cava can then be adequately exposed from the suprarenal level to the common iliac veins. Ligation and division of the ventral pararenal lymphatics, right lateral lumbar veins, and anterior crossing left gonadal vein will aid in caval mobilization during proximal and distal circumferential dissection. Vascular tapes may be placed around the proximal and distal exposed segments of the vena cava to facilitate vascular control. Care should be taken to not avulse medial lumbar veins with over aggressive mobilization of the vena cava during these maneuver

Answer 83

For extended retrohepatic IVC exposure, a right thoracoabdominal incision may be performed with the patient positioned in a left lateral decubitus position. Once the peritoneal cavity is entered, the right triangular ligament and lateral and posterior peritoneal attachments to the right hepatic lobe can be divided. Medial retraction of the right hepatic lobe can then be performed to facilitate visualization of the lateral surface of the retrohepatic IVC (FIG 6). Hepatic compression here, especially following placement of self-retaining retractors, can increase hepatic congestion and ischemia and should be minimized to the greatest extent possible. In situations where caval visualization is not adequate despite optimal hepatic retraction, proximal extension or even division of the sternum may be necessary to facilitate safe exposure. Once adequate exposure is achieved, circumferential control can be achieved following ligation and division of small hepatic venous branches that course between the caudate lobe of the liver and the IVC in this region. The suprahepatic IVC can be exposed following ligation and division of the round ligament and wide division of the falciform and coronary ligaments. Caudal retraction of the bare dome of the liver facilitates visualization of the suprahepatic vena cava and at least two of the three main hepatic veins. Careful dissection of the areolar tissue surrounding these veins allows for circumferential exposure of each of these veins as well as this segment of the vena cava.

Answer 84

Specific isolation of the retrohepatic vena cava requires control of both the hepatic inflow and outflow. Inflow control is achieved with cross-clamping of the infrahepatic vena cava as well as with a Pringle maneuver (clamping of the hepatic artery and portal vein). Outflow control is achieved with suprahepatic or infradiaphragmatic clamping of the IVC.

Answer 85

In order to maintain the smooth blood flow of the fistula, orificium fistulae were made between superficial femoral veins (which were branches of bilateral saphenous veins and were with the diameter of about 3 mm) and superficial femoral arteries (Figure 2D and and2E).2E). Venous pressure above the anastomosis before and after fistulation decreased from 29 mm Hg to 18 mm Hg, indicating that the arteriovenous fistula was smooth. Finally, the incision was closed. Need a pressure gradiant > 4mmHg; if > 4, no need for AVF

Answer 86

Abre, wall stent, venovo

Answer 87

BL Femoral artery cutdown and thrombectomy Thrombectomy of one side--> close arteriotomy Shoot angio to evaluate hypo if occluded must balloon protect contralateral hypo

Answer 88

ASA/statin smoking cessation Control of diabetes, HTN, HLD

Answer 89

Zone 1: This is the area between the clavicles and the cricoid cartilage. This zone contains vital structures which include the innominate vessels, the origin of the common carotid artery, the subclavian vessels and the vertebral artery, the brachial plexus, the trachea, the esophagus, the apex of the lung, and the thoracic duct. Furthermore, surgical exposure and access can be difficult in this zone, because of the presence of the clavicle and bony structures of the thoracic inlet. Zone II: This is the area between the cricoid cartilage and the angle of the mandible. The following structures are located here: the carotid and vertebral arteries, the internal jugular veins, the trachea, and the esophagus. This zone has comparatively easy access for clinical examination and surgical exploration. It is the largest zone and the most commonly injured in the neck. Zone III: This is the area between the angle of the mandible and the base of the skull. This area contains the distal carotid and vertebral arteries and the pharynx. Since it is very close to the base of the skull, this area is less amenable to physical examination and difficult to explore during surgical evaluation.

Answer 90

1. pulsatile bleeding 2. Refactory hypotension 3. expanding hematoma 4. distal ischemia with loss of pulses

Answer 91

1. history of bleeding in the field 2. stable hematoma 3. Penetrating injury in proximity to major vessel

Answer 92

Airway- can patient speak, need to intubate? Breathing- confirm adequate ventilation Circulation- Assessment of hemodynamics, 2 large bore IV access

Answer 93

Grade 1: impulse control, surveillance imaging Grade 2: impulse control, surveillance imaging, Delayed TEVAR vs surveillance Grade 3: impulse control, surveillance imaging, Delayed TEVAR vs surveillance Grade 4: Emergent TEVAR Surveillance: CT on admission, 48h, 1 month, 6 month, 1 yr.

Answer 94

reduces aortic wall stress SBP < 120 HR < 60 Meds: Esmolol, Nicardipene (CCB), Nitroprusside

Answer 95

Primary Interposition graft: GSV, SFA, Rifampin soaked graft last resort

Answer 96

Biffl injury grade Angiograhic characteristics I Luminal irregularity or dissection with < 25% luminal narrowing II Dissection or intramural hematoma with ≥25% luminal narrowing III Pseudoaneurysm IV Occlusion V Transection with active extrav

Answer 97

Eyes Verbal Motor

Answer 98

After induction of general anesthesia US guided percutaneous access to R CFA with preclose technique, 8Fr 5Fr access to the left groin for imaging guidance Heparinize patient IVUS to size the aorta, select graft with 10% oversizing LAO angiogram to define anatomy Right sided large bore sheath advanced to descending TA Deploy endograft Pull pigtail back Balloon seal zones? Completion angiogram CLose the groins Neurovascular exam upon emergence from anesthesia

Answer 99

all penetrating hematomas should be explored (except zone 4, often tamponade)

Answer 100

Zone 1: always explore Zone 2/3: surgical exploration only performed with rapidly expanding hematoma Vascular review p251

Answer 101

Midline laparotomy Reflect omentum and transverse colon cephelad mobilize left lobe of liver(triangular ligamanet) Enter lesser sac (through gastro hepatic ligament) Mobilize crus muscle Feel for NGT to differentiate E from A

Answer 102

ligation often well tolerated consider temp clamp and observing for perfusion changes

Answer 103

<30% primary 30-50% vein patch >50% 14-20mm ringed PTFE

Answer 104

consider pelvic binder

Answer 105

1. parallel dissection of iliac artery and reflect cephalad 2. Ligate hypo to assist with mobilization 3. Transection of CIA with reconstruction caution to avoid ureters

Answer 106

2 incision 4 compartment The anterior and lateral compartments of the lower leg are approached through the same lateral, longitudinal skin incision parallel to the tibia and positioned approximately 4 lateral to the anterior edge of the tibia. The incision extends a distance that is one half the distance from the lateral tibial tuberosity to the lateral malleolus. Through this skin incision, the anterior compartment is opened via a longitudinal incision of the fascia. It is important during this step to visualize and firmly palpate the tibia under the superior or medial skin flap to verify that the anterior, not the lateral, compartment is released. The intermuscular septum between the anterior and the lateral compartments must be identified after opening of the anterior compartment by making a transverse incision in the anterior fascia. The lateral compartment is opened via a longitudinal incision 1 cm posterior to the intermuscular septum. Protection of the common peroneal nerve, which lies behind the head of the fibula, is important at the superior extent of the incision while decompressing the anterior and lateral compartments. The superficial and deep posterior compartments of the lower leg are approached through the same medial skin incision 2 to 3 cm posterior to the medial border of the tibia. Like the lateral leg incision, it should be at least one half to three quarters the distance from the medial tibial tuberosity to the medial malleolus. A longitudinal opening in the fascia is created 2 to 3 cm posterior to the posteromedial border of the tibia, opening the superficial posterior compartment Decompression of the deep posterior compartment requires detaching the soleus from the posterior edge of the tibia and the underlying interosseous membrane. This maneuver can be facilitated by elevating the upper skin flap and palpating the tibia at its confluence with the soleus fibers. The deep posterior compartment is then opened nearly the length of the skin incision by carefully incising the interosseous fascial membrane, taking care not to injure the distal posterior tibial artery as it becomes more superficial in the lower leg.

Answer 107

To release the superficial volar compartment of the forearm (see Fig. 53-1), a curvilinear skin incision should be started on the ulnar aspect of the arm anterior to the medial epicondyle and proximal to the anticubital fossa (Fig. 53-7). At this location the medial antebrachial cutaneous nerve can be identified and protected near the medial epicondyle. To create a curvilinear fasciocutaneous release, the incision should be initially directed distal and radially toward the brachioradialis to open the mobile wad or lateral compartment. The mobile wad can be decompressed by elevating the medial fascial flap resulting from the fasciotomy of the superficial flexor compartment. In the proximal one third of the forearm, the incision should be transitioned back toward the ulna and the radial aspect of the flexor carpi ulnaris tendon in the distal one third of the forearm (Fig. 53-7). Maintaining the incision and fascial opening to the ulnar side at the midforearm and distal forearm lessens the likelihood of injury to the median nerve and its branches in the arm and hand. Finally, the incision should be continued in a transverse orientation along the wrist and at the midpoint, vertically extending onto the palm crossing the carpal tunnel. Although controversial, release of the transverse carpal ligament at the carpal tunnel is generally considered necessary to fully decompress the volar compartment and median nerve. This is especially true in the setting of electrical injury. To open the deep compartment of the arm, the space between the flexor carpi ulnaris and the flexor digitorum superficialis muscles must be identified, and the ulnar nerve and artery, which can be visualized in the deep flexor compartment, must be manually separated. A longitudinal fasciotomy of the deep compartment is performed by retracting the vessel and nerve laterally. A longitudinal incision is created from the lateral epicondyle of the humerus and is extended to the distal one third of the posterior forearm. Extensor fasciotomy is performed between the extensor carpi radialis brevis and the extensor digitorum communis muscles, avoiding injury to the posterior cutaneous nerves.

Answer 108

used for claudication 100mg BID c/i in CHF with EF<30%

Answer 109

1mg q3-5minutes Bradycardia carotid sinus .2mg

Answer 110

Premedication with prednisone, 50 mg given orally, 13, 7, and 1 hour before the procedure with 50 mg of diphenhydramine given 1 hour before the procedure reduces the risk of a contrast-induced allergic reaction For an emergent procedure, intravenous regimen includes 50 mg of diphenhydramine given 1 hour before contrast loading and 40 mg of methylprednisolone

Answer 111

supervised walking program 30-45min/day, 3-4x/week, for 3 months

Answer 112

picture a result of displacing blood out of the way can not use above the diaphragm CO2 tends to dissolve within a vessel in 30 seconds to 60 seconds. If practicing caution, injections should be performed at least 2 minutes apart. do not use with nitrogen oxide (decreases CO2 absorption in blood) Embolus, trendelenburg, LL decubitus, 100percent O2

Answer 113

5 mg of verapamil and 200 µg of nitroglycerin intra-arterially for every transradial access procedure after placement of the sheath. The medications are mixed into 20 mL of the patient’s blood, aspirated from the radial sheath, to reduce discomfort on administration.

Answer 114

the infusion of the lytic agent is halted at least temporarily if the fibrinogen levels fall below 100 mg/dL (or <50% initial value) because there is an increased likelihood of hemorrhagic complications below this threshold.

Answer 115

ELISA SRA Argatroban bivalrudin lepirudin lioprost

Answer 116

50mcg/dose fent 1-2.5mg/dose versed

Answer 117

P1: from adductor hiatus to the top of the patella. P2: from top of the patella to center of the knee joint. P3: from center of the knee joint to anterior tibial artery origin

Answer 118

Place patient in supine position. Rotate leg laterally, flex the leg, and place a bump underneath the knee joint. Place a 10- to 12-cm longitudinal incision along the groove formed between the edges of the vastus medialis (anteriorly) and the sartorius muscles (posteromedially) (dashed line A in FIG 3A). The incision is carried through the subcutaneous tissue and fascia. Place self-retaining retractor. Take care not to trap and injure the great saphenous vein and the saphenous nerve. The great saphenous vein is likely to be encountered more posteromedially to the incision in the subcutaneous tissue. The saphenous nerve may be encountered at distal end of the incision as it joins the saphenous vein near the medial aspect of the knee. Incise the deep fascia longitudinally and above the sartorius muscle to enter the popliteal fossa. The popliteal artery can be palpated up against the posterior surface of the femur (FIG 3B). The popliteal artery is often surrounded by multiple venous collaterals, or “venae comitantes” in Latin; the popliteal vein is usually posterolateral to the artery in this location. The popliteal and/or superficial femoral veins may be duplicated throughout the popliteal fossa and distal thigh. Isolation and control of the artery usually requires ligation and division of surrounding collateral veins.

Answer 119

Lateral exposure of the above-knee (AK) popliteal artery is useful in a variety of circumstances—for instance, axillopopliteal bypass or when the medial approach has previously been developed or is complicated by infection or injury. Place patient in supine position. Rotate leg medially, flex the knee, and place a bump underneath the knee joint. Place 10- to 12-cm longitudinal incision between the vastus lateralis and the biceps femoris muscles (dashed line A in FIG 4A). The incision is carried through the subcutaneous tissue and fascia. Make a generously cruciate incision (“T-ed”) at both ends on the fascia lata to prevent bypass graft impingement by its dense fibers. Place retractor and enter the popliteal space. Sciatic nerve then popliteal vein will be encountered first before popliteal artery. Gently retract sciatic nerve downward. Then mobilize and retract popliteal vein to expose and control the popliteal artery.

Answer 120

Posterior exposure may be the preferred approach for management of popliteal artery entrapment, popliteal cyst, focal popliteal artery aneurysm, or arterial injury following traumatic posterior knee dislocation. Although direct and relatively uncomplicated, posterior access is limited by the heads of the gastrocnemius muscle distally and the biceps femoris/“hamstring” muscles proximally; only focal, limited popliteal artery access is achievable through this incision. Patient is placed in prone position with pillow to prop up the lower leg and foot. The incision is S-shaped, across the posterior crease of the knee joint, with its superior extent beginning medially. The incision is carried anteriorly through the subcutaneous tissue and superficial fascia to enter the popliteal fossa. Exposure is maximized by mobilizing the popliteal artery between the two heads of the gastrocnemius muscle inferiorly and between semimembranosus and biceps femoris muscle superiorly. The muscles are gently retracted to expose the entire popliteal fossa. The tibial and common peroneal nerves are encountered superficially in this exposure. The popliteal artery is anterior, or deep to the vein, in the depths of the wound. It may be necessary to mobilize the popliteal vein with ligation and division of popliteal venous tributaries to fully expose the artery. Once the appropriate segment is exposed, silastic vessel loops are placed proximally and distally.

Answer 121

The most common approach is a medial one (FIG 3A). Place patient in supine position. Rotate leg laterally, flex the leg, and place a bump underneath the knee joint. Make a longitudinal incision from below the edge of the tibia along the course of the great saphenous vein (dashed line B in FIG 3A). Carry the incision through subcutaneous tissue and fascia into the deep posterior compartment. The below-knee (BK) popliteal vessels reside deep in the wound and are partially covered by the origin of the soleus muscle. Division of the soleus origin medially (FIG 3C) will facilitate exposure of the tibioperoneal trunk, and origin of the anterior tibial artery, but is not really necessary for exposure of the popliteal artery itself. As was described for the posterior approach, the artery lies in close proximity to the popliteal vein and tibial nerve. Mobilization of the popliteal vein from the adjacent artery is necessary for sufficient exposure of all relevant structures, including the anterior tibial artery, tibioperoneal trunk, and derivative branches (posterior tibial and peroneal arteries). It is usually necessary to ligate and divide the anterior tibial vein at its confluence with the (often paired) popliteal vein to gain sufficient exposure to isolate and mobilize the more distal branches. Dissection must proceed deliberately to avoid injury to the neighboring tibial nerve and its distal branches.

Answer 122

The lateral approach is rarely required but may be particularly useful to avoid scarring from a previous medial approach. Place the incision posterior to the head of the fibula and extend along the course of the fibula. Dissect directly onto fibula (incision is marked as dashed line B in FIG 4A). Note the location of the common peroneal nerve, which courses from posterior to anterior around the neck of the upper fibula just below its head, before it branches into the superficial and deep peroneal nerves. Circumferentially elevate the periosteum of the fibula and excise the exposed segment of the fibula with a saw. The popliteal vessels and branches are found directly beneath the fibular periosteum, with the artery usually located anterior to the posterior tibial nerve and the popliteal vein. Extending the dissection distally allows exposure and control of distal popliteal artery, as well as the origins of the anterior tibial and the tibioperoneal trunk.

Answer 123

Exposure of the Anterior Tibial Artery Proximal segment The proximal segment of the anterior tibial artery is exposed in a fashion similar to the exposure for the infragenicular popliteal artery and its branches. Middle segment The middle segment exposure of the anterior tibial artery is useful when there is limited length of autogenous vein. Place an axial incision in a vertical plane about two fingerbreadths lateral to the anterior edge of the tibiaDeepen the incision between the tibialis anterior and the extensor hallucis longus muscles. The anterior tibial artery is superficial to the interosseus membrane between the cleft formed by these two muscles. Dissecting away the overlying collateral veins allows exposure and control of the middle segment of the anterior tibial artery. Use of a proximal sterile tourniquet during exposure of all the crural arteries may significantly accelerate the dissection while limiting bleeding from the numerous and redundant collateral veins.

Answer 124

Exposure of the Posterior Tibial Artery Proximal segment The proximal segment of the posterior tibial artery is approached in a similar fashion to the exposure for the infragenicular popliteal artery and its branches and requires taking down the soleus muscle from the tibia. Middle segment The middle segment exposure of the posterior tibial artery is useful when there is limited length of vein graft to bypass to the posterior tibial artery. Incision is made just anterior to the soleus muscle. Divide the overlying soleus to expose the underlying vessels (FIG 5B). The posterior tibial artery lies anterior to soleus muscle with the peroneal artery located laterally, in the same plane, between the soleus and tibialis posterior muscles. Avoid injury to the tibial nerve, which commonly runs between the posterior tibial and peroneal vessels.

Answer 125

Proximal and middle segments Exposure of the proximal segment of the peroneal tibial artery is via distal extension of the infragenicular popliteal artery approach. Middle segment The middle segment may also be approached anterolaterally. The following description relates to lateral exposure requiring fibulectomy. Place a vertical incision over the fibula at the desired level (FIG 5C). Carry down the incision through the overlying muscle down to the fibula. Elevate the periosteum of the fibula circumferentially. Transect the overlying segment of fibula. Incise the inner periosteal membrane. The peroneal vessels are found immediately beneath. The artery usually is anterior to flexor hallucis longus and posterior to the tibialis posterior muscles. The peroneal artery is exposed and controlled after mobilization from circumferential collateral veins and the main peroneal vein.

Answer 126

Distal posterior tibial exposure enables pedal bypass at or below the ankle, which may be especially useful in patients with advanced diabetes. Make a longitudinal incision through skin and fascia at the midpoint between the medial malleolus and the Achilles tendon. If this exposure is used for an in situ bypass procedure, the incision should be sighted slightly more anteriorly to accommodate the anterior course of the great saphenous vein as it crosses the medial malleolus. Identify and divide the flexor retinaculum as needed to provide optimal exposure. The posterior tibial vessels are located between the flexor digitorum longus and flexor hallucis longus muscles/tendons. Place a small Weitlaner self-retaining retractor. The neurovascular bundle is usually enveloped by fatty tissue below the fascia. Dissection proceeds along the neurovascular bundle. The posterior tibial artery is usually anterior to the tibial nerve. There is typically a rich network of venous collaterals present. These may either be mobilized or (more commonly) divided to facilitate distal posterior tibial artery exposure.

Answer 127

Exposure of the Supramalleolar Anterior Tibial Artery The distal anterior tibial artery may serve as a suitable distal bypass target, especially when substantial disease is present more proximally. It may also be preferable to bypass to this segment in the presence of a dorsal foot wound. The incision is placed between the tibialis anterior medially and extensor hallucis longus and the extensor digitorum longus laterally (FIG 6B). Anterior tibial artery and peroneal nerve usually course through the groove between them. Dissect between these tendons and retract them to expose the supramalleolar segment of anterior tibial artery.

Answer 128

Exposure of the Dorsal Pedal Artery The dorsal pedal artery (or “dorsalis pedis” in Latin) is the extension of the anterior tibial artery as it passes beneath the extensor retinaculum. It can serve as a suitable distal bypass target, especially in patients with diabetes. The artery is best exposed beyond the inferior extensor retinaculum. Place an incision between the 1st and 2nd metatarsal shafts and distal to the extensor retinaculum (FIG 6B). The dorsalis pedis artery resides in the groove between the 1st and 2nd metatarsal heads, usually just lateral to the extensor hallucis longus tendon, which is readily identified by dorsiflexion of the great toe, and medial to extensor hallucis brevis. Carry down dissection through subcutaneous tissue and longitudinally divide the fascia to expose and control the artery.

Answer 129

The PFA is exposed through an incision placed along the lateral border of the sartorius muscle 4 to 6 cm below the anterior superior iliac spine (FIG 5). The sartorius and superficial femoral vessels can be retracted medially to expose the adductor longus. Its overlying fascia is divided, and with medial retraction, the PFA is exposed.

Answer 130

SFV can be a suitable graft for reconstruction, with a low incidence of recurrent or uncontrolled infection.4 Preoperative evaluation should include duplex imaging of the SFV to exclude deep venous thrombosis and to determine the vessel diameter. Dissection can be performed through an incision placed over the lateral border of the sartorius (FIG 6). The vein should be dissected from its confluence with the profunda femoris vein distally to obtain sufficient length for reconstruction. Care should be taken to preserve the profunda femoris vein and the common femoral vein and to stop the dissection at the adductor canal. These limits will preserve important collateral circulation between the profunda femoris and the popliteal vein, which will minimize postoperative leg edema. Once harvested, branches of the SFV should be doubly ligated or suture ligated a distance 2 mm from their junction with the SFV to prevent slippage of the ligature once the conduit is pressurized. The SFV can be used in a reversed manner or nonreversed after disrupting the valves.

Answer 131

control co-morbidities ASA/statin HgA1C smoking cessation walking program BP control 5 year outcomes 75% stable 20% worsen 5% limb loss, 1%/yr

Answer 132

ABI <.04 Ankle pressure < 50mmHg Toe pressure <30mmHg Flat/minimally pulsatile Trans-met PVR

Answer 133

Normal: .9-1.4 PAD +: <.9

Answer 134

PAD+ with TBI <.7 PAD+ with TP < 50mmHg

Answer 135

PPCI (Low thigh-calf pressure)/low thigh pressure >0.25 = no benefit

Answer 136

PSV >300 Vr > 3.5 Low PSV < 45 ABI drop >.15

Answer 137

Step 1: Skin Incision Quickly cleanse the neck, and grasp the larynx with the nondominant hand. Use the index finger of the nondominant hand to identify the thyroid cartilage, cricothyroid membrane, and cricoid ring. Once the underlying structures have been identified, use the dominant hand to make a vertical incision over the cricothyroid membrane (Fig. 1B). Place the nondominant index finger into the vertical incision and move it side to side to clearly feel the cricothyroid membrane (Fig. 1C). Step 2: Incision of Cricothyroid Membrane Remove the nondominant index finger from the cricothyroid membrane, and make a 5-mm horizontal incision through the cricothyroid membrane (Fig. 2A). Watch the depth of incision, to avoid injury to the underlying esophagus. Place the elastic bougie into the defect, and advance it until resistance is appreciated (Fig. 2, B and C). This indicates entry into the right main stem bronchus. Step 3: Endotracheal Tube Placement Advance the preselected cuffed endotracheal tube over the elastic bougie (Fig. 3), up to the cricothyroid membrane. Ensure that the bevel of the endotracheal tube is lined up with the horizontal incision of the cricothyroid membrane before advancing further. Apply gentle pressure while advancing the endotracheal tube through the divided cricothyroid membrane. As the bevel of the endotracheal tube is passing through the membrane, it will push the cricothyroid membrane laterally. This will open the defect, allowing placement of the larger endotracheal tube. Once the endotracheal tube cuff has entered the trachea, stop advancing. Remove the elastic bougie, and inflate the endotracheal tube cuff.

Answer 138

This condition is a permanent flexion deformity at the wrist and fingers that results in a claw-like presentation of the hand. causes: compartment syndrome of forearm

Answer 139

Transverse incision 1cm distal to antecubital skin crease S- shaped with proximal aspect placed medially across the medial border of biceps dissect through skin, SubQ bicipital aponeurosis is incised exposing the brachial artery (brachioradialis, pronator teres)

Answer 140

to get entirety of cephalic arch

Answer 141

The clinical syndrome of unilateral finger ischemia, caused by digital artery occlusions from embolization from the palmar ulnar artery associated with repetitive striking of the palm, has been called the hypothenar hammer syndrome (HHS) Hypothenar Hammer Syndrome is post-traumatic digital ischemia from thrombosis of the ulnar artery at Guyon's canal (It extends between the proximal boarder of the pisiform bone and distally at the hook of the hamate. Houses ulnar artery and nerve) -hand and forearm prepped and draped, palmar surface up -oblique incision made in hypothenar crease extending from radial border of pisiform to distal transverse palmar crease - incision deepened to level of palmaris brevis muscle - ulnar identified is identified at proximal edge of muscle and traced distally as the muscle is incised - careful to watch for branches of ulnar nerve Positive allens test=do not ligate

Answer 142

poor collateralization between ulnar and radial artery

Answer 143

Need 4/5 1. age < 45 2. Tobacco use 3. exclusion of other disease 4. normal arteries proximal to pop or brachial 5. Digital artery occlusion well documented

Answer 144

Spiral GSV bypass (chest tube as diameter guide) vs 10-14mm PTFE Inflow IJ vs inominate Outflow R atrial appendage 1st line: conservative, steroids, diueretics, head of bed elevated malignant: tumor burden reduction, chemo/radiation

Answer 145

ABduction of arm to 90degrees, patient turns head to ipsi side, deep inspiration pain or decreased radial pulse --> positive test

Answer 146

surrender position, have patient open and close hands x 3 minutes

Answer 147

ABduction of arm to 90degrees,, wrist dorsiflexion-->pain = positive flex head to contralateral side--> pain=positive

Answer 148

1st stage: R Carotid-subclavian bypass 2nd stage: Repair of origin of the aneurysm with plugging and TEVAR vs L posterolateral thoracotomy

Answer 149

In the emergent setting, the optimal approach to the proximal left subclavian artery is via an anterolateral thoracotomy in the third or fourth intercostal space. A supraclavicular approach or median sternotomy can help to gain access to the proximal left subclavian artery.[6] Exposure of the axillary artery via the extension of the infraclavicular incision to the deltopectoral groove is occasionally necessary to obtain distal subclavian artery control. A “trap door” incision or upper median sternotomy to connect the anterolateral thoracotomy and supraclavicular incisions should be avoided due to the high morbidity of this incision. A left anterolateral thoracotomy incision is made with a cold scalpel, beginning with a large cutaneous incision at the 5th intercostal space, rapidly located in the male just below the left nipple and in the female in the inframammary fold. The curvilinear skin incision extends from the left edge of the sternum medially to the mid-axillary line laterally. The incision is carried through the subcutaneous and musculo-fascial planes and then through the pleura along the upper edge of the lower rib to preserve the intercostal pedicle. After pleural incision, exposure is gained by insertion of a Finochetto-type retractor placed transversely to keep the intercostal space wide open. To gain access to the posterior mediastinum through the pleural cavity, the operator must push the left lung forward with his non-dominant hand. If pleural adhesions are present, they are rapidly lysed by the operator's hand. Then the surgeon's dominant hand follows the plane of the ribs posteriorly just above the diaphragm until it abuts on the lateral rim of the last thoracic vertebral bodies. The aorta is the first structure encountered, immediately in front of the spine but it may be difficult to recognize in the severely hypotensive patient where it may be collapsed rather a firm pulsatile mass. It should not be confused with the esophagus, which lies deeper and more anteriorly; the presence of a previously placed nasogastric tube may facilitate identification of the esophagus. Once the thoracic aorta is well identified by digital palpation, the peri-aortic tissues are lysed by fingers or scissor dissection of their parietal pleura covering, as low as possible just above the diaphragm in a vertical axis, while remaining in contact with the lateral surface of the aorta. During this maneuver, one should avoid injury to the intercostal arteries as much as possible, which may cause additional morbidity. The thoracic aorta can then be cross-clamped using a Crawford or Debakey clamp whose tip should be abutted against the spine under digital or visual control. Complete release of the peri-aortic attachments is necessary to avoid slipping of the vascular clamp whose correct positioning must be verified to ensure the completeness of the aortic occlusion.

Answer 150

A chest radiograph is obtained to determine the presence or absence of a cervical rib, but other imaging studies of the brachial plexus are usually not helpful. * Conventional electromyography and nerve conduction studies (EMG/NCS) may be performed to exclude peripheral nerve compression disorders or cervical radiculopathy, but these tests are usually negative or nonspecific in neurogenic TOS. * After clinical diagnosis, almost all patients should undergo an anterior scalene or pectoralis minor muscle block with a short-acting local anesthetic to support the clinical diagnosis of neurogenic TOS and to help predict the reversibility of symptoms with treatment.18 * After an appropriate course of physical therapy that has been directed by a therapist with specific expertise of neurogenic TOS, surgical treatment is recommended for patients with substantial disability who have not made significant improvement. Surgical treatment may also be recommended in selected patients with persistent or recurrent symptoms of neurogenic TOS after a previous operation, when there has been no response to appropriate conservative measures. In each of these situations we find that supraclavicular decompression, with or without pectoralis minor tenotomy, provides the most definitive approach for surgical treatment. * Angiography with magnetic resonance imaging or computed tomography is performed to determine the presence or absence of a subclavian artery aneurysm in patients with a cervical rib or first rib anomaly suspected of having arterial TOS. Similar imaging studies are performed in patients who have presented with upper extremity arterial thromboembolism to detect a proximal source of embolism in the subclavian artery or the axillary artery. Surgical treatment based on supraclavicular decompression is recommended for all patients with subclavian artery aneurysms. This should include arterial reconstruction for subclavian aneurysms that have already produced distal emboli, those associated with imaging evidence of intimal ulceration or mural thrombus, or those greater than twice the normal diameter of the subclavian artery. * Upper extremity venography is the initial diagnostic step for patients with venous TOS who most frequently present with the axillary-subclavian vein “effort thrombosis” syndrome. Duplex imaging of the subclavian vein is usually inaccurate in this setting because of a high false-negative rate. Contrast venography is immediately followed by thrombolytic therapy, preferably with current pharmacomechanical approaches. Completion venograms typically reveal a focal area of residual subclavian vein stenosis or occlusion at the level of the first rib, often with enhancement by positional maneuvers. Balloon angioplasty of these residual stenoses is usually not helpful, and placement of stents in the subclavian vein is strongly discouraged. * First rib resection is recommended for patients with previous axillary-subclavian vein thrombosis who remain symptomatic despite anticoagulation and restricted activity, as well as for asymptomatic individuals in whom long-term anticoagulation and restrictions on upper extremity activity are undesirable. The addition of an infraclavicular incision can be used, if needed, along with the supraclavicular approach to ensure complete medial first rib resection and to facilitate direct subclavian vein reconstruction.

Answer 151

Unilateral or bilateral upper extremity symptoms present for at least 12 weeks that meet at least one criterion in each of the following three categories yet are not satisfactorily explained by another condition: * Manifesting symptoms * Pain in the neck, anterolateral chest, medial upper back, shoulder, arm, and/or hand * Complaint of numbness or paresthesias in the hand, especially in digits 4 and 5 * Complaint of weakness in the arm or hand * Paresthesias that radiate from the supraclavicular or infraclavicular space to the arm and/or hand * Clinical history * Symptoms that began after head, neck, or upper extremity injury (occupational or recreational) * Symptoms exacerbated by overhead or work-related activities, including repetitive strain * Presence of a cervical rib or previous fracture of the clavicle or first rib * Physical examination * Local tenderness on palpation over the scalene triangle and/or subcoracoid space * Reproduction of hand or digit paresthesias on palpation over the scalene triangle and/or subcoracoid space * Weak handgrip, intrinsic muscles, digit 5, or thenar or hypothenar atrophy * Positive upper limb tension test or 3-minute elevated arm stress test Exclusion of other conditions typically includes nonspecific or negative findings on physical examination (Spurling’s test, axial compression test, Tinel’s sign over the carpal tunnel or cubital tunnel, and Phalen’s test), imaging studies (magnetic resonance imaging of the cervical spine and shoulder), and conventional electrophysiologic tests (upper extremity electromyography and nerve conduction studies). Adapted from the preliminary consensus diagnostic criteria developed by the Consortium for Research and Education on Thoracic Outlet Syndrome.

Answer 152

Under general anesthesia, the patient is positioned supine with the head of the bed elevated 30 degrees. The hips and knees are flexed, and the neck is extended and turned to the opposite side. An inflatable thyroid pillow is placed between the shoulders to help extend the neck. The neck, upper chest, and affected upper extremity are prepped into the field, with the arm wrapped in a stockinette and held comfortably across the abdomen (Fig. 15-2). A transverse neck incision is made parallel to and just above the clavicle, beginning at the lateral border of the sternocleidomastoid muscle and extending to the anterior border of the trapezius muscle (see Fig. 15-2). The incision is carried through the platysma muscle, the edge of the sternocleidomastoid muscle is lifted and retracted medially, and the scalene fat pad is mobilized, beginning by separating its medial portion from the lateral edge of the internal jugular vein. A short segment of the omohyoid muscle is resected, and the ends are allowed to retract. The scalene fat pad is mobilized from its inferior and superior attachments. Deliberate division and ligation is the preferred method because lymphatic leak is a potential complication. On the left side, the thoracic duct is usually identified entering the venous system near the inferomedial aspect of the scalene fat pad, where it is divided between silk ligatures. he scalene fat pad is lifted and the underlying tissue plane is gently dissected with the tip of a finger. The fat pad is progressively reflected laterally, exposing the underlying anterior scalene muscle and phrenic nerve. Further mobilization of the scalene fat pad reveals the brachial plexus along the lateral edge of the anterior scalene muscle, followed by the middle scalene muscle behind the brachial plexus, where it attaches to the upper surface of the lateral first rib. The long thoracic nerve is observed as it emerges from the middle scalene muscle to pass across the lateral aspect of the first rib. During this dissection a small nerve stimulator may be used to verify the identity of specific nerves, but this is usually not necessary. Having all preceding structures under direct vision represents the first critical view to be obtained during supraclavicular decompression (Fig. 15-3). The scalene fat pad is subsequently held in position with several silk retraction sutures, and the exposure is maintained with a three-arm Henley self-retaining retractor, using the third arm to hold the edge of the sternocleidomastoid muscle. The brachial plexus and subclavian artery are dissected away from the lower lateral edge of the anterior scalene muscle, allowing a fingertip to be introduced behind the muscle just above the first rib. With posterior displacement of the neurovascular structures, fingertip dissection is continued behind the anterior scalene muscle toward its medial edge, where the proximal subclavian artery and the phrenic nerve must also be well visualized and protected. Once the insertion of the anterior scalene muscle onto the first rib has been isolated under direct vision (Fig. 15-4), it is sharply divided using curved scissors. By elevating the end of the divided anterior scalene muscle, additional slips of muscle, fascia, or tendon are divided, including direct attachments of the muscle to the subclavian artery and the thickened extrapleural fascia. The anterior scalene muscle is passed underneath to the medial side of the phrenic nerve and progressively lifted farther, with division of its posterior attachments and protection of the upper brachial plexus nerve roots, until it is held on a pedicle from its origin on the transverse process of the cervical spine (Fig. 15-5). The anterior scalene muscle is then sharply divided from its origin, and the entire muscle is removed. Scalene minimus muscle anomalies are usually identified during resection of the anterior scalene muscle. These are represented by additional muscle fibers that originate in the plane of the middle scalene muscle and pass between the brachial plexus nerve roots before inserting on the extrapleural fascia or first rib (either along with or independently of the anterior scalene muscle) (Fig. 15-6). Any scalene minimus muscle identified during anterior scalenectomy is therefore resected at this stage in the procedure. A number of different anomalous fibrofascial bands may also be observed after anterior scalene muscle resection, typically passing in front of the lower brachial plexus nerve roots (see Fig. 15-6). These structures are also resected as they are encountered to ensure thorough decompression and full mobility of the nerve roots. The brachial plexus nerve roots are separated from the front edge of the middle scalene muscle, sequentially identifying each nerve root from C5 to T1, until a small malleable retractor can be placed behind the brachial plexus. The attachment of the middle scalene muscle to the lateral first rib is then exposed by medial retraction of the brachial plexus and posterolateral reflection of the long thoracic nerve (Fig. 15-7). The anterior portion of the middle scalene muscle is initially divided on the top of the rib using electrocautery. Moving posteriorly along the top of the first rib, the middle scalene muscle is further detached using electrocautery and a periosteal elevator, extending to a point parallel with the T1 nerve root. The plane separating the middle and posterior scalene muscles is defined by the oblique course of the long thoracic nerve, which is represented by two or three branches that pass through the muscle at this level. Any muscle tissue lying anterior to this nerve is considered to be the middle scalene muscle; this muscle is divided, leaving the long thoracic nerve intact, and the middle scalene muscle is thereby removed. First Rib Resection After complete anterior and middle scalenectomy, the intercostal muscle attachments to the lateral edge of the first rib are divided under direct vision using electrocautery or a periosteal elevator. A fingertip is placed between the brachial plexus and the inner side of the first rib, and with blunt dissection the extrapleural tissues are swept away from the undersurface of the bone. The posterior neck of the first rib is exposed to the level where the T1 nerve root emerges from underneath the rib to join the C8 nerve root above the rib, thereby forming the lower trunk of the brachial plexus. A right-angled clamp is passed underneath the rib to separate remaining intercostal muscle and to displace the first intercostal nerve. With the C8 and T1 nerve roots under direct vision, modified Giertz-Stille rib shears are inserted around the neck of the first rib (Fig. 15-8). Mobility of the nerve roots is verified and the bone is divided. A Kerrison bone rongeur is used to remove additional bone needed to ensure that the remaining posterior stump of the first rib does not impinge upon the lower nerve roots, and the end of the bone is sealed with bone wax. Using sharp and blunt dissection, the remaining intercostal muscle and fascial attachments to the anterior first rib are divided up to the level of the scalene tubercle. The clavicle is elevated with a small Richardson retractor, and the proximal portion of the rib is displaced inferiorly if necessary, with fingertip pressure on the free posterior end of the rib, to open the anterior costoclavicular space. The Giertz-Stille rib shears are inserted around the anterior first rib and positioned immediately medial to the scalene tubercle under direct vision (Fig. 15-9). The proximal first rib is then divided, and the specimen is extracted from the operative field (Fig. 15-10). The remaining anterior end of the first rib is remodeled to a smooth surface with a Kerrison and Stille-Luer duckbill bone rongeur and sealed with bone wax. hen a cervical rib is present, it is first encountered within the plane of the middle scalene muscle during the course of scalene muscle resection, where it lies behind the brachial plexus and subclavian artery. The anterior end of the cervical rib may be free, with a ligamentous extension that attaches to the first rib, or it may terminate in a junction with the first rib, often forming a true joint. The cervical rib is carefully exposed along its course to protect the brachial plexus nerves, much as described for the middle scalene muscle and the first rib. In most cases the posterior cervical rib is divided or resected before proceeding to first rib resection, with exposure and division of its posterior aspect in the same manner. The anterior cervical rib is then divided and the bone is removed. When the cervical rib forms a true joint with the first rib, the anterior portion is left attached while the first rib resection is completed, and the two are removed together as a single specimen (see Fig. 15-10, E). Brachial Plexus Neurolysis After scalenectomy and removal of the first rib, attention is returned to the brachial plexus to ensure that each of the contributing nerve roots is meticulously dissected free of perineural fibrous scar tissue. This aspect of the operation is not complete until each nerve root from C5 to T1 is dissected throughout its course in the operative field to ensure full mobility. Pectoralis Minor Tenotomy To ensure thorough relief of brachial plexus nerve compression for neurogenic TOS, pectoralis minor tenotomy is performed as an addition to supraclavicular thoracic outlet decompression when indicated by previous clinical findings or as an isolated procedure when this site is the dominant location of nerve compression symptoms. In the presence of distinct localizing findings, pectoralis minor tenotomy may also be performed in patients with persistent or recurrent neurogenic TOS who have previously undergone thoracic outlet decompression by other approaches. A short, vertical infraclavicular incision is made in the deltopectoral groove, beginning just below the coracoid process (Fig. 15-11). The fascia between the deltoid and the pectoralis major muscles is divided medial to the cephalic vein and separated with a self-retaining retractor. The lateral edge of the pectoralis major muscle is gently retracted medially and lifted to expose the underlying fascia. The pectoralis minor muscle is exposed and encircled near its insertion on the coracoid process, taking care to protect the underlying neurovascular bundle (see Fig. 15-11). The pectoralis minor tendon is then divided under direct vision, within 2 cm of the coracoid, using electrocautery. The medial edge of the divided muscle is oversewn to ensure hemostasis, and the remaining clavipectoral fascia is opened to the level of the clavicle. No further dissection of the brachial plexus or axillary vessels is performed once the pectoralis minor muscle has been divided.

Answer 153

Management of an Associated Subclavian Artery Aneurysm Patients with arterial TOS are characterized by formation of poststenotic subclavian artery aneurysms, which typically arise within several centimeters of the scalene triangle where the subclavian artery crosses over the first rib and underneath the clavicle. Subclavian artery aneurysms almost always occur in association with a cervical rib or anomalous first rib. Regardless of size or potential for rupture, these lesions are frequently complicated by intimal ulceration, mural thrombus, and distal thromboembolism. Surgical treatment may initially require treatment of distal arterial occlusions because of emboli to the brachial, radial, ulnar, or a combination of these arteries. Definitive imaging assessment of the subclavian artery may be accomplished by intraoperative catheter-based arteriography, intravascular ultrasound, or both to identify intimal ulceration, mural thrombus, or wall thickening. For small aneurysms without evidence of ulceration or mural thrombus, thoracic outlet decompression alone may suffice; however, even small aneurysms with evidence of ulceration or previous thromboembolism should be repaired. After supraclavicular decompression, as described earlier for neurogenic TOS (including removal of the cervical and first ribs), the subclavian artery is mobilized in preparation for interposition graft repair of the aneurysmal segment. In the event that satisfactory distal control of the nonaneurysmal subclavian artery cannot be obtained from the supraclavicular exposure alone, a transverse infraclavicular incision is made with division of the pectoralis minor muscle tendon, and the axillary artery is isolated for distal vascular control. The proximal subclavian artery is clamped immediately distal to the vertebral artery, and the distal subclavian artery is clamped immediately beyond the aneurysm. The intervening segment of subclavian artery is excised, and the artery is replaced with an interposition bypass graft using beveled end-to-end anastomoses. Although reversed saphenous vein grafts are typically too small in caliber for subclavian artery replacement, conduits more suitable for this type of reconstruction include Dacron or polytetrafluoroethylene prosthetic grafts, cryopreserved femoral artery allografts, and autologous deep vein (e.g., superficial femoral) or artery (e.g., iliac) grafts. In most cases a completion arteriogram is performed to evaluate the subclavian artery reconstruction in different positions of the arm and to reassess the distal circulation.

Answer 154

Operative management for venous TOS begins with supraclavicular decompression, as described earlier for neurogenic TOS, except that the anterior first rib is not yet divided. To accomplish complete resection of the anteromedial portion of the first rib, a second transverse skin incision is made one fingerbreadth below the medial clavicle. The upper and middle portions of the pectoralis major muscle are spread, and the anteromedial cartilaginous portion of the first rib is identified. This is facilitated by applying downward fingertip pressure to the divided posterior segment of the first rib from within the supraclavicular incision, which places the attachments between the medial first rib and the clavicle under tension and allows the superior edge of the first rib to be dissected from its soft tissue attachments through the infraclavicular incision. The subclavius muscle tendon, the costoclavicular ligament, and the muscles of the first intercostal space are all divided under direct vision without entering the subclavian vein, and the first rib is divided adjacent to the sternum with Giertz-Stille rib shears. The entire first rib is then withdrawn from the operative field as a single specimen. The axillary-subclavian vein is identified underneath the clavicle through the lateral portion of the infraclavicular exposure and carefully separated from the subclavius muscle. Collateral vein branches that enter the subclavian vein are ligated and divided, and the subclavius muscle is resected. Further exposure of the subclavian vein is undertaken through the supraclavicular exposure and continued medially toward the junction of the subclavian and internal jugular veins to form the innominate vein. The internal jugular vein is fully exposed several centimeters superior to its junction with the subclavian vein, and the innominate vein is exposed for several centimeters into the upper mediastinum. A significant collateral branch of the subclavian vein is usually present underneath the medial clavicle, which must be ligated and divided to permit the subclavian vein to fall away from the clavicle. The course of the phrenic nerve into the upper mediastinum is also noted, and the nerve is protected where it passes underneath the subclavian vein. Pathologic changes in the central portion of the subclavian vein are assessed both visually and by digital palpation. Because the subclavian vein is typically found to harbor a focal area of fibrous wall thickening resulting from chronic repetitive injury, residual scar tissue surrounding the vein is excised (circumferential external venolysis). In up to 50% of patients with venous TOS, this results in reexpansion of the previously constricted segment of the vein; if the underlying vein is soft to palpation and easily compressible, with evidence of rapid filling and emptying during respiratory variation, it is likely that no further venous reconstruction is necessary. When external venolysis does not alleviate subclavian vein obstruction, or when intraoperative venography demonstrates a residual stenosis despite the apparent success of external venolysis, additional venous reconstruction is performed. After systemic anticoagulation (dextran and heparin), clamp control is obtained of the distal subclavian and internal jugular veins and a pediatric Satinsky clamp is passed around the upper portion of the innominate vein. A longitudinal venotomy is created along the superior aspect of the subclavian vein, and the lumen is thoroughly inspected. If the luminal surface is smooth and free of thrombus, a vein patch angioplasty is performed using a segment of the great saphenous vein or a cryopreserved femoral vein allograft. When performing this step it is important to construct the patch angioplasty along the entire length of the affected vessel, both proximal and distal to the stenotic segment, including extension into the anteromedial aspect of the innominate vein. When dense fibrosis remains within the wall of the subclavian vein despite external venolysis, or if there is ulceration and mural thrombus present upon inspecting the lumen, the affected segment of the subclavian vein is excised and replaced by interposition bypass. The distal portion of the interposition graft is constructed using a widely beveled end-to-end anastomosis to the unaffected axillary-subclavian vein. The proximal anastomosis is constructed in a wide end-to-side anastomosis, extending the graft into the anteromedial innominate vein. Because the caliber of the saphenous vein is usually too small to match the subclavian vein, use of the saphenous vein requires creation of a panel graft to increase the diameter to twice that of the native saphenous vein. Alternatively, subclavian vein interposition bypass can be performed with a cryopreserved femoral vein allograft, which can be readily obtained in a suitable size without the need for panel graft construction. Finally, intraoperative venography is used to confirm satisfactory subclavian vein reconstruction, typically performed through the cephalic vein in the distal forearm. Our operative approach also includes frequent construction of a temporary radiocephalic arteriovenous (AV) fistula between the end of the distal cephalic vein and the side of the radial artery at the wrist, used as an adjunct to increase upper extremity venous blood flow during the first several months after the operation. The AV fistula is maintained until 12 weeks after surgical treatment, at which time it is ligated under local anesthesia at 12 weeks and a follow-up contrast venogram is performed.

Answer 155

Closure The apex of the pleural membrane is purposefully opened, and a round 19-Fr fluted silicone closed-suction Blake drain (Ethicon, Somerville, New Jersey) is placed into the supraclavicular field with a trocar through a separate stab wound, where it is placed behind the brachial plexus with its end lying within the upper posterior aspect of the pleural space (Fig. 15-12). Two small 12.5-cm multihole catheters are placed within the wound, one adjacent to the brachial plexus and one within the bed of the resected first rib. These catheters exit the skin adjacent to the wound and are connected to a sustained-infusion delivery system for postoperative administration of 0.25% to 0.5% bupivacaine (On-Q PainBuster system, I-Flow/Kimberly Clark, 400 mL at 2 mL/hr through each catheter, catalog No. PM028-A). A 100 × 130 × 0.02 mm sheet of bioresorbable polylactide film (SurgiWrap, Mast Biosurgery, catalog No. 27202-05) is placed around the brachial plexus nerve roots to limit the potential for postoperative perineural fibrosis. The film is held together with several 5-0 polydioxanone sutures (Ethicon) and attached to the base of the scalene fat pad. The scalene fat pad is reapproximated over the brachial plexus and held in position with interrupted 3-0 silk sutures to the back of the sternocleidomastoid muscle and the periclavicular fascia. The edges of the platysma muscle are reapproximated with interrupted sutures, and the skin is closed with a subcuticular stitch.

Answer 156

Postoperative Care * An upright chest radiographic examination is performed in the recovery room and each day after surgery. Small air or pleural fluid collections are observed with the expectation of spontaneous resolution. * Postoperative pain medication is provided by intravenous opiates (patient-controlled analgesia) until adequate control can be achieved by oral medications alone. The continuous-infusion anesthesia system is discontinued on postoperative day 3. Oral narcotics, a muscle relaxant, and a nonsteroidal antiinflammatory agent are routinely prescribed upon hospital discharge and for at least several weeks after surgery. * Patients with venous TOS are maintained on intravenous dextran for 48 hours and then switched to heparin or warfarin and clopidogrel. Anticoagulation and antiplatelet therapy are both discontinued 12 weeks after the operation, along with outpatient ligation of the AV fistula and follow-up venography. * Patients are usually discharged from the hospital 4 to 6 days after the operation. The closed suction drain is removed as an outpatient procedure 7 to 10 days after surgery, when the daily output of serous fluid has decreased to less than 50 mL. * Physical therapy is resumed the day after surgery and continued upon hospital discharge. Patients are advised to avoid excessive reaching overhead or heavy lifting with the affected upper extremity and are cautioned against activities that can result in muscle strain, spasm, and significant pain in the trapezius and other neck muscles. * A gradual return to use of the upper extremity is encouraged, with the majority of patients permitted a cautious return to light-duty work activities by 4 to 6 weeks after the operation. Work restrictions are recommended to prevent heavy activity during the early stages of return to work, particularly to avoid excessive use of the upper extremity by lifting or repetitive activities that may contribute to postoperative complaints. * Physical therapy is continued for as long as necessary to allow the patient to return to an optimal level of function, and patients are seen at least every 3 months in the first year to assess long-term results.

Answer 157

Postoperative Complications * Residual neurologic symptoms. Symptoms of numbness and tingling in the hand or fingers are common early after thoracic outlet decompression, arising as a result of previous neurologic damage, intraoperative mobilization of the brachial plexus, and postoperative inflammation and perineural wound healing. The use of continuous local anesthetic infusions for pain control may also result in sensory neurologic symptoms. More pronounced neurologic dysfunction including motor deficiencies are rarely observed, particularly arm weakness and loss of handgrip strength but may represent temporary brachial plexus neuropraxia or pain-limited restrictions in mobility. Spontaneous resolution of such symptoms usually occurs within several days to weeks but may persist for several months. Patients with longstanding neurogenic TOS can often display residual symptoms of pain, dysesthesias, numbness, weakness, and other complaints that may not be eliminated by thoracic outlet decompression. Although these symptoms may be tolerable and are expected to gradually improve, the surgeon must provide continuing support and reassurance during the prolonged period of recovery and rehabilitation. * Pleural Effusion. Mild to moderate pleural fluid collections are often observed on the side of surgery after supraclavicular decompression, consisting of serosanguineous fluid that can be expected to spontaneously resorb within several days to weeks. Although well tolerated by most patients, some may experience shortness of breath with exertion until the fluid has resolved. In such individuals chest radiographs are useful to distinguish the presence of a pleural effusion from the effects of diaphragmatic elevation because of phrenic nerve dysfunction. * Bleeding. Postoperative bleeding is uncommon but can result in wound hematomas or when substantial may lead to a hemothorax. Early anticoagulation after operations for venous TOS can elevate the risk of bleeding complications. Although often self-limited, reexploration of the supraclavicular wound allows the operative site to be directly inspected and any specific site of bleeding to be controlled. Evacuation of hemothorax can usually be achieved through this approach as well, avoiding the need for chest tube placement. * Lymph leak. If there is persistent or increasing drain output of lymphatic fluid of more than 250 mL/day, particularly when chylous in appearance and on the left side, a clear liquid diet is maintained, along with administration of octreotide to reduce the volume of lymph flow, and removal of the closed-suction drain is deferred until the leak has subsided. Early supraclavicular reexploration is recommended for persistent high-volume lymph leaks (>500 mL/day for >5 days) or those resulting in chylothorax. * Phrenic nerve dysfunction. Elevation of the ipsilateral diaphragm on postoperative chest radiographs indicates the presence of phrenic nerve dysfunction, which may be associated with shortness of breath on exertion or supine reclining, as well as lower lateral chest discomfort. Most individuals compensate satisfactorily with the contralateral diaphragm and intercostal muscles, and many become asymptomatic within a short period, but patients with severe underlying pulmonary disease may be at risk for significant disability. Postoperative phrenic nerve dysfunction is usually a temporary finding because of intraoperative mobilization of the nerve or postoperative infusion of local anesthetic, but on occasion phrenic neuropraxia can persist for several weeks; in rare situations, phrenic neuropraxia may be prolonged up to 9 to 10 months before signs of reinnervation appear. Most patients should be managed expectantly. * Long thoracic nerve dysfunction. Postoperative dysfunction of the long thoracic nerve is occasionally observed after thoracic outlet decompression, resulting in a winged scapula defect because of weakness of the serratus anterior muscle. Scapular dysfunction because of this defect is readily detectable by physical examination, and it may interfere with shoulder girdle mechanics and physical therapy, thereby prolonging full recovery from operation. Although there is no specific treatment, long thoracic neuropraxia is usually self-limited and recovery can be expected within several months.

Answer 158

Preoperative Preparation * True effort thrombosis almost always produces acute symptoms, and the patient usually presents to the clinic or emergency department with a swollen, blue, painful arm. Clinical clues include a history of vigorous activity, often with the affected arm overhead, and even if the onset of swelling is acute, a history of intermittent swelling, discoloration associated with activity, or both is common. Patients may have prominent chest wall or shoulder collaterals. * Duplex imaging should be performed to confirm the diagnosis. * If duplex is negative or equivocal, computed tomography or magnetic resonance venography can be considered. The patient with a duplex ultrasound venous thrombosis should be anticoagulated, with intravenous access established in the contralateral extremity. * Success of catheter-directed thrombolytic therapy rapidly decreases from onset of symptoms to intervention. Therefore, although not an emergency, treatment should be initiated within hours to a day or so after diagnosis unless contraindications exist. Although algorithms differ, pharmacologic or pharmacomechanical thrombolysis followed by transaxillary first rib resection during the same admission is an accepted approach. If thrombolysis is planned, pregnancy testing should be performed and renal function should be assessed. Pitfalls and Danger Points * Pulmonary embolism * Vessel perforation * Bleeding risk after thoracic outlet decompression is increased if surgery is performed within hours to days after thrombolysis. * Venous occlusion while awaiting thoracic outlet decompression may occur in 10% to 33% of patients if surgery is delayed for months, but is uncommon (5%) if surgery is performed within several days of thrombolysis.

Answer 159

Timing * Thrombolysis—initiation. Catheter-directed thrombolysis is most effective if performed as soon after thrombosis as possible. The success rate nears 100% if initiated within a few days of symptom onset but drops significantly if initiated after 7 to 14 days. In three series, no patient with symptoms persisting for longer than 7, 8, and 10 days, respectively, had successful lysis.8-10 The success rate in patients at the University of Rochester with symptoms of less than 14 days’ duration has been 84% over the past decade.11 * Thrombolysis—duration. Thrombolysis should be continued for approximately 48 hours before concluding that no further clot lysis can be achieved. Recent reports have demonstrated that pharmacomechanical lysis may be highly beneficial using the AngioJet (Medrad Interventional/Possis; Minneapolis, Minn.), EkoSonic (EKOS, Bothell, Wash.), or Trellis (Bacchus Vascular, Santa Clara, Calif.) systems with recanalization of the occluded vein within minutes to hours. If residual thrombus remains, a trial of standard catheter-based lytic infusion can be continued. * Decompression. After clot dissolution, the thoracic outlet must be decompressed to relieve compression at the costoclavicular junction, although the timing of the second procedure has been the subject of debate. It was originally recommended that thoracic outlet decompression be delayed 3 months to allow the vessel to heal and to lessen the risk of surgical complications.12 However, it was later recognized that rethrombosis occurs in up to one third of patients so treated. Most now recommend that decompression follow thrombolysis as soon as possible—ideally during the same admission. This may result in a somewhat higher complication rate but better long-term success; modern series following this algorithm show long-term symptom-free status in 95% to 100% of patients.6,13 * Angioplasty and stenting before bony decompression. After thrombolysis a significant number of patients are shown to have intrinsic venous defects, and essentially all have extrinsic compression at the costoclavicular junction. Angioplasty and even stenting of these patients is tempting, but the costoclavicular junction is unyielding, and angioplasty before decompression will commonly fail.14 It has been suggested that angioplasty prior to decompression may worsen venous patency by further damaging the vein wall.15 Stenting of the vein may also be complicated by stent fracture in some, deformation in nearly all, and rethrombosis rates as high as 40%.14 Stents complicate subsequent repair and therefore should be avoided. * Angioplasty and stenting after bony decompression. It is tempting to perform angioplasty, stenting, or both when residual defects are seen after thoracic outlet decompression. In one recent study stent patency was 64% at 3.5 years in 14 patients who were stented after decompression, compared with 100% at 4 years in 9 patients undergoing angioplasty alone.16 Although this may simply represent selection of more extensive residual lesions, some evidence suggests that postdecompression balloon angioplasty and observation alone for residual defects yield good long-term results. Anecdotal experience suggests that many “intrinsic” defects result from residual external scarring and that external venolysis can eliminate the need for endoluminal intervention in at least some cases (Fig. 17-4). Molina advocates aggressive direct venous reconstruction at the time of thoracic outlet decompression, which eliminates the need for angioplasty and stenting.13,17 Many clinicians simply leave such lesions alone, citing the very high, long-term symptom-free status in almost all cases.

Answer 160

Access The entire arm should be circumferentially prepped into the operative field to maximize sterility and surgical options. It is critically important to achieve access into the deep venous system—in order of preference, the basilic vein medial to the antecubital fossa, the brachial-axillary veins in the midupper arm, or the brachial veins surrounding the brachial artery in the antecubital fossa, which is less convenient for the patient. The cephalic or antecubital veins should not be used, because entry to the deep system is high in the arm at the deltopectoral groove. Therefore the axillary, brachial, and basilic veins may not be visualized or accessible. Even if pathology is central to the deltopectoral groove, access to central veins is difficult and there is a high rate of cephalic vein obliteration. The more central brachial-axillary veins within the axillary sheath are also a poor choice, because of the increased risk of axillary sheath hematoma. Access to all vessels is best performed using ultrasound guidance. Sheath Placement After placement of a guidewire, a conventional sheath is placed. Because of the high likelihood of requiring intervention and the benign nature of venous access, a 6-Fr short, conventional sheath can be placed because manipulation is relatively straightforward. Thrombolysis The procedure begins with full diagnostic venography. Hand injection in aliquots of 20 cc of 50% contrast provides excellent visualization, although use of a power injector allows reduced radiation exposure to the surgeon. The entire arm central to the sheath should be imaged as the brachial vein is often partially or fully thrombosed, but attention should be focused on the costoclavicular junction. If complete thrombosis is present, a flow void with or without meniscus is typically seen (Fig. 17-6), and the arm drains via prominent collaterals. Even if the lesion does not appear critical, the presence of collaterals documents its hemodynamic significance. If inflow is brisk and collaterals are not observed, the test should be repeated with the arm abducted greater than 90 degrees. If stenosis, occlusion, or new collaterals are seen, venous compression at the costoclavicular junction is confirmed, although thrombolysis is not needed. Finally, if the situation is unclear, intravascular ultrasound can be used, although its sensitivity and specificity has not been well defined in this situation. As with any thrombolytic procedure, the first step is crossing the lesion with a wire. It is almost always appropriate to use a combination of an angled “vertebral” catheter along with a hydrophilic wire; if support is not adequate, the working sheath can be exchanged for a long sheath placed near the lesion. As with any attempt to cross a vascular occlusion, skill and experience are required to recognize extravascular wire passage. If needed, a puff of contrast through a catheter can distinguish an intraluminal from an extraluminal position. Extravascular wire passage in this circumstance is relatively benign and should be treated by withdrawing the wire and catheter to a confirmed intravascular location with another attempt through a different plane. The exception occurs in the treatment of lesions in the superior vena cava, where fatal tamponade can occur. The observation that successful wire passage is a predictor of successful thrombolysis in occluded arterial segments does not seem to hold true in primary axillary-subclavian vein thrombosis. Wire passage is almost always possible, but in many patients the vein cannot be successfully opened. This may be due to the greater incidence of intrinsic fibrotic damage to the vein itself. Available options, including conventional pharmacologic thrombolysis or pharmacomechanical thrombolysis, are described as follows: * Conventional pharmacologic thrombolysis is performed using conventional techniques. Venography is used to delineate the length of the thrombosed segment, and an infusion catheter is selected with an infusion length sufficient to treat the entire lesion. Frequently such lesions are shorter than the shortest available catheter; in this situation the excess length should be positioned peripheral to the occlusion. Although many pharmacologic options exist, a commonly used protocol includes tissue plasminogen activator (tPA) at a rate of 1 mg/hr through the infusion catheter, with heparin concomitantly infused through the sheath at a rate of 500 units/hr. Laboratory values do not need to be routinely monitored in this situation, and the patient may be admitted to a conventional floor bed. Ideally venography should be repeated at 8- to 12-hour intervals, but the very short segment being treated, low-pressure venous access, and young age of the majority of these patients makes reevaluation the next day safe. Should residual thrombus be noted, thrombolysis should be continued for up to 48 hours before concluding that maximum benefit has been achieved. * Pharmacomechanical thrombolysis is an excellent option and can be carried out with the AngioJet device, using the “power pulse spray” mode (Fig. 17-7). After wire passage a solution of 20 mg of tPA in 250 cc of saline solution is readied. Under fluoroscopic guidance, 10 mg of tPA is infused under pressure over 5 minutes to thoroughly impregnate the thrombus, followed by a 20- to 30-minute dwell time. Conventional AngioJet aspiration is then performed with saline followed by repeat imaging. If partial success is seen, aspiration is repeated. Once the vein is fully opened or further aspiration will be of little added benefit, the procedure is halted. If the vein is completely open, the sheath can be left in place for subsequent imaging at the time of thoracic outlet decompression, whereas if residual defects are seen, thrombolysis should be continued overnight followed by repeat imaging. If residual defects are thought to be extrinsic or fibrotic, continued thrombolysis is unlikely to be beneficial. Angioplasty and Stenting Angioplasty of residual lesions will not be of benefit unless the costoclavicular junction is decompressed and may, in fact, be unnecessary after decompression. Angioplasty should be reserved for significant residual lesions after first rib resection; therefore, if surgery is performed soon after thrombolysis, the sheath should be left in place for repeat imaging during surgery. Stenting before decompression may be harmful and should rarely be needed even after decompression. Some controversy exists regarding management of the vein that remains completely occluded after complete, aggressive endovascular intervention. Some recommend first rib resection because a significant number of such patients spontaneously recanalize18 and the majority become symptom free. Forcible dilation and stenting may lead to eventual stent fracture and rethrombosis. Completion Studies If a residual defect is observed, the sheath may be left in place for venography immediately after first rib resection with the need to perform angioplasty individualized.

Answer 161

Postoperative Care * A chest radiograph is obtained in the recovery room and on the first postoperative day to exclude a pneumothorax. Radiographic examination also confirms removal of the correct rib and may be performed in the operating room if there is any question. After thrombolysis the risk of bleeding is significant, and close attention paid to both physical examination and findings on the chest radiograph. * Anticoagulation. Heparin is administered intravenously at 500 units/hr beginning 6 hours after surgery, with transition to full anticoagulation by 12 to 18 hours. Warfarin is administered on the evening of the first postoperative day and in young, healthy adults an oral dose of 10 mg on each of the first two days after surgery is an appropriate loading dose. Discharge is almost always possible before the international normalized ratio is between 2.0 and 3.0, and in this situation the patient may be bridged with self-injected, subcutaneous low-molecular-weight heparin. Anticoagulation is continued for 3 to 6 months. * Analgesia. The patient is placed on a patient-controlled anesthesia pump immediately after surgery, and on the first postoperative day oral narcotic analgesia is begun. * Drains. If a drain is left, it can be removed by the first postoperative day assuming there is no significant bleeding, the drainage is not chylous, and no pneumothorax is seen. * Physical therapy. Active range of motion maneuvers should begin on the first postoperative day, with active rehabilitation begun in 3 to 4 weeks. * Postoperative imaging. The patient is seen 3 to 4 weeks after surgery for examination and duplex ultrasound imaging. The patient is reassessed at 6 months and if the vessel is patent, warfarin is discontinued, and the patient reevaluated at 1 year and yearly thereafter. If the vessel remains occluded, warfarin can be continued with follow-up every 6 months, if there are no contraindications to its use. Coumdain should be discontinued if recannalization has not occurred by 2 years. Complications * Access site complications. Local access complications are quite minor, because the venous system alone is involved. Inadvertent arterial puncture can cause axillary sheath hematoma or distal ischemia or emboli, but this can be minimized by the use of ultrasound-guided access techniques and access via the relatively peripheral basilic vein. * Local bleeding. Local bleeding is common but relatively minor and can be managed by pressure, reinforcing the dressing, or occasionally placing a purse string suture around the catheter. * Systemic bleeding. Systemic bleeding is rare. Routine monitoring of fibrin degradation products is not necessary, and most patients can be monitored on a surgical floor. * Pulmonary embolism. Clinically relevant pulmonary embolism is exceedingly rare during venous thrombolysis, but subclinical embolism is probably frequent.11 * Morbidity. A recent review showed that complications after first rib resection occurred in up to 5.6% of patients.1 Bleeding complications after subsequent thoracic outlet decompression are significantly increased if surgery is performed within hours to days after thrombolysis. These can manifest as a wound hematoma or hemothorax if communication with the pleural space has occurred.

Answer 162

- after induction of general anesthesia place a shoulder roll and turn head to the opposite side with the arm prepped and draped into the field. - make transverse supraclavicular incision and infraclavicular incisions (1cm above and below the clavicle 10cm in length) - from the supraclavicular incision, make subplatysmal flaps, mobilize and retract the scalene fat pad superolaterally, identify and protect the phrenic nerve - indentify the thoracic duct medially at the confluence of the brachiocephalic vein and ligate it to prevent leaks - dissect the anterior scalene and middle scalene muscles off the first rib, taking care to identify and preserve the long thoracic nerve - from the infraclavicular approach, split the pec major muscle and identify the subclavian vein - remove the first rib using the supraclavicular and infraclavicular incision, taking care not to violate the pleura - perform external venolysis - pleural leak test and close the space over a drain

Answer 163

close the pleura with absorbable suture and do a bubble test at the end of the procedure with anesthesia doing a valsalva (forceful exhalation against closed airway) venous patch angioplasty

Answer 164

- after induction of general anesthesia place a shoulder roll and turn head to the opposite side with the arm prepped and draped into the field. - make transverse supraclavicular incision and infraclavicular incisions (1cm above and below the clavicle 10cm in length) - from the supraclavicular incision, make subplatysmal flaps, mobilize and retract the scalene fat pad superolaterally, - identify the thoracic duct medially at the confluence of the brachiocephalic vein and ligate it to prevent leaks - mobilize the subclavian vein, identify and protect the phrenic nerve, divide the anterior scalene off the first rib - dissect the middle scalene muscle off the first rib, taking care to identify and preserve the long thoracic nerve - identify the subclavian artery and dissect it free proximally and distally - Free the first rib of its attachments and resect it with a bone cutter (remove cervical rib with a rongeur if present) - remove the first rib using the supraclavicular and infraclavicular incision, taking care not to violate the pleura - Heparinize the patient with 80-100u/kg heparin and wait for ACT > 250 - clamp the arteries proximally and distally, resect the aneurysm and perform interposition bypass - pleural leak test, reapproximate the scalene fat pad, and close the space over a drain

Answer 165

lymphatic leak MCFA diet, antibiotics and continued drainage rexploration and drainage NPO w TPN x 2 weeks VATS right Thoracic duct ligation

Answer 166

- after induction of general anesthesia, a bean bag is used to place the patient in the left lateral decubitus position and an arm retractor is used to support the arm - Incision just inferior to the hair bearing portion of the axilla, carry down to the chest wall, keeping the latissimus dorsi posterior and pec major anterior - elevate arm and secure the retractor, using lighted retractors, elevate the tissue off the rib cage until the first rib is identified - clean off the anterior surface of the first rib with periosteal elevator - divide anterior scalene off the first rib sharply and divide subclavius tendon - free bottom of the rib anteriorly and posteriorly and then divide the rib with a bone cutter. Any further posterior rib should be taken back carefully with a rongeur to avoid the brachial plexus injury - perform neurolysis - saline valsalva maneuver to eval for pleural leak - close in 2 layers

Answer 167

- hx cervical trauma, repetitve use injuries, carpal tunnel - physical exam EAST, Elveys, supraclavicular tenderness or masses - Imaging, MRI, CT, Xray - PT x 6 months - Referral to pain specialist for anterior scalene muscle block success---> surgery (conservative trt with botox injection)

Answer 168

high TG >110mg/dl low chol <200mg/dl

Answer 169

The first step in a transmetatarsal amputation (TMA) is to make a curved fish-mouth incision just proximal to the infected tissue of the foot (see the image below). The incision runs from the midshaft of the fifth metatarsal laterally to the midshaft of the first metatarsal medially through a midplane axis. The incision is started at the dorsal surface and extended downward to bone. As the incision is deepened, hemostasis is achieved by means of electrocuatery or vessel ligation and ties. The bony landmarks of the metatarsals are identified and presented by means of a periosteal elevator. The metatarsals are cut with a saw, and the bony ends are rounded with a bone nibbler Next, the plantar incision is made. A plantar flap is created. Plantar and dorsal tendons are stripped off their insertions and cut. Copious amounts of irrigant fluid are then used. The flaps are approximated with nylon

Answer 170

The right/left foot was prepped and draped in a sterile fashion. A skin tear shaped skin incision was then performed in the web space around the toe. The apex of the incision is dorsal. The dorsal part of the incision is carried proximally over the metatarsophalangeal joint. With sharp and blunt dissection, the surrounding skin and subcutaneous tissue are reflected aside. All bleeders are cauterized. The extensor and flexor tendons are pulled distally and severed at their most proximal portion in the wound. The periosteum was then elevated with a periosteal elevator. The bone was then transected at the metatarsophalangeal level. Hemostasis was then secured and the wound was irrigated. The skin was then closed with interrupted sutures of 4-0 nylon.

Answer 171

11.3.1 SMA Aneurysm If symptomatic, most SMA aneurysms are mycotic in nature and require treatment. Treat with resection and saphenous vein interposition and 6 weeks antibiotic therapy based on intraoperative cultures.(Lee et al. 2008 Nov-Dec)

Answer 172

Repair all pseudoaneurysms, or if size > 3cm, or at any size if of childbearing age. Consider splenectomy vaccines pre-treatment (covers encapsulated organisms Shigella, Haemophilus influenzae, and Neisseria). Post splenic aneurysm embolization, L flank pain in stable patients likely represents splenic infarction. Treat with hydration and analgesia. Rates are lower in stented patients.(Kwong, Rockman, and Kashyap, n.d.; Piffaretti et al. 2007; Zhu et al. 2019) Splenic artery embolization also an effective way to treat thrombocytopenia, particularly chemo induced, when splenectomy is too high risk.

Answer 173

Median arcuate ligament syndrome (MALS), which has many names (Dunbar syndrome, celiac axis compression syndrome, etc.) is a somewhat controversial entity that occurs when repeated compression of the celiac artery occurs against the median arcuate ligament during respiratory variation. The thing you want to visualize here is that during full exhalation, the lungs are completely emptied, and the diaphragm moves up at a sharper angle. This angulation kinks off the celiac artery more severely, so velocities in exhalation are higher in MALS. However, these findings are common in asymptomatic patients, and so just like chronic mesenteric ischemia, the clinical presentation is key. They’ll have a similar presentation as chronic mesenteric ischemia patients, with post-prandial pain, food fear, and weight loss, but often the symptomatology is a little more indolent in these patients. Because of this, these patients have frequently gotten the million dollar workup for nonspecific GI pain. Duplex ultrasound of shows celiac PSV >200 and EDV >50, normalizes during deep inspiration, and post-stenotic spectral broadening.(Zwolak et al. 1998) The treatment of choice for suspected MALS is a laparoscopic median arcuate ligament release, frequently performed by a MIS/foregut surgeon. A key point here is that you don’t want to be fooled into putting a stent in these patients before they’ve gotten their median arcuate ligament release, because the dynamic motion of the diaphragm is likely to crimp or bend the stent if that hasn’t been treated yet. It may be that some patients benefit from endovascular treatment after release, though, as some think that the chronic damage from MALS can result in intimal damage/scarring that persists even after the extrinsic compression is treated by the median arcuate ligament release.

Answer 174

SMA syndrome, also called Wilkie’s Syndrome is a rare entity where the 3rd portion of the duodenum gets compressed between the SMA and the aorta, causing a functional gastric outlet obstruction. Patients are typically emaciated, having lost a significant amount of weight before their symptom onset. What’s happened is they’ve lost the retroperitoneal fat pat that normally surrounds the SMA, and so the angle between the SMA and the aorta becomes more acute, pinching off the duodenum. Classic findings in fluoroscopic swallow in SMA syndrome are delayed gastric emptying, a dilated duodenum, to and fro peristalsis in the proximal duodenum and cutoff in the third portion. EGD can show pulsation in the 3rd portion of the duodenum.(Warncke et al. 2019) The treatment of choice here is enteral feeding with a nasojejunal tube or other surgically placed tube and TPN, because what really will help them here is weight gain. GJ bypass or duodenal mobilization is sometimes needed for treatment, but is controversial. It’s not really a mesenteric vascular disease, but it sometimes shows up on exams as a related entity.

Answer 175

Incision The appropriate incision for open surgical treatment of an aneurysm in the middle portion of the splenic artery is either a midline laparotomy or a bilateral subcostal approach. An aneurysm in the distal portion of the splenic artery can be approached from either a left subcostal or a midline abdominal incision. Exposure of the Splenic Artery After initial exploration of the abdominal cavity, the greater omentum is reflected upward while downward traction is maintained on the transverse colon. The omentum is separated using sharp dissection, and the lesser sac is entered. The posterior gastric wall is swept away from the underlying pancreas, and the entire pancreas is exposed from its head to the hilum of the spleen. The splenic artery and vein are located as they run along the superior surface of the body and tail of the pancreas. An incision in the posterior peritoneum allows direct exposure of the origin and middle portion of splenic artery, where most splenic artery aneurysms are located. If the aneurysm is located in the distal splenic artery or adjacent to the splenic hilum and concomitant splenectomy is planned, the lesser sac may be entered via the gastrosplenic ligament using medial traction on the stomach. The distal portion of the splenic artery can be palpated after its course along the upper margin of the pancreas. The peritoneum overlying the vessel is incised, proximal vascular control is gained, and the artery, along with the splenic vein, is ligated. Splenectomy with the distally located aneurysm can then be performed en bloc. Ligation of the Splenic Artery Aneurysm The operative treatment of splenic artery aneurysms almost never requires formal vascular reconstruction. There is a rich collateral network of blood vessels supplying the spleen and emanating from the short gastric arteries, and splenic infarction is rare. When the aneurysm is located in the distal splenic artery, adjacent to the splenic hilum, splenectomy is performed. When the aneurysm is located in the middle portion of the splenic artery, formal ligation of the splenic artery both proximal and distal to the aneurysm is the preferred treatment (Fig. 42-3). Although some authors have reported performing excision of the aneurysm, if small, with a primary end-to-end anastomosis to reestablish flow in the splenic artery, this is not clinically necessary to maintain adequate perfusion of the spleen. After the aneurysm has been located and confirmed by palpation within the lesser sac, gentle dissection of the proximal splenic artery is performed close to its origin from the celiac artery trunk; the artery is mobilized and encircled with a vessel loop. Similarly, dissection of the splenic artery distal to the aneurysm is performed. When the aneurysm is relatively small, this is relatively simple to accomplish. However, when an extremely large or “giant” splenic artery aneurysm is present, location of the normal proximal and distal splenic artery may be difficult, with visualization compromised by the large aneurysm. Once control of the splenic artery proximal and distal to the aneurysm has been obtained, the vessels may be clamped and the aneurysm may be opened. If small pancreatic branches are bleeding from within the aneurysm sac, these may be ligated from within. A portion of the aneurysm wall may be excised for pathology if this is deemed necessary, but it is not necessary to remove the aneurysm sac. The proximal and distal arteries are then ligated using running monofilament suture.

Answer 176

I would perform a timeout Confirm correct patient, site and procedure Atx, allergies and surgical plan

Answer 177

I would obtain a history and physical exam - specific to case I would also want: past medical history current medications/allergies prior surgeries for the PE I would perform a full physical focusing on ... --> labs, imaging

Answer 178

>70% stenosis PSV > 300 Vr >3.5 PSV < 45cm/s ABI drop > 0.15

Answer 179

I've never done this procedure, but I understand this is how it is done. I would ask my senior partner for assistance.

Answer 180

at least 1 cm 2cm proximal and distal landing zone

Answer 181

> 80% PSV > 340, Vr: ICA/CCA >4.15

Answer 182

CIA diameter: 17mm EIA: 6.5-25mm IIA: 6.5-13.5mm Distance from lowest renal 165mm unilateral IBE, 195 bilateral Length 10cm graft, 23mm proximal

Answer 183

-Access bilateral CFA with preclose technique and ultrasound guidance - heparinize - Stiff wires, upsize to interventional sheaths - Use omni to advance glidewire over aortic bifurcation - snare it and remove from opposite groin - Exchange glide for stiff wire - Advance IBE with precannulation of IIA gate - retrograde angio, position and deploy IBE to contra gate - Advance contralateral sheath into IIA gate - Select IIA, Advance and position stent graft, deply into IIA - angioplasty distal landing zone - Finish out IBE - Deploy main body stent graft - cannulate contra gate

Answer 184

- after general anesthesia place patient in right lateral decubitus position, right side down, axillary roll and padding of both legs - Make a curvilinear thoracoabdominal incision along the 8th intercostal space to just lateral to the umbilicus - divide the obliques and open fascia throughout the remainder of the inciison, leaving rectus intact - enter RP space just medial to the rib and develop a plane avoiding injury to the spleen - continue lateral dissection until the psoas muscle is exposed, medializing all bowel contents to the patients right - divide the diaphragm circumferentially to the left crus using marking stitches to assist with closure later - dissect out the aorta and its branches from distal thoracic aorta to the iliacs - heparinize the patient and give 1/2 mg/kg mannitol, wait for ACT > 250 - clamp proximal aorta and bilateral CIAs - aortotomy to the level of the supra celiac aorta, oversew any bleeding lumbars and administer cold perfusate to kidneys (20ml/min, 4C) - perform end to end anastamosis with a dacron graft with a beveled anastamosis incorporating RRA, celiac, SMA - move clamp down on to graft and evaluate hemostasis - check signals in celiac, SMA and RRA - bypass tot eh left renal and confirm patency with doppler - extend aortotomy to tge aortic bifurcation and perform end to end distal anastamosis to re-establish in line flow - check IMA for back bleeding and evaluate for re-implantation - close diaphragm, approximate ribs, bring muscle and fascial layers back together, chest tube prior to closure

Answer 185

- the patient is placed supine - left chest rotated 20 degrees up - anterior and lateral chest, shoulder and axilla prepped and raped - let transverse curvilinear incision made over the fifth rib from lateral sternal border to anterior axillary line - pectoral fascia and muscle fibers split to reach the intercostal muscles - divide the intercostal muscles on top of the fifth rib - parietal pleura incised, lung allowed to collapse away from the chest wall - internal thoracic artery and vein should be ligated and divided near lateral sternal border - rib spreader inserted and use to open the rib space - superior lobe of the left lung is retracted downward - aortic arch seen under mediastinal pleura, this is incised being careful for left vagus - subclavian exposed

Answer 186

mid- 6th intercostal space - patient placed in right lateral position - posterolateral thoracotomy made in 6th intercostal space curvilinear inscision from below left nipple to below the tip of the scapula - incision carried through skin and fascia - latissimus dorsi, serratus anterior and trap muscles are divided - the 6th interspace is entered - left lung allowed to collapse - rib spreaders placed - descending thoracic aorta identified anterior to vertebrae beneath pleura - pleura incised - aorta controlled

Answer 187

- right subcostal incision 4cm below and parallel to inferior costal margin from midline laterally ( can be carried across midline as chevron) The incision extends through the anterior rectus fascia, rectus muscle, internal oblique, transverse abdominis, transversalis fascia, and peritoneum. - midline laparotomy - hepatoduodenal ligament exposed by retracting right lobe of liver superiorly and packing intestines and right colon into the inferior wound - hepatoduodenal ligament incised transversely near superior wall of duodenum - hepatic artery is located on left side of common duct - artery mobilized and encircled with vessel loops on both side of the GDA

Answer 188

- bilateral subcostal incision - self-retaining retractor for cranial elevation of superior wound - transverse colon elevated and small intestines retracted to the right - left colon mobilized by incising lateral peritoneal attachements and plane between left colon mesentary and anterior surface of gerotas fascia is developed - mobilize colon to splenic flexure - spleen is mobilized by incising splenophrenic and splenorenal ligaments - plane between pancreas and gerotas fascia developed bluntly, allowing spleen and pancreas to be reflected anteromedially - splenic artery identified near superior border of the pancreas

Answer 189

- midline laparotomy - transverse colon elevated and small intestines retracted to the right - left colon mobilized by incising lateral peritoneal attachements and plane between left colon mesentary and anterior surface of gerotas fascia is developed - mobilize colon to splenic flexure - spleen is mobilized by incising splenophrenic and splenorenal ligaments - plane between pancreas and gerotas fascia developed bluntly, allowing spleen and pancreas to be reflected anteromedially - left renal vein identified crossing anterior to aorta, mobilized by ligating gonadal adrenal and lumbar branches - renal artery identified posterior to vein

Answer 190

- midline lap - small intestines retracted to the left - right colon peritoneal attachements incised and mobilized from cecum to hepatic flexure -duodenum mobilized by incising retroperitoneal attachments (kocher maneuver) reflecting duodenum and pancreas medially - this exposes IVC - right renal vein identified and encircled with tape - right renal artery identified posterior to vein, lateral to vena cava - IVC may need to be mobilized with leftward retraction

ORAL BOARDS Flashcards

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