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Flashcards in peripheral vascular problems Deck (20):
1

64yo woman complains of R calf pain and swelling. she recently underwent an uncomplicated L hemicolectomy for diverticular disease. a duplex US confirms the presence of DVT of the calf. which of the following is the most appropriate initial management of this pt?
a. pneumatic compression stockings
b. warfarin
c. heparin
d. thrombolysis
e. IVC filter

C

heparin --> bridge to warfarin

2

for the first 6h following a long and difficult surgical repair of a 7cm abdominal aortic aneurysm, a 70yo man has a total urinary output of 25mL since the operation. which of the following is the most appropriate diagnostic test to evaluate the cause of his oliguria?
a. renal scan
b. aortogram
c. L heart preload pressures
d. urinary sodium concentration
e. creatinine clearance

C

hypovolemia = ? distributive v. cardiogenic

dx of oliguria ESP AFTER CARDIAC SURGERY
1) Swan-Ganz catheter
2) FeNA; BUN/Cr

3

72yo man undergoes a aortobifemoral graft for symptomatic aortoiliac occlusive disease. the IMA is ligated at its aortic attachment. 24h after surgery, the pt has abdominal distension, fever, and bloody diarrhea. which of the following is the most appropriate diagnostic study for this pt?
a. aortogram
b. MRI
c. CT
d. sigmoidoscopy
e. barium enema

D
==> ischemic bowel dz in the rectosigmoid

sxs = abdomnal distention, fever, high WBC, bloody diarrhea in postop period

dx = sigmoidoscopy

4

25yo woman presents to the ED complaining of redness and pain in her R foot up to the level of the midcalf. she reports that her RLE has been swollen for at least 15y, but her L leg has been normal. on exam, she has a temp of 39C (102.2F), and the RLE is nontender with nonpitting edema from the groin down to the foot. there is cellulitis of the R foot without ulcers or skin discoloration. the L leg is normal. which of the following is the most likely underlying problem
a. congenital lymphedema
b. lymphedema praecox
c. venous insufficiency
d. DVT
e. acute arterial insufficiency

B


U/L primary lymphedema --> b/c cause is unknown
90% = hypoplasia of the lymphatic csystem of the LE
Sxs --> inadequacy of lympathic system --> repeated episodes of cellulitis

congenital --> if at birth
praecox --> if <35yo
tarda --> if >35yo

5

76yo woman presents with acute onset of persistent back pain and hypotension. a Ct scan shows an aorta that looks way too big and with indistinct borders, with a fractured ring of calcification & significant density in the para-aortic area. The pt is emergently taken to the OR. 3d after surgery, she complains of abdominal pain and bloody mucus per rectum. which of the following is the most likely diagnosis?
a. staphylococcal enterocolitis
b. diverticulitis
c. bleeding AV malformation
d. ischemia of the L colon
e. bleeding colonic carcinoma


--> ruptured aortic aneurysm

complications of ruptured aortic aneurysm
- sigmoid ischemc colitis = 2% after rupture, 6-10%after repair
--> IMA is usualy ligated at the time of aneurysm repair.
--> esp. bad if SMA is stenotic/occluded

RFs for ischemic colitis after ruptured aortic aneurysm and/or repair
- hx of visceral angina
- those found to have a patent IMA
- those w/ episode of hyptoension after rupture of aneurysm
- preop angiograms reveal occlusion of SMA
- if Doppler flow signals along the mesenteric border cease after the occlusion of the IMA.

Dx = reimplantation of the IMA into the graft to restore flow

6

80yo man is found to have an asymptomatic pulsatile mass. an arterigram is obtained, showing an abdominal aneurysm at the level of the R kidney (more like than left). which of the following is the most frequent and lethal complication of this condition?
a. rupture
b. acute thromboembolism
c. dissection
d. high output CHF
e. MI

A

AAA
- focal dilation of an artery >1.5x the normal diameter (nml = 2cm)

complications of AAA
- RUPTURE
- acute thromboembolism

Tx
-- symptomatic AAA ==> REPAIR
-- asymptomatic AAA
if healthy, >4cm ==> REPAIR

7

75yo man is found by his interist to have an asymptomatic carotid bruit. which of the following is the most appropriate next test?
a. transcranial doppler studies
b. doppler US
c. spiral CTA
d. arch aortogram with selective carotid artery injections
e. MRA

B. likely carotid stenosis


dx
1) doppler US
2) MRA, CTA
3) carotid arteriography (where suspicion is high but doppler is negative)

8

69 yo man with mild HTn and COPD presents with transient ischemic attacks and the angiogram shows "interruption" of the internal carotid artery, near the bifirucation of the common carotid. which of the following is the most appropriate treatment recommendation?
a. medical therapy with aspirin 325mg/day and medical risk factor management
b. mediclal therapy with warfarin
c. angioplasty of the carotid lesion followed by carotid endarterectomy if the angioplasty is unsuccessful
d. carotid endarterectomy
e. medical risk factor management and carotid endarterectomy if neurologic sxs develop

D. carotid endarterectomy

carotid stenosis

he has already had neurologic sxs (TIA) --> could lead to full blown stroke

indications
- Asymptomatic - for 80-99% carotid stenosis
- symptomatic - for >50% stenosis

9

55yo man with recent onset of A-fib presents with a cold, numb, pulseless LE. he is immediately taken to the OR for an embolectomy of the L popliteal artery. which additional procedure should be performed along with the embolectomy?
a. electromyography (EMG) of the leg
b. measurement of the anterior compartment pressure in the leg
c. fasciotomy of the anterior compartment in the leg
d. fasciotomy of all the compartments in the leg
e. application of a posterior splint to the leg

D

b/c likely to cause compartment syndrome of the leg

indications for prophylactic fasciotomy (would be all 4 compartments - anterior, lateral, superficial posterior, deep posterior)
- acute arterial occlusion without collateral inflow
- rapid reperfusion of the ischemic muscle

Dx
- abnormal EMG
- compartment pressures >40mmHG

10

58yo man presents with pain in the L leg after walking >1 block that is relieved with rest. On exam, distal pulses are not palpable in the L foot, and there is dry gangrene on the tip of his L 5th toe. an ankle-brachial index on the same side is 0.5. which of the pt's sxs or signs of arterial inssuficiency qualifies him for reconstructive arterial surgery of the LLE?
a. ABI < 0.7
b. rest pain
c. claudication
d. absent palpable pulses
e. toe ganrene

E. and amputation of that toe

<0.9 is not normal --> means stenosis

stages of arterial insufficiency / ischemia
- MILD = claudication --> daily exercise, cessation of smoking, weight loss
- ADVANCED = rest pain (persistent pain in the extremity), gangrene --> arterial reconstructive surgery

11

64yo man with a hx of tripe CABG 2y ago presents with peripheral arterial occlusive disease. his only med is thiazide diuretic. which of the following meds would be most appropriate in the medical management of his atherosclerosis?
a. aspirin
b. warfarin
c. low dose heparin
d. high dose heparin
e. low molecular weight heparin

A.

the others are for concerns of clots

atherosclerosis - inflammatory change with deposition of plaques
1) aspirin
2) statins
3) smoking cessation

- NO anticoagulation for atherosclerosis

12

a pt who has had angina as well as claudication reports feeling light-headed on exertion, esp. when lifting and working with his arms. the subclavian steal syndrome is associated with which of the following hemodynamic abnormalities?
a. antegrade flow thru a vertebral artery
b. venous congestion of the upper extremities
c. occlusion of the carotid artery
d. occlusion of the vertebral artery
e. occlusion of the subclavian artery

E

light-headed --> decreased blood flow to the brain

subclavian steal syndrome (L>>R)
==> atherosclerotic occlusion of the subclavian artery proximal to the vertebral artery
==> WITH EXERCISE: the involved extremity develops relative ischemia --> reversal of flow through vertebral artery --> diminished flow to the brain

sxs
- HEAD: light-headedness
- UE: intermitten claudication

tx
- carotid-subclavian bypass
- subclavian-carotid transposition
- dilatation & stenting of the artery

13

66yo woman presents with severe RLE claudication. surgery is considered, but her HTn, smoking, and DM puts her at risk for associated coronary heart disease. which test is most predictive of postop ischemic cardiac events following surgery?
a. exercise stress testing
b. ECG
c. coronary angiography
d. dipyridamole-thallium imaging
e. transesophgeal echo

D. dipyridamole-thallium imaging = detects reversible perfusion defects

surgery is a stress on the heart

sxs
- ischemic rest pain
- early onset of claudication after minimal exercise

14

60yo man is admitted to the CCU with a large anterior wall MI. on his HD2, he beings to complain of sudden onset of numbness in his R foot and an inability to move his R foot. on exam, the F femoral, popliteal, and pedal pulses are no longer palpable. the LLE is normal. which of the following is the most appropraite management of the pt?
a. duplex imaging of the RLE
b. CTA of the RLE
c. CTA of the b/l LE
d. embolectomy of the R femoral artery
e. embolectomy of the R femoral artery with exploration of the C/L femoral artery

D

cholesterol embolism --> after cardiac procedure

indications for EMERGENCY surgical intervention of embolism w/out imaging:
- acute arterial insufficiency, with neurologic comprommise of LE from thromboembolic dz with hx of cardiac problem
- clear diagnosis --> otherwise would lead to worsened ischemia & risk of limb loss

SOURCE
- diseased valves, endocarditis, LA in unstable atrial arrhythmias

tx
- embolectomy of femoral artery w/ local anaesthesia
- prep of C/L side in case flow is not erstored via simple thrombectomy --. if so, femoral-femoral bypass needed to provide inflow to affected limb
- exploration of C/L side ONLY with sxs

15

60yo man is found on routine physical examination to have a 3cm pulsatile mass int he R popliteal fossa. xray of the RLE is shown, with licency of the femur, but the medial femoral condyle down the tibia / fibula is all black. nothing seen.
a. antiplatelet therapy
b. anticoagulation
c. thrombolytic therapy
d. surgery
e. reassurance & rexamination if the pt develops sxs

D

AVM / aneurysm of the poplteal artery as it goes into the abductor hiatus

aneurysm that is blocking all of the bone past the abductor hiatus

==> most common peripheral arterial aneurysm

sxs
- chronic limb ischemia
- acute thromboembolism
- RARELY rupture

tx
1) symptomatic aneurysm ==> surgical repair w/ ligation of aneurysm (& left in situ)
2) asymptomatic aneurysm >2cm ==> surgical repair w/ ligation of aneurysm (& left in situ)
3) acute limb ischemia ==> thrombolytic therapy - revascularize and decrease limb loss

16

65yo male cigarette smoker reports onset of claudication of his RLE approx 3 weeks previously. he can walk 3 blocks before the onset of claudication. exam reveals palpable pulses in the entire LLE, but no pulses are palpable below the R groin level. noninvasive flow studies are obtained, showing
R thigh: pressure = 140mmHg
R calf pressure = 110mmHg
R ankle pressure = 80mmHg
L thigh: pressure = 150mmHg
L calf pressure = 150mmHg
L ankle pressure = 150mmHg

what is the level of the occlusive process in this pt?
a. R anterior tibial artery
b. R superficial femoral artery
c. R profunda ffemoris artery
d. R external iliac artery
e. R internal iliac artery

B

R and L thigh are within spitting distance

likely between R thigh and R calf ==> sharp decrease in BP below level of common femoral artery

17

56yo woman presents to her PCP for a routine chekcup . she states that she was recently hospitalized for surgery and was told she had some metal placed in a large blood vessel to prevent blood clots from moving to her lungs. an AXR is shown with what looks to be a hyperlucent device with multiple legs just left of midline, several inches superior to the pelvis. which of the following is the most appropriate indication for placement of this device?
a. recurrent PE despite adequate anticoagulation therapy
b. axillary vein thrombosis
c. PE due to DVT of the LE that occurs 2w postop
d. DVT in a pt with metastatic carcinoma
e. PE in a pt with metastatic carcinoma

A

==> IVC filter

placed for failed or contraindications to anticoagulation

18

2d after admission to the hospital for a MI, a 65yo man complains of severe, unremitting midabdominal pain. his cardiac index is 1.6. Exam is remarkable for an absence of peritoneal irritation or distention despite the pt's persistent complaint of severe pain. serum lactate is 9mmol/L (normal <3mmol/L). which of the following is the most appropriate next step in this pt's management?
a. perform CT
b. perform mesenteric angiography
c. perform laparoscopy
d. perform flexible sigmoidoscopy to assess the distal colon and rectum
e. defer decision to explore the abdomen until the arterial lactate is >10mmol/L.

B

nml cardiac index = 2.5-3

mid-abdomen pain --> mesenteric ischemia ==> mesenteric angiography (dx & tx with thrombolysis)

LUQ pain --> ischemic bowel disease ==> flex sig

tx
==> give lots of fluids

19

a postop pt with swelling & pain in his R calf is suspected of having a DVT. prior to initiating treatment with anticoagulants, he requires a confirmatory examination. which of the following is a limitation of the duplex US in evaluating a DVT?
a. it is not very sensitive for detecting calf thrombi in symptomatic pts
b. it is invasive
c. it cannot differentiate between acute and chronic venous thrombi
d. it is expensive
e. it cannot image the proximal veins (iliac veins, IVC)

E. for evaluation of iliac veins & IVC for DVTs --> use magnetic resonance venography

A, B, C, D = NOT TRUE

can in fact differentiate acute v. chronic thrombi

20

a 72yo woman with severe COPD who requires home O2 is unable to ambulate inside her home w/out experiencing severe L hip pain. she was hospitalized 1y ago for a viral pneumonia and was ventilator-dependent at that time for 6w. on exam, her BP is 165/80. he has weakly palpable b/l femoral pulses. an angiogram demonstrates severe aortoiliac disease involving b/l iliac vessels. which of the following is the most appropriate vascular procedure for this pt?
a. femorofemoral bypass
b. axillofemoral bypass
c. femoropopliteal bypass
d. aortobifemoral bypass
e. common femoral and profundda femoral endarterectomies.

B. bypass that part of the femur

axillofemoral bypass graft (extra-aortic - no risk of anaesthesia) ==> for high-risk pts with:
- b/l iliac disease
- infected aortic aneurysm / graft

femorofemoral bypass ==> for U/L iliac artery occlusive disease

** anything with aorta is most risky

aortofemoral bypass ==> young, healthy, U/L iliac artery occlusive disease

aortobifemoral bypass = best long-term patency