Vascular Flashcards

Question

Re-implant IMA/ hypogastric artery

Answer 1

Re-implant IMA if: IMA back pressure < 40, SMA stenosis, previous colon surgery, or if flow seems inadequate Re-implant one hypogastric artery into the Internal iliac) if: -Performing aortobifemoral repair and there is poor back bleeding from bilateral internal iliac arteries (hypogastric arteries) -Prevents pelvic ischemia (buttock claudication MC sx, impotence, bladder issues)

Answer 2

MCC of death overall after AAA and MCC early: Myocardial infarction MC late: Renal failure RF for AAA repair mortality: Renal failure Cr >1.8 is #1, Previous MI (Q waves on EKG) CHF, EKG ischemia, pulmonary dysfunction, older age, females

Answer 3

-Pelvic ischemia (internal iliac artery) – buttock Claudication, sexual dysfunction -Spinal cord ischemia -Colonic ischemia: sigmoidoscopy to dx: If necrosis: ex lap -AKI 2/2 to renal occlusion

Answer 4

Right renal artery – crosses posterior to IVC Left renal vein – Crosses anterior to aorta, tucked under SMA

Answer 5

Common during proximal cross clamp, when you have retro-aortic left renal vein, usually left renal is anterior

Answer 6

Cold foot after aorto-bifemoral repair (and has no femoral pulse): return to OR for a groin exploration (patient has a thrombosed graft branch): balloon thrombectomy and intra-op angiography If cold foot and normal proximal pulses: atherosclerotic debris from aneurysm, observe

Answer 7

-Treat the symptomatic one first -If elective, do colon first (get dirty case out of the way)

Answer 8

Type I - proximal or distal graft attachment site has inadequate seal. Tx: All need repair (found intra-op generally). Balloon expandable stent, balloon angioplasty or place overlapping stent cuff *Ia- proximal aortic – use extension cuffs here *Ib- distal iliac – use iliac extension limb here Type II is most common 80%. Collaterals (IMA, lumbar, intercostals) fill aneurysm sac. Tx: Observe unless persisting > 6 months, expanding, or symptoms: Tx: Embolize Type III – Mechanical failure of graft. Graft tear or separation. Tx: Placement another graft stent on graft failure site Type IV - Graft wall porosity or suture holes. Tx: Usually just Observe. Can place non-porous stent if fails Type V – (endotension) Expansion of aneurysm without leak Tx: Predisposes to rupture. No intervention. Needs close follow up Type I and III are associated with increased risk of rupture and need urgent repair

Answer 9

Common femoral aa diameter needs to be > 8 mm

Answer 10

Suprarenal aneurysm – The aneurysm involves the origins of one or more visceral arteries (SMA) but does not extend into the chest - requires separate renal artery reconstruction Pararenal – The renal arteries arise from the aneurysmal aorta but doesn’t extend above it, and does not include SMA Juxtarenal – aneurysm just below renal arteries. 0-1 cm distal to renal artery Infrarenal – aneurysm > 1 cm below renal artery

Answer 11

-Descending thoracic aortic aneurysm = distal to left subclavian artery to diaphragm -Associated with connective tissues disorders (marfans and Ehlers Danlos) -Can get compression of vertebra (back pain), RLN (voice changes), bronchi (dyspnea PNA), or esophagus (Dysphagia)

Answer 12

- Any size with symptoms (rupture, dissection, dysphagia, PAIN!!) - ≥ 5.5 cm - > 5 cm with Marfan’s, Ehlers Danlos, Turners - increase in size > 1 cm/yea

Answer 13

- Ascending aortic aneurysm: median sternotomy, with cardiopulmonary bypass, and composite graft - Descending aortic aneurysm: TVAR is best. If open need left sided thoracotomy

Answer 14

ischemic spinal cord injury: CAUSES PARAPLEGIA= injury to artery of Adamkiewicz T8-L1) Place CSF drains prevent this

Answer 15

Ehlers-Danlos Syndrome – Many subtypes Hypermobile joints Associated with Osgood-Schlatter (pain at tibial tubercle): lump at knee Associated with aortic root aneurysm and aortic dissection 2/2 to cystic medial necrosis: lose collagen and elastic fibers -Marfans has this too Defect in collagen type III

Answer 16

Aortic dissection - All ascending need open repair regardless of symptoms - Descending is medically managed, unless has any sign of mal-perfusion, peritonitis, LE ischemia, persistent HTN or chest pain, expanding hematoma: TVAR (thoracic) - Medical management: B blocker (esmolol) HR60-70, BP systolic 100-110 Stanford classification for aortic dissection: - Class A: Any dissection that involves the ascending aorta. Can be ascending + descending. Aorta. - Class B: Does not involve the ascending aorta. Distal to left subclavian. DeBakey classification for aortic dissection – based on site of tear and extent of dissection - Type I – ascending, arch and descending aorta - Type II - ascending only - Type III – Dissections that originate distal to left subclavian. descending only

Answer 17

Inflammatory aneurysms (No infection here) CT shows thickened aneurysmal wall above calcification on CT scan. Often get adhesions to 3rd and 4th portion of duodenum, ureters (hydro), IVC, left renal vein. Has elevated ESR. Tx: resect aneurysm and place graft vs EVAR. Avoid trying to free up involved structures, (inflammatory process resolves after resection and graft placement)

Answer 18

Mycotic AAA – MCC staph aureus. Bacteria infects plaque and causes aneurysm. Periaortic fluid/gas on CT = key to make diagnosis -Tx: Extra-anatomic bypass. Axillary to fem with fem-fem crossover and resection of infected aorta. -Can also place autogenous vein instead of bypass.

Answer 19

Aortic graft infection - MCC overall and early staph aureus (1st 2 weeks). MCC late staph epidermidis. Tx: Axillary to fem with fem-fem crossover, resect entire graft. -Can also do in situ reconstruction using LE deep veins, cadaveric arterial allografts, or abx impregnated graft. Wrap omentum around them Best way to diagnose infected aneurysm: CT and positive blood culture. WBC is scan outdated Staph epi infections -Much less virulent, do not present with systemic signs of infection. That’s why it is found later -Blood cultures generally negative Rest of organisms will present early and with sepsis

Answer 20

MC occurs 1-5 years post op MCC is infection with an anastomotic pseudoaneurysm that erodes into bowel MC 3rd or 4th portion of duo. MC presentation is GI bleeding. Usually, these patients get a EGD for GIB work up. #1 first step CTA will show fluid/inflammation/air around perigraft (likely won’t show extravasation) If CTA negative: EGD to look at duodenum. Treatment: Only close hole in duodenum,, Fistula takedown and resect the ENTIRE graft and extra-anatomic bypass, Axillary to fem with fem-fem crossover. Wrap graft in omentum. - Can also do in situ reconstruction using LE deep veins, cadaveric arterial allografts, or abx impregnated graft. Wrap omentum around them

Answer 21

Forms from abnormal pressure gradients Circumflex iliac to subcostal arteries. Circumflex femoral to gluteal. Geniculate around knee.

Answer 22

Claudication, absent femoral pulses, erectile dysfunction Tx: aortobifemoral bypass

Answer 23

hair loss, pallor, Rubor – sign of more severe disease. Redness goes away with elevation ABI < 0.9 is abnormal = reduced perfusion

Answer 24

Cramping or burning sensation while walking but resolves with rest. -ABI 0.5-0.9 = claudication -Typically occurs in calves, thighs, buttocks -Treatment is medical: Statin, aspirin, exercise -Cilastazol phosphodiesterase inhibitor – decreases plt aggregation -Surgery/endovascular intervention if above fails

Answer 25

Needs work up and intervention - ABI < 0.4 = rest pain - ABI < 0.4 is associated with tissue loss (ulcers and wounds) - Typically manifests as SEVERE FOOT pain at rest - REST PAIN OR ULCERS/WOUNDS

Answer 26

pain is located below the level of stenosis - Aortoiliac – buttock and thigh pain - Common femoral – thigh pain - SFA – calf - Tibial/peroneal - foot

Answer 27

- Start with ABI and US to check presence of PAD, Pulse volume (waveform) recording (doppler US) – Gives you level of stenosis - ABI artificially elevated with DM and ESRD 2/2 to medial calcinosis in artery of tibial vessels: Instead you should use doppler wave forms, pulse volume recordings or check toe pressures in these patients. - Diabetics MC have tibial artery disease - Imaging workup US/CTA/MRA or straight to angiography - If you suspect aortoiliac disease due to loss of femoral pulse need CTA of abdomen with run off - Intervention is warranted for failure of medical management of Intermittent claudication or presence of critical limb ischemia

Answer 28

Indications to revascularize – life style limitation despite medical tx, rest pain, threatened limb, ABI <0.5, ulcers Fix the most proximal problem 1st - ALL patients need cardiac workup prior. Patients with PAD have a 25% 5-year mortality from CVA and cardiac related issues - Endovascular treatment is usually the preferred treatment in intermittent claudication - Performed through retrograde femoral access of the contralateral extremity - Endovascular used for FOCAL lesions (generally < 10-15 cm), surgery reserved for multifocal and advanced disease - If performing open surgery: Need vein mapping first. Need 3 mm veins

Answer 29

Popliteal artery entrapment syndrome, adventitial cystic disease presents with claudication relieved with rest. But these patients are young, don’t smoke, no HLD, HTN

Answer 30

Presents with aching of the LE with pain and edema relieved with elevation. Will see varicosities with lipodermatosclerosis (brawny skin discoloration). Can have history of DVT

Answer 31

Burning sensation or paresthesia in forefoot. Key here is the pain is constant NOT relieved by rest or position

Answer 32

Compression from spinal stenosis. Presents with burning and cramping with walking. Key is that it extends from buttock to foot. Relieved by sitting and bending forward.

Answer 33

SFA at hunter’s canal. Sartorius lies over this

Answer 34

Usually at charcot’s joint (head of 2nd MTP) and HEEL 2/2 to neuropathy Diabetic foot osteomyelitis dx: - Start with X-ray - MRI is best if concerned for osteomyelitis - Don’t do bone biopsy for diabetic osteomyelitis of foot work up. For all other cases bone biopsy is best for dx. Treatment: Abx with local wound care: sharp debridement

Answer 35

Usually occurs at distal aspect of the extremity (toes) If patient presents with an arterial ulcer that is INFECTED and septic, hold off on surgical revascularizing of PAD (as long as not threatened). Treat the infected ulcer first. Then work up and treat PAD Work-up – start with ABI. <.4 = tissue loss Treatment *Endovascular intervention is best for iliac *Long segment stenosis: bypass -Patients with tissue loss have multilevel dz and thus bypass is the best option in this case (usually)

Answer 36

All patients after bypass need to be on DAPT (Plavix and aspirin) for 1-6 months after the procedure. After that lifelong single antiplatelet therapy (aspirin or clopidogrel)

Answer 37

Usually, occlusive disease is not amenable to stenting and must do open repair. Stenting used for stenotic lesions. Aortoiliac disease is the exception TASC A and B lesions: angioplasty and stent - < 10 cm CIA and EIA stenosis - Unilateral occlusion of CIA and EIA TASC C and D lesions: Aortobifemoral bypass. If high risk surgical patient: Axillofemoral bypass Isolated iliac stent/occlusion: PTA with stent, if that fails fem-fem crossover graft - If chronic iliac occlusion in patient with severe co-morbid conditions (COPD): fem-fem bypass

Answer 38

- Early (<48 hours) – reperfusion injury - Intermediate (3-7 days) – DVT - MC! Late (>7 days) – lymphedema: compression stockings

Answer 39

- Early < 30 days: technical - Intermediate 30 days – 2 years: intimal hyperplasia - Late > 2 years: vein atherosclerosis

Answer 40

- PSV >300 - PSV ratio >3.5 - End diastolic velocity >20 - >70% diameter reduction on angio

Answer 41

Dry gangrene (no infection) – Tx: NWB Wet gangrene (infection) – early debridement. Surgical emergency if pus coming out of toes with red streaks: Ray amputation. Or if septic shock: amputation

Answer 42

Predictors of healing post LE amputation: #1. Transcutaneous O2 >40 #2 presence of proximal pulses - TCOM < 20 = poor healing

Answer 43

LOSS of pulse -1st start with giving aspirin and heparin bolus 80 units/kg then drip 18 units/kg/hr -MC site of emboli from heart: common femoral -MC UE site emboli from heart: Brachial - For Acute arterial emboli: usual treatment is open embolectomy, can consider thrombolytics if non-threatened - For Acute arterial thrombosis and threatened: heparin, open embolectomy - For Acute arterial thrombosis and non-threatened: thrombolytics, heparin. - Emboli to aortoiliac bifurcation (loss of both femoral pulses): BL femoral artery cut downs and transfemoral retrograde embolectomy - Femoral pulse must be present for thrombolytics. Otherwise these would need open embolectomy. So, any loss of femoral pulse= open embolectomy - If infant has loss of femoral pulse (from a line) and cold foot: too hard to operate= Tx: heparin - Thrombosis of LE graft (PTFE or vein)  if non-threatened: thrombolytics. Threatened: OR for thrombectomy

Answer 44

- If motor and sensation intact: clot likely distal (usually at trifurcation): tPA and run for 24-48 hours - Thrombolytics are better at trifurcation, too difficult to perform embolectomy here. - If any loss of motor or sensation: need cut down and open balloon catheter embolectomy - Never do tPA (thrombolytics) for common femoral (loss of femoral pulse) or more proximal clot: open embolectomy

Answer 45

- Need to follow fibrinogen levels because using fibrinolytics causes hypofibrinogenemia - Fibrinogen 150 or less increases risk of bleeding. (normal 200-400) - Absolute contraindications: Recent stroke/TIA (3 months) , active bleeding, recent head bleed, intracranial mass - Most effective in patients with ischemia < 2 weeks - Can use for up to 48 hours - Bleeding risk increases with low fibrinogen and longer time - The reversal for tPA is cryoprecipitate, if this is not available, then you can use aminocaproic acid vs TXA

Answer 46

Threatened = Class IIb Class I – heparin, can do thrombolytics or OR as well Class IIa: MINIMAL Sensory loss, ONLY TOES HERE. heparin + thrombolytics Class IIb: Sensory or motor loss: OR Class III: amputation

Answer 47

50% mortality within 3 years for leg amputation BKA: 80% heal, 70% walk again, 5% mortality AKA: 90% heal, 30% walk again, 10% mortality

Answer 48

MCC of renal artery stenosis: atherosclerosis Atherosclerotic renal artery stenosis: DO NOT STENT. Medical treatment is best Renal artery stenosis caused by atherosclerosis usually older male. MORE proximal on renal artery close to aorta= spillover from aorta

Answer 49

MC site of upper extremity stenosis: subclavian artery Upper extremity occlusive disease: proximal lesions usually asymptomatic due to collaterals (subclavian)

Answer 50

Tight proximal subclavian stenosis, causes reversal of flow in ipsilateral vertebral artery into distal subclavian artery. Tx: PTA and stent. Common carotid to subclavian bypass if that fails -Subclavian steal can also occur in patients with previous CABG and left internal mammary (comes off of subclavian) artery to left anterior descending= blood taken away from heart = ANGINA Tx: subclavian stent Vascular steal can also occur in femoral-to-femoral cross-over grafts who have proximal stenosis in the DONOR artery (proximal iliac stenosis in the donor leg). Tx: PTA with stent

Answer 51

MCC of mesenteric ischemia – embolic Never do percutaneous endovascular treatment (thrombolytics) of mesenteric ischemia if the patient is unstable or has peritonitis

Answer 52

Hx of atrial fibrillation, endocarditis, recent MI, recent angiography Pain out of proportion to exam; pain usually sudden onset. Hematochezia and peritoneal signs are late findings. See meniscus sign 3-10 cm distal to origin of SMA MC the proximal jejunum and transverse colon is spared – lands distal to middle colic, just after jejunal artery branches Treatment; Heparin given initially to prevent clot propagation *MC do this for embolism!!! Especially if peritonitic/septic/sick/ischemic bowel: ex lap and open embolectomy with Fogarty catheter *Transverse arteriotomy using embolectomy balloon catheter – Will need bypass if embolectomy does not produce blood flow SMA exposure: divide ligament of Treitz; SMA to the right near base of transverse colon mesentery Planned 2nd look laparotomy: best to not resect questionable/ marginally perfused bowel; leave abdomen open and re-explore in 24 hours

Answer 53

Occlusion right at ORIGIN of SMA or 1-2 cm from it Typically, these patients have previous chronic abdominal angina (food fear, weight loss over months to years) Sx similar to embolism; may have developed collaterals MC jejunum and transverse colon is involved (entire midgut) Tx: *Longitudinal arteriotomy: needed for bypass *Typically requires bypass – Use #1 suprarenal aorta, infrarenal aorta, right iliac artery -Bypass with Greater Saphenous vein graft *Simple thrombectomy rarely useful because of extensive disease *Intraoperative retrograde superior mesenteric artery angioplasty and stenting is another option

Answer 54

- Method 1 Lateral: reflect TV colon superiorly and small bowel to the right. Take down ligament of treitz. SMA is palpated to the right of ligament of Treitz over 3-4 portion of duo - Method 2 Anterior: TV up, SB to right, trace middle colic, horizontal incision at root of mesentery is made. SMA is found medial to SMV

Answer 55

Critically ill state; low cardiac output Watershed areas most vulnerable Tx: give volume and abx; can give intra-arterial papaverine; give dobutamine if 2/2 to CHF *volume resuscitation and improve cardiac output*

Answer 56

Short segments of intestine involved Subacute: multiple days of bloody diarrhea and crampy abdominal pain Heparin only!!! Only operation to do is bowel resection if needed. Patient should be screened for hypercoagulable state/Cancer If continued abd pain without peritonitis: thrombolytics can be used in the ARTERIAL system!!= catheters in SMA and splenic artery

Answer 57

-Fear of eating, weight loss -Disease is usually at origin of artery. Celiac or SMA -Dx: Duplex US is used for screening, confirmed with CTA -Tx: Indications for treatment: weight loss, food fear, chronic symptoms *Best treatment is endovascular angioplasty with stent. Only treat if > 70% stenosis. Only need to treat one artery *If long segment or fibromuscular dysplasia: bypass

Answer 58

Griffith’s point – splenic flexure – middle colic to left colic Sudak’s point – upper rectum – superior rectal, middle rectal

Answer 59

Collateral between the SMA and IMA

Answer 60

-Compression of 3rd portion of duodenum between SMA and vertebral column. -Postprandial epigastric pain and vomiting. Fear of eating= weight loss. -Lying prone or right lateral decubitus improves symptoms -RF: MCC weight loss and surgery for scoliosis, supine immobilization, body cast, eating disorders -Aortomesenteric angle < 25 = SMA syndrome. Normal 35-65 -Tx: For ALL refeeding 1st, NJ tube etc. Try to increase fat pat. Usually can avoid surgery and this refeeding alone suffices Once nutritional status restored and still symptomatic= duodenojejunostomy Usually, acute cases resolve with medical management Chronic cases more likely to need surgery

Answer 61

-Causes celiac artery compression. -Hear bruit at epigastrium -Weight loss, chronic pain, and diarrhea. -Tx: transect median arcuate ligament

Answer 62

Rupture – MC complication of aneurysm above inguinal ligament. Emboli – MC complication for below inguinal ligament

Answer 63

Two types: - Visceral arterial aneurysm  true aneurysm. Lower risk of rupture - Visceral arterial pseudoaneurysm  high risk of rupture Risk factors: medial fibrodysplasia, portal HTN, pregnancy Repair all splanchnic visceral aneurysm > 2 cm (hepatic, left gastric, SMA)  Covered stent or coil embolization (preferred) if that fails  ligation of aneurysm with bypass, or just ligation, if it has lots of collaterals like gastric arteries If patient has a ruptured aneurysm  need open surgery with ligation, proximal and distal +/- bypass Hepatic artery: embolization

Answer 64

Common iliac > 3.0 cm= covered stent Renal artery > 2 cm= covered stent common femoral > 3.0 cm= resection with interposition bypass graft, avoid stents across joint lines

Answer 65

MC visceral artery aneurysm MC in women Overall rupture risk is much lower than other visceral aneurysms. Patients present with “double rupture – initially ruptured splenic artery is contained in the lessar sac. Patients are non-distended, normotensive. Then lessar sac ruptures through foramen of Winslow, and patient becomes hypotensive. Repair if: - Symptomatic, pregnant, women of child bearing age, >2 cm Treatment options (endovascular is preferred): - Endovascular embolization (preferred): if in distal 1/3 of artery and hilum. - Endovascular stent placement if in proximal or middle 1/3 of artery (preserves spleen) - Open repair, resection with end-to-end repair: if in proximal and middle 1/3. - If ruptured aneurysm or pregnant (radiation): open with ligation - Can also do laparoscopic ligation of (proximal and distal) - DON’T need splenectomy with above

Answer 66

*Popliteal aneurysm – MC peripheral aneurysm *MCC atherosclerosis *MC male in 50-60s, smoker *Prominent popliteal pulses *50% are BL *30% have a AAA= need to be screened for AAA if you find this *MC get #1 thrombosis and limb ischemia or #2 emboli *Rarely rupture *Dx: duplex *Indications for surgery: > 2 cm, symptomatic, mycotic, distal embolization, intramural thrombus inside artery (regardless of size) Tx: * LIGATE and bypass: Use saphenous, ligate proximally and distally (medial approach) * If patient presents with compressive symptoms, venous congestion, paresthesia: aneurysmorrhaphy with interposition graft (posterior approach): Open aneurysm, place bypass graft in aneurysm sac and close it. * Acute thrombosis of popliteal aneurysm: Usually involves trifurcation vessels so open embolectomy difficult: treatment is tPA acutely with definitive repair (bypass) as above during that admission

Answer 67

*Often BL *Presents as intermittent Claudication in a YOUNG patient, men 20s and 30s WHO DO NOT SMOKE *Loss of pulses with plantarflexion *MCC is medial deviation of popliteal artery around the medial head of gastrocnemius muscle *Dx: CT angio *Tx: Resect medial head of gastrocnemius. May need reconstruction of popliteal artery with saphenous graft Symptoms may progress to parasthesias as they develop fibrosis of the popliteal artery, which occurs from arterial compression; fribrosis can lead to complete occlusion or thrombis

Answer 68

*Claudication, Men in 30’s – 50’s *These patients get claudication *Change in symptoms with knee flexion/extension. *MC area is popliteal fossa. Occurs in peripheral vessels close to a joint *Dx: CT angio will see scimitar sign = compression of artery from a cyst!!. *Tx: resection of cyst. May need graft

Answer 69

*MC location is femoral artery *Dx: Duplex: Will show a “to and fro” pattern *If 2/2 to percutaneous intervention= US guided thrombin. Need urgent OPEN repair if expanding, nerve compression or compromised skin *If 2/2 to disrupted suture line (Between graft and artery) with recent bypass = technical error= open repair *If late after bypass (months-years)= infection= resect entire graft and bypass through non-contaminated field *If femoral artery and IV drug user= ligation without reconstruction (yes ligate the femoral artery). Has collaterals.

Answer 70

Key is digital necrosis with long history of smoking Criteria (need all 5): 1. Age < 45 2. Smoker 3. Distal extremity ischemia (ulcer, gangrene, rest pain) 4. Angiogram with corkscrew collaterals 5. Need to exclude autoimmune, hypercoagulable, DM, emboli Dx: angiogram: -Need to see corkscrew collaterals with severe distal disease (digits) -NORMAL arterial tree proximal to popliteal/brachial. This is a small vessel disease Tx: Stop smoking

Answer 71

*Young women, 50% have bilateral lesions, have risk of cerebral aneurysms *Presentations: #1 HTN (RAS), #2 headaches/stroke (carotid), claudication (iliac), *MC variant is medial type fibrodysplasia *MC vessel involved: #1 Renal artery, most commonly on the right, then #2 is carotid, #3 is SMA *Causes stenosis that is usually MORE DISTAL than atherosclerosis *Dx: Angiogram= string of beads *Treatment: PTA WITHOUT stent, open bypass if it fails. No endarterectomy, no stent

Answer 72

medium-large vessels (aortic arch + branches including carotids) Older white women 70s. RF: Polymyalgia rheumatica Tx: steroids

Answer 73

*Granulomatous vasculitis with MASSIVE intimal fibrosis and vascular narrowing *MC aortic arch and branches (subclavian, carotid). Can involve pulm and coronary arteries *MC Asian women in 20s-30s *Symptoms: Has antecedent inflammatory phase (fever, malaise, elevated ESR) followed by pulselessness phase. Pulseless UE, neuro symptoms, headaches, seizure, claudication, angina, abdominal pain. *Dx: CTA and High ESR. *Tx: Steroids. If that fails, do bypass ONLY when inflammation subsides

Answer 74

*Pulses are NORMAL *Small vessel disease *Treatment of raynaud’s  Avoidance of cool temp, diltiazem

Answer 75

MCC is trauma (GSW). Tachycardia is improved with shunt compression Sx: arterial insufficiency, MC claudication * CHF (pulm edema, tachy, * Aneurysm * Limb length discrepancy * Low diastolic pressure and venous HTN Dx: Duplex – will feel a thrill or bruit Treatment is open repair with lateral venous suture; patch arterial side. Interpose muscle between artery and vein to avoid recurrence

Answer 76

For short term dialysis access: right internal jugular temporary non-tunneled catheter = BEST (shortest route). 2nd line is left IJ 3rd option is femoral - Avoid subclavian, can cause stenosis, especially if they may need lifelong dialysis (issues with AV fistula) Tunneled catheters are usually not placed in the acute, intensive care unit setting but are reserved for the subacute phase when a patient needs long-term access (>3 weeks)

Answer 77

Once a patient reaches Stage 4 CKD (GFR<30): they should be referred to a surgeon for AVF creation In a CKD patient avoid ALL PICC lines and subclavian lines All patients must have duplex for venous mapping prior to fistula formation Obtain venography to rule out central stenosis in patients with hand swelling or previous central/PICC lines

Answer 78

Radiocephalic fistula (cimino) is the first choice for AV access procedures. #2 is brachiocephalic, #3 brachio-basilic #4 synthetic graft For grafts: #1 radial artery to brachial vein, #2 distal brachial artery to proximal brachial vein, #3 distal brachial artery to distal axillary vein Prefer non-dominant arm, Requires at least >3 mm size vein, Need a diameter of 2 mm for artery Cimino – radial artery to cephalic vein – wait 6 weeks to allow vein to mature  MC nerve injured is superficial radial

Answer 79

AV graft – takes 2 weeks to mature AV fistula – takes at least 4-6 weeks to mature Rule of 6's: at 6 weeks need fistula of 6 mm diameter, 6 cm length (to allow 2 needle access), depth < 6 mm, flow rate > 600 cc/min

Answer 80

Venogram – used only to check for central stenosis: if you did AVF/graft then arms swelling: need to rule out central stenosis

Answer 81

Hemodialysis Reliable outflow graft – Used when there is central vein stenosis. Uses right atrium as venous outflow connected to brachial artery

Answer 82

MC failure of A-V graft = venous obstruction 2/2 to intimal hyperplasia at the graft-venous anastomosis MCC of early failure – technical. Late = intima hyperplasia

Answer 83

Most are detected during dialysis High venous pressure, poor arterial inflow indicates access problems Diagnostic test of choice is a fistulogram

Answer 84

Hand swelling after AV graft or AVF: venous obstruction Elevation generally improves symptoms = 1st treatment. Should resolve in a few weeks. If persistent or SEVERE: suggests major venous outflow obstruction: MC this is at the venous anastomosis. Can also be central stenosis Dx: Fistulogram: Tx: PTA without a stent

Answer 85

- Will see hand pain with dialysis - AVF grafts much more at risk than fistula - Severe ischemia - Mild symptoms: Pain with use or dialysis, cold hand, paresthesia: No treatment - Severe symptoms: Rest pain, motor dysfunction, tissue loss/ulcers

Answer 86

-usually upper arm grafts -Symptoms: loss of pulse, motor weakness, intolerable pain, rest pain = all need intervention Diagnosis: -Compressing the fistula improves symptoms = confirms the diagnosis -Start with Duplex, However US will not find proximal stenosis if there is one, -So, if duplex is normal you need an angiogram (not fistulogram) to rule out out-flow problems

Answer 87

- If there is a proximal inflow stenosis): percutaneous angioplasty - If you don’t find the above then do below - Distal Revascularization-Interval Ligation (DRIL) (ligate artery distal to anastomosis, place another bypass graft) - Leaves the fistula undisturbed - Revision Using Distal Inflow (RUDI): The fistula is ligated on the venous side followed by a revision from a more distal arterial source to the venous limb. In contrast to the DRIL procedure, the RUDI procedure maintains the native arterial circulation. - Ligation of fistula: avoid this… can’t use graft after

Answer 88

Caused by incompetent valves, inadequate muscle pump function, DVT Sx: leg pain, fatigue, heaviness, edema, brawny skin, ulceration, talengectasias RF: obesity, smoking, low activity or long standing Venous ulcer= medial malleolus – treated medically first

Answer 89

Duplex: You are looking for: 1. Incompetent sapheno-femoral valve - dx made if relief of muscle pressure proximally (thigh) causes retrograde flow in the vein 2. Incompetent perforator veins 3. DVT – need to make sure patient does not have a DVT 4. Incompetent deep system (femoral, popliteal, trifurcation) Normal venous duplex = augmentation of antegrade flow with distal compression OR release of proximal compression Perforator veins direct blood from superficial system to the deep system Duplex US tells you if there is reflux in the superficial (saphenous), perforators or deep veins

Answer 90

-Medical 1st with leg elevation, compression, avoid standing, weight loss, stop smoking. -Ulcers < 3 cm usually heal with medical tx  compressive stockings If that fails: surgery= Fundamentals of surgery = ablation of reflux source (escape point) CI to surgery: DVT, venous outflow obstruction, pregnant Need post op US to make sure there is not DVT at the saphenofemoral junction.

Answer 91

- Venous insufficiency, venous ulcers, varicosities: if their US reveals reflux in perforators or superficial veins they are candidates for intervention - There are no techniques to address deep vein issues - Telangiectasias and small varicosities without reflux: sclerotherapy - Superficial venous system (saphenous): # 1 MC radiofrequency ablation (best, least invasive) - Perforator reflux: Endoscopic perforator ablation or US guided sclerotherapy - If you see reflux in both perforator and superficial system: * Treat incompetent superficial valves 1st (saphenous), usually resolves the perforator issue - If still having issues: treat perforators incompetence= US guided sclerotherapy

Answer 92

Will see pus with fluctuation, fever, high WBC, red streaking: remove IV and start abx. If there is pus: I&D Superficial thrombophlebitis – will see erythema: warm compress, remove iv Staph aureus is MC for both

Answer 93

Woody edema MCC of cellulitis here is streptococcus Dx: Rule out other causes of edema 1st. Lymphoscintigraphy and indocyanine green map lymphatics Tx: Compression, PT (manual lymphatic massage)

Answer 94

1st PC drainage. Lymphocele resection if that fails. Can give isosulfan blue dye into foot to find lymphocele

Answer 95

-Structures of carotid sheath: Carotid artery, internal jugular vein, vagus nerve -Segments of vertebral artery: -V1: origin off subclavian to foramina of C6 -V2 (Foraminal): From the transverse foramen of C2-C6 -V3: From C2 to Dura -V4: intracranial -Structure commonly overlies carotid artery bifurcation: facial vein off of IJ generally overlies bifurcation -First branch of external carotid artery: superior thyroid artery -External carotid artery flow high or low resistance: high resistance (flows to muscular facial muscles), triphasic flow on doppler, brief reversal of flow -External carotid can be tied off to help control excessive facial bleeding in trauma -Internal carotid artery main blood supply to brain, first branch is the ophthalmic -Low resistance as it is supplying brain tissue -> continuous forward flow= biphasic doppler signal; long diastolic phase

Answer 96

-V1: origin off subclavian to foramina of C6 -V2 (Foraminal): From the transverse foramen of C2-C6 -V3: From C2 to Dura -V4: intracranial

Answer 97

-Likely injury to Vagus nerve -From clamping the carotid the vagus nerve was also clamped

Answer 98

-Likely hypoglossal nerve injury -Nerve lies just cephalad to carotid bifurcation so can easily be damaged

Answer 99

-Marginal mandibular injury -From retraction on mandible, generally when trying to expose high lesions

Answer 100

-Glossopharyngeal

Answer 101

-Intima and part of the media

Answer 102

-Carotid bifurcation due to turbulence

Answer 103

-Symptomatic (stroke or TIA), 50-70% warrants surgery -Asymptomatic – controversial if over 80% or EDV (end diastolic velocity) > 140 cm/s (which correlates with 80% stenosis) -Should start with medical management aspirin and a statin What if patient is symptomatic but duplex shows <50% stenosis? -No surgery indicated -Optimize medical management – aspirin, Plavix and a statin What if patient has a stroke and imaging shows a completely occluded carotid artery? -Anticoagulation to prevent progression, no benefit to recanalizing

Answer 104

-Crescendo TIAs: TIA symptoms are recurring and becoming more severe or lasting longer in duration

Answer 105

-Myocardial infarction

Answer 106

-Small stroke or TIA – within two weeks once symptoms resolve -Hemorrhagic stroke – 6-8 weeks

Answer 107

-Return to OR to evaluate for intimal flaps or thrombus -In OR start with US

Answer 108

-Hx of neck dissection, neck irradiation, recurrent carotid disease -Severe cardiac disease -TCAR (Transcarotid Artery Revascularization) or transfemoral stenting should be considered in patients with previous neck surgery or radiation. TCAR has lowest stroke rate.

Answer 109

-Although most due to progressive degeneration, must culture excised graft to rule out coagulase-negative Staphylococcus infection

Answer 110

Aiming the needle more cephalad facilitates penetration of the vessel at the broader confluence of the great veins

Answer 111

Zone 1: aorta, IVC, SMA, renal arteries Zone 2: renal veins, renal arteries Zone 3: pelvic area= iliac arteries, iliac veins Zone 4: liver= hepatic veins, portal vein, hepatic artery

Vascular Flashcards

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