Flashcards in VASCULAR Deck (129):
Normal toe pressure
First step in bypassing for vascular occlusion
Find distal target first!
If there is no target then you are done with the case.
Steps of bypass for vascular occlusion
Find distal target first!
Then evaluate proximal inflow (may have todo endarterectomy)
if SFA is too calcified - need to go to profunda patch
Harvest Vein 20-30 % more than you need.
Reverse the vein.
mark for orientation
Medications for vascular path
Contraindications for cilostazol
this is pletal
no if in cardiac failure
Treatment for lesion just proximal to aortic bifurcation
(not enough room for stance- they would set timer for 30 minutes just running to each other)
Trial of asymptomatic carotid disease
60 % angio (80% by duplex) occlusion
11% risk of CEA on meds
5% risk of stroke with CEA
Trial of symptomatic carotid disease
70% stenosis of angio or duplex
26% stroke risk meds
9% stroke risk with CEA
vericle incision along SCM
enter carotid sheath
facial vein ligate and divide
btw IJ and common carotid is vagus nerve - this is protected
encircle with vessel loops
Verify with ACT
Order of clamping:
If no change on neuromonitor EEG or awake and fine- then no need to shunt
endarterectomy : feather, tack as needed
Temp open each clamp
External - fills with blood
What is white clot
Super celiac aortic control
Vertical Midline incision
Opened gastrohepatic ligament (pars facida)
(watch replaced left heptic)
Take down triangular ligament - retract left lateral lobe of liver) to the right
Grab the OG and move esophagus to patient's LEFT
compress aorta against spine (wait for anesthesia to catch up - then can place clamp)
What is a argyle shot made out of
What is alternative to argyle shunt
Alternative proximal just to control technique
(you can also inject heparin through this baloon)
Imaging for a ruptured AAA
Noncontrast CT scan
Permissive hypotension systolic in the 90s
Initial step in managing acute mesenteric ischemia
Where it is in black usually lodge in the SMA
Distal to the middle colic take off
Management of chronic mesenteric ischemia
Usually open operation(because stenting is associated with higher the operation rate)
Bypass option for chronic mesenteric ischemia SMA
supra celiac aorta
from the chest
stent via open approach retrograde
(can just bypass one artery)
when to reimplant IMA
Aortoenteric fistula stable patient
Stable post herold bleed
Aortic proximal control
Iliac distal control
Take out the graft
Repair the duodenum
Aortoenteric fistula unstable patient
Endograft seals whole
then ax bifem
take out graft and stent
Super celiac control
Resect repair duodenum
If doing well then do
if not doing well:
oversew stump of aorta and
If not doing well
types of vascular shunts
Argyle - vinyl conduit
Pruitt–Inahara shunt - double balloon
Bard Javid Carotid Bypas Shunt - T - SHUNT WITH
treatment of SMV thrombosus
lysis is not standard of care - but people do it and this can be mentioned
Claudication numbers and presentation
ABI above .5
Medical managemnt of claudicant
2 Statin LDL goal
Occlution at bifurcation of Aorta
Aorto bi illiac - graft open
stent one side then do fem-fem
Steps of thrombectomy and possible bypass for Acute limb ischemia - oclusion of below knee pop
Prep - groin to toes
Duples saphenous in lower calf
Medial incision to finger bredth posterior to proximal tibia
expose posterior compartment
Retract gastroc muscle down
this exposes bundle of nerve artery and vien
mobalize vein - to expose below knee popliteal artery
then inferiroly reflect the soleus from periostium - this exposes the trifurcation
This exposes anterior tibial vein - mobilize to expose the anterior tibial artery
encircle anterior tibial trunk
transverse arteriotomy for emolectomy just proximal to trifurcation - this allows cannulation of AT, PT, and peroneal with fogarty
check for signals at the foot
the superficail posterior compartment is already done having exposed the trifurcation
to release the complete DEEP posterior compartment release - you must release the entire solus off of the tibia (this is done if true compartment syndrome
Lateral incision just anterior to fibula
transferse superfical entrance of facia
release mets pointed away from septurm fascia anterior to intermuscular septum knee to ankle (careful of superficial peroneal n can have variable course not in its normal position posterior to septum)
Then release posterior to intermuscular septum sissors pointed away from septum.
massive hyper K
(may need to reocclude)
(may have to pull off first liter of blood)
first choice thrombectomy
if too sick:
lysis takes time and may get neuro - motor def
Trauma steps pop a GSW
Prep BOTH legs
proximal control of above knee pop
Is patient going to live
vein from other leg
watch for reperfussion syndrome
Exposure of ABOVE knee pop
Incision interval btw vastus and adductor hiatus
Mobalize greater saphanous
Sartorius mobalized and retracted posterior
This gives access to above knee popliteal artery
Basic indications for IVC filter
contraindication of anti coag
expansion of clot while anticoag (theraputic)
w/n 6 mo - need
Compare PB in booth arms to make sure no subclavian disease
do they have pain when they have that hand - does it hurt or do they get dizzy - assess for arterial sufficiancy
Hx of vein problems: PICC line, central line probs, ssx venous congestion
min vein diameter: 3 mm or greater
management of pain in hand post brachial cephalic fistula
dose pain resolve with occlusion of the fistula?
distal revasc interval ligation
This is simply bypass with vein proximal to fistula to distal to fistula so blood with go into that connection first and what is left over will go to fistula
Then can ligate the segment of artery distal to fistula (so it does not continue to draw blood and you do not need this flow anymore because bypass)
Management of patient in recovery who has pain that persists even after compressing the fistula
Ischemic Monomelic Neuropathy
May need to ligate the fistula - osler vascular answer
Surgery has little to offer in established IMN - emedicine answer
Management of hand swelling post AV fistula
elevate hand normal
Management of severe UE swelling post AV fistula
Look for central venous thromb
balloon and fix
How fast can you use AV fistula
How fast can you use graft
What may be happening and what is management of if you stick the graft for dialysis run and you get a lot of blood coming back
MOST common is neointermal hyperplasia of of DISTAL anstimosis
(may be central venous occlusion / thromb)
balloon / cutting balloon
(very rarely patch distal anastimosis)
pseuodaneurysm at lower extremity bypass
eval for infection
if bypass was for claudication - can just remove the graft - because will just get claudication again - no big deal (they lived with occluded vessel prior to surgery)
if bypass was done for rest pain or limb ischemia:
remove graft and tunnel in unaffected tissue
Clinical scenarios cards
What imaging should be done for AAA besides CT scan
requirements for EVAR
60 (min tortuosity)
15 mm infra renal neck
greater than 5 mm illiac (6-8 mm)
graft oversized by 20-30 % of proximal landing zone
Management if AAA is associated with a concomitant iliac aneurysm
May include one of the INTERNAL iliac arteries with coil and Cover with graft
Management of iliac if bilateral concomitant iliac aneurysms with AAA
Bypass internal to external iliac
Basic steps of EVAR
Nipples to toes
Bilateral femoral cutdown's
Bilateral ilial femoral sheets placed
Captures place in the aorta and renal arteries marked
Verify Lanks internal iliac arteries
Body of the Integraph inserted over stiff wire and deployed just below the renal arteries
Contralateral Gate is opened and cannulated - stiff wires introduced
Contralateral lamb is introduced over the wire and docked into the main body and deployed
Balloon angioplasty performed the Upper and lower fixation sites as well as graft junctions
Smooth out any wrinkles in the graft
Confirm exclusion of AAA and evaluate for endoleak
Wires and sheets are removed
flow confirmed to distal arteries
groin wounds closed
Distal extremity pulses are checked
Postoperative management after EVAR
Diet is immediately advanced
Home on postoperative day one or two
Types of Endo leak
Type I -failed to seal
Type II - feeding branch
Type III - leak between junctions of the graft - if expanding aneurysm then meet need to be addressed endovascular – Coil
Type IV - leak through the pores of graft
Type V - seroma
Type I and type III in the leaks are repaired immediately
Abdominal and pelvic CT scan:
One, six, 12 months
Then annually if no leak
open AAA repair steps of the operation
Prep Nipples to toes
Transverse bowel retracted cephalad
Small bowel retracted to the patient's right
Reset the duodenum off of the aorta
Expose the aorta blow the renal arteries
Expose bilateral common iliac arteries
Left renal vein maybe divided if needed for exposure to the aorta
Diuresis if the patient can tolerate
Administer heparin for activated clotting time of 250
Clamp lax then aorta– Alert anesthesia
Enter aneurysm ( at the level of the IMA)
So the proximal graft in place
ligate lumbar if there is could back bleeding from it
Re-implant IMA if there is port back bleeding
(careful, may just ligate if completely included – already dependent on collateral)
So in proximal graft then distal graft
Back bleed clot and debris
Stage reperfusion of legs
Close the aneurysm sac over the graft
Check distal extremity pulses
Close the abdomen
Which is fixed first aortic aneurysm or colon cancer
Aorta aneurysm (this is considered most immediately life threatening problem)
Wait six weeks then : cancer
If near obstruction colon cancer EVAR would be best
Findings and tx with acute reperfusion
acute renal failure,
increasing serum creatinine phosphokinase
Supportive management fluid resuscitation
Renal replacement therapy if needed
un explained incr WBC post AAA
watch colonic ischemia
Tricky presentation of ruptured aorta aneurysm
varicocele - ruptured into IVC with subsequent IVC fistula
femoral nerve compression
Survival of patient with ruptured aortic aneurysm
1/3 to 1/2 of patients will die before arriving to the hospital
In the hospital, mortality can reach 40%
Graft choices for a endovascular approach with ruptured aortic aneurysm
Bifurcated end of graft
(the contralateral gate is open cannulated cannulated in the contralateral lamb is docked into the in the graft and deployed)
CO2 angiography may be used
Options for rapid proximal control of ruptured aortic aneurysm
Aortic occlusion balloon inserted transfemoral or trans brachial
This can minimize drop in blood pressure with general anesthesia
Be careful to limit kidney and mesenteric and spinal ischemia time
watch for abdominal compartment sydndrome
What are the defined numbers for abdominal compartment syndrome
Abdominal compartment pressure greater than 25 mm per mercury with 50-100 mL of fluid instilled
increase rupture risk
DX of HIT
platelet agglutination tests,
however treatment should not
be delayed awaiting the test results
Anticipate reperfusion syndrome of acute mesenteric ischemia with findings of
elevated liver enzymes.
The patient may require prolonged respiratory support
One week after surgery the patient returns to the emergency department with
a severe headache and hypertension (200/100 mmHg). management of treatment
She is suffering from
hyperperfusion and requires prompt treatment (of blood pressure).
CT scan of the
head to evaluate for cerebral hemorrhage or edema.
hospitalized for blood pressure control.
Failure to control her blood pressure
could result in seizures, cerebral edema, and cerebral hemorrhage.
The patient returns one week after surgery with the complaint of drooling. management and treatment
left lower lip appears to droop and she has a small amount of drooling.
most likely represents an injury to the marginal mandibular nerve due to
The nerve injury is usually transient and the patient can expect a
2 months after surgery the patient returns for a follow-up carotid duplex
which shows slightly elevated peak systolic and end diastolic velocities in the
left internal carotid artery consistent with a 50%-69% stenosis.
This most likely represents neointimal hyperplasia.
absence of symptoms:
moderate stenosis can be treated with continued
duplex ultrasound surveillance and anti-platelet therapy.
The indications for
progression of disease to severe
Often, these patients can be treated with balloon angioplasty and
The anterior compartment of the lower leg consists of:
deep peroneal nerve
anterior tibial artery a
extensor hallucis longus,
extensor digitorum longus,
diagnostic criteria to determine severity of stenosis.
70% stenosis velocities
higher than 230 cm/s
remember this like systolic bp:
up to 125 is treated as normal
125 - 230 dangerous
greater than 230 severe danger
hyper coag work up
factor V Leiden,
prothrombin 20210 A,
protein C or S deficiency,
need lifelong anti-coagulation
Consideration of intervention with DVT
Consideration for surgical
in patients with extensive ileofemoral DVT and signs of phlegmasia cerulea
dolens or venous gangrene:
DVT in pregnant patient:
treat with low molecular weight heparin
because Warfarin is contraindicated during pregnancy due to
6 weeks after AV fistula and is about to start dialysis.
arm brachiocephalic arteriovenous fistula is pulsatile and the vein is not well
This most likely represents a stenosis of the cephalic vein.
evaluated with a duplex ultrasound or a fistulogram.
include balloon angioplasty
A 55 year old man has had a left forearm loop AV graft with PTFE for 1 year.
He was admitted to the emergency department with bleeding from the AV
graft that has been controlled with prolonged direct pressure. Physical exam
of the bleeding area reveals a localized outpouching of the AV graft with skin
This represents a pseudoaneurysm of the AV graft. It poses a
hemorrhagic risk because of the overlying skin breakdown and should be
repaired surgically with an interposition graft that is routed around the area of
A 62-year-old man returns to the office 2 weeks after a left forearm
arteriovenous graft was place using PTFE. Physical exam reveals erythema,
induration, and expressible purulence from his left antecubital incision.
represents a graft infection and requires prompt surgery for removal of the
entire graft. Partial graft salvage or preservation is not possible in a newly
placed graft because it is not incorporated and therefore the infection involves
the entire graft. The outflow vein can be oversewn while the arterial defect left
when the graft is removed should be patched with autogenous tissue if
The most convenient muscle flap for groin
sartorius muscle rotation
infected pseudoaneurysm of the proximal fem-pop anastomosis
constitutes a surgical emergency. The patient should be taken to the
operating room for hemostatic control and removal of the infected graft.
Imaging needs and revascularization options will have to be determined intraoperatively
Pre-operative imaging studies demonstrate that the patient’s infected bypass
graft is occluded.
As long as the patient’s foot is viable and not ischemic, the
entire bypass graft can be removed and no revascularization procedure is
The patient’s gunshot wound to the thigh does not demonstrate any hard
signs of arterial injury and his ABI is in the injured leg is 1.0.
This patient does
not require operative intervention or further diagnostic imaging. His normal
ABI indicates an extremely low probability of a missed vascular injury.
Arteriography for a proximity injury in the absence of hard signs and a normal
ABI is not warranted
Absence of femoral pulses after tube graft repair: most likely represents
technical error of distal anastomosis; treat with conversion to aorto-iliac or
The patient’s pre-operative evaluation revealed severe coronary artery
disease with an ejection fraction of 20%.
with symptomatic greater than 70% carotid
This patient represents a high
surgical risk. According to FDA guidelines, patients with symptomatic, severe
carotid stenosis who present a high risk for surgery because of medical or
anatomic conditions are appropriate candidates for carotid angioplasty and
antihypertensives to use for bp of 240/ 120 po CEA
look these up
wedge goal for ressus
indications for HD
lemia, acidosis, or fluid overload/pulm edema.
thrombolisis for PE post AAA
Well, I will proceed with direct thrombolisis, only if patient is very symptomatic because the care is difficult,
monitoring TPA with fibrinogen levels will increase the risk of bleeding ( I gave her other details ).
Can you give thrombolisis any other way ?
Me: yes, you can give systemic, but with a fresh aortic repair, he will bleed!!!
asystole during AAA
ABCs are important here, and I state that I ask if the ETT is correctly positioned, not clogged, and that the A-line is functioning properly. When told that these are fine, I state that I examine the pericardium to ensure that it is not bulging that might indicate a tamponade injury from placing the central line (I read of this complication on an old exam).
• Through the pericardium I see the heart quivering, so I open it from the abdomen and use paddles to cardiovert.
• What settings? Start at 10 J and go up to 20 J.
Further I administer Ca (for cardiac stabilization), Mg, lidocaine and start a Nitroglycerin drip. I also ask the anesthesiologist to check all of his lines and the ETT
I finish my repair and open the clamp, at which point the patient arrests again. So, I re-clamp the aorta, then re-shock the patient. He recovers.
What probably caused the second arrest
Acute hypovolemia (I could have averted this if I mentioned that I would open the aortic clamp one click at a time, thought of that while having beers later on), and a reperfusion process whereby lactic acid and K+ are washed out. These would be treated by IVF, administering bicarb, possibly giving Mannitol (free radical scavenger) and treating hyperkalemia aggressively (described the usual shift/protection protocols).
K+ of 6.8 with peaked Ts
What were my criteria for dialysis
inability to control electrolytes or fluid status,
A – Acidosis – metabolic acidosis with a pH 6.5 mEq/L or rapidly rising potassium levels; see previous postfor a review of the causes and management of hyperkalemia
I – Intoxications – use the mnemonic SLIME to remember the drugs and toxins that can be removed with dialysis: salicylates, lithium, isopropanol, methanol, ethylene glycol
O – Overload – volume overload refractory to diuresis
U – Uremia – elevated BUN with signs or symptoms of uremia, including pericarditis, neuropathy, uremic bleeding, or an otherwise unexplained decline in mental status (uremic encephalopathy)
ARF causes from AAA repair
(ischemia, hypotension, supraaortic X-clamp, cholesterol plaque emboli, nephrotoxicity from CT…)
Describe a retroperitoneal approach.
- What do you do if the neck of the aneurysm is right at the renal arteries?
- Would you repair it with a tube graft or a Y graft?
look these up
where is it
what is tx
- stenosis just prox to vert
-tx: carotid subclavian bypass
Endovascular anatomy requirements
o Infrarenal neck: 10mm length
o Non-aneurysmal common iliac arteries for distal landing zone
o 7mm in diameter
exposures for chest trauma by injured structure
o Descending thoracic aorta: posterolateral left thoracotomy
o Right subclavian artery: median sternotomy
o Proximal left subclavian artery: anterolateral left thoracotomy
o Distal left subclavian artery: supraclavicular incision
o Thoracic duct: right thoracotomy
o Left main stem bronchus: left posterolateral thoracotomy
Headache symptoms not due to technical error after CEA
Get a CT scan
This may be reperfusion
12 months after surgery the patient returns for a follow-up carotid duplex
which shows slightly elevated peak systolic and end diastolic velocities in the
left internal carotid artery consistent with a 50%-69% stenosis. She remains
what is dx and what tx
This most likely represents neointimal hyperplasia. In the
absence of symptoms, moderate stenosis can be treated with continued
duplex ultrasound surveillance and anti-platelet therapy. The indications for
intervention are neurologic symptoms, progression of disease to severe
stenosis. Often, these patients can be treated with balloon angioplasty and
Chronic mesenteric ischemia and bypass options
When do you fix a abdominal aneurysm in female versus male
Female 5.0 cm
male 5.5 cm
Where is also ration scene in varicose vein disease
Test varicose veins clinically
Stand for 30 seconds with below the knee tourniquet
If when the trinket is released, there is more blood that goes to the varicosities then Val is incompetent
Factor five lighting
Study work up for varicose vein disease
Eval valve competence
Deep or superficial perforators
? Ascending venography locate the level
Russia advocate for compression stockings
30 – 40 millimeters of mercury
Treatment for varicosities without venous insufficiency
Endovenous ablation (Radio frequency)
Contraindication to performing venous oblation
Deep system Venus obstruction
Patients with a reversible cause of DVT may be then treated how long and what are exceptions
exception active diagnosis of cancer:
3 months of LMWH.
Newer treatment modalities for DVT
goal of thrombolysis for DVT
decrease the chance long-term sequelae of DVT, chronic venous insufficiency.
Chronic venous insufficiency
due to longstanding venous hypertension,
It occurs in up to 30% to 40% of patients 5 years after developing a DVT, with an even higher incidence in those with iliofemoral DVT and those with ipsilateral recurrent DVT.
Risk factors for chronic venous insufficiency
hormone replacement therapy,
In younger patients without a clear etiology what should you look for as cause of unprovoked DVT
compression of the left iliac vein by the overlying right iliac artery,
Treatment of the May-Thurner syndrome
venoplasty and stenting
venoplasty, and stenting
with severe symptoms of leg swelling and extensive DVT, more aggressive intervention is indicated.
In the most severe form,
phlegmesia cerulea dolens
require venous decompression in order to decrease the chance of venous gangrene and the associated 20% to 50% amputation rate.
catheter-directed catheter-directed thrombolysis,
fail to respond to thombolysis:
open venous thrombectomy
In severe cases with limb threat:
fasciotomy after or simultaneous with thrombolysis or thrombectomy may be required to avoid amputation.
Thrombolysis for DVT
prepping the bilateral lower extremities circumferentially.
accessed in the groin
peripherally at the popliteal area.
guidewire is passed across the lesion and position confirmed within the distal vein,
an infusion catheter may be placed with an infusion run overnight.
mechanical catheters are also used.
may decrease both the amount of thrombolysis needed and also the time thrombolysis is required
open thrombectomy for DVT
femoral vein is exposed through a groin incision.
Cephalad and caudad control is obtained with vessel loops and
a venotomy is made through the vein itself or a sidebranch.
Five or six French venous thrombectomy catheters may be carefully passed in order to remove thrombus and reestablish venous flow.
In patients with a chronic DVT, the femoral vein often contains webs (scar tissue) that requires removal.
Once adequate flow is established,
venotomy may be closed with a polypropylene suture or with a patch of vein or polyester.
A completion duplex is
In some patients, an additional venogram may be needed in order to confirm adequate clearance of clot.
a low-flow state. This requires the use of intraoperative duplex in order to evaluate for technical errors that may be easily remedied at the time of the initial procedure but may be catastrophic at a later point
disseminated intravascular coagulation
usually manifests 3 to 10 days after administration of heparin,
time can be reduced with prior exposure.
can complicate thrombolysis and requires the serial measurement of fibrinogen levels.
Outflow into pelvic veins thrombus treatment
can usually be treated using combination
stenting and venoplasty.
lack of inflow into pelvic veins treatment
additional stent placement across the inguinal ligament
creation of an arteriovenous fistula in order to augment inflow
Postoperative Management after thrombectomy for DVT
can reduce the incidence of chronic venous insufficiency (postthrombotic syndrome) by 50% and should be recommended to all patients with DVT along with adequate anticoagulation.
Contraindications to thromboembolism prophylaxis
Severe trauma to head
with hemorrhage in the last 4 wk
Intracranial hemorrhage within last year!
Craniotomy within 2 wk
Intraocular surgery within 2 wk
Gastrointestinal, genitourinary hemorrhage within last month
Thrombocytopenia (18 s)
End-stage liver disease
Postoperative bleeding concerns
Immune-mediated heparin-induced thrombocytopenia
Epidural analgesia with spinal catheter (current or planned)
Surgery for Axial Venous Incompetence
conventional stab phlebectomy
powered phlebectomy (TRIVEX, Inavein, Lexington, MA).
The patient’s varicosities are marked after standing to allow for optimal dilation and visualization of affected veins.
local anesthesia with tumescence and IV sedation.
First, 1-mm incisions are made along Langer skin lines and the vein is retrieved with a hook.
Continuous retraction of the vein segment affords maximal removal of the vein and direct pressure is applied over the site.
Incisions are made at approximately 2-cm intervals.
The extremity is wrapped with a layered compression dressing, and patients are instructed to ambulate on the day of surgery.
Compression stockings are worn for 2 weeks following the procedure.
access to the great or small saphenous vein. Tumescent anesthesia is administered along the course of the vein to be treated, which is then examined for complete administration with the duplex. Closure of the vein is accomplished with radiofrequency heat or laser.
Deep leg veins
Where do you make your anastomosis if you're going to make a arterial venous fistula for low venous flow problem
At the ankle on the OPPOSITE side:
Posterior tibial artery
What does heparin and inhibit
What where does Lovenox work
What is the name of aortic occlusion balloon