VASCULAR Flashcards
(165 cards)
1
Q
Antithrombotic intrinsic properties of vascular tissue
A
- Endothelium surface
- Protein C
- Protein S
2
Q
Layers of vessel from inside out
A
- Intima
- Media
a Internal elastic lamina
b External elastic lamina - Adventisia (what you grab with pickups
3
Q
First signs of atherosclerosis
A
FATTY streak
lidi and macrophage
4
Q
Progression of atherosclerosis
A
fatty streak Fibrous plaques (encapsulated by collagen and elastin)
5
Q
Most common site of atherosclerotic plaques
A
Coronary arteries
Carotid bifurcation
Proximal ilicac arteries
Adductor canal region
6
Q
Pathophys mechanics of where / why plaques dvlp
A
LOW shear stress
7
Q
Main constituent responsible for extrinsic pathway coag
A
TISSUE FACTOR
8
Q
Most common cause of occult bleeding risk
A
vonWillibrands (pTT)
9
Q
Tx of most VWD
A
DDAVP
10
Q
Most common hypercoagulability
A
Factor V Leiden
11
Q
Why is there transient hypercoagulability with coumadin
A
Protein C is taken out first (short T1/2) and this is a natural anticoagulant in endothelium
12
Q
Where is factor 8 found
A
endothelium
13
Q
Most severe clotters of any hypercoagulability
A
hyperHOMOCYSTEIN
14
Q
Tx of hyperhomocysteinemia
A
Folic acid
Vit B 6 and 12
15
Q
Define aneurysm
A
More than 1.5 normal diameter
16
Q
Fusiform aneurysm
A
diffusely dilated
17
Q
Saccular aneurysm
A
eccentric outpuch
18
Q
Most common sites of aneurysm
A
Infrarenal aorta Icliac arteries Splenic Renal, Hepatic, SMA, Celiac Popliteal arteries Femoral
19
Q
Risk of popliteal aneurysm
A
pop aneurysm on one side has 60% chance of contralateral
50% chance of AAA
20
Q
What is biochem associated with aneurysm
A
MMP
Matrix-metalloproteinase
21
Q
Syndroms associated inherited connected tissue aneurysms
A
Marfan’s
Ehler-Danlos
Cystic medial necrosis
22
Q
Aneurysm associated with pregancy
A
Pregnancy (SPLENIC, mesenteric, Renal)
23
Q
Aneurysms associated with arteritis
A
Takayau’s disease
Giant cell arteritis
Polyarteritis nodosa
Systemic lupis
24
Q
Best screening for aortic and peripheral aneurysms
A
US
25
When to tx AAA
greater than 5.5 cm males 5.0 female
(smaller if sx / syndrome)
Incr size greater than 0.5 cm / 6 mo
26
Most common organism for mycotic AAA
MOST common staph AURUS
| Most common spont bug salmonela
27
What is special about staph eip
slime layer
28
When do you fix popliteal aneurysm
greater than 2 cm
evidence of thrombus in wall
sx of showering
29
How do you fix pop aneurysm
saph graft
30
What do you watch for with colon post repair of AAA
Colon ischemia:
ligation of IMA, periop hypotention,
Sigmoid scope
31
Type I endoleak
Bad seal btw wall and graft
| Fix right away
32
Type II endoleak
Leak from collateral
| Watch
33
Type III endoleak
bad seal between components
| Fix right awy
34
Type IV endoleak
Leaking through pores of material
| Watch
35
Type V endoleak
Gradual build-up of thrombus pushes graft away from wall
| Watch
36
What manuever is needed to clamp the super celiac
Must take down triangular ligament down
| Free esophagus
37
Two options to approach infected graft
Sick: excise graft
Stable: Abx and in situ graft replacement (but most will undergo graft excision)
38
Prognosis of pop aneurysm that is showering thrombi
50% amputation rate!
39
Stanford type A dissection
A is for Assending
| ANY dissection that involves the ascending aorta (even if it goes right down the groin..
40
Stanford type B dissection
B is for below - BELOW ascending
41
What defines distal aorta dissection
distal to SUBCLAIVAIN
42
Tx of Aortic dissection sx
Nitropruside
43
Aortoiliac occlusive disease
YOUNG:
| 40-60 yo, smokers, hyperlipid,
44
Leriche syndrome
impotence
absence of femoral pulse
lower extremity claudication
muscl wastin fo the buttocks
45
Where are foot findings with peripheral arterial diease
ulcers of DORSAL foot
HEEL
TOES
46
Where are foot findings with peripheral venous insuf
MEDIAL or lateral MALLEOLUS (gaiter zone)
47
Charoct's foot
diabetic ulcers - planter or lateral foot with DM neuropathy:
Injury to autonomi motor and sensory
48
Beurger's sign
dependent rubor with PVD
49
Cilostazol
Pletal:
50
What is med tx for PVD
betablockers
statin
ACE
51
Aortofemoral bypass grafting patency rate at 5 years
greater then 90%
52
How do patency rates for extraantomic bypass compare
lower
53
Where do you see fibromuscular hyperplasia
renal artery stenosis
54
Where do you revasc celiac
common hepatic artery
55
What is principle collateral between celiac and superior mesenteric arteries
Gastroduodenal artery
56
Major watershed of bowel
Splenic flecture
| Sigmoid
57
What bowel arteries can be sacrficed
IMA
| NOT SMA
58
What pathophysio findings of stenosis indicated you should stent versus angioplasty
Atherosclerosis: STENT
| Fibromuscular dysplasia: angioplsty
59
What is fibromuscular dysplasia
middle to distal portion of the renal artery (spares the proximal renal artery)
Involves: intima medial or adventitia (all 3 layers)
60
Renal artery stenosis
Fibromuscular dysplasia
Bilateral 50%!
3 times more in FEMALE
Diastolic hypertension
61
Tx of renal artery steosis
Plasty if proximal (because this is usually just an extension of the aortic plaque.
Then stent because usually recurs.
62
Meseneric ischemia
Embo to SUPERIOR mesenteric artery 50% of all cases of ACUTE mesenteric ischemia
Thrombus is 25%
63
Where do most SMA emboli lodge
distal 3-10 cm from the origin of the SMA
64
Tx of SMA occlusion
Embolectomy and ALWAYS a second look.
Anticoag
W/u embo source
65
Diagnosis of renal artery stenosis
CTA
66
NASCET
North American SYMPTOMATIC Carotid Endarterectomy Trial:
70% occlusion - CVA or death risk in 2 years:
26% with antiplatelet alone
9% with CEA
50-69% stenosis:
risk reduced with CEA also
67
ACAS
ASYMPTOMATIC Carotid Atheroslerosis Study:
60% occlusion:
11% stroke in 5 yrs with antiplatelet
5% with CEA
68
CREST
Open increase risk of MI
| Stent increased risk of stroke
69
Other common causes of carotid artery occlusion besides hamburgers
Fibromuscular dysplasia
Takaysu arteritis
Dissection
Trauma
70
Vertebral Basilar disease
Subclavian steal syndrome:
Occlusion proximal to the origin of vertebral artery causes dcreased perfusion of the subclavian artery (this makes the vertebral artery act as a collateral in arm circulation)
Sx: ipsilateral brachal artery pressure is reduced by 40 mmHg
Left sublavian is more likely because increased length.
71
Treatment of subclavian steal syndrome
bypass from vertebral artery to distal subclavian occulusion site
72
Which side is more likely to develop iliac DVT
LEFT by 4 times!
| Aortic bifurcation compresses the left iliac vein
73
Pagets Shroder
TPA and first rib resection
74
Adson's test
diappearance of the radial pulse with abduction and external rotation of the shoulder
Non-specific TOS sign
75
Hyperhydrosis
middle and internal gangion
76
Retroperitoneum zones and treatment
```
Zone I:
midline - Aorta vena cava
Zone II:
Perinephric -
Zone III:
Pelvic - iliac vessels - watch if blunt non expanding
Explore any penetrating trauma
Explore any zone I injury
```
77
How do you get proximal control of Zone I and II retroperitoneal injuries
Proximal control of the aorta just below the diaphragm
78
How do you get proximal control of pelvic retroperitoneal hematoma
This is Zone III:
| Control at the level of infrarenal aorta
79
Inflammatory aneurysm define
Careful not the same as mycotic (infected) aneurysm.
| Ruputure risk not greater than noninflammatory aneurysm of same diameter
80
Inflammatory aneurysm comorbidity
Often involves the 4th portion of the duodenum
Inferior vena cava
LEFT renal vein
Ureters - hydronephrosis spont resolve
81
Tx of Inflammatory aneurysm
DO NOT dissect the duodenum off the aorta
May need to divide the renal vein if densely adherent (divide near IVC)
Use left retroperitoneal approach - elevated left kidney
Juxtarenal involvement may preclude endovascular approach.
82
AAA anatomy required for EVAR
15 mm proximal neck
25-30 mm max diameter
Less than 60 degree angulation btw the proximal neck and the suprarenal aorta
Adequate access caliber 7-8 mm with out prohibitive friable calcification
83
When does renal artery stenosis need to be fixed
Sudden worsening of preexisting hypertention
Resistant HTN despite 3 meds
Worsening Renal function after ACE
Unexplained atrophy of one kidney
HTN causing end organ damage (renal insuf, recurrent CHF)
84
Complications of Heparin
HIT: dcr platelet (by 50% of baseline) - usually within the first 2 days
Skin necrosis
Osteopenia
OK to use with pregnancy
85
Complications of Warfarin
```
Skin necrosis (Protein C)
Cholestatic hepatic injury with prolonged use
```
86
What is proximal control for truly emergent ruptured AAA
Clamping the aorta a the diaphragm (take down triangular lig - mob esoph)
87
Risk of AAA rupture per year with size
4-4.5cm: 1-3%
5.5 -5.9 cm 9%
6 - 6.9 cm: 10%
>7 cm: 32%!
88
Indications for IMA replant
Poor back bleeding from IMA (colaterals not well dvlpd)
Pressure greater than 40 mmHg adequate collaterals
Signs of rich collaterals with arch of Riolan (btw middle colic off the SMA and the LEFT colic artery off the IMA)
Poor colonic doppler
Intramural colonic pH acidosis
89
Intraop gross signs of heparin resistance
```
RED thrombus occluding graft
No change in clotting time
(More common in CPBP)
Cause: deficiency in antithrombin III
Tx: give FFP that has antithrombin III
```
90
when to fix Asx iliac artery aneurysm
3.5 cm
91
how to fix iliac artery aneurysm
Endo first choice ("but" higher risk of butt claudication to occlusion of internal iliac)
open prosthetic ok
92
work up for aortic enteric fistula
```
upper GI (possible ped c-scope)
second choice: CT
```
93
Treatment of infected IV drug abuse femoral artery aneurysm
Ligate!
94
Management of penetrating trauma to lower extremity with absent pulse
OR!
95
What penetrating trauma might get an angio before OR
Zone I neck
Zone III neck
Transmediastinal GSW
96
Most common symptom of popliteal aneurysm
Thrombus (chronic ischemia)
49% followed by distal emoblization
Later compresses pop vein
97
What is considered rapid expansion of AAA on survelence
>1 cm / yr
98
Management of frostbite
Rapid rewarming 40-42C bath until sensation returns
(tissue injury is worsened by partial rewarming and reexposure to cold)
Remove clear blisters (leave hemorrhagic blisters)
Avoid debridement
Delay amputation for prolonged (3-4 months!) demarcation and internal healing
Limb elevation
Antibiotics and tetnus
99
Mechanism of frostbite
```
Ice crystals form in extracellular space
Loss of osmotic transport of water out of cell
Leads to cellular dehydration
Hypercoaguation state
Tissue injury
```
100
most common aortic emergency
spontaneous dissection
101
medical management of aortic dissection
```
#1 nitroprusside
#2 beta blocker
```
102
diagnosis of aortic dissection
```
transesophageal echocardiogram
(But doesn't visualized distal aorta)
```
103
pathophysiology and risk factors responsible for AAA
MMP ( not atherosclerosis) were
hypertension makes it worse
Smoking activates MMP
( diabetes is not associated with aneurysm)
104
d-dimer used to diagnosis
aortic dissection
PE
Clot breakdown products
105
reentry operation for dissection
composite graft the bowel trunk
106
artery responsible for spinal cord ischemia
artery of Adamkiewicz
| level the lumbar
107
anterior spinal symptoms
loss of pain and temperature
| theStill have proprioception
108
What is percent occlusion that impede blood flow
70-75%!
109
were or findings associated with renal artery stenosis
fibrointimal hyperplasia:
the string of beads sign
distal two thirds of renal artery
110
treatment of renal artery stenosis due to atherosclerosis
stent
111
treatment of renal artery stenosis to do fibrointimal hyperplasia
angioplasty
112
what does the artery or Riolon collateralized between
SMA and IMA in circle
113
which does be meandering artery of Drummond collateralized
SMA and IMA and the outer circle
114
what is the collateral between the gastroduodenal artery and the SMA
pancreaticoduodenal artery
115
which lower extremity is more likely to embolize
the left because of less acute angle of common iliac
116
what is the Mattox maneuver
LEFT visceral medial rotation
Anterior transperitoneal approach
Trauma vascular access
117
what is the Cattel-Barrash maneuver
RIGHT visceral medial rotation (Bill developed for head of pancreas)
118
described the relationship between the renal artery and the renal vein
renal artery more CRANIAL
| Renal vein VENTRAL
119
where is the splenic artery when compared to splenic vein
splenic artery more cranial (like renal artery)
120
first-line treatment for thrombosis of AV fistula
TPA!
| If venous component affected angioplasty
121
where his procedure of choice with hand ischemia after AV fistula
```
DRIL procedure distal revascularization interposition ligation
#1 ligated distal radial artery (Because blood is flowing from radial to ulnar artery and then to the vein)
#2 jump graft from proximal to distal we ligated artery the
```
122
venous insufficiency signs
MEDIAL malleolus
123
Most common risk factor for spontaneous venous thromboembolism
factor V Leiden
is a Autosomal dominant
mechanism: in activation by activated protein C
a 6 fold increase in thrombus in the left homozygous vein 80 fold
124
name hypercoagulable disorders
```
#1 factor V Leiden-most common
#2 anti-thrombin 3 deficiency
#3 prothrombin gene mutation
#4 protein C and S. deficiency
#5 elevated homocysteine
#6 antiphospholipid syndrome
#7 smoking, obesity, pregnancy, oral contraceptives, malignancy
```
125
who has a highest risk of venous thromboembolism all comers
TRAUMA
| Spinal cord injury
126
which side is more common to get a iliac vein DVT
LEFT
| Left iliac vein compressed by right iliac artery note is May Turner syndrome
127
superficial venous thrombosis
rate of concomitant DVT 5-40%
Duplex ultrasound essential
If within 1 cm of saphenofemoral junction can propagate into the deep system-this case needs anticoagulation or ligation of the saphenous vein and junction
128
suppurative thrombophlebitis
taken out IV
Antibiotic
Sometimes surgical removal of infected vein
129
heparin-induced thrombocytopenia
caused by platelet activating antibody
Increases thrombin generation
Present 5-10 days after heparin
10 being present because of previous exposure-platelet count drops for 10 days in this case
130
Management of heparin-induced thrombocytopenia
```
alternative anticoagulants:
argaroban
lepirudin
Both thrombin inhibitors
both monitored by partial thromboplastin
both irriversible
```
131
how it is argatroban cleared
hepatic
132
how is Lepirudin cleared
kidney
133
treatment of Paget Schroeder syndrome
```
axillary-subclavian vein thrombosis
Diagnosis duplex ultrasonography
Treatment:
Immediate heparin
Catheter and directed thrombolyis
angioplasty some recommend first rib resection
```
134
EKG findings with PE
```
sinus tachycardia
S1, q.3, T3
Prominent S wave in lead one
Q wave
Inverted T in lead 3
This is consistent with right ventricular strain but not commonly present
```
135
treatment of spontaneous left iliac femoral vein thrombosis
Rule out May turner syndrome
Thrombolytic therapy
If thrombectomy is successful but residual stenosis present recommend spent (not just angioplasty)
RARE to recommend operative embolectomy- phlegmasia alba dolens does not response to thrombolysis
136
absolute indications for permanent IVC filter
1. development of DVT or PE with contraindication to anticoagulation her acute GI bleed)
2. A new venous thromboembolism that develops despite receiving anticoagulation
3. Patient with venous thromboembolism developed hemorrhage while already receiving anticoagulation
137
relative indications for RETRIEVABLE IVC filter
```
#1 before planned from the lysis of new DVT
#2 recent DVT in plan to Maj. surgery
#3 prophylaxis and severe trauma of head, pelvis, spinal cord
```
138
relative indications for permanent IVC filter
```
#1 venous thromboembolism in poorly compliant patient
#2 recurrent episodes of venous thromboembolism
#3 large free-floating thrombus in IVC
```
139
reddish blue nodule develops and left arm a 70-year-old woman after chronic swelling for 20 years post modified radical mastectomy
```
lymph angiosarcoma
“Stuart Treves syndrome”
rare highly lethal malignancy
Caused by chronic lymphedema
A rigid firm blood vessels instead of lymphatics (better name is angiosarcoma )
```
140
Exam findings of lymph angiosarcoma
Purple colored patches form plaques and nodules
Palpable subcutaneous mass
poorly healing eschar with recurrent bleeding and infection
141
treatment of lymph angiosarcoma
Surgical
Wide local excision equal outcome to amputation
Does NOT respond well to chemotherapy or radiation
Poor prognosis high recurrence rate high metastatic rate
142
Kaposi's sarcoma
similar findings to lymphangioma sarcoma
| Very rarely develops in lymphedematous extremity
143
most common cause of primary lymphedema
lymphedema praecox
144
3 types of primary ymphedema
```
#1 congenital ( one type is Milroy disease)
#2 lymphedema praecox
#3 lymphedema tarda
```
145
lymphedema praecox
most common-80-90%
developed during childhood or teenage
10 times more common in women
starts in the foot or lower leg usually
146
lymphedema tarda
start after the age of 35
147
secondary lymphedema
more common than primary lymphedema
most common worldwide: filariasis ( Wuchereria Bancrofti)
most common cause in the United States: post axillary node dissection
148
clinical findings of lymphedema
```
#1 nonpitting
#2 involves toes unlikely venous
#3 recurrent cellulitis
#4 peau d'orange
```
149
test for lymphedema
only needed his diagnosis in question with no recent surgery
Best tests: Lymphoscintigraphy-
Once diagnosis has been made CT or MRI health rule out pathology
150
factors that warfarin inhibits
PACs and liver inhibiting vitamin K dependent procoagulant factors:
2, 7, 9, 10
Protein C, protein S
151
Warfarin skin necrosis
first days of therapy
Associated with deficiencies of:
Protein C, protein S, factor VII, malignancy
152
Heparin mechanism of action
potentiate anti-thrombin inhibition of thrombin and activated factor X
drops the level of anti-thrombin 3
153
factor V Leiden deficiency affect what vessels
vein and ARTERIES
154
prothrombin 20210 defect
THE second most common inherited hypercoagulability
155
antiphospholipid syndrome
Lupus anticoagulant- anti- cardiolipin antibody
156
autoimmune association with hypercoagulability
```
(anti-cardiolipin antibody)
#1 systemic lupus erythematous
#2 social and syndrome
#3 rheumatoid arthritis
```
157
elevated homocystine
most severe cloters of the hypercoagulability disorders
lowered with vitamin B = better ( and folate)
158
What kind of trauma injury has highest risk of venous thromboembolism
spinal cord injury HIGHEST
Fracture of femur or tibia
Other factors include older age, blood transfusion, need for surgery
159
Argatroban
```
direct thrombin inhibitor
Used for heparin-induced thrombocytopenia
Monitored by active partial thromboplastin time
Half-life the 40-50 minutes
The ureter were stable
Cleared by HEPATIC
Used for treatment of:
one HIT
#2 coronary intervention
```
160
Lepirudin
```
monitored by activated partial thromboplastin time
#2 direct inhibitor of thrombin
#3 irreversible
#4 out 560 and 90 minutes
#5 cleared by KIDNEY
#6 reversed by thrombin
```
161
management of thrombosis of greater saphenous vein
even though “greater” saphenous this is a SUPERFICIAL vein
Duplex venous system
Nonsteroidal anti-inflammatories
NOT Heparin
unless 1 cm within the saphenofemoral junction
162
treatment of venous insufficiency disease failed compression therapy
stripping greater saphenous vein ( WITHOUT high ligation)
163
Linton procedure
large open incision associated with significant wound healing complications
164
subfascial approach for venous disease
endoscopic trochars with carbon dioxide insufflation
Perforators clipped and divided
MODEST have patent deep system
165
the vein valve transplantation
interposing brachial vein to the popliteal vein
| 40-50% of patients have persistent recurrence of ulcers in the long-term if preoperative ulceration present
