Vascular

Question 1

Collateral path to provide blood flow to lower extremity in setting of complete aortoiliac occlusion?

Answer 1

Collaterals of Winslow: subclavian arteries connected to external iliac arteries through the internal mammary (superficial epigastric) and inferior epigastric

Question 2

How does blood usually reach the foot when SFA is occluded?

Answer 2

Profunda collateralizes through the genicular artery to the popliteal artery

Question 3

What clinical test is performed to evaluate the patency of ulnar and radial arteries?

Answer 3

Allen’s test

Question 4

MC site of UE stenosis?

Answer 4

Subclavian artery

Question 5

Tibioperoneal occlusive disease:

• -who is at increased disease?
• -why are these lesions more dangerous?
• -indications for surgery?

Answer 5

• -diabetes and Bueger’s disease
• -fewer collaterals
• -limb salvage and ischemic ulcers only

Question 6

Surgical options for tibioperoneal disease?

Answer 6

Femorotibial or femoropopliteal bypass

Question 7

Causes of UE occlusive disease?

Answer 7

Embolism
Trauma
Thoracic outlet syndrome
Arteritis (Buerger's and Takayasu's)
Vasospastic disorders (Raynaud's syndrome)

Question 8

What is the procedure of choice for subclavian artery stenosis in a patient without carotid occlusive disease?

Answer 8

Common carotid to subclavian artery bypass with PTFE conduit

OR
Can transect the subclavian artery and transpose the distal end to perform an end-to-side anastomosis

Question 9

Syme’s amputation

Answer 9

Amputation of the foot

Question 10

Ray amputation

Answer 10

Removal of the MT head and digit of foot

Question 11

Transmetatarsal amputation (TMA)

Answer 11

Foot amputation at the level of the metatarsals

Question 12

Which flap as has the blood supply for a BKA - anterior or posterior?

Answer 12

Posterior flap - closer proximity to popliteal artery

Question 13

Best type of suture for apposing the muscle fascia layer of a BKA or an AKA?

Answer 13

Absorbable (such as vicryl)

Question 14

Best predictor of failure of a BKA to heal?

Answer 14

Absence of popliteal arterial pulsation on palpation or Doppler

Question 15

What toe pressure is though to correlate with the failure of a TMA or toe amputation to heal?

Answer 15

Systolic toe pressures <45

Question 16

How do plaques in carotid disease differ from those in vertebrobasilar disease?

Answer 16

Carotid: high incidence of ulcerated plaques
Vertebral: usually a smooth intimal surface

Question 17

Drop attacks are associated with what disease?

Answer 17

Vertebrobasilar disease

Patient suddenly falls to the ground because of bilateral LE motor deficit (+/- LOC with rapid recovery)

Question 18

Three main mesenteric arteries

Answer 18

Celiac: stomach to ampulla of vater (2nd portion of duodenum)
SMA: to the splenic flexure of the colon
IMA: to the rectum

Question 19

Watershed areas of the colon

Answer 19

Splenic flexure

Question 20

Branches of the celiac artery?

Answer 20

L gastric
Splenic
Common hepatic

Question 21

First two branches of the SMA?

Answer 21

Inferior pancreaticoduodenal artery

Middle colic artery

Question 22

Branches of the IMA?

Answer 22

L colic
Sigmoid
Superior rectal

Question 23

Collateral pathway between celiac and SMA

Answer 23

Celiac –> Common hepatic –> GDA –> superior PD artery –> inferior PD artery –> SMA

Question 24

Collateral pathway between SMA and IMA

Answer 24

SMA –> middle colic –> arch of Riolan –>left colic –> IMA
SMA –> marginal artery of Drummond –> IMA

Arch of Riolan (meandering mesenteric artery): runs pRoximal to mesenteric root
marginal artery of Drummond: runs Distal to mesenteric root

Question 25

Renal arteries located at what lumbar level?

Answer 25

L1 to L2

Question 26

Is the right renal artery anterior or posterior to the IVC?

Answer 26

Posterior

Question 27

How is the right renal artery exposed intraoperatively?

Answer 27

Cattel and Kocher maneuvers (medial mobilization of the hepatic flexure of the colon and the third portion of the duodenum) +/- retraction of the IVC for exposure of the most proximal portion of the renal artery

Question 28

MC site of visceral embolism causing acute mesenteric ischemia?

Answer 28

Proximal SMA (at the SMA origin or at the takeoff of the middle colic artery) SMA takeoff is at an acute angle

Question 29

Symptoms of acute mesenteric ischemia?

Answer 29

severe abd pain, pain out of proportion to the signs on physical exam

Question 30

When is bowel nonviability determined?

Answer 30

After the revascularization procedure

Question 31

How is bowel viability assessed intraoperatively?

Answer 31

Gross exam: palpable pulses, pink color, visible peristalsis Wood's lamp inspection after IV fluorescein Doppler US of mesenteric artery adjacent to the bowel in question

Question 32

Classic angiographic findings for embolus/thrombosis/nonocclusive etiologies?

Answer 32

Embolus: abrupt occlusion with a meniscus sign, usually 5-8 cm from origin of SMA

Question 33

Revascularization options/treatment for acute mesenteric ischemia

Answer 33

SMA thrombosis: mesenteric bypass or reimplantation of SMA to aorta SMA embolism: embolectomy +/- SMA patch angioplasty Non-occlusive mesenteric ischemia: correct underlying condition, consider catheter directed intraarterial infusion of vasodilator

Question 34

Mesenteric bypass retrograde vs antegrade

Answer 34

Retrograde: from iliac artery or infrarenal aorta to SMA Antegrade: from supraceliac aorta to SMA

Question 35

What do the terms antegrade and retrograde refer to in describing aortovisceral bypass?

Answer 35

Site of aortic anastomosis with respect to the origin of the mesenteric vessel being bypassed Antegrade - proximal to origin Retrograde - distal to origin

Question 36

Why is antegrade bypass preferred?

Answer 36

Longer-term patency | but retrograde is faster/easier

Question 37

Why is mortality rate so high for acute mesenteric ischemia?

Answer 37

Delayed diagnosis

Question 38

#1 peripheral aneurysm

Answer 38

popliteal aneurysm 50% are bilateral 1/3 have AAA

Question 39

#1 visceral aneurysm

Answer 39

splenic aneurysm | Tx if >2 cm, child bearing age or planning pregnancy, or symptomatic

Question 40

Bloody diarrhea first few days s/p AAA repair

Answer 40

Needs flex sig/colonoscopy to evaluate for ischemic colon (due to loss of IMA)

Question 41

#1 CN injury with CEA

Answer 41

vagus nerve --> hoarseness

Question 42

fibromuscular dysplasia typical pt

Answer 42

young woman with HTN usually R renal a. tx: angioplasty

Question 43

MC bacteria that cause mycotic AAA?

Answer 43

S. epidermidis S. aureus Salmonella

Question 44

Classic physical exam finding of ruptured AAA?

Answer 44

Ecchymosis in the inguinal and groin region

Question 45

What is graft material of choice for AAA?

Answer 45

Dacron (woven or knitted, +/- collagen impregnation) | 2nd choice - PTFE

Question 46

What are two surgical approaches for AAA repair?

Answer 46

Midline laparotomy | RP approach through L flank incision

Question 47

In a patient with a ruptured AAA, what is first step after midline laparotomy? What are the next steps?

Answer 47

Immediate compression of the supraceliac aorta against the vertebral bodies through the lesser sac L crus of the diaphragm is divided, the supraceliac aorta is clamped, the neck of the AAA (usually infrarenal) is exposed and clamped, the supraceliac clamp is removed, and the graft is placed

Question 48

What frequently obstructs access to the neck of the AAA in the transabdominal approach?

Answer 48

L renal vein

Question 49

What is the presentation of aortocaval fistula?

Answer 49

High output CHF, hypotension, cyanosis, venous distension of the LE, abdominal bruit, and palpable abdominal thrill

Question 50

What is the treatment of aortocaval fistula?

Answer 50

The fistula is closed: - -Achieve proximal and distal control of the aorta and IVC - -make and incision in the aortic graft - -repair the fistula from within graft with large suture bites - -close the aortic graft

Question 51

What is excluded in the setting of pseudoaneurysm?

Answer 51

Graft infection

Question 52

ACAS trial

Answer 52

asymptomatic, >60% stenosis | CEA reduces 5 year stroke rate from 11 to 5%

Question 53

NASCET trial

Answer 53

symptomatic, >70% stenosis CEA reduces 5 year stroke rate from 26 to 9%

Question 54

#1 CN injury with CEA

Answer 54

Vagus nerve -> hoarseness

Question 55

Atherosclerosis pathology

Answer 55

type I foam cells (lipids in macrophages; II fibrointimal lesion = smooth muscle proliferation due to mac's growth factors; III: disruption exposes collagen -> thrombosis