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Flashcards in Vascular Deck (44):

2 types of aneurysms

Saccular (outpouching, mushroom)
Fusiform (entire diameter grows)


Difference bt aneurysm and dissection

aneurysm = all layers of arterial wall (intima, media, adventitia)
dissection = defect in intima, allows blood to go bt layers


Branches of abd aorta

celiac trunk
renal arteries
gonadal arteries
95% of abd aneurysms are distal to the takeoff of the renal arteries.


PhysEx for abd ao aneurysm

pulsatile abd mass
lower extremity pallor, cool temp, unequal/diminished pulses


Diagnostic eval for abd aneurysms

US- size and if there's a clot in the arterial lumen
CT or MRI- anatomic detail and localization
Aortogram- can check for involvement of other vessels, help plan surgery


Rx for abd ao aneurysm

If asx: depends on size-
<4cm medical- beta blockers
4-5cm- can do early op or can do close followup.
5+cm surgical repair.
surgery- new use of stent grafts via femoral

If ruptured/leaking- fluids and immed op


Surgical repair of AAA

midline incision or oblique over 11th IC space.
Midline: push bowel to right, incision of posterior peritoneum to the L of the Ao exposes entire Ao.
Oblique- only for retroperitoneal approach. Entire peritoneal contents pushed to right, exposing Ao.

Get prox and distal control, give heparin before clamping, place graft w permanent sutures.
If transabd approach, close peritoneum over graft.


branches off of thoracic aorta

brachiocephalic, L common carotid, L subclavian, bronchial arteries, esophageal, intercostal arteries


Cause of thoracic Ao aneurysms

Cystic medial necrosis or atherosclerosis
less common- trauma, dissection, infection


HPE for thoracic Ao aneurysm

Most are asx
if ruptured- chest pain/prs
if expanded- can compress tracha --> cough, if erodes into trachea --> hemoptysis
if close to Ao valve, can cause dilation of the annulus--> Ao insuff and chest pain, dyspnea, syncope
on physEx- hypotension, tachycard
if involves annulus, ao regurg and CHF


Dx Eval for thoracic Ao aneurysm

CXR- wide mediastinum
EKG- myocardial ischemia
If asx- do CT or echo
Aortography for planning op


Rx for thoracic Ao aneurysm

If asx, operate if 5+cm
Sxtic- immed op


Why do Ao dissections occur (path)?

HTN, trauma, Marfan syndrome, Ao coarctation


HPE Ao dissection

Immediate onset severe pain, tearing, in chest, back, abd.
Also nausea, lightheadedness
May be hypotensive, may have diminished periph pulses


Dx Eval of Ao dissection

CXR- wide mediastinum
CT- may show dissection or clot in arterial lumen
Dx via TEE, MRI, or aortogram


Classifications of Ao dissection

DeBakey Type I: both ascending and descending Ao
Type II: just ascending
Type III: just descending


Rx for Ao dissection

Depends on type. DeBakey Type II (ascending)- surgery! bc can go retrograde to Ao root. Give anti-HTN before surgery to halt progression
DeBakey Type III (descending)- medical only. give anti-HTN: Na+Nitroprusside and B Block.


From where does the common carotid arise?

On right side: from brachiocephalic (which comes off of Ao)
On left: directly from Ao.


What arteries does the common carotid branch into?

Bifurcates into Internal and External branches.
Internal carotid gives of opthalmic artery, then continues to circle of willis in brain.


Why does carotid artery disease occur (pathogenesis)?

But you get the stroke bc of plaque rupture, ulceration, hemorrhage, thrombosis, low flow states.


Pt Hx in carotid artery dz

Prev neurologic events:
TIA (24 hr resolution); fixed neuro deficit
Amarosis fugax


What is amarosis fugax

transient mono-ocular blindness
shade being pulled down.
d/t occlusion of a branch of the opthalmic artery (which is a branch of the internal carotid


PhysEx in carotid artery dz

May have fixed neuro deficit
Hollenhorst plaques on retinal exam = evidence of previous emboli
Carotid bruit - evidence of turbulent carotid flow


Dx Eval of carotid artery dz

Carotid duplex scanning
Angiography more accurate for assessing degree of stenosis


Rx for carotid artery dz

Depends on Hx, degree of stenosis, and plaque characteristics.
Anti-plt therapy w aspirin prevents neurologic events
If acute event and CT confirms it's non-hemorrhagic: give heparin
Carotid endarterectomy only in serious pts.
Stenting being researched.


What patients should get a carotid endarterctomy?

Pts w:
>75% stenosis
>70% stenosis + sx
bilateral dz + sx
>50% stenosis and recurring TIA despite aspirin


Carotid endarterectomy procedure

IV abx (1st gen ceph) before incision
Incision over anterior border of SCM
ligate facial vein --> expose carotid
carotid is just medial to JV
don't injure hypoglossal nerve or spinal accessory nerve.
give heparin, open artery, dissect out plaque.
close with patch.


What is the celiac axis?

arterial supply to liver, spleen, pancreas, stomach


thrombosis of which vein can cause visceral ischemia?

Superior mesenteric vein


Acute ischemia of mesentery occurs how? (path)

acute embolization
acute thrombosis
non-occlusive ischemia
mesenteric vein thrombosis


Acute mesenteric ischemia- HPE

May have hx of prev embolic events, Afib, CHF.
Abd pain is sudden and severe, w diarrh/vom
Pain out of proportion to exam
Abd may be distended
Rectal exam - guaiac+ stool


Chronic mesenteric ischemia- HPE

Hx of crampy abd pain after eating--> decrsd oral intake and weight loss.
can have naus/vom/diarrh/constipation
Can be mistaken for malignancy d/t weight loss
May have abd bruits, guaiac+ stool, PVD or CAD


Dx Eval of acute mesenteric ischemia

elevated WBC, metabolic acidosis, elevated hematocrit (d/t fluid sequestering in infarcted bowel)
Abd XR normal early on, but later shows thumbprinting of bowel wall.


Rx of acute mesenteric ischemia

Laparotomy, exam and resect any infarcted bowel.
Sometimes angiography can be dxtic/therapeutic.
Mortality extremely high even with intervention.


Rx for acute mesenteric vein thrombosis

Laparotomy if there is susp of necrotic bowel


Peripheral vascular dz occurs in what arteries?

Common and superficial femoral
Anterior tibial
Posterior tibial

Even tho there are 3 vessels that supply the ankle/foot, you only need 1 to be adequate for life.


Pathogenesis of acute vs chronic PVD

acute- caused by embolus, usu from Ao or heart (Afib)
chronic- from progressive atherosclerotic dz--> narrowing of lumen and decreased blood flow


HPE of acute PVD

sudden/severe lower extremity pain and paresthesias.
5 P's:
pain, parasthesia, pulselessness, pallor, poikilothermia (coolness)


HPE of chronic PVD

claudication- pain on activity, relieved on rest.
butt claudication = aortoilliac dz; calf claudication = femoral atherosclerosis.
may have ulcers too.
can have loss of hair, pallor on elevation, rubor on dependent positioning, wasting, thick nails, thin skin


Dx Eval of PVD

Angiography for acute PVD
doppler for chronic (normal = triphasic. as progresses, becomes bi, mono, then absent.
Arteriography is gold standard for defining level/extent of dz and surgery planning


Ankle brachial index in PVD

Claudication ABI = 0.5
Rest pain ABI = 0.3-0.5
Gangrene ABI = <0.3


Rx for acute ischemic embolus in PVD

heparin, thrombolysis, embolectomy


Rx for chronic ischemia in PVD

smoking cessation and graded exercise


Peripheral bypass operation for PVD

Usu have CAD too, so give Bblocker intraoperatively. Plus IV 1st gen ceph. artery is dissected, use either synthetic grafts or, if infra-popliteal, use in situ or reversed saphenous vein.