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Vascular and Cardiac/Thoracic Flashcards

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1
Q

pulse volume recording

A

type of plethysmography which is used with a doppler to assess perfusion of distal extremities assuming that change in volume corresponds to change in arterial pressure

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2
Q

Ankle brachial index categories

A

> or equal to 1= normal
0.5-0.7= claudication
<0.3= ischemic rest pain, gangrene

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3
Q

what penile brachial index indicates vascular etiology for impotence

A

PBI <0.6

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4
Q

post arteriography guidelins

A

maintain patient supine for at least 6h
check for hematomas, aneurysms
check neuro status (embolus r/O)
well hydrated state

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5
Q

to be a TIA, resolves in

A

24h

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6
Q

earliest sign of acute arterial insufficiency in lower extremity

A

distribution of peroneal nerve- no dorsiflexion,foot drop

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7
Q

likely site of occlusion: can feel femoral but no popliteal or pedal pulses

A

localize lesion above site where pulse first loss

here- likely in thew superficial femoral artery (SFA)

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8
Q

common sites of atheroembolism

A

distal vessels, usually lower extremity- common femoral and popliteal
suspect esp if digital ischemia WITH palpable pulses (since at least one of the proximal vessels is still patent)

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9
Q

most common sites of chronic ischemia

A

infrarenal aorta, iliac arteries, superior femoral artery

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10
Q

Leriche syndrome

A

aortoiliac disease- claudication, impotence, decreased/absent femoral pulses

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11
Q

subclavian steal syndrome

A

cerebrovascular symptoms with mild arm claudication due to decreased flow to PCA when blood flows retrograde through vertebral artery to subclavian artery

due to proximal SCA lesion
if neuro symptoms- then consider carotid stenosis also

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12
Q

Syme

A

amputation at base of tibia and fibula- for terminal arterial disease of distal foot
uncommon

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13
Q

when is below knee amputation contraindicated

A

gangrene more proximal than ankle or if patient has hip or knee contractures, and for elderly non ambulatory patients

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14
Q

postphlebitic syndrome

A

after DVT, patients get chronic venous insufficiency due to vascular incompetence of recanalized veins.

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15
Q

Degenerative aneurysm

A

atherosclerosis- intima replaced by fibrin, fragmented media.
Imbalance in elastin metabolism- between elasase and alpha-1-antithrombin

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16
Q

Poststenotic aneurysm

A

occurs distal to cervical rib in thoracic outlet syndrome, distal to coarctation of aorta, or to valvular stenosis

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17
Q

Anastomotic aneurysm

A

separation between graft and native artery (can be seen in CFA wit aortofemoral bypass)
painless, pulsatile groin mass

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18
Q

size at which AAA considered for surgical repair

A

5cm

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19
Q

AAA Open vs Endovascular repair

A

Open repair
Endovascular- involves grafts, stents, and a delivery mechanism. considered in elderly patients or patients with high comborbidities. in this case, aneurysm isnt actually resected

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20
Q

in pregnant women, ilaic aneurysms associated with

A

fibromuscular dysplasia

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21
Q

which lower extremity arteries affected in diabetes

A

spares aortoiliac
distal profunda femoris, popliteal, tibial, digital

intimal and basement membrane thickening

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22
Q

why might ABI be falsely elevated or normal in diabetes

A

vessel calcification- increases pressure

false elevation when ischemia/claudication actually exists

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23
Q

patient with a left carotid bruit and duplex showing stenosis of 70% of left internal carotid

A

2 options: aspirin or surgical (carotid endarterectomy)

-with stenosis of 70% or more- surgical management advantageous for stroke prevention

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24
Q

What structures and nerves at risk with a carotid endarterectomy?

A

the cut is made along the SCM, and the carotid sheath is opened

  • vagus runs alongside internal carotid
  • need to protect carotid body at external/internal carotid junction
  • exposure up to hypoglossal nerve which needs to be protected

-marginal mandibular branch of facial nerve
facial vein

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25
first branch of internal carotid, transient blindness
ophthalmic artery= amaurosis fugax
26
when should revascularization done after acute arterial embolus
immediate! apply heparin and go to the OR | -more than 6 h after ischemia can result in sev impaired limb or even amputation
27
surgical procedure for acute embolus
balloon catheter embolectomy
28
pt after embolectomy cant dorsiflex foot and has tenderness in calf with good pedal pulses
muscular compartment syndrome (ischemia- reperfusion injury)- reperfusion leads to edema. edema increases pressure, with further ischemic injury 20-40mm Hg= irreversible injury to muscles and nerves
29
location of atherosclerotic lesions in legs
usually popliteal and pedal pulses absent= so occlusion of SFA (adductur hiatus)
30
describe the normal doppler waveform
triphasic 1) rapid systolic flow 2) brief reversal flow due to elastic recoil 3) prolonged diastolic flow with atherosclerosis- lose the reversal flow first
31
how to tx arteriogram showing occlusion of SFA with distal reconstitution
saphenous vein graft from common femoral to popliteal artery to bypass obstruction
32
[patient with arteriogram showing occlusion of common and external iliac arteries with patent distal aorta and femoral artery
Percutaneous angioplasty if short segment iliac stenosis Aortobifemoral bypass due to loss of bilateral femoral pulses
33
What is a trash foot and tx
large, cyanotic big toe after revascularization due to atheroembolization blocking digital arteries and microvasculature during unclamping. usually will heal tx: antiplatelet therapy, protect toe. debridement if necrosis present
34
post op revascularization instructions/meds
pt should report if has fever (graft infection) | aspirin and prophylactic abx
35
abdominal aortic replacement=post op fever and bloody diarrhea
ischemic injury to colon (IMA damage) | immediate sigmoidoscopy for diagnosis
36
upper GI bleeding in patient who had aortic surgery with vascular graft
aortoenteric fistula development (erosion of graft into third or fourth part of duodenum)
37
low dose heparin doses for operative prophylaxis for DVT
5000U subcut preop | every 8-12 h post op
38
rare exception to how a PE could result with normal perfusion scan
saddle embolus at bifurcation of right and left pulmonary arteries, but may not have affected smaller arteries. use pulmonary angiography for definite dx (but higher risk than the duplex+ mismatched v/q)
39
second line PE tx (if pt gets PE on heparin)
IVC interruption using Greenfield filter- works as most PE originates from lower limbs
40
woman with cervical cancer extending into pelvic wall has acute edematous, cyanotic left leg
phlegmasia cerulea dolnes= acute interruption of the venous outflow from obstruction due to pelvic malignancy---can lead to venous gangrene
41
Tx of PE w/ hemodynamic instability, hypoxia, thrombolytic therapy contraindicated
pulmonary embolectomy (assoc tho with 20-60% mortality)
42
Tx of PE w/ hemodynamic instability, hypoxia, thrombolytic therapy contraindicated
pulmonary embolectomy (assoc tho with 20-60% mortality)
43
next steps in evaluation of 2 cm mass in right middle lobe of lung and lymphnode at mainstem bronchus
bronchoscopy- tissue diagnosis, location Mediastinoscopy- state of LN
44
Pneumonectomy vs Lobectomy with sleeve
Pneumonectomy: divide mainstem bronchus distal to carina and close it, and dividing pulmonary artery and 2 main pulmonary veins Sleeve lobectomy- divide mainstem bronchus above and below origin of right upper lobe bronchus and reattach the bronchus. SAFER, but may not be possible if PA invaded
45
imaging used for detecting lung cancer mets
PET scan
46
tx for pancoast tumor
irradiation of area over 6 weeks, followed by surgical resection
47
25 yo with hemoptysis, shortness of breath, and CXR showing partial collapse of right upper lobe of lung
atelectasis with hemoptysis likely due to obstructed bronchus young, non smoker= bronchial adenoma
48
where do bronchial adenomas come from 2 types dx tx
come from within the bronchi and then obstruct them! they do have malignany potential. 2 types: carcinoid, adenocystic dx- CT and bronchoscopy (need to be careful as they are vascular and can bleed) tx: lobectomy
49
what may a pleural effusion without heart failure in65yo man indicate
bronchogenic cancer or mesothelioma others: from pneumonia, empyema, TB
50
purpose of water seal type drain in pneumothorax
water seal maintains neg pressure in pleural space and chest tube, so air can escape the chest. one way valve mechanism preventing re-entry from the tube
51
how to manage recurrent pneumothorax, persistent air leaks
pleurodesis (thoracoscopic excision of blebs and pleural abrasion). irritation of visceral and parietal pleura causes them to adhere- prevent further pneumothorax.
52
increased pain, shortness of breath, fever, after tx with abx for pneumonia
empyema (s. pneum., hospital- staph and gm-), if aspiration/alcohol/unconscious= anaerobes
53
three vessel disease and tx
three major coronary vessels blocked w/ left main- indication for coronary artery bypass other: PTCA with stents for patency- may reobstruct
54
which vessels used to bypass obstructed coronary arteries
greater saphenous vein and internal thoracic artery (aka internal mammary- has better patency rate)
55
how is the heart stopped for bypass surgery?
cardioplegia solution- has enough potassium to stop the heart, but heart doesnt get ischemic (esp with addition of agents to protect against ischemia and free radicals). can also give blood with this- increasing buffering hypothermia- decrease metabolic rate
56
off-bypass coronary surgery
arterial anastomoses without using cardiopulmonary bypass. avoids complications of bypass (inflammatory response leading to resp, hemorrhagic, myocardial complications) mainly for high risk patients or pts with couple of easily accessible obstructed arteries
57
devpt of zenker diverticulum
abnormal constriction of cricopharyngeus increases pressure and forms a pulsion diverticulum
58
tx of achalasia
distal esophageal dilation- either with incision through muscular layers allowing mucosa bulgin out or by transesophageal dilation
59
dx of a squamous cell carcinoma mid-esophagus
staging based on wall penetration and LN -endoscopic ultrasound, with CT of chest and abdomen (check for celiac node involvement also)
60
primary tx of cervical and upper third esophageal tumors mid esophageal
chemoradiation resection if obstructing mid esophageal- more likely to invade structures (chemorad to reduce size and then resect)
61
transhiatal esophagectomy vs formal esophagectomy
transhiatal- bring stomach up and connect to pharynx formal- upper abdominal and right thoracotomy incision, excise esophagus, and gastroestophageal anastomosis
62
older man with severe dysphagia, cough, and weight loss why the cough?
esophageal cancer cough due to cancer eroding into trachea= aspiration advanced- palliation
63
likely anterior vs posterior mediastinum tumors
anterior: lymphatic, lymphoma (hodgkin), bronchiogenic cyst posterior: neurogenic tumors
64
patient is pale, cold, pulsesless, painful lower extremity that started suddenly. no pulses felt on lower legs. pulse at radial is irregular
need to do emergency fogarty embolic recovery from afib sending of emboli
65
how to study dissection of aorta. difference if in ascending vs descending aorta?
need to give B blockers or nitrates to lower BP since the force of the dye could add to shearing of vessel. emergency surgery for ascending aorta, and intensive therapy for HTN for descending aorta
66
how is a diagnosis of TIA confirmed and treated
angiogram, treat with carotid endarterectomy
67
man with untreated HTN has severe headache and lapses into a coma
neuro catastrophe due to hemorrhagic stroke- only can do supportive tx. use CT to note blood in head

Surgery (4 decks)

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