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Vascular Surgery Flashcards

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1
Q

What’s an indication for CABG?

A

Three vessels with 50% or more stenosis in 3 vessels or 2 vessels that includes the left decending coronary then there has to be less than 50% LV ejection fraction

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2
Q

What are the risk factors for mortality of CABG?

A

AGE**
Previous cardiac surgery**
(%) Ejection fraction
left main stenosis and total number of vessels w/ stenosis

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3
Q

What vessels are used for CABG?

A

Most commonly internal thoracic artery (best long term patency)

    • Saphenous vein
    • Gastroepiploic artery
    • inferior epigastric artery
    • Radial artery
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4
Q

What determines intravenous percutaneous intervention vs coronary artery bypass surgery?

A

1-2 vessel disease, intravenous intervention can be performed, but if more than that and criteria of 3 vessels or 2 with left decending and LV dysfunction = CABG

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5
Q

What are the disadvantages of a tissue heart valve placement?

A

– deteriorates over time, 30% of people need replacement in 10 years and 50% in 15 years.

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6
Q

Who gets what kind of heart valve mechanic vs tissue?

A
  • -If younger than 65 without contraindications to anticoagulants and can be reliable in taking anticoagulants = Mechanic (since tissue will degrade before they die)
  • -If older than 65, do not want or cannot take anticoagulants, and women of childbearing age = Tissue Valve replacement
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7
Q

What is the major disadvantage to a mechanical heart valve replacement?

A

Need for life-long coagulation

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8
Q

What are causes of thrombosis from valve obstruction?

A
  • Poor anticoagulation
  • formation of fibrous tissue ingrowth
  • vegetations due to poor antibiotic prophylaxis
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9
Q

What are possible prosthetic valve complications?

A

Wrong size causing leakage or too big
Hemolysis of RBCs
Tissue entrapment in the valve
Paravalvular leak around the edges

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10
Q

If a gram positive organism with dextrans and insoluble to bile is found to have colonized a heart valve, when might the individual have been infected?

A

Typically after damage to the valve over time, so Strep Viridans most commonly affects individuals years after placement with valve endocarditis.

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11
Q

What are the types of infections that can lead to late prosthetic valve endocarditis?

A

Dental infections or any kind of dental work
GI or GU infections, even a small amount of bacteria can colonize the valve.
use prophalyxis when known exposure is going to occur

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12
Q

What types of organisms are responsible for early valvular endocarditis? (can colonize at the time of surgery)

A 
Staph Aureus
Staph Epidermidis
Gram-Negative (HACEK Organisms)
[Culture negative organisms, hard to grow]
-- Haemophilus
-- Actinobacillus (Aggregatibacter)
-- Cardiobacterium
-- Eikenella
-- Kingella
**Pseudomonas
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13
Q

What is the most common arterial aneurysm and where is it located?

A

Abdominal Aorta

- below the renal arteries

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14
Q

What are the risk factors for developing an AAA?

A

– Caused by atherosclerosis weakening the walls of the vessel, thus AGE (55+), Smoking, Hypertension

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15
Q

How do you diagnose and screen for AAA?

A

Men between 65-75 should have one abdominal ultrasound performed.
Abdominal Ultrasound should be performed when AAA is suspected, highly specific and sensative

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16
Q

What are the indications for surgery correction of AAA?

A

When the risk of rupture exceeds the risk of mortality from the repair.

    • Diameter 5.5cm+
    • Rapidly increasing size on observational ultrasounds
    • Symptomatic (back pain and limb ischemia)
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17
Q

What are the types of surgical repair of an AAA?

A

Open abdomen surgery

Endovascular aneurysm repair – reduced 30day post-operative mortality

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18
Q

What are complications associated with AAA repair?

A
  • Renal Failure from emboli from aorta atherosclerosis or too much contrast
  • Ischemic colitis – IMA occluded during surgery
  • Spinal cord ischemia – disruption of T12 artery of Adamkiewicz leading to anterior cord syndrome
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19
Q

What is the most common cause of arterial embolization and where at?

A

Atrial thrombi production from Afib or recent MI (mural thrombi) – typically travel to brain or lower extremities (more rare)

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20
Q

What are the 6 Ps of arterial occlusion?

A

Pulselessness
Pain – severe sudden onset at rest
Paralysis – reflects degree of neuron damage
Pallor
Paresthesia – pins and needles, peripherial nerve ischemia
Poikilothermia – skin is cold distally

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21
Q

What is the key amount of time the occlusion needs to be reperfused to prevent permanent damage?

A

6 hours before necrosis

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22
Q

What is the first step in management of a patient with a cool distal extremity?

A

Begin a bolus of IV Heparin, then constant flow of heparin

+ Emergent vascular surgery evaluation

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23
Q

What is Fogarty balloon catheter embolectomy used for?

A

Used in treating arterial occlusions from embolization in limb ischemia

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24
Q

What should be performed at the same time as revascularization of an artery in limb ischemia?

A

Fasciotomy. This is performed to prevent compartment syndrome when the artery is reperfused and edema occurs in the comparment from the damaged muscle

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25
What is the physical cause of an aortic dissection?
A tear in the tunica intima, which then causes a true and false lumen both filling with blood. The false lumen can expand and expand down the aorta until it ruptures.
26
What are the predisposing risk factors for aortic dissection?
HTN*** - Connective Tissue Disease (Marfans/Ehlers-Danlos) - Bicuspid Aortic Valve - Coarctation - Vasculitis (Takayasu, Giant Cell, Syphilitic) - Crack cocaine
27
If a patient presents with sudden onset tearing chest pain that radiates to the back with diaphoresis with unequal pulse pressures with BP taken on each arm, what might be cause?
Aortic Dissection
28
What are clinical manifestations of progessing aortic dissection?
- - Dissection of media layer of aorta can move proximally to the heart occluding the RCA -- Posterior MI - - Rupture through adventitia -- hemorrhage, most common cause of death - - Rupture into cardiac sac --> cardiac tamponade
29
What are the different types of aortic dissections?
Type A -- proximal in the ascending aorta can involve the descending as well, MOST COMMON and most dangerous Type B -- descending aorta only that can extend down
30
What will be suspicious on a CXR for an aortic dissection?
- Loss of aortic knob - Widened mediastinum** (sensative, no specific) - tracheal deviation to the right - calcium layer displacement in aorta
31
If a patient is suspected of having an aortic dissection and vital signs are unstable, what should be ordered to confirm the diagnosis?
Transesophageal echocardiography - TEE | Cannot do CTA, due to unstable vital signs
32
What are the imaging options for evaluating an aortic dissection?
- TTE - CTA Chest -- only if stable vital signs - MRI/MRA -- worst option due to time requirement
33
How is the management of Type A and Type B dissections different?
Type A dissections require emergent surgery | Type B only requires medical management of HTN and observation
34
What should be the initial treatment of aortic dissection to prevent worsening?
Blood Pressure Control! - - Beta Blockers -- Labetalol - - Reduce afterload -- Clevidipine, Nicardipine, Nitroprusside * *Give B-blockers first to prevent reflexive tachycardia
35
What are signs and risk factors for developing a venous ulcer?
Varicose Veins Venous Stasis Dermatits (hemosiderin deposition = hyperpigmentation) Heaviness in the legs, improves with elevation Chronic edema
36
What is the most common location of venous stasis ulcers?
Medial aspect of the ankle and calf
37
What is an underlying cause of venous stasis and ulcers? How can you diagnose?
Incompetent venous valves | -- Venous doppler duplex scan (Ultrasound)
38
What are the best treatment options for venous stasis ulcers?
Elevation, Compression, Unna boots (compression dressing with zinc oxide to help healing)
39
What is Ankle Brachial index? When is it useful to assess?
ABI is where you use the doppler to check systolic blood pressure in the upper extremities using the higher of the two brachial arteries, then use find the DP and PT of the feet, using the higher of the two. ABI = Pressure-Leg / Pressure-Arm (should be around 1, the smaller the ratio the worse Peripherial Vascular Disease)
40
What are the key characteristics of arterial ulcers?
Arterial usually are painful especially at night due to decreased blood flow. Typically located on dorsum of the toes, feet, and ankle -- increased pressure areas. Appears as necrotic tissue with a "punched out" lesion.
41
How do venous ulcers usually appear?
Typically medial aspect of the calf and ankle - - Granulation tissue present - - shallow irregular margins - - Painless
42
Where do most DVTs occur at?
Proximal to popliteal vein in the femoral / iliac veins | --- Risk of embolization to the lungs
43
What are the risk factors in developing a DVT?
Virchow's Triad - Venous stasis - Damage to endothelium - Hypercoagulability
44
What are key risk factors for developing a DVT?
- Recent Surgery, orthopedic - Pregnancy - Cancer (hypercoagulable) - Significant immobilization -- plane ride - Prolonged Bedrest
45
What are the classic symptoms of a DVT?
Unilateral leg pain and swelling with warmth | -- Confirmed with Compression Ultrasound, which would show a noncompressible venous lumen
46
What can be used to exclude a DVT from differential diagnosis?
Negative Ultrasound | Negative - Normal level D-Dimer (high negative predictive value)
47
What are factors that increase risk of extension of DVT?
- Malignancy - Hospitalization - DVT close to proximal veins - 5cm+ in length
48
If a patient without risks of extension of a DVT and has an isolated distal DVT, what is the treatment?
Supportive and Observation | - Early Ambulation with follow up ultrasound to monitor progression of the thrombosis
49
Who should be started on anticoagulation for DVT?
Patients with a proximal DVT with risk of extension or signs of embolization.
50
What kind of patients is a IVC filter useful to prevent pulmonary embolization?
Patients who have contraindications to anticoagulation therapy and/or have recurrent DVT with failed therapy
51
What is the most significant risk factor in PAD?
Smoking, even more significant than CAD
52
Where is the most common location for stenosis in PAD?
superficial femoral artery at the level of adductor canal
53
What are the common symptoms associated with PAD?
intermittent claudication with improvement at rest, cramping/tightness/tiredness
54
What are some common clincal manifestations of PAD?
- dry skin, arterial skin ulcers, loss of hair growth | - ED and buttock/hip claudication
55
What is the best way to evaluate for PAD and severity?
Ankle-Brachial Index - Normal ratio of brachial to ankle systolic BP is 0.9-1.3 If below 0.9 ratio of leg to arm = PAD, the lower the worse.
56
What is the best treatment for PAD?
Exercise! Promotes collateral circulation | -- Cilostazol, PDE inhibitor, shown to increase walking distance and intermittent claudication
57
When is surgical treatment useful for patients with PAD?
If failure of medical therapy with continued ABI below 0.4, percutaneous transluminal angioplasty with or without stenting or bypass grafting If damage is irreversible, amputation
58
What are the differences in ascending and descending thoracic anuerysms?
Ascending typically attributed to genetic and mechanical factors Descending - atherosclerosis from HTN, HLD, Smoking
59
What are the pathologic steps involved in development of an aneurysm?
HTN most important risk factor. -- Hypertrophy of media (to combat HTN) > diminished blood flow to aortic wall (since dependent on diffusion) > loss of smooth muscle in media > Weakness of wall
60
What are the genetic factors that contribute to aortic aneurysms?
Marfan's Syndrome Ehlers-Danlos Loeys-Dietz syndrome Copper metabolism defects
61
How does syphilis contribute to aortic aneurysms? When to suspect?
Treponema Pallidum invades the vaso vasorum of the ascending and transverse aortic arch weakening the walls in a similar process as HTN. -- New onset diastolic murmur of the aortic valve (this is due to the dilation of the aorta and backflow around the valve usually from aneurysm)
62
What is the most common cause of varicose veins and where?
Incompetence of venous valves in superficial or deep systems most commonly located in saphenous vein. - the back up causes dilation and tortuosity
63
What are the risk factors for developing varicose veins?
Increasing Age, Female Oral contraceptives Pregnancy DVT
64
What are the clinical characteristics of varicose veins?
Visible long dilated tortuous superficial veins in the thigh and lower leg - - evidence of venous stasis with hyperpigmentation and ulceration on the medial aspect of lower leg - - heaviness in the legs
65
How can you definitively test to ensure clinical findings are varicose veins?
Brodie-Trendelenberg Test -- supine patient raises leg and the saphenous vein is compressed at the thigh, then have patient stand up. If veins fill from top down, conclusive evidence incompetent valves
66
What are best treatments for varicose veins?
Leg elevation and/or compression stockings - If further treatment is needed, then injection sclerotherapy or laser therapy of saphenous and tributaries. Consideration must be made in case patient ever might need the saphenous later.
67
What are clinical signs of superficial thrombophlebitis?
Inflammation over superficial vein that causes pain - Palpable cord (distention of vein) - Pain - Mild fever
68
Where does superficial thrombophlebitis usually occur?
Past IV site | Varicose veins of the lower extremities
69
If a patient is found to have thrombophlebitis of the lower extremity, should the patient be concerned for PE?
NO. Thrombophlebitis does not have a risk of embolizing to PE or DVT. -- NO Anticoagulation should be used Best Treatment -- ASA + Warm compresses and time.

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