Vascular Surgery, C66 P489-516 Flashcards
(223 cards)
1
Q
What is atherosclerosis?
P489
A
Diffuse disease process in arteries; atheromas containing cholesterol and lipid form within the intima and inner media, often accompanied by ulcerations and smooth muscle hyperplasia
2
Q
What is the common theory
of how atherosclerosis is
initiated?
P490
A
Endothelial injury → platelets adhere →
growth factors released → smooth
muscle hyperplasia/plaque deposition
3
Q
What are the risk factors for
atherosclerosis?
P490
A
Hypertension, smoking, diabetes
mellitus, family history, hypercholesterolemia,
high LDL, obesity,
and sedentary lifestyle
4
Q
What are the common sites
of plaque formation in
arteries?
P490
A
Branch points (carotid bifurcation), tethered sites (superficial femoral artery [SFA] in Hunter’s canal in the leg)
5
Q
What must be present for a
successful arterial bypass
operation?
P490
A
- Inflow (e.g., patent aorta)
- Outflow (e.g., open distal popliteal
artery) - Run off (e.g., patent trifurcation
vessels down to the foot)
6
Q
What is the major principle
of safe vascular surgery?
P90
A
Get proximal and distal control of the
vessel to be worked on!
7
Q
What does it mean to
“POTTS” a vessel?
P490
A
Place a vessel loop twice around a vessel
so that if you put tension on the vessel
loop, it will occlude the vessel
8
Q
What is the suture needle orientation through graft versus diseased artery in a graft to artery anastomosis? P490
A
Needle “in-to-out” of the lumen in
diseased artery to help tack down the
plaque and the needle “out-to-in” on the
graft
9
Q
What are the three layers of
an artery?
P490
A
- Intima
- Media
- Adventitia
10
Q
Which arteries supply the
blood vessel itself?
P490
A
Vaso vasorum
11
Q
What is a true aneurysm?
P490
A
Dilation ( >2x nL diameter) of all three
layers of a vessel
12
Q
What is a false aneurysm
(a.k.a pseudoaneurysm)?
P490
A
Dilation of artery not involving all three
layers (e.g., hematoma with fibrous
covering)
Often connects with vessel lumen and
blood swirls inside the false aneurysm
13
Q
What is “ENDOVASCULAR”
repair?
P491 (picture)
A
Placement of a catheter in artery and
then deployment of a graft intraluminally
14
Q
PERIPHERAL VASCULAR DISEASE
Define the arterial anatomy:
P491 (picture)
A
- Aorta
- Internal iliac (hypogastric)
- External iliac
- Common femoral artery
- Profundi femoral artery
- Superficial femoral artery (SFA)
- Popliteal artery
- Trifurcation
- Anterior tibial artery
- Peroneal artery
- Posterior tibial artery
- Dorsalis pedis artery
15
Q
PERIPHERAL VASCULAR DISEASE How can you remember the orientation of the lower exterior arteries below the knee on A-gram? P492
A
Use the acronym “LAMP”:
Lateral Anterior tibial
Medial Posterior tibial
16
Q
PERIPHERAL VASCULAR DISEASE
What is peripheral vascular
disease (PVD)?
P492
A
Occlusive atherosclerotic disease in the
lower extremities
17
Q
PERIPHERAL VASCULAR DISEASE What is the most common site of arterial atherosclerotic occlusion in the lower extremities? P492
A
Occlusion of the SFA in Hunter’s canal
18
Q
PERIPHERAL VASCULAR DISEASE
What are the symptoms of
PVD?
P492
A
Intermittent claudication, rest pain,
erectile dysfunction, sensorimotor
impairment, tissue loss
19
Q
PERIPHERAL VASCULAR DISEASE
What is intermittent
claudication?
P492
A
Pain, cramping, or both of the lower
extremity, usually the calf muscle, after
walking a specific distance; then the
pain/cramping resolves after stopping for
a specific amount of time while standing;
this pattern is reproducible
20
Q
PERIPHERAL VASCULAR DISEASE
What is rest pain?
P492
A
Pain in the foot, usually over the distal
metatarsals; this pain arises at rest
(classically at night, awakening the
patient)
21
Q
PERIPHERAL VASCULAR DISEASE
What classically resolves rest
pain?
P492
A
Hanging the foot over the side of the bed
or standing; gravity affords some extra
flow to the ischemic areas
22
Q
PERIPHERAL VASCULAR DISEASE How can vascular causes of claudication be differentiated from nonvascular causes, such as neurogenic claudication or arthritis? P492
A
History (in the vast majority of patients)
and noninvasive tests; remember,
vascular claudication appears after a
specific distance and resolves after a
specific time of rest while standing (not
so with most other forms of claudication)
23
Q
PERIPHERAL VASCULAR DISEASE What is the differential diagnosis of lower extremity claudication? P492
A
Neurogenic (e.g., nerve entrapment/ discs), arthritis, coarctation of the aorta, popliteal artery syndrome, chronic compartment syndrome, neuromas, anemia, diabetic neuropathy pain
24
Q
PERIPHERAL VASCULAR DISEASE
What are the signs of PVD?
P493
A
Absent pulses, bruits, muscular atrophy,
decreased hair growth, thick toenails,
tissue necrosis/ulcers/infection
25
```
PERIPHERAL VASCULAR DISEASE
What is the site of a PVD
ulcer vs. a venous stasis
ulcer?
P493
```
PVD arterial insufficiency ulcer—usually
on the toes/foot
Venous stasis ulcer—medial malleolus
(ankle)
26
PERIPHERAL VASCULAR DISEASE
What is the ABI?
P493
Ankle to Brachial Index (ABI);
simply, the ratio of the systolic blood
pressure at the ankle to the systolic blood
pressure at the arm (brachial artery) A:B;
ankle pressure taken with Doppler; the
ABI is noninvasive
27
```
PERIPHERAL VASCULAR DISEASE
What ABIs are associated
with normals, claudicators,
and rest pain?
P493
```
Normal ABI— ≥1.0
| Claudicator ABI— <0.4
28
PERIPHERAL VASCULAR DISEASE
Who gets false ABI
readings?
P493
Patients with calcified arteries, especially
| those with diabetes
29
PERIPHERAL VASCULAR DISEASE
What are PVRs?
P493
```
Pulse Volume Recordings; pulse wave
forms are recorded from lower
extremities representing volume of
blood per heart beat at sequential
sites down leg
Large wave form means good collateral
blood flow
(Noninvasive using pressure cuffs)
```
30
```
PERIPHERAL VASCULAR DISEASE
Prior to surgery for chronic
PVD, what diagnostic test
will every patient receive?
P493
```
A-gram (arteriogram: dye in vessel and
x-rays) maps disease and allows for
best treatment option (i.e., angioplasty
vs. surgical bypass vs. endarterectomy)
Gold standard for diagnosing PVD
31
```
PERIPHERAL VASCULAR DISEASE
What is the bedside
management of a patient
with PVD?
P493
```
1. Sheep skin (easy on the heels)
2. Foot cradle (keeps sheets/blankets off
the feet)
3. Skin lotion to avoid further cracks in
the skin that can go on to form a
fissure and then an ulcer
32
PERIPHERAL VASCULAR DISEASE
What are the indications for
surgical treatment in PVD?
P494
```
Use the acronym “STIR”:
Severe claudication refractory to
conservative treatment that affects
quality of life/livelihood (e.g., can’t
work because of the claudication)
Tissue necrosis
Infection
Rest pain
```
33
PERIPHERAL VASCULAR DISEASE
What is the treatment of
claudication?
P494
```
For the vast majority, conservative
treatment, including exercise, smoking
cessation, treatment of HTN, diet,
aspirin, with or without Trental
(pentoxifylline)
```
34
```
PERIPHERAL VASCULAR DISEASE
How can the medical
conservative treatment for
claudication be remembered?
P494
```
```
Use the acronym “PACE”:
Pentoxifylline
Aspirin
Cessation of smoking
Exercise
```
35
PERIPHERAL VASCULAR DISEASE
How does aspirin work?
P494
```
Inhibits platelets (inhibits cyclooxygenase
and platelet aggregation)
```
36
PERIPHERAL VASCULAR DISEASE
How does Trental®
(pentoxifylline) work?
P494
Results in increased RBC deformity and
flexibility (Think: pentoXifylline = RBC
fleXibility)
37
PERIPHERAL VASCULAR DISEASE
What is the risk of limb loss
with claudication?
P494
5% limb loss at 5 years (Think: 5 in 5),
| 10% at 10 years (Think: 10 in 10)
38
PERIPHERAL VASCULAR DISEASE
What is the risk of limb loss
with rest pain?
P494
>50% of patients will have amputation of
| the limb at some point
39
```
PERIPHERAL VASCULAR DISEASE
In the patient with PVD, what
is the main postoperative
concern?
P494
```
```
Cardiac status, because most patients
with PVD have coronary artery
disease; ≈20% have an AAA
MI is the most common cause of
postoperative death after a PVD
operation
```
40
PERIPHERAL VASCULAR DISEASE
What is Leriche’s syndrome?
P495
```
Buttock Claudication, Impotence (erectile
dysfunction), and leg muscle Atrophy
from occlusive disease of the iliacs/distal
aorta
Think: “CIA”:
Claudication
Impotence
Atrophy
(Think: CIA spy Leriche)
```
41
PERIPHERAL VASCULAR DISEASE
What are the treatment
options for severe PVD?
P495
1. Surgical graft bypass
2. Angioplasty—balloon dilation
3. Endarterectomy—remove diseased
intima and media
4. Surgical patch angioplasty (place patch
over stenosis)
42
PERIPHERAL VASCULAR DISEASE
What is a FEM-POP bypass?
P495 (picture)
Bypass SFA occlusion with a graft from the
| FEMoral artery to the POPliteal artery
43
PERIPHERAL VASCULAR DISEASE
What is a FEM-DISTAL
bypass?
P496 (picture)
```
Bypass from the FEMoral artery to a
DISTAL artery (peroneal artery, anterior
tibial artery, or posterior tibial artery)
```
44
PERIPHERAL VASCULAR DISEASE
What graft material has the
longest patency rate?
P496
Autologous vein graft
45
PERIPHERAL VASCULAR DISEASE
What is an “in situ” vein
graft?
P496
```
Saphenous vein is more or less left in
place, all branches are ligated, and the
vein valves are broken with a small hook
or cut out; a vein can also be used if
reversed so that the valves do not cause a
problem
```
46
```
PERIPHERAL VASCULAR DISEASE
What type of graft is used
for above-the-knee FEM-POP
bypass?
P496
```
Either vein or Gortex® graft; vein still has
| better patency
47
```
PERIPHERAL VASCULAR DISEASE
What type of graft is used
for below-the-knee FEM-POP
or FEM-DISTAL bypass?
P496
```
Must use vein graft; prosthetic grafts
| have a prohibitive thrombosis rate
48
PERIPHERAL VASCULAR DISEASE
What is DRY gangrene?
P496
Dry necrosis of tissue without signs of
| infection (“mummified tissue”)
49
PERIPHERAL VASCULAR DISEASE
What is WET gangrene?
P497
Moist necrotic tissue with signs of
| infection
50
PERIPHERAL VASCULAR DISEASE
What is blue toe syndrome?
P497
Intermittent painful blue toes (or fingers)
due to microemboli from a proximal
arterial plaque
51
LOWER EXTREMITY AMPUTATIONS
What are the indications?
P497
Irreversible tissue ischemia (no hope for
revascularization bypass) and necrotic
tissue, severe infection, severe pain with
no bypassable vessels, or if patient is not
interested in a bypass procedure
52
LOWER EXTREMITY AMPUTATIONS
Identify the level of the
following amputations:
P497 (picture)
1. Above-the-Knee Amputation (AKA)
2. Below-the-Knee Amputation (BKA)
3. Symes amputation
4. Transmetatarsal amputation
5. Toe amputation
53
LOWER EXTREMITY AMPUTATIONS
What is a Ray amputation?
P497
Removal of toe and head of metatarsal
54
ACUTE ARTERIAL OCCLUSION
What is it?
P498
Acute occlusion of an artery, usually by
embolization; other causes include acute
thrombosis of an atheromatous lesion,
vascular trauma
55
```
ACUTE ARTERIAL OCCLUSION
What are the classic
signs/symptoms of acute
arterial occlusion?
P498
```
```
The “six P’s”:
Pain
Paralysis
Pallor
Paresthesia
Polar (some say Poikilothermia—you
pick)
Pulselessness
(You must know these!)
```
56
```
ACUTE ARTERIAL OCCLUSION
What is the classic timing of
pain with acute arterial
occlusion from an embolus?
P498
```
Acute onset; the patient can classically
tell you exactly when and where it
happened
57
ACUTE ARTERIAL OCCLUSION
What is the immediate
preoperative management?
P498
1. Anticoagulate with IV heparin (bolus
followed by constant infusion)
2. A-gram
58
ACUTE ARTERIAL OCCLUSION
What are the sources of
emboli?
P498
```
1. Heart—85% (e.g., clot from AFib, clot
forming on dead muscle after MI,
endocarditis, myxoma)
2. Aneurysms
3. Atheromatous plaque (atheroembolism)
```
59
```
ACUTE ARTERIAL OCCLUSION
What is the most common
cause of embolus from the
heart?
P498
```
AFib
60
```
ACUTE ARTERIAL OCCLUSION
What is the most common
site of arterial occlusion by
an embolus?
P498
```
Common femoral artery (SFA is the most
common site of arterial occlusion from
atherosclerosis)
61
ACUTE ARTERIAL OCCLUSION
What diagnostic studies are
in order?
P498
1. A-gram
2. ECG (looking for MI, AFib)
3. Echocardiogram ( ± ) looking for clot,
MI, valve vegetation
62
ACUTE ARTERIAL OCCLUSION
What is the treatment?
P499
```
Surgical embolectomy via cutdown and
Fogarty balloon (bypass is reserved for
embolectomy failure)
```
63
ACUTE ARTERIAL OCCLUSION
What is a Fogarty?
P499
Fogarty balloon catheter—catheter with
a balloon tip that can be inflated with
saline; used for embolectomy
64
ACUTE ARTERIAL OCCLUSION
How is a Fogarty catheter
used?
P499
Insinuate the catheter with the balloon
deflated past the embolus and then inflate
the balloon and pull the catheter out; the
balloon brings the embolus with it
65
```
ACUTE ARTERIAL OCCLUSION
How many mm in diameter
is a 12 French Fogarty
catheter?
P499
```
Simple: To get mm from French
measurements, divide the French
number by ∏, or 3.14; thus, a 12 French
catheter is 12/3 = 4 mm in diameter
66
```
ACUTE ARTERIAL OCCLUSION
What must be looked for
postoperatively after
reperfusion of a limb?
P499
```
Compartment syndrome,
hyperkalemia, renal failure from
myoglobinuria, MI
67
ACUTE ARTERIAL OCCLUSION
What is compartment
syndrome?
P499
Leg (calf) is separated into compartments
by very unyielding fascia; tissue swelling
from reperfusion can increase the
intracompartmental pressure, resulting
in decreased capillary flow, ischemia, and
myonecrosis; myonecrosis may occur
after the intracompartment pressure
reaches only 30 mm Hg
68
```
ACUTE ARTERIAL OCCLUSION
What are the signs/
symptoms of compartment
syndrome?
P499
```
Classic signs include pain, especially after
passive flexing/extension of the foot,
paralysis, paresthesias, and pallor; pulses
are present in most cases because
systolic pressure is much higher than
the minimal 30 mm Hg needed for the
syndrome!
69
ACUTE ARTERIAL OCCLUSION
Can a patient have a pulse
and compartment syndrome?
P499
YES!
70
ACUTE ARTERIAL OCCLUSION
How is the diagnosis made?
P499
History/suspicion, compartment pressure
| measurement
71
ACUTE ARTERIAL OCCLUSION
P500What is the treatment of
compartment syndrome?
P500
Treatment includes opening compartments
via bilateral calf-incision fasciotomies of
all four compartments in the calf
72
ABDOMINAL AORTIC ANEURYSMS
What is it also known as?
P500
AAA, or “triple A”
73
ABDOMINAL AORTIC ANEURYSMS
What is it?
P500 (picture)
Abnormal dilation of the abdominal aorta
( >1.5–2x normal), forming a true
aneurysm
74
ABDOMINAL AORTIC ANEURYSMS
What is the male to female
ratio?
P500
≈6:1
75
ABDOMINAL AORTIC ANEURYSMS
By far, who is at the highest
risk?
P500
White males
76
ABDOMINAL AORTIC ANEURYSMS
What is the common
etiology?
P500
Believed to be atherosclerotic in 95%
| of cases; 5% inflammatory
77
ABDOMINAL AORTIC ANEURYSMS
What is the most common
site?
P500
Infrarenal (95%)
78
ABDOMINAL AORTIC ANEURYSMS
What is the incidence?
P500
5% of all adults older than 60 years
| of age
79
```
ABDOMINAL AORTIC ANEURYSMS
What percentage of patients
with AAA have a peripheral
arterial aneurysm?
P500
```
20%
80
ABDOMINAL AORTIC ANEURYSMS
What are the risk factors?
P501
Atherosclerosis, hypertension, smoking,
male gender, advanced age, connective
tissue disease
81
ABDOMINAL AORTIC ANEURYSMS
What are the symptoms?
P501
```
Most AAAs are asymptomatic and
discovered during routine abdominal
exam by primary care physicians; in
the remainder, symptoms range from
vague epigastric discomfort to back and
abdominal pain
```
82
ABDOMINAL AORTIC ANEURYSMS
Classically, what do testicular
pain and an AAA signify?
P501
Retroperitoneal rupture with ureteral
| stretch and referred pain to the testicle
83
ABDOMINAL AORTIC ANEURYSMS
What are the risk factors for
rupture?
P501
Aneurysm diameter (value + progression), HTN, symptomatic, COPD
84
ABDOMINAL AORTIC ANEURYSMS
What are the signs of
rupture?
P501
Classic triad of ruptured AAA:
1. Abdominal pain
2. Pulsatile abdominal mass
3. Hypotension
85
ABDOMINAL AORTIC ANEURYSMS
By how much each year do
AAAs grow?
P501
≈3 mm/year on average (larger AAAs
| grow faster than smaller AAAs)
86
```
ABDOMINAL AORTIC ANEURYSMS
Why do larger AAAs rupture
more often and grow faster
than smaller AAAs?
P501
```
Probably because of Laplace’s law
| wall tension = pressure x diameter
87
```
ABDOMINAL AORTIC ANEURYSMS
What is the risk of rupture
per year based on AAA
diameter size?
P501
```
<5cm = 4%
5-7cm = 7%
7 cm = 20%
88
ABDOMINAL AORTIC ANEURYSMS
What are other risks for
rupture?
P501
Hypertension, smoking, COPD
89
ABDOMINAL AORTIC ANEURYSMS
Where does the aorta
bifurcate?
P501
At the level of the umbilicus; therefore,
when palpating for an AAA, palpate
above the umbilicus and below the
xiphoid process
90
ABDOMINAL AORTIC ANEURYSMS
What is the differential
diagnosis?
P501
Acute pancreatitis, aortic dissection,
mesenteric ischemia, MI, perforated
ulcer, diverticulosis, renal colic, etc.
91
ABDOMINAL AORTIC ANEURYSMS
What are the diagnostic
tests?
P502
Use U/S to follow AAA clinically; other
tests involve contrast CT scan and A-gram;
A-gram will assess lumen patency and
iliac/renal involvement
92
ABDOMINAL AORTIC ANEURYSMS
What is the limitation of
A-gram?
P502
AAAs often have large mural thrombi,
which result in a falsely reduced diameter
because only the patent lumen is visualized
93
ABDOMINAL AORTIC ANEURYSMS
What are the signs of AAA
on AXR?
P502
Calcification in the aneurysm wall, best
seen on lateral projection (a.k.a.
“eggshell” calcifications)
94
ABDOMINAL AORTIC ANEURYSMS
What are the indications for
surgical repair of AAA?
P502
```
AAA >5.5 cm in diameter, if the patient
is not an overwhelming high risk for
surgery; also, rupture of the AAA, any
size AAA with rapid growth, symptoms/
embolization of plaque
```
95
ABDOMINAL AORTIC ANEURYSMS
What is the treatment?
P502 (picture)
1. Prosthetic graft placement, with
rewrapping of the native aneurysm
adventitia around the prosthetic graft
after the thrombus is removed; when
rupture is strongly suspected, proceed
to immediate laparotomy; there is
no time for diagnostic tests!
2. Endovascular repair
96
ABDOMINAL AORTIC ANEURYSMS
What is endovascular
repair?
P502
Repair of the AAA by femoral catheter
| placed stents
97
ABDOMINAL AORTIC ANEURYSMS
Why wrap the graft in the
native aorta?
P503
To reduce the incidence of enterograft
| fistula formation
98
```
ABDOMINAL AORTIC ANEURYSMS
What type of repair should
be performed with AAA and
iliacs severely occluded or
iliac aneurysm(s)?
P503
```
Aortobi-iliac or aortobifemoral graft
| replacement (bifurcated graft)
99
```
ABDOMINAL AORTIC ANEURYSMS
What is the treatment if the
patient has abdominal pain,
pulsatile abdominal mass,
and hypotension?
P503
```
Take the patient to the O.R. for emergent
| AAA repair
100
```
ABDOMINAL AORTIC ANEURYSMS
What is the treatment if the
patient has known AAA and
new onset of abdominal pain
or back pain?
P503
```
CT scan:
1. Leak → straight to OR
2. No leak → repair during next elective
slot
101
```
ABDOMINAL AORTIC ANEURYSMS
What is the mortality rate associated with the following
types of AAA treatment:
Elective?
P503
```
Good; <4% operative mortality
102
```
ABDOMINAL AORTIC ANEURYSMS
What is the mortality rate associated with the following
types of AAA treatment:
Ruptured?
P503
```
≈50% operative mortality
103
```
ABDOMINAL AORTIC ANEURYSMS
What is the leading cause
of postoperative death in a
patient undergoing elective
AAA treatment?
P503
```
Myocardial infarction (MI)
104
ABDOMINAL AORTIC ANEURYSMS
What are the other
etiologies of AAA?
P503
Inflammatory (connective tissue
diseases), mycotic (a misnomer because
most result from bacteria, not fungi)
105
ABDOMINAL AORTIC ANEURYSMS
What is the mean normal
abdominal aortic diameter?
P503
2 cm
106
ABDOMINAL AORTIC ANEURYSMS
What are the possible
operative complications?
P503
MI, atheroembolism, declamping
hypotension, acute renal failure
(especially if aneurysm involves the renal
arteries), ureteral injury, hemorrhage
107
```
ABDOMINAL AORTIC ANEURYSMS
Why is colonic ischemia a
concern in the repair of
AAAs?
P503
```
Often the IMA is sacrificed during
surgery; if the collaterals are not adequate,
the patient will have colonic ischemia
108
ABDOMINAL AORTIC ANEURYSMS
What are the signs of
colonic ischemia?
P504
```
Heme-positive stool, or bright red blood
per rectum (BRBPR), diarrhea,
abdominal pain
```
109
```
ABDOMINAL AORTIC ANEURYSMS
What is the study of
choice to diagnose colonic
ischemia?
P504
```
Colonoscopy
110
ABDOMINAL AORTIC ANEURYSMS
When is colonic ischemia
seen postoperatively?
P504
Usually in the first week
111
```
ABDOMINAL AORTIC ANEURYSMS
What is the treatment of
necrotic sigmoid colon from
colonic ischemia?
P504
```
1. Resection of necrotic colon
2. Hartmann’s pouch or mucous fistula
3. End colostomy
112
```
ABDOMINAL AORTIC ANEURYSMS
What is the possible longterm
complication that often
presents with both upper
and lower GI bleeding?
P504
```
```
Aortoenteric fistula (fistula between aorta
and duodenum)
```
113
ABDOMINAL AORTIC ANEURYSMS
What are the other possible
postoperative complications?
P504
Erectile dysfunction (sympathetic plexus
injury), retrograde ejaculation, aortovenous
fistula (to IVC), graft infection, anterior
spinal syndrome
114
ABDOMINAL AORTIC ANEURYSMS
What is anterior spinal
syndrome?
P504
```
Classically:
1. Paraplegia
2. Loss of bladder/bowel control
3. Loss of pain/temperature sensation
below level of involvement
4. Sparing of proprioception
```
115
```
ABDOMINAL AORTIC ANEURYSMS
Which artery is involved
in anterior spinal cord
syndrome?
P504
```
Artery of Adamkiewicz—supplies the
| anterior spinal cord
116
```
ABDOMINAL AORTIC ANEURYSMS
What are the most common
bacteria involved in aortic
graft infections?
P504
```
1. Staphylococcus aureus
2. Staphylococcus epidermidis
(usually late)
117
```
ABDOMINAL AORTIC ANEURYSMS
How is a graft infection with
an aortoenteric fistula
treated?
P504
```
Perform an extra-anatomic bypass with
| resection of the graft
118
ABDOMINAL AORTIC ANEURYSMS
What is an extra-anatomic
bypass graft?
P505 (picture)
```
Axillofemoral bypass graft—graft not
in a normal vascular path; usually,
the graft goes from the axillary artery to
the femoral artery and then from one
femoral artery to the other (fem-fem
bypass)
```
119
ABDOMINAL AORTIC ANEURYSMS
What is an endovascular
repair?
P505
Placement of a stent proximal and distal
to an AAA through a distant percutaneous
access (usually through the groin); less
invasive; long-term results pending
120
```
CLASSIC INTRAOP QUESTIONS DURING
AAA REPAIR
Which vein crosses the neck
of the AAA proximally?
P505
```
Renal vein (left)
121
```
CLASSIC INTRAOP QUESTIONS DURING
AAA REPAIR
What part of the small
bowel crosses in front of
the AAA?
P505
```
Duodenum
122
```
CLASSIC INTRAOP QUESTIONS DURING
AAA REPAIR
Which large vein runs to the
left of the AAA?
P505
```
IMV
123
```
CLASSIC INTRAOP QUESTIONS DURING
AAA REPAIR
Which artery comes off the
middle of the AAA and runs
to the left?
P505
```
IMA
124
```
CLASSIC INTRAOP QUESTIONS DURING
AAA REPAIR
Which vein runs behind the
RIGHT common iliac artery?
P506
```
LEFT common iliac vein
125
CLASSIC INTRAOP QUESTIONS DURING
AAA REPAIR
Which renal vein is longer?
P506
Left
126
MESENTERIC ISCHEMIA
CHRONIC MESENTERIC ISCHEMIA
What is it?
P506
```
Chronic intestinal ischemia from
long-term occlusion of the intestinal
arteries; most commonly results from
atherosclerosis; usually in two or more
arteries because of the extensive
collaterals
```
127
MESENTERIC ISCHEMIA
CHRONIC MESENTERIC ISCHEMIA
What are the symptoms?
P506
Weight loss, postprandial abdominal
pain, anxiety/fear of food because of
postprandial pain, ± heme occult,
± diarrhea/vomiting
128
MESENTERIC ISCHEMIA
CHRONIC MESENTERIC ISCHEMIA
What is “intestinal angina”?
P506
Postprandial pain from gut ischemia
129
MESENTERIC ISCHEMIA
CHRONIC MESENTERIC ISCHEMIA
What are the signs?
P506
Abdominal bruit is commonly heard
130
MESENTERIC ISCHEMIA
CHRONIC MESENTERIC ISCHEMIA
How is the diagnosis made?
P506
A-gram, duplex, MRA
131
```
MESENTERIC ISCHEMIA
CHRONIC MESENTERIC ISCHEMIA
What supplies blood to the
gut?
P506
```
1. Celiac axis vessels
2. SMA
3. IMA
132
```
MESENTERIC ISCHEMIA
CHRONIC MESENTERIC ISCHEMIA
What is the classic finding
on A-gram?
P506
```
Two of the three mesenteric arteries are
occluded, and there is atherosclerotic
narrowing of the third patent artery
133
```
MESENTERIC ISCHEMIA
CHRONIC MESENTERIC ISCHEMIA
What are the treatment
options?
P506
```
Bypass, endarterectomy, angioplasty,
| stenting
134
MESENTERIC ISCHEMIA
ACUTE MESENTERIC ISCHEMIA
What is it?
P506
Acute onset of intestinal ischemia
135
MESENTERIC ISCHEMIA
ACUTE MESENTERIC ISCHEMIA
What are the causes?
P506
1. Emboli to a mesenteric vessel from
the heart
2. Acute thrombosis of long-standing
atherosclerosis of mesenteric artery
136
```
MESENTERIC ISCHEMIA
ACUTE MESENTERIC ISCHEMIA
What are the causes of
emboli from the heart?
P507
```
AFib, MI, cardiomyopathy, valve disease/
| endocarditis, mechanical heart valve
137
```
MESENTERIC ISCHEMIA
ACUTE MESENTERIC ISCHEMIA
What drug has been
associated with acute
intestinal ischemia?
P507
```
Digitalis
138
```
MESENTERIC ISCHEMIA
ACUTE MESENTERIC ISCHEMIA
To which intestinal artery do
emboli preferentially go?
P507
```
Superior Mesenteric Artery (SMA)
139
```
MESENTERIC ISCHEMIA
ACUTE MESENTERIC ISCHEMIA
What are the signs/
symptoms of acute
mesenteric ischemia?
P507
```
Severe pain—classically “pain out of
proportion to physical exam,” no
peritoneal signs until necrosis, vomiting/
diarrhea/hyperdefecation, ± heme stools
140
```
MESENTERIC ISCHEMIA
ACUTE MESENTERIC ISCHEMIA
What is the classic triad of
acute mesenteric ischemia?
P507
```
1. Acute onset of pain
2. Vomiting, diarrhea, or both
3. History of AFib or heart disease
141
```
MESENTERIC ISCHEMIA
ACUTE MESENTERIC ISCHEMIA
What is the gold standard
diagnostic test?
P507
```
Mesenteric A-gram
142
```
MESENTERIC ISCHEMIA
ACUTE MESENTERIC ISCHEMIA
What is the treatment of a
mesenteric embolus?
P507
```
```
Perform Fogarty catheter embolectomy,
resect obviously necrotic intestine, and
leave marginal looking bowel until a
“second look” laparotomy is performed
24 to 72 hours postoperatively
```
143
```
MESENTERIC ISCHEMIA
ACUTE MESENTERIC ISCHEMIA
What is the treatment of
acute thrombosis?
P507
```
```
Papaverine vasodilator via A-gram
catheter until patient is in the OR;
then, most surgeons would perform a
supraceliac aorta graft to the involved
intestinal artery or endarterectomy;
intestinal resection/second look as
needed
```
144
MEDIAN ARCUATE LIGAMENT SYNDROME
What is it?
P507
Mesenteric ischemia resulting from
narrowing of the celiac axis vessels by
extrinsic compression by the median
arcuate ligament
145
MEDIAN ARCUATE LIGAMENT SYNDROME
What is the median arcuate
ligament comprised of?
P507
Diaphragm hiatus fibers
146
MEDIAN ARCUATE LIGAMENT SYNDROME
What are the symptoms?
P508
Postprandial pain, weight loss
147
MEDIAN ARCUATE LIGAMENT SYNDROME
What are the signs?
P508
Abdominal bruit in almost all patients
148
MEDIAN ARCUATE LIGAMENT SYNDROME
How is the diagnosis made?
P508
A-gram
149
MEDIAN ARCUATE LIGAMENT SYNDROME
What is the treatment?
P508
Release arcuate ligament surgically
150
```
CAROTID VASCULAR DISEASE
ANATOMY
Identify the following
structures:
P508 (picture)
```
1. Internal carotid artery
2. External carotid artery
3. Carotid “bulb”
4. Superior thyroid artery
5. Common carotid artery
(Shaded area: common site of plaque
formation)
151
```
CAROTID VASCULAR DISEASE
ANATOMY
What are the signs/
symptoms?
P508
```
Amaurosis fugax, TIA, RIND, CVA
152
```
CAROTID VASCULAR DISEASE
ANATOMY
Define the following terms:
Amaurosis fugax
P508
```
Temporary monocular blindness (“curtain
coming down”): seen with microemboli
to retina; example of TIA
153
```
CAROTID VASCULAR DISEASE
ANATOMY
Define the following terms:
TIA
P508
```
Transient Ischemic Attack: focal
neurologic deficit with resolution of all
symptoms within 24 hours
154
```
CAROTID VASCULAR DISEASE
ANATOMY
Define the following terms:
RIND
P509
```
Reversible Ischemic Neurologic Deficit:
transient neurologic impairment (without
any lasting sequelae) lasting 24 to 72 hours
155
```
CAROTID VASCULAR DISEASE
ANATOMY
Define the following terms:
CVA
P509
```
```
CerebroVascular Accident (stroke):
neurologic deficit with permanent brain
damage
```
156
```
CAROTID VASCULAR DISEASE
ANATOMY
What is the risk of a CVA in
patients with TIA?
P509
```
≈10% a year
157
```
CAROTID VASCULAR DISEASE
ANATOMY
What is the noninvasive
method of evaluating carotid
disease?
P509
```
Carotid ultrasound/Doppler: gives
| general location and degree of stenosis
158
```
CAROTID VASCULAR DISEASE
ANATOMY
What is the gold standard
invasive method of
evaluating carotid disease?
P509
```
A-gram
159
```
CAROTID VASCULAR DISEASE
ANATOMY
What is the surgical
treatment of carotid
stenosis?
P509
```
Carotid EndArterectomy (CEA): the
removal of the diseased intima and media
of the carotid artery, often performed
with a shunt in place
160
```
CAROTID VASCULAR DISEASE
ANATOMY
What are the indications for
CEA in the ASYMPTOMATIC
patient?
P509
```
Carotid artery stenosis 60% (greatest
benefit is probably in patients with >80%
stenosis)
161
```
CAROTID VASCULAR DISEASE
ANATOMY
What are the indications for
CEA in the SYMPTOMATIC
(CVA, TIA, RIND) patient?
P509
```
Carotid stenosis >50%
162
```
CAROTID VASCULAR DISEASE
ANATOMY
Before performing a CEA in
the symptomatic patient, what
study other than the A-gram
should be performed?
P509
```
Head CT
163
```
CAROTID VASCULAR DISEASE
ANATOMY
In bilateral high-grade carotid
stenosis, on which side should
the CEA be performed in the
asymptomatic, right-handed
patient?
P509
```
Left CEA first, to protect the dominant
| hemisphere and speech center
164
```
CAROTID VASCULAR DISEASE
ANATOMY
What is the dreaded
complication after a CEA?
P509
```
Stroke (CVA)
165
```
CAROTID VASCULAR DISEASE
ANATOMY
What are the possible
postoperative complications
after a CEA?
P510
```
CVA, MI, hematoma, wound infection,
hemorrhage, hypotension/hypertension,
thrombosis, vagus nerve injury (change in
voice), hypoglossal nerve injury (tongue
deviation toward side of injury—“wheelbarrow”
effect), intracranial hemorrhage
166
```
CAROTID VASCULAR DISEASE
ANATOMY
What is the mortality rate
after CEA?
P510
```
≈1%
167
```
CAROTID VASCULAR DISEASE
ANATOMY
What is the perioperative
stroke rate after CEA?
P510
```
Between 1% (asymptomatic patient) and
| 5% (symptomatic patient)
168
```
CAROTID VASCULAR DISEASE
ANATOMY
What is the postoperative
medication?
P510
```
Aspirin (inhibits platelets by inhibiting
| cyclo-oxygenase)
169
```
CAROTID VASCULAR DISEASE
ANATOMY
What is the most common
cause of death during the
early postoperative period
after a CEA?
P510
```
MI
170
```
CAROTID VASCULAR DISEASE
ANATOMY
Define “Hollenhorst
plaque”?
P510
```
Microemboli to retinal arterioles seen as
| bright defects
171
CLASSIC CEA INTRAOP QUESTIONS
What thin muscle is cut right
under the skin in the neck?
P510
Platysma muscle
172
```
CLASSIC CEA INTRAOP QUESTIONS
What are the extracranial
branches of the internal
carotid artery?
P510
```
None
173
CLASSIC CEA INTRAOP QUESTIONS
Which vein crosses the
carotid bifurcation?
P510
Facial vein
174
CLASSIC CEA INTRAOP QUESTIONS
What is the first branch of
the external carotid?
P510
Superior thyroidal artery
175
CLASSIC CEA INTRAOP QUESTIONS
Which muscle crosses the
common carotid proximally?
P510
Omohyoid muscle
176
CLASSIC CEA INTRAOP QUESTIONS
Which muscle crosses the
carotid artery distally?
P510
Digastric muscle
| Think: Digastric = Distal
177
```
CLASSIC CEA INTRAOP QUESTIONS
Which nerve crosses
approximately 1 cm distal to
the carotid bifurcation?
P511
```
Hypoglossal nerve; cut it and the tongue
will deviate toward the side of the injury
(the “wheelbarrow effect”)
178
CLASSIC CEA INTRAOP QUESTIONS
Which nerve crosses the
internal carotid near the ear?
P511
Facial nerve (marginal branch)
179
CLASSIC CEA INTRAOP QUESTIONS
What is in the carotid sheath?
P511
1. Carotid artery
2. Internal jugular vein
3. Vagus nerve (lies posteriorly in 98%
of patients and anteriorly in 2%)
4. Deep cervical lymph nodes
180
SUBCLAVIAN STEAL SYNDROME
What is it?
P511 (picture)
Arm fatigue and vertebrobasilar
insufficiency from obstruction of the left
subclavian artery or innominate proximal to
the vertebral artery branch point; ipsilateral
arm movement causes increased blood flow
demand, which is met by retrograde flow
from the vertebral artery, thereby “stealing”
from the vertebrobasilar arteries
181
SUBCLAVIAN STEAL SYNDROME
Which artery is most
commonly occluded?
P512
Left subclavian
182
SUBCLAVIAN STEAL SYNDROME
What are the symptoms?
P512
Upper extremity claudication, syncopal
attacks, vertigo, confusion, dysarthria,
blindness, ataxia
183
SUBCLAVIAN STEAL SYNDROME
What are the signs?
P512
Upper extremity blood pressure
discrepancy, bruit (above the clavicle),
vertebrobasilar insufficiency
184
SUBCLAVIAN STEAL SYNDROME
What is the treatment?
P512
Surgical bypass or endovascular stent
185
RENAL ARTERY STENOSIS
What is it?
P512
Stenosis of renal artery, resulting in
decreased perfusion of the juxtaglomerular
apparatus and subsequent activation of the
renin-angiotensin-aldosterone system (i.e.,
hypertension from renal artery stenosis)
186
RENAL ARTERY STENOSIS
What is the incidence?
P512
```
≈10% to 15% of the U.S. population have
HTN; of these, ≈4% have potentially
correctable renovascular HTN
Also note that 30% of malignant HTN
have a renovascular etiology
```
187
RENAL ARTERY STENOSIS
What is the etiology of the
stenosis?
P512
```
≈66% result from atherosclerosis
(men > women), ≈33% result from
fibromuscular dysplasia (women >
men, average age 40 years, and 50%
with bilateral disease)
Note: Another rare cause is hypoplasia of
the renal artery
```
188
```
RENAL ARTERY STENOSIS
What is the classic profile of
a patient with renal artery
stenosis from fibromuscular
dysplasia?
P512
```
Young woman with hypertension
189
RENAL ARTERY STENOSIS
What are the associated
risks/clues?
P512
Family history, early onset of HTN, HTN
| refractory to medical treatment
190
RENAL ARTERY STENOSIS
What are the signs/
symptoms?
P513
Most patients are asymptomatic but may
have headache, diastolic HTN, flank
bruits (present in 50%), and decreased
renal function
191
RENAL ARTERY STENOSIS
What are the diagnostic tests?
A-gram
P513
Maps artery and extent of stenosis (gold
| standard)
192
RENAL ARTERY STENOSIS
What are the diagnostic tests?
IVP
P513
80% of patients have delayed nephrogram
| phase (i.e., delayed filling of contrast)
193
```
RENAL ARTERY STENOSIS
What are the diagnostic tests?
Renal vein renin ratio
(RVRR)
P513
```
If sampling of renal vein renin levels
shows ratio between the two kidneys
≥1.5, then diagnostic for a unilateral
stenosis
194
RENAL ARTERY STENOSIS
What are the diagnostic tests?
Captopril provocation test
P513
Will show a drop in BP
195
RENAL ARTERY STENOSIS
Are renin levels in serum
ALWAYS elevated?
P513
```
No: Systemic renin levels may also be
measured but are only increased in
malignant HTN, as the increased
intravascular volume dilutes the elevated
renin level in most patients
```
196
RENAL ARTERY STENOSIS
What is the invasive
nonsurgical treatment?
P513
Percutaneous Renal Transluminal
Angioplasty (PRTA)/stenting:
With FM dysplasia: use PRTA
With atherosclerosis: use PRTA/stent
197
RENAL ARTERY STENOSIS
What is the surgical
treatment?
P513
Resection, bypass, vein/graft
| interposition, or endarterectomy
198
```
RENAL ARTERY STENOSIS
What antihypertensive
medication is
CONTRAINDICATED in
patients with hypertension
from renovascular stenosis?
P513
```
```
ACE inhibitors (result in renal
insufficiency)
```
199
SPLENIC ARTERY ANEURYSM
What are the causes?
P513
Women—medial dysplasia
| Men—atherosclerosis
200
RENAL ARTERY STENOSIS
How is the diagnosis made?
P514
Usually by abdominal pain → U/S or CT
scan, in the O.R. after rupture, or
incidentally by eggshell calcifications
seen on AXR
201
RENAL ARTERY STENOSIS
What is the risk factor for
rupture?
P514
Pregnancy
202
```
RENAL ARTERY STENOSIS
What are the indications for
splenic artery aneurysm
removal?
P514
```
Pregnancy, >2 cm in diameter, symptoms,
| and in women of childbearing age
203
RENAL ARTERY STENOSIS
What is the treatment for
splenic aneurysm?
P514
Resection or percutaneous catheter
embolization in high-risk (e.g., portal
hypertension) patients
204
POPLITEAL ARTERY ANEURYSM
What is it?
P514
Aneurysm of the popliteal artery caused
by atherosclerosis and, rarely, bacterial
infection
205
POPLITEAL ARTERY ANEURYSM
How is the diagnosis made?
P514
Usually by physical exam → A-gram, U/S
206
```
POPLITEAL ARTERY ANEURYSM
Why examine the
contralateral popliteal
artery?
P514
```
50% of all patients with a popliteal artery
aneurysm have a popliteal artery aneurysm
in the contralateral popliteal artery
207
```
POPLITEAL ARTERY ANEURYSM
What are the indications for
elective surgical repair of a
popliteal aneurysm?
P514
```
1. ≥2 cm in diameter
2. Intraluminal thrombus
3. Artery deformation
208
```
POPLITEAL ARTERY ANEURYSM
Why examine the rest of the
arterial tree (especially the
abdominal aorta)?
P514
```
```
75% of all patients with popliteal
aneurysms have additional
aneurysms elsewhere; >50% of
these are located in the abdominal
aorta/iliacs
```
209
POPLITEAL ARTERY ANEURYSM
What size of the following aneurysms are usually
considered indications for surgical repair:
Thoracic aorta?
P514
>6.5 cm
210
POPLITEAL ARTERY ANEURYSM
What size of the following aneurysms are usually
considered indications for surgical repair:
Abdominal aorta?
P514
>5.5 cm
211
POPLITEAL ARTERY ANEURYSM
What size of the following aneurysms are usually
considered indications for surgical repair:
Iliac artery?
P515
>4 cm
212
POPLITEAL ARTERY ANEURYSM
What size of the following aneurysms are usually
considered indications for surgical repair:
Femoral artery?
P515
>2.5 cm
213
POPLITEAL ARTERY ANEURYSM
What size of the following aneurysms are usually
considered indications for surgical repair:
Popliteal artery?
P515
>2 cm
214
MISCELLANEOUS
Define the following terms:
“Milk leg”
P515
```
A.k.a. phlegmasia alba dolens (alba
white): often seen in pregnant women
with occlusion of iliac vein resulting
from extrinsic compression by the uterus
(thus, the leg is “white” because of
subcutaneous edema)
```
215
```
MISCELLANEOUS
Define the following terms:
Phlegmasia cerulea
dolens
P515
```
```
In comparison, phlegmasia cerulea dolens
is secondary to severe venous outflow
obstruction and results in a cyanotic leg;
the extensive venous thrombosis results
in arterial inflow impairment
```
216
MISCELLANEOUS
Define the following terms:
Raynaud’s phenomenon
P515
Vasospasm of digital arteries with color
changes of the digits; usually initiated
by cold/emotion
White (spasm), then blue (cyanosis), then
red (hyperemia)
217
MISCELLANEOUS
Define the following terms:
Takayasu’s arteritis
P515
Arteritis of the aorta and aortic branches,
resulting in stenosis/occlusion/
aneurysms
Seen mostly in women
218
MISCELLANEOUS
Define the following terms:
Buerger’s disease
P515
```
A.k.a. thromboangiitis obliterans:
occlusion of the small vessels of the
hands and feet; seen in young men
who smoke; often results in digital
gangrene → amputations
```
219
MISCELLANEOUS
What is the treatment for
Buerger’s disease?
P515
Smoking cessation, +/– sympathectomy
220
MISCELLANEOUS
What is blue toe syndrome?
P515
Microembolization from proximal
atherosclerotic disease of the aorta
resulting in blue, painful, ischemic toes
221
MISCELLANEOUS
What is a “paradoxical
embolus”?
P516
```
Venous embolus gains access to the left
heart after going through an intracardiac
defect, most commonly a patent foramen
ovale, and then lodges in a peripheral
artery
```
222
MISCELLANEOUS
What size iliac aneurysm
should be repaired?
P516
>4 cm diameter
223
MISCELLANEOUS
What is Behçet’s disease?
P516
Genetic disease with aneurysms from loss
of vaso vasorum; seen with oral, ocular, and
genital ulcers/inflammation (↑ incidence in
Japan, Mediterranean)
