Vascular Surgery, C66 P489-516 Flashcards Preview

Section II General Surgery P203Surgical Recall Sixth > Vascular Surgery, C66 P489-516 > Flashcards

Flashcards in Vascular Surgery, C66 P489-516 Deck (223):
1

What is atherosclerosis?
P489

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

What is the common theory
of how atherosclerosis is
initiated?
P490

Endothelial injury → platelets adhere →
growth factors released → smooth
muscle hyperplasia/plaque deposition

3

What are the risk factors for
atherosclerosis?
P490

Hypertension, smoking, diabetes
mellitus, family history, hypercholesterolemia,
high LDL, obesity,
and sedentary lifestyle

4

What are the common sites
of plaque formation in
arteries?
P490

Branch points (carotid bifurcation),
tethered sites (superficial femoral artery
[SFA] in Hunter’s canal in the leg)

5

What must be present for a
successful arterial bypass
operation?
P490

1. Inflow (e.g., patent aorta)
2. Outflow (e.g., open distal popliteal
artery)
3. Run off (e.g., patent trifurcation
vessels down to the foot)

6

What is the major principle
of safe vascular surgery?
P90

Get proximal and distal control of the
vessel to be worked on!

7

What does it mean to
“POTTS” a vessel?
P490

Place a vessel loop twice around a vessel
so that if you put tension on the vessel
loop, it will occlude the vessel

8

What is the suture needle
orientation through graft
versus diseased artery in a
graft to artery anastomosis?
P490

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

What are the three layers of
an artery?
P490

1. Intima
2. Media
3. Adventitia

10

Which arteries supply the
blood vessel itself?
P490

Vaso vasorum

11

What is a true aneurysm?
P490

Dilation ( >2x nL diameter) of all three
layers of a vessel

12

What is a false aneurysm
(a.k.a pseudoaneurysm)?
P490

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

What is “ENDOVASCULAR”
repair?
P491 (picture)

Placement of a catheter in artery and
then deployment of a graft intraluminally

14

PERIPHERAL VASCULAR DISEASE
Define the arterial anatomy:

P491 (picture)

1. Aorta
2. Internal iliac (hypogastric)
3. External iliac
4. Common femoral artery
5. Profundi femoral artery
6. Superficial femoral artery (SFA)
7. Popliteal artery
8. Trifurcation
9. Anterior tibial artery
10. Peroneal artery
11. Posterior tibial artery
12. Dorsalis pedis artery

15

PERIPHERAL VASCULAR DISEASE
How can you remember the
orientation of the lower
exterior arteries below the
knee on A-gram?
P492

Use the acronym “LAMP”:
Lateral Anterior tibial
Medial Posterior tibial

16

PERIPHERAL VASCULAR DISEASE
What is peripheral vascular
disease (PVD)?
P492

Occlusive atherosclerotic disease in the
lower extremities

17

PERIPHERAL VASCULAR DISEASE
What is the most
common site of arterial
atherosclerotic occlusion in
the lower extremities?
P492

Occlusion of the SFA in Hunter’s canal

18

PERIPHERAL VASCULAR DISEASE
What are the symptoms of
PVD?
P492

Intermittent claudication, rest pain,
erectile dysfunction, sensorimotor
impairment, tissue loss

19

PERIPHERAL VASCULAR DISEASE
What is intermittent
claudication?
P492

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

PERIPHERAL VASCULAR DISEASE
What is rest pain?
P492

Pain in the foot, usually over the distal
metatarsals; this pain arises at rest
(classically at night, awakening the
patient)

21

PERIPHERAL VASCULAR DISEASE
What classically resolves rest
pain?
P492

Hanging the foot over the side of the bed
or standing; gravity affords some extra
flow to the ischemic areas

22

PERIPHERAL VASCULAR DISEASE
How can vascular causes of
claudication be differentiated
from nonvascular causes,
such as neurogenic
claudication or arthritis?
P492

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

PERIPHERAL VASCULAR DISEASE
What is the differential
diagnosis of lower extremity
claudication?
P492

Neurogenic (e.g., nerve entrapment/
discs), arthritis, coarctation of the aorta,
popliteal artery syndrome, chronic
compartment syndrome, neuromas,
anemia, diabetic neuropathy pain

24

PERIPHERAL VASCULAR DISEASE
What are the signs of PVD?
P493

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)