Vascular & Thoracic

Question 1

Predicted post op FEV1 & DLCO needed for safe lung resection

Answer 1

> 60%

If 30-60%, need low-technology exercise testing

PPO FEV1 = preoperative FEV1× (1 – y/z)
PPO DLCO = preoperative DLCO × (1 – y/z)
y = Number of functional or unobstructed lung segments removed.
z = Total number of functional segments (~19)

Question 2

Light’s criteria for pleural effusions

Answer 2

An effusion with any of the following characteristics is classified as an exudate:
1. pleural:serum ratio > 0.5
2. pleural:serum LDH ratio > 0.6
3.pleural LDH > 2/3 of the upper limit of normal for the serum.

Question 3

Indications for CEA & initial medical management

Answer 3

Indications for CEA → Symptomatic >50%; Asymptomatic >70-80% or EDV > 140 cm/s

Stroke: RULE OUT A FIB FIRST, needs echo & ekg

Start aspirin, clopidogrel, statin & obtain HbA1c

TIming of CEA
Crescendo TIAs: Emergently
Small/TIA: Wait 2 days, but perform within 2 weeks
Hemorrhagic stroke: 6-8 weeks

Question 4

CEA steps

Answer 4

1. Shoulder roll, neck slightly extended
2. Incision along anterior border of SCM
3. Identify & ligate facial vein, open carotid sheath, retract SCM & IJ laterally
4. Dissect carotid; identify & protect vagus nerve; control w vessel loops
5. Heparinize, clamp ICA, CCA, ECA, make longitudinal arteriotomy, place shunt
6. Carotid endarterectomy (remove intima and part of media) with patch angioplasty using bovine pericardium
7. Remove clamps (ECA, CCA, ICA) & shunt, flush carotid
8. Confirm good repair with U/S

Question 5

EVAR steps

Answer 5

1. Bilateral CFA access, insert sheaths
2. Aortogram
3. Flush main trunk w heparinized saline, deploy in proximal neck, just inferior to lowest renal artery
4. Similarly deploy contralateral limb via contralateral sheath
5. IVUS if any questions
6. Completion angiogram, check distal pulses
7. Perclose vs cut down to repair arteries

Question 6

Indications for AAA repair & ideal criteria for EVAR

Answer 6

Repair indications
≥ 5.5 cm for average male patient
≥ 5.0 cm for women or those w/ high rupture risk (eg severe COPD, numerous relatives w/ rupture, poorly controlled HTN, eccentric shape)

Growth > 1.0 cm/yr

Symptomatic or infected (mycotic)

Ideal criteria for EVAR
Neck
-Neck length > 10 mm
-Neck diameter < 32 mm
-Neck angulation < 60 °s
CIA
-CIA length > 10 mm?
-CIA diameter > 8 mm
-Non-tortuous, noncalcified iliac arteries
-Lack of neck thrombus

Question 7

Endoleaks and treatments

Answer 7

I: Proximal (A) or distal (B) attachment sites, means endograft isn’t sealed
Need to tx → Extension cuffs

II: Collaterals from lumbars
May be able to observe; if expanding, tx → coil embolization

III: Overlap sites when using multiple grafts or graft tears
Need to tx → Secondary endograft

IV: Graft wall porosity or suture holes
May be able to observe; tx → new endograft

Question 8

Rutherfords classification for ALI

Answer 8

Question 9

CFA thromboembolectomy

Answer 9

1. Systemic heparin 80U/kg bolus followed by gtt to PTT 2x baseline; prep both legs
2. Verticle skin incision below inguinal ligament, expose CFA, SFA, profunda & loop w vessel loops
3. Heparinize to ACT>250
4. Secure vessel loops, perform transverse arteriotomy over bifurcation
5. Pass 4/5F fogarty proximally until clean & distally 2x, establishing inflow and outflow
6. Close arteriotomy, shoot angiogram, check distal pulses
7. Close groin in layers, place drain

Question 10

How to perform ABI

Answer 10

1. Apply the blood pressure cuff.
2. Listen for waveforms with the Doppler pen.
3. Pump up the cuff (20 mmHg above when you hear the last arterial beat).
4. Slowly release the pressure and record when the first arterial beat returns.

Do this for bilateral brachial, DP, & PT arteries

Highest brachial P is the denominator, highest DP vs PT is numerator for L & R

Question 11

Exposure of anterior tibial artery, posterior tibial artery, peroneal artery

Answer 11

Anterior tibial a.
Exposure → Lateral incision, halfway between tibia & fibula, into plane between tibialis anterior & EHL/EDL
Anterior tibial vessels will be most anterior
Deep peroneal nerve will be most posterior

Posterior tibial a. Exposure → Medial incision, 2 cm posterior to tibia; gastrocnemius m. retracted posteriorly & soleus m. is taken off tibia

Peroneal a. Exposure
Medial approach as above, deeper dissection to anterior FHL m.
Lateral approach, requires partial fibulectomy

Question 12

Retroperitoneal exposure of aortic bifurcation

Answer 12

1. Left flank incision along lateral border of rectus
2. Divide EO, IO, TA muscles
3. Separate & mobilize peritoneum, reflect peritoneum to the right
4. Identify iliopsoas muscle & ureter; develop plane between colon anteriorly & ureter posterior, mobilize colon to the right
5. Dissect infrarenal aorta & CFA

Question 13

GSV ablation steps

Answer 13

1. Access GSV at knee with micropuncture kit, insert 7F sheath over wire
2. Insert ablation catheter to saphenofemoral junction
3. Inject tumescence around GSV along course of vein
4. Ablate starting 2 cm distal to saphenofemoral junction
5. U/S to assess for clot in CFV
6. If Venous stasis ulcer: Tx w unna boot (zinc compression wrap) following GSV ablation

Question 14

Dialysis work up

Answer 14

Ask for handedness, time needed to dialyze, life expectancy

Vein should be 3 mm, artery should be 2 mm (can increase following axillary block)

Question 15

Rule of 6 dialysis

Answer 15

6 mm diameter, < 6 mm deep, > 600 mL/min flow, cannulated two needles 8 cm apart