27 Vascular Flashcards
1
Q
Most common congenital hypercolaguable disorder?
A
Resistance to activated protein C (Factor V leiden)
2
Q
Most common acquired hypercoagulable disorder?
A
Smoking
3
Q
Stage 1 of atherosclerosis
A
Foam cells
Macrophages that have absorbed fat and lipids in the vessel wall
4
Q
Stage 2 of atherosclerosis
A
Smooth muscle proliferation
Caused by growth factors released from macrophages (PGDF)
Results in wall injury
5
Q
Stage 3 of atherosclerosis
A
Intimal disruption (from smooth muscle cell proliferation) Leads to collagen exposure --> thrombus formation --> fibrous plaques
6
Q
Risk factors for atherosclerosis
A
Smoking HTN Hypercholesterolemia DM Hereditary factors
7
Q
Most important risk factor for stroke?
A
HTN
8
Q
Most common site of carotid stenosis?
A
Carotid bifurcation
9
Q
Carotids supply ____ of blood flow to brain?
A
85%
10
Q
What is the normal flow of the internal carotid?
A
Continuous forward flow
11
Q
What is the first branch of the internal carotid artery?
A
Ophthalmic artery
12
Q
What is the normal flow of the external carotid?
A
Triphasic flow
13
Q
Communication between the ICA and ECA occurs via?
A
Opthalmic artery (ICA) Internal maxillary artery (ECA)
14
Q
Most commonly diseased intracranial artery?
A
Middle cerebral artery
15
Q
MCC of cerebral ischemic events?
A
Arterial embolization from ICA
Others:
- Thrombosis
- Low-flow state through a severely stenotic lesion
- Emboli from heart (second most common source)
16
Q
Arterial source of event?
Mental status changes, release, slowing
A
Anterior cerebral artery
17
Q
Arterial source of event?
Contralateral motor and speech if dominant side)
Contralateral facial droop
A
Middle cerebral artery events
18
Q
Arterial source of event?
Vertigo, tinnitus, drop attacks, incoordination
A
Posterior cerebral artery
19
Q
Visual changes - shade coming down over eyes
Hollenhorst plaques on ophthalmologic exam
A
Amaurosis fugax
Occlusion of the ophthalmic branch of ICA
Transient
20
Q
Treatment of carotid traumatic injury with major fixed deficit?
A
If occluded - do NOT repair (can exacerbate injury with bleeding)
If not occluded - repair with carotid stent or open procedure
21
Q
Indications for carotid endarterectomy
A
Symptomatic >70% stenosis
Asymptomatic >80% stenosis
22
Q
When do you perform a CEA after a stroke?
A
Wait 4-6 weeks and then perform CEA if it meets criteria
23
Q
When do you perform an emergent CEA?
A
Fluctuating neurologic symptoms
Crescendo/evolving TIA
24
Q
When do you need to use a shunt during CEA?
A
Stump pressures < 50
Contralateral side is tight
25
With bilateral carotid artery stenosis - how do you decide which side to repair first?
Repair tightest side first
| If they are equally tight - dominant side first
26
Complication after CEA: hoarseness
Vagus nerve injury
| Secondary to vascular clamping
27
MC cranial nerve injury after CEA
Vagus nerve injury
28
Complication after CEA: speech and mastication difficulty
Hypoglossal nerve injury
| Tongue deviates to the side of injury
29
Complication after CEA: Difficulty swallowing
Glossopharyngeal nerve injury
| Rare - occurs with high carotid dissection
30
Complication after CEA: Loss of innervation to strap muscles
Ansa cervicalis
| No serious deficit
31
Complication after CEA: Changes in the corner of the mouth, difficulty smiling
Mandibular branch of facial nerve
32
Complication after CEA: Acute event immediately after CEA, what do you do?
Back to OR
| Check for flap or thrombosis
33
Complication after CEA: Pulsatile, bleeding mass
Pseudoaneurysm
Tx: drape and prep before intubation
Intubate, then repair
34
Complication after CEA: Hypertension
Injury to carotid body
| Tx: Nipride to avoid bleeding
35
MCC cause of non-stroke morbidity and mortality following CEA?
Myocardial infarction
36
Rate of restenosis after CEA
15%
37
Indications for carotid stenting (versus CEA)
Previous CEA with restenosis
Multiple medical comorbidities
Previous neck XRT
38
Anatomy of the vertebrobasilar artery system
Subclavian arteries --> vertebral arteries --> combine --> basilar artery --> splits --> posterior cerebral arteries
39
Source of arterial deficit:
| Diplopia, vertigo, tinnitus, drop attacks, incoordination
Basilar artery or bilateral vertebral artery disease - vertebrobasilar insufficiency
Causes: atherosclerosis, spurs, bands
Tx: PTA with stent
40
Painless neck mass, near carotid bifurcation
Carotid body tumor
Origin - neural crest cells
Extremely vascular
Tx: resection
41
Aortic arch vessels antomy
Innominate artery (--> right subclavian and right common carotid artery)
Left common carotid artery
Left subclavian artery
42
Ascending aortic aneurysm
Often picked up on CXR
| Sx are due to compression: back pain (vertebra), voice changes (RLN), dyspnea/PNA (bronchi), dysphagia (esophagus)
43
Indications for treatment of ascending aortic aneurysm?
Acutely symptomatic
>5.5cm (with Marfan's >5.0cm)
Rapid increase in size (>0.5 cm/yr)
44
Indications for treatment of descending aortic aneurysm?
If endovascular repair possible >5.5cm
| If open repair needed >6.5cm
45
How do you prevent paraplegia with open repair for a descending aortic aneurysm?
Reimplant intercostal arteries below T8
46
Stanford classification: any ascending aortic involvement?
Class A
47
Stanford classification: only descending aortic involvement?
Class B
48
Debakey classification: ascending and descending
Type I
49
Debakey classification: ascending only
Type II
50
Debakey classification: descending only
Type III
51
Where do most dissections start?
Ascending aorta
52
Risk factors for aortic dissection?
Severe HTN
Marfan's syndrome
Previous aneurysm
atherosclerosis
53
Diagnosis of aortic dissection?
Chest CT with contrast
54
Where does dissection occur within the blood vessel?
Medial layer of the wall
55
Cause of death in ascending aortic dissection?
Cardiac failure secondary to aortic insufficiency, cardiac tamponade or rupture
56
Initial treatment of aortic dissection?
Medical - control BP (B-blockers and Nipride)
57
Surgical intervention for aortic dissection?
```
All ascending (open repair, graft)
Descending if: visceral/extremity ischemia, contained rupture (endograft, open repair, fenestrations)
Follow with lifetime serial MRI
```
58
Most common complications for thoracic aortic surgery?
MI
Renal failure
Paraplegia (descending)
59
Cause of paraplegia after descending thoracic aorta ?
Spinal cord ischemia due to occlusion of intercostal arteries and artery of Adamkiewicz
60
Normal aorta diameter?
2-3cm
61
Cause of abdominal aortic aneurysm?
Degeneration of the medial layer
62
Risk factors for AAA?
Male, age, smoking, family history
63
Presentation of AAA?
Rupture
Distal embolization
Compression of adjacent organs
64
How do you diagnose AAA rupture?
```
US
Abdominal CT (fluid in retroperitoneal space and extraluminal contrast)
```
65
Most likely location for AAA rupture?
Left posterolateral wall, 2-4cm below renals
66
Co-morbid medical conditions that can lead to AAA expansion?
HTN
| COPD
67
Treatment of AAA?
Repair if:
Symptomatic
>5.5cm
Growth >0.5cm/year
68
Indications for reimplantation of inferior mesentaric artery in AAA repair?
If back pressure is <40mmHg (poor back bleeding)
Previous colonic surgery
Stenosis at the superior mesenteric artery
Flow to left colon appears inadequate
69
If you perform an aorto-bifemoral repair instead of a straight tube graft for AAA repair, what must you ensure?
Flow to at least one internal iliac artery (hypogastric artery) to avoid vasculogenic impotence
70
What major vein can get injured with cross clamping of the aorta?
Rero-aortic left renal vein
71
MCC of acute death after AAA repair?
MI
72
MCC of late death after AAA repair?
Renal failure
73
Risk factors for mortality after AAA repair?
```
Creatinine >1.8
CHF
EKG ischemia
Pulmonary dysfunction
Older age
Female
```
74
AAA graft infection rate
1%
75
Incidence of pseudoaneurysm formation after AAA repair?
1%
76
MCC late complication after aortic graft placement?
Atherosclerotic occlusion
77
Bloody diarrhea after AAA repair?
Ischemic colitis
IMA typically sacrificed - left colon most common
Dx: endoscopy or abdomianl CT (middle and distal rectum)
OR if: peritoneal signs, mucosa is black on endoscopy, part of colon looks dead on CT
78
Ideal criteria for AAA endovascular repair?
```
Neck length >15mm
Neck diameter 20-30mm
Neck angulation <60 degrees
Common iliac artery length >10mm
Common iliac artery diameter 8-18mm
Non-tortuous, noncalcified iliac arteries
Lack of neck thrombus
```
79
Endoleak - at site of proximal or distal graft attachment
Type I endoleak
| Tx: extension cuffs
80
Endoleak - through collaterals
Type II endoleak
| Tx: Observe - if vessels are pressurizing the aneurysm --> perutaneous coil emolization
81
Endoleak - via overlap sites when multiple grafts were used or fabric tear
Type III endoleak
| Tx: Secondary endograft to cover overlap site or tear
82
Endoleak - via graft wall porosity or suture holes
Type IV endoleak
| Tx: observe - can place nonporous stent if that fails
83
Endoleak - expansion of aneurysm without evidence of leak
Type V - endotension
| Tx: repeat EVAR or open repair
84
Inflammatory aneurysm
NOT due to infection
Can get adhesion in 3/4th porttion of the duodenum
Can get ureteral entrapment (place stents before repair)
Wt loss, increased ESR
CT scan shows thickened rim above calcifications
Inflammatory process resolves after aortic graft placement
85
Mycotic aneurysm
Salmonella, Staphylococcus
Bacteria infects atherosclerotic plaque
Pain, fever, positive blood cultures
Periaortic fluid, gas, retroperitoneal soft tissue edema, LAD
Need extra-anatomic bypass and resection of infrarenal abdominal aorta to clear infection
86
Aortic graft infections
Staphylococcus, E. Coli
Fluid, gas, thickening around graft
Blood cultures negative
Tx: bypass through non-contaminate field and then resect infected graft
87
Most common graft to get infected?
Those going to the groin
88
Aortoenteric fistula
Occurs 6mo after abdominal aortic surgery
Herald bleed with hematemesis, then blood per rectum
Graft erodes into 3/4th portion of the duodenum near proximal suture line
Tx: bypass through non-contaminate field, resect graft, then close hole in duodenum
89
Contents of the anterior leg compartment
Deep peroneal nerve (dorsiflexion, sensation b/t 1/2nd toes)
| Anterior tibial artery
90
Contents of the lateral leg compartment
Superficial peroneal nerve (eversion, lateral foot sensation)
91
Contents of the deep posterior leg compartment
Tibial nerve (plantar flexion)
Posterior tibial artery
Peroneal artery
92
Contents of the superficial posterior leg compartment
Sural nerve
93
Signs of peripheral artery disease
Pallor
Dependent rubor
Hair loss
Slow capillary refill
Most commonly due to atherosclerosis
94
Number one preventive agent of atherosclerosis?
Statin drugs
95
Medical treatment of claudication
ASA
Smoking cessation
Exercise until pain occurs to create collaterals
96
Source of obstruction - buttock claudication
Aortoiliac disease
97
Source of obstruction - mid-thigh claudication
External iliac
98
Source of obstruction - calf claudication
Common femoral artery
| Proximal superifical femoral artery
99
Source of obstruction - foot claudication
Distal superficial femoral artery
| Popliteal disease
100
Lumbar stenosis can mimic which symptom of PAD?
Claudication
101
Diabetic neuropathy can mimic which symptom of PAD?
Rest pain
102
No femoral pulses
Buttock or thigh claudication
Impotence
Leriche syndrome
Lesion at aortic bifurcation or above
Impotence is due to decreased flow in the internal iliacs
Tx: aorto-bifemoral bypass graft
103
Most common atherosclerotic occlusion in lower extremities?
Hunter's canal - distal superficial femoral artery exits
| Sartorius muscle covers Hunter's canal
104
Borders of the adductor canal
Hunter's canal
Anterior - sartorius
Lateral - vastus medialis
Posterior - adductor longus and magnus
105
What collateral circulation forms in the lower extremities from abnormal pressure gradients?
Circumflex iliacs to subcostals
Circumflex femoral arteries to gluteal arteries
Geniculate arteries around the knee
106
Ankle-brachial index - start to get claudication
<0.9
107
Ankle-brachial index - start to get rest pain
<0.5 (distal arch and foot)
108
Ankle-brachial index - ulcers
<0.4 (starts in toes)
109
Ankle-brachial index - gangrene
<0.3
110
What patients can have inaccurate ABIs? what do you do instead?
Diabetes and severe calcification
Incompressible vessels
Doppler waveforms
111
Pulse volume recordings
Used to find significant occlusion and at what level
112
Indications for arteriogram in PAD
PVRs suggesting significant disease
| Can also perform intervention
113
Surgical indications for PAD
Rest pain
Ulceration or gangrene
Lifestyle limitation
Atheromatous embolization
114
PTFE (Gortex)
Only for bypasses above the knee
| Use vein for below the knee
115
Dacron
Good for aorta and large vessels
116
Treatment of aortoiliac occlusive disease
Aorto-bifemoral repair
Ensure flow to atleast 1 internal iliac artery (hypogastric artery) to prevent vasculogenic impotence and pelvic ischemia
117
Treatment of isolated iliac lesions
PTA with stent (first choice)
| If that fails - femoral-to-femoral crossover
118
Femoropopliteal grafts
75% 5-year patency
Better for claudication versus limb salvage
Popliteal artery exposure below knee - gastrocnemius (post), popliteus (ant)
119
Femoral-distal grafts
Peroneal, anterior tibial or posterior tibial artery
50% 5-year patency (NOT influenced by level of distal anastomosis
Distal lesions are more threatening due to lack of collaterals
Bypasses to distal vessels are only for limb salvage
120
What do you use below the knee? Why?
Saphenous vein
| Synthetic grafts have decreased patency below the knee
121
When do you use extra-anatomic grafts?
To avoid hostile conditions in the abdomen (i.e. infection, multiple previous abdominal operations, frail patient)
122
Complication of femoral-to-femoral crossover graft?
Vascular steal in donor leg due to doubling of the blood flow to the donor artery
123
Early swelling following lower extremity bypass?
Reperfusion injury and compartment syndrome
| Tx: Fasciotomy
124
Late swelling following lower extremity bypass?
DVT
Dx: US
Tx: Heparin, Coumadin
125
Complications of reperfusion of ischemic tissues?
Compartment syndrome
Lactic acidosis
Hyperkalemia
Myogloinuria
126
MCC of early failure of reversed saphenous vein grafts
Technical problem
127
MCC of late failure of reversed saphenous vein grafts
Atherosclerosis
128
Treatment of patients with heel ulceration to bone
Amputation
129
Dry gangrene
Noninfectious
If small or just toes - autoamputation
Large lesions - amputate
First see if there is a correctable vascular lesion
130
Wet gangrene
Infectious
Tx: remove infected necrotic material and antibiotics
Surgical emergency: extensive infection or systemic complications (guillotine amputation)
131
Mal perforans ulcer
At metatarsal head - 2nd MTP joint most common
Diabetics - risk for osteomyolitis
Tx:
- Non-weight bearing
- Debridement of metatarsal head (remove cartilage)
- Antibiotics
- May need revascularization
132
Percutaneous transluminal angioplasty
Excellent for common iliac artery stenosis
Best for short stenosis
Intima ruptures and media stretched - pushes plaque out
133
Compartment syndrome
Reperfusion injury
Cessation of blood flow to extremity and reperfusion >4-6hrs later
Causes swelling of muscle compartments - increases pressures, overwhelming blood flow - ischemia
Dx: clinical, compartment pressures >20-30mmHg
Tx: fasciotomy (5-10 days before closure)
134
What cells are responsible for reperfusion injury?
PMNs
135
Compartment most likely to get compartment syndrome?
Anterior compartment
| You get foot drop
136
Popliteal entrapment syndrome
Mild, intermittent claudication
Men, 40s - loss of pulses with plantar flexion
Medial deviation of popliteal artery around medial heat of gastrocnemius muscle
Tx: resection of medial head of gastrocnemius
137
Advential cystic disease
Men, 40s, popliteal fossa most common
BILATERAL
Ganglia originate from adjacent joint capsule or tendon sheath
Sx: intermittent claudication, change with knee flexion/extension
Dx: Angiogram
Tx: resection of cyst, vein graft if vessel is occluded
138
Sources of arterial autografts?
Radial artery grafts for CABG
| IMA for CABG
139
Indications for amputation?
Gangrene
Large, non-healing ulcers
Unrelenting rest pain, not amenable to surgery
140
Indications for emergency amputation?
Systemic complications
| Extensive infection
141
Outcomes of BKA
80% heal
70% walk again
5% mortality
142
Outcomes of AKA
90% heal
30% walk again
10% mortality
143
Characteristics of acute arterial embolism
Arrhythima
No prior claudication or rest pain
Normal contralateral pulses
No physical findings of chronic limb ischemia
Do not have collaterals
Sx: pain, paresthesia, poikilothermia, paralysis
144
Characteristics of acute arterial thrombosis
No arrhythmia
History of claudication or rest pain
Contralateral pulses absent
Physical findings of chronic limb ischemia
145
Progression of extremity ischemia?
Pallor (white) > cyanosis (blue) > marbling
146
MCC acute arterial embolism
Afib*
Recent MI with left ventricular thrombus
Myxoma
Aorto-iliac disease
147
Most common site for peripheral obstruction from emboli?
Common femoral artery
148
Treatment of acute arterial embolism
Embolectomy; after pulse return do a post-op angiogram
| Consider fasciotomy if ischemia >4-6hrs
149
Patient presents with acute loss of both femoral pulses?
Aortoiliac emboli
| Tx: bilateral femoral artery cutdowns and bilateral embolectomys
150
Most common site of atheroma embolization?
Renal arteries
151
Atheroma embolism
Cholesterol clefts that can lodge in small arteries
Dx: chest/abdomen/pelvis CT scan (for aneruysmal source), ECHO (clot/myxoma in heart)
Tx: anerusyms repair or arterial exclusion with bypass
152
Blue toe syndrome
Flaking atherosclerotic emboli off abdominal aorta or branches
Typically have good distal pulses
Aortoiliac disease most common source
153
Acute arterial thrombosis
Tx:
- Threatened limb (loss of sensation or motor function): heparin and thrombectomy
- Non-threatened limb: angiography for thrombolytics
154
Thrombosis of PTFE graft
Threatened limb - OR for thrombectomy
| Non-threatened limb - thrombolytics adn anticoagulation
155
Course of the right renal artery in relation to the IVC?
Posterior
156
Causes of renovascular HTN?
Renal atherosclerosis
| Fibromuscular dysplasia
157
Renovascular HTN?
```
Bruits, diastolic BP >115, HTN
Children or premenopausal women
HTN resistant to drug therapy
Dx: Angiogram
Tx: PTA, place stent if due to atherosclerotic disease
```
158
Renal atherosclerosis
Left side
Proximal 1/3
Men
159
Renal fibromuscular dysplasia
Right side
Distal 1/3
Women
160
Indications for nephrectomy with renal HTN?
Atrophic kidney <6cm with persistently high renin levels
161
UE occlusive disease
Proximal lesions asymptomatic due to collaterals
MC site - subclavian
Tx: PTA with stent, common carotid to subclavian artery bypass if that fails
162
Subclavian steal syndrome
Proximal subclavian artery stenosis resulting in reversal of flow through ipsilateral vertebral artery into the subclavian artery
Operative if limb or vertebrobasial symptoms
Tx: PTA with stent to subclavian artery, common carotid to subclavian artery bypass if that fails
163
Thoracic outlet syndrome
Sx: back/neck/arm pain/weakness/tingling; worse with palpation/manipulation
Dx: MRI (cervical spine and chest), duplex US (vascular etiology)
Neurologic involvement more common than vascular
164
Normal anatomy of subclavian vein
Passes over the 1st rib, anterior to the anterior scalene muscle, then behind clavicle
165
Normal anatomy of brachial plexus and subclavian artery
Pass over the 1st rib posterior to the anterior scalene muscle and anterior to the middle scalene muscle
166
MC anatomic abnormality in thoracic outlet syndrome
Cervical rib
167
MC cause of pain in thoracic outlet syndrome
Brachial plexus irritation
168
Brachial plexus irritation with TOS
Normal neurological exam; positive Tinsel's test
Ulnar nerve distribution most common
Tx: cervical rib and 1st rib resection; divide anterior scalene muscle
169
Symptoms of ulnar nerve deficits
C8-T1
Inferior portion of brachial plexus
Tricep muscle, intrinsic muscles of hand, weak wrist flexion
170
Effort induced thrombosis of subclavian vein
Page-von shrotter disease
Acutely painful, swollen blue limb
Dx: venography (gold standard), duplex US
Tx: thrombolytics, then same admission repair (cervical rib and 1st rib resection, divide anterior scalene muscle)
171
Compression of subclavian artery secondary to anterior scalene hypertrophy
Weight lifters
Least common cause of TOS
Sx: hand pain from ischemia, absent radial pulse with head turned to ipsilateral side (Adson's test)
Dx: duplex US or angiogram (gold standard)
Tx: surgery (cervical rib and 1st rib resection, divide anterior scalene muscle, possible bypass graft if artery is too damaged or aneurysmal
172
Why does motor function of the hand remain in digits after prolonged hand ischemia?
Motor groups are located in the proximal forearm
173
Most common artery in mesenteric ischemia?
Superior mesenteric artery
174
Abdominal CT findings that suggest intestinal ischemia?
Vascular occlusion
Bowel wall thickening
Intramural gas
Portal venous gas
175
Most common causes of visceral ischemia?
Embolic occlusion - 50%
Thrombotic occlusion - 25%
Nonocclusive - 15%
Venous thrombosis - 5%
176
SMA embolism
Occurs near origin of SMA (heart - Afib)
Sx: pain out of proportion, sudden onset; hematochezia and peritoneal signs are late findings
Ass. hx: afib, endocarditis, recent MI, recent angiography
Dx: angiogram or abdominal CT with IV contrast
Tx: embolectomy, resect infarcted bowel
177
Exposing the SMA
Divide ligament of Treitz
| SMA is to teh right of the near the base of the transverse colon mesentary
178
SMA thrombosis
History of chronic problems (food fear, weight loss)
Ass. hx: vasculitis or hypercoagulable state
Sx: history of chronic food problems
Dx: angiogram or abdominal CT with IV contrast
Tx: Thrombectomy; may need PTA with stent or open bypass if residual stenosis; resect infarcted bowel
179
Mesenteric vein thrombosis
Involves short segments of intestine - bloody diarrhea, crampy abdominal pain
Ass. hx: vasculitis, hypercoagulable state, portal HTN
Dx: abdominal CT or angiogram with venous phase
Tx: heparin, resect infarcted bowel
180
Non-occlusive mesenteric ischemia
Spasm, low-flow states, hypovolemia, hemoconcentratio, digoxin - low cardiac output to visceral vessels
Risk: prolong shock, CHF, prolong cardiopulmonary bypass
Sx: bloody diarrhea, pain
Tx: volume resuscitation, catheter-directed nitroglycerin (increase visceral blood flow), increase cardiac output (dobutamine); resect infarcted bowel
181
Griffith's watershed area
Splenic flexure
182
Sudak's watershed area
Upper rectum
183
Median arcuate ligament syndrome
Causes celiac artery compression
Bruit near epigastrium, chronic pain, weight loss, diarrhea
Tx: transect median arcuate ligament, may need arterial reconstruction
184
Chronic mesenteric angina
Food angina
Dx: lateral visceral vessel aortography to see origins of celiac and SMA
Tx: PTA and stent - bypass if that fails
185
Arc of Riolan
Collateral that forms between the SMA and celiac
186
MCC of aneurysm above inguinal ligament
Rupture
187
MCC of aneurysm below inguinal ligament
Thrombosis and emboli
188
Risk factors for visceral artery aneurysm
Medial fibrodysplasia
Portal HTN
Arterial disruption secondary to inflammatory disease (i.e. pancreatitis)
189
Indications for repair of visceral artery aneurysms
>2cm (except splenic)
Tx: covered stent; exclusion with bypass if that fails
190
Splenic artery aneurysm
Repair if: symptomatic, pregnant, woman of childbearing age, >3-4cm
Usually ruptures in the third trimester
Splenic artery can be ligated if open procedure - good collaterals
191
Renal artery aneurysm
Treat if >1.5cm
| Tx: Covered stent
192
Iliac artery aneurysm
Treat if >3.0cm
| Tx: covered stent
193
Femoral artery aneurysm
Treat if >2.5cm
| Tx: covered stent
194
Popliteal artery aneurysm
Prominent popliteal pulses
50% bilateral, 50% associated with other aneurysms
Complications: thrombosis or emboli with limb ischemia; pain from compression of adjacent structures
Dx: US
Surgical indications: symptomatic, >2cm mycotic
Tx: exclusion and bypass (NOT covered stent)
195
MC visceral artery aneurysm
Splenic artery aneurysm
196
MC peripheral artery aneurysm
Popliteal artery aneurysm
197
Pseudoaneurysm
Collection of blood in continuity with the arterial system, but NOT enclosed by all three layers of the arterial wall
Risk: percutaneous intervention; disruption of a suture line between graft and artery
Tx: after PTI - US guided compression with thrombin injection, surgical repair if it fails; suture line - surgical repair
198
MC location for pseudoaneurysm
Femoral artery
199
Pseudoaneurysm that occurs at suture lines late after surgery (month to years)
Suggests graft infection
200
Course of the greater saphenous veins
Joins femoral vein near groin
| Runs medially
201
Can you clamp the IVC?
NO - will tear
202
Ligating the renal veins - which and where?
Left can be ligated near the IVC - has multiple collaterals (left gonadal vein, left adrenal vein)
Right side does NOT have these collaterals
203
Most common failure of AV grafts for dialysis?
Venous obstruction secondary to intimal hyperplasia
204
Cimino AVF
Radial artery to cephalic vein
| Wait 6 weeks to use - allows vein to mature
205
Interposition graft
Brachiocephalic loop graft
| Wait 6 weeks to use - allows for fibrous scar formation
206
Acquired AV fistulas
Trauma -> peripheral arterial insufficiency, CHF, aneurysm, limb-length discrepancy
Repair - lateral venous suture; arterial side may need patch or bypass graft; place interposing tissue so it does not recur
207
Varicose veins
Smoking, obesity, low activity
| Tx: sclerotherapy
208
Venous ulcers
Secondary to venous valve incompetence
Above and posterior to malleoli
<3cm will heal without surgery
Tx: unna boot; if fails, ligate perforates or have vein stripping of greater saphenous vein
209
Fibromuscular dysplasia
Young women, HTN (renal), headaches, stroke (carotid)
String of bead apperance
Medial fibrodysplasia
Tx: PTA, bypass if that fails
210
Buerger's disease
Young men, smokers
Severe rest pain with bilateral ulceration; gangrene of digits
Corkscrew collaterals on aginogram; normal arterial tree proximal to popliteal and brachial vessels
Tx:
stop smoking
211
Marfan's disease
Fibrillin defect (connective tissue elastic fibers)
Marfanoid habitus
Retinal detachment
Aortic root dilation
212
Ehlers-Danlos syndrome
```
Collagen defect
Sx: easy bruising, hypermobile joints, tendency for arterial rupture
Aneurysms and dissections
NO angiogram - increased risk of rupture
Too difficult to repair - ligate vessels
```
213
Temporal arteritis
Larger artery, inflammation
Women, >55yo, headache, fever, blurred vision
Dx: Temporal artery biopsy (giant cell arteritis, granulomas)
Long segment of smooth stenosis alternating with segments of larger diameter
Tx: Steroids, bypass of large vessels if needed; NO endarterectomy
214
Polyarteritis nodosa
```
Medium artery
Weight loss, rash, arthralgias, HTN, kidney dysfunction
Aneurysms that thrombose or rupture
Most common renal arteries
Tx: Steroids
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215
Kawasaki's disease
Medium artery
Children, febril illness with erythematous mucosa and epidermis
Aneurysms of coronary arteries and brachiocephalic vessels
Die from arrhythmias
Tx: steroids, (ASA at initial illness), eventual CABG
216
Hypersensitivity angiitis
Small artery
Secondary to drug or tumor antigen
Sx: palpable purpura, fever, symptoms of end-organ dysfunction
Tx: CCB, pentoxifylline, stop offending agent
217
Early radiation arteritis
Sloughing and thrombosis
| Obliterative endarteritis
218
Late radiation arteritis
1-10 years
| FIbrosis, scar, stenosis
219
Late late radiation arteritis
3-30 years
| Advanced atherosclerosis
220
Raynaud's disease
Young women
Pallor > cyanosis > rubor
Tx: CCB, warmth
221
Venous insufficiency
Aching, swelling, night cramps, brawny edema, venous ulcers
Incompetent perforators and/or valves
Tx: leg wraps, ambulation with avoidance of long standing
Sx: grater saphenous veins stripping, removal of perforators (severe symptoms or recurrent ulcers)
222
Superficial thrombophlebitis
Nonbacterial inflammation
| Tx: NSAIDs, warm packs, ambulation
223
Suppurative thrombophlebitis
Pus filled vein
Fever, increased WBC, erythema, fluctuance
Following infected peripheral IV
Tx: resect entire vein
224
Migrating thrombophlebitis
Trousseau syndrome
| Pancreatic CA
225
Normal findings on doppler US
Augmentaton of flow with distal compression or release of proximal compression
226
Benefit of sequential compression devices
Prevent blood clots
Decreases venous stasis
Increased tPA release
227
Why are DVTs more common in the left leg?
Longer iliac vein gets compressed by right iliac artery
228
Virchow's triad
Venous stasis
Hypercoagulability
Venous wall injury
229
Phlegmasia alba dolens
Tenderness, pallor (whiteness), edema
| Tx: heparin
230
Phlegmasia cerulea dolens
Tenderness, cyanosis (blueness), massive dedma
| Tx: heparin, rarely surgical intervention
231
DVT treatment
Heparin, coumadin
232
Indications for IVCF
Contraindications to anticoagulation
PE while on coumadin
Free-floating ileofemoral thrombi
After pulmonary embolectomy
233
Venous thrombosis with central line
Pull of line if not needed, then heparin
| If access site is important - systemic heparin or tPA down the line
234
Where do you NOT find lymphatics?
Bone, muscle, tendon, cartilage, brain, cornea
235
Lymphedema
Obstructed lymphatics, too few numbers or nonfunctional
Leads to woody edema secondary to fibrosis in subQ tissue
Cellulitis, lymphangitis --> leads to complications
MC infection - strep
Congenital lymphedema L>R
Tx: leg elevation, compression, antibiotics for infection
236
Lymphagiosarcoma
Raised blue/red coloring
| Early metastases to lung
237
Lymphangiosarcoma associated with breast axillary dissection and chronic lymphedema
Stewart-Treves syndrome
238
Lymphocele following surgery
Dissection of groin
Leakage of clear fluid
Tx: Percutaneous drainage; resection if that fails
