27 Vascular Flashcards
Most common congenital hypercolaguable disorder?
Resistance to activated protein C (Factor V leiden)
Most common acquired hypercoagulable disorder?
Smoking
Stage 1 of atherosclerosis
Foam cells
Macrophages that have absorbed fat and lipids in the vessel wall
Stage 2 of atherosclerosis
Smooth muscle proliferation
Caused by growth factors released from macrophages (PGDF)
Results in wall injury
Stage 3 of atherosclerosis
Intimal disruption (from smooth muscle cell proliferation) Leads to collagen exposure --> thrombus formation --> fibrous plaques
Risk factors for atherosclerosis
Smoking HTN Hypercholesterolemia DM Hereditary factors
Most important risk factor for stroke?
HTN
Most common site of carotid stenosis?
Carotid bifurcation
Carotids supply ____ of blood flow to brain?
85%
What is the normal flow of the internal carotid?
Continuous forward flow
What is the first branch of the internal carotid artery?
Ophthalmic artery
What is the normal flow of the external carotid?
Triphasic flow
Communication between the ICA and ECA occurs via?
Opthalmic artery (ICA) Internal maxillary artery (ECA)
Most commonly diseased intracranial artery?
Middle cerebral artery
MCC of cerebral ischemic events?
Arterial embolization from ICA
Others:
- Thrombosis
- Low-flow state through a severely stenotic lesion
- Emboli from heart (second most common source)
Arterial source of event?
Mental status changes, release, slowing
Anterior cerebral artery
Arterial source of event?
Contralateral motor and speech if dominant side)
Contralateral facial droop
Middle cerebral artery events
Arterial source of event?
Vertigo, tinnitus, drop attacks, incoordination
Posterior cerebral artery
Visual changes - shade coming down over eyes
Hollenhorst plaques on ophthalmologic exam
Amaurosis fugax
Occlusion of the ophthalmic branch of ICA
Transient
Treatment of carotid traumatic injury with major fixed deficit?
If occluded - do NOT repair (can exacerbate injury with bleeding)
If not occluded - repair with carotid stent or open procedure
Indications for carotid endarterectomy
Symptomatic >70% stenosis
Asymptomatic >80% stenosis
When do you perform a CEA after a stroke?
Wait 4-6 weeks and then perform CEA if it meets criteria
When do you perform an emergent CEA?
Fluctuating neurologic symptoms
Crescendo/evolving TIA
When do you need to use a shunt during CEA?
Stump pressures < 50
Contralateral side is tight
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
Complication after CEA: hoarseness
Vagus nerve injury
Secondary to vascular clamping
MC cranial nerve injury after CEA
Vagus nerve injury
Complication after CEA: speech and mastication difficulty
Hypoglossal nerve injury
Tongue deviates to the side of injury
Complication after CEA: Difficulty swallowing
Glossopharyngeal nerve injury
Rare - occurs with high carotid dissection
Complication after CEA: Loss of innervation to strap muscles
Ansa cervicalis
No serious deficit
Complication after CEA: Changes in the corner of the mouth, difficulty smiling
Mandibular branch of facial nerve
Complication after CEA: Acute event immediately after CEA, what do you do?
Back to OR
Check for flap or thrombosis
Complication after CEA: Pulsatile, bleeding mass
Pseudoaneurysm
Tx: drape and prep before intubation
Intubate, then repair
Complication after CEA: Hypertension
Injury to carotid body
Tx: Nipride to avoid bleeding
MCC cause of non-stroke morbidity and mortality following CEA?
Myocardial infarction
Rate of restenosis after CEA
15%
Indications for carotid stenting (versus CEA)
Previous CEA with restenosis
Multiple medical comorbidities
Previous neck XRT
Anatomy of the vertebrobasilar artery system
Subclavian arteries –> vertebral arteries –> combine –> basilar artery –> splits –> posterior cerebral arteries
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
Painless neck mass, near carotid bifurcation
Carotid body tumor
Origin - neural crest cells
Extremely vascular
Tx: resection
Aortic arch vessels antomy
Innominate artery (–> right subclavian and right common carotid artery)
Left common carotid artery
Left subclavian artery
Ascending aortic aneurysm
Often picked up on CXR
Sx are due to compression: back pain (vertebra), voice changes (RLN), dyspnea/PNA (bronchi), dysphagia (esophagus)
Indications for treatment of ascending aortic aneurysm?
Acutely symptomatic
>5.5cm (with Marfan’s >5.0cm)
Rapid increase in size (>0.5 cm/yr)
Indications for treatment of descending aortic aneurysm?
If endovascular repair possible >5.5cm
If open repair needed >6.5cm
How do you prevent paraplegia with open repair for a descending aortic aneurysm?
Reimplant intercostal arteries below T8
Stanford classification: any ascending aortic involvement?
Class A
Stanford classification: only descending aortic involvement?
Class B
Debakey classification: ascending and descending
Type I
Debakey classification: ascending only
Type II
Debakey classification: descending only
Type III
Where do most dissections start?
Ascending aorta
Risk factors for aortic dissection?
Severe HTN
Marfan’s syndrome
Previous aneurysm
atherosclerosis
Diagnosis of aortic dissection?
Chest CT with contrast
Where does dissection occur within the blood vessel?
Medial layer of the wall
Cause of death in ascending aortic dissection?
Cardiac failure secondary to aortic insufficiency, cardiac tamponade or rupture
Initial treatment of aortic dissection?
Medical - control BP (B-blockers and Nipride)
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
Most common complications for thoracic aortic surgery?
MI
Renal failure
Paraplegia (descending)
Cause of paraplegia after descending thoracic aorta ?
Spinal cord ischemia due to occlusion of intercostal arteries and artery of Adamkiewicz
Normal aorta diameter?
2-3cm
Cause of abdominal aortic aneurysm?
Degeneration of the medial layer
Risk factors for AAA?
Male, age, smoking, family history
Presentation of AAA?
Rupture
Distal embolization
Compression of adjacent organs
How do you diagnose AAA rupture?
US Abdominal CT (fluid in retroperitoneal space and extraluminal contrast)
Most likely location for AAA rupture?
Left posterolateral wall, 2-4cm below renals
Co-morbid medical conditions that can lead to AAA expansion?
HTN
COPD
Treatment of AAA?
Repair if:
Symptomatic
>5.5cm
Growth >0.5cm/year
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
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
What major vein can get injured with cross clamping of the aorta?
Rero-aortic left renal vein
MCC of acute death after AAA repair?
MI
MCC of late death after AAA repair?
Renal failure
Risk factors for mortality after AAA repair?
Creatinine >1.8 CHF EKG ischemia Pulmonary dysfunction Older age Female
AAA graft infection rate
1%
Incidence of pseudoaneurysm formation after AAA repair?
1%
MCC late complication after aortic graft placement?
Atherosclerotic occlusion
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
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
Endoleak - at site of proximal or distal graft attachment
Type I endoleak
Tx: extension cuffs
Endoleak - through collaterals
Type II endoleak
Tx: Observe - if vessels are pressurizing the aneurysm –> perutaneous coil emolization
Endoleak - via overlap sites when multiple grafts were used or fabric tear
Type III endoleak
Tx: Secondary endograft to cover overlap site or tear
Endoleak - via graft wall porosity or suture holes
Type IV endoleak
Tx: observe - can place nonporous stent if that fails
Endoleak - expansion of aneurysm without evidence of leak
Type V - endotension
Tx: repeat EVAR or open repair
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
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
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
Most common graft to get infected?
Those going to the groin
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
Contents of the anterior leg compartment
Deep peroneal nerve (dorsiflexion, sensation b/t 1/2nd toes)
Anterior tibial artery
Contents of the lateral leg compartment
Superficial peroneal nerve (eversion, lateral foot sensation)
Contents of the deep posterior leg compartment
Tibial nerve (plantar flexion)
Posterior tibial artery
Peroneal artery
Contents of the superficial posterior leg compartment
Sural nerve
Signs of peripheral artery disease
Pallor
Dependent rubor
Hair loss
Slow capillary refill
Most commonly due to atherosclerosis
Number one preventive agent of atherosclerosis?
Statin drugs
Medical treatment of claudication
ASA
Smoking cessation
Exercise until pain occurs to create collaterals
Source of obstruction - buttock claudication
Aortoiliac disease
Source of obstruction - mid-thigh claudication
External iliac
Source of obstruction - calf claudication
Common femoral artery
Proximal superifical femoral artery
Source of obstruction - foot claudication
Distal superficial femoral artery
Popliteal disease
Lumbar stenosis can mimic which symptom of PAD?
Claudication
Diabetic neuropathy can mimic which symptom of PAD?
Rest pain
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
Most common atherosclerotic occlusion in lower extremities?
Hunter’s canal - distal superficial femoral artery exits
Sartorius muscle covers Hunter’s canal
Borders of the adductor canal
Hunter’s canal
Anterior - sartorius
Lateral - vastus medialis
Posterior - adductor longus and magnus
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
Ankle-brachial index - start to get claudication
<0.9
Ankle-brachial index - start to get rest pain
<0.5 (distal arch and foot)
Ankle-brachial index - ulcers
<0.4 (starts in toes)
Ankle-brachial index - gangrene
<0.3
What patients can have inaccurate ABIs? what do you do instead?
Diabetes and severe calcification
Incompressible vessels
Doppler waveforms
Pulse volume recordings
Used to find significant occlusion and at what level
Indications for arteriogram in PAD
PVRs suggesting significant disease
Can also perform intervention
Surgical indications for PAD
Rest pain
Ulceration or gangrene
Lifestyle limitation
Atheromatous embolization
PTFE (Gortex)
Only for bypasses above the knee
Use vein for below the knee
Dacron
Good for aorta and large vessels
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
Treatment of isolated iliac lesions
PTA with stent (first choice)
If that fails - femoral-to-femoral crossover
Femoropopliteal grafts
75% 5-year patency
Better for claudication versus limb salvage
Popliteal artery exposure below knee - gastrocnemius (post), popliteus (ant)
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
What do you use below the knee? Why?
Saphenous vein
Synthetic grafts have decreased patency below the knee
When do you use extra-anatomic grafts?
To avoid hostile conditions in the abdomen (i.e. infection, multiple previous abdominal operations, frail patient)
Complication of femoral-to-femoral crossover graft?
Vascular steal in donor leg due to doubling of the blood flow to the donor artery
Early swelling following lower extremity bypass?
Reperfusion injury and compartment syndrome
Tx: Fasciotomy
Late swelling following lower extremity bypass?
DVT
Dx: US
Tx: Heparin, Coumadin
Complications of reperfusion of ischemic tissues?
Compartment syndrome
Lactic acidosis
Hyperkalemia
Myogloinuria
MCC of early failure of reversed saphenous vein grafts
Technical problem
MCC of late failure of reversed saphenous vein grafts
Atherosclerosis
Treatment of patients with heel ulceration to bone
Amputation
Dry gangrene
Noninfectious
If small or just toes - autoamputation
Large lesions - amputate
First see if there is a correctable vascular lesion
Wet gangrene
Infectious
Tx: remove infected necrotic material and antibiotics
Surgical emergency: extensive infection or systemic complications (guillotine amputation)
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
Percutaneous transluminal angioplasty
Excellent for common iliac artery stenosis
Best for short stenosis
Intima ruptures and media stretched - pushes plaque out
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)
What cells are responsible for reperfusion injury?
PMNs
Compartment most likely to get compartment syndrome?
Anterior compartment
You get foot drop
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
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
Sources of arterial autografts?
Radial artery grafts for CABG
IMA for CABG
Indications for amputation?
Gangrene
Large, non-healing ulcers
Unrelenting rest pain, not amenable to surgery
Indications for emergency amputation?
Systemic complications
Extensive infection
Outcomes of BKA
80% heal
70% walk again
5% mortality
Outcomes of AKA
90% heal
30% walk again
10% mortality
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
Characteristics of acute arterial thrombosis
No arrhythmia
History of claudication or rest pain
Contralateral pulses absent
Physical findings of chronic limb ischemia
Progression of extremity ischemia?
Pallor (white) > cyanosis (blue) > marbling
MCC acute arterial embolism
Afib*
Recent MI with left ventricular thrombus
Myxoma
Aorto-iliac disease
Most common site for peripheral obstruction from emboli?
Common femoral artery
Treatment of acute arterial embolism
Embolectomy; after pulse return do a post-op angiogram
Consider fasciotomy if ischemia >4-6hrs
Patient presents with acute loss of both femoral pulses?
Aortoiliac emboli
Tx: bilateral femoral artery cutdowns and bilateral embolectomys
Most common site of atheroma embolization?
Renal arteries
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
Blue toe syndrome
Flaking atherosclerotic emboli off abdominal aorta or branches
Typically have good distal pulses
Aortoiliac disease most common source
Acute arterial thrombosis
Tx:
- Threatened limb (loss of sensation or motor function): heparin and thrombectomy
- Non-threatened limb: angiography for thrombolytics
Thrombosis of PTFE graft
Threatened limb - OR for thrombectomy
Non-threatened limb - thrombolytics adn anticoagulation
Course of the right renal artery in relation to the IVC?
Posterior
Causes of renovascular HTN?
Renal atherosclerosis
Fibromuscular dysplasia
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
Renal atherosclerosis
Left side
Proximal 1/3
Men
Renal fibromuscular dysplasia
Right side
Distal 1/3
Women
Indications for nephrectomy with renal HTN?
Atrophic kidney <6cm with persistently high renin levels
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
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
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
Normal anatomy of subclavian vein
Passes over the 1st rib, anterior to the anterior scalene muscle, then behind clavicle
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
MC anatomic abnormality in thoracic outlet syndrome
Cervical rib
MC cause of pain in thoracic outlet syndrome
Brachial plexus irritation
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
Symptoms of ulnar nerve deficits
C8-T1
Inferior portion of brachial plexus
Tricep muscle, intrinsic muscles of hand, weak wrist flexion
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)
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
Why does motor function of the hand remain in digits after prolonged hand ischemia?
Motor groups are located in the proximal forearm
Most common artery in mesenteric ischemia?
Superior mesenteric artery
Abdominal CT findings that suggest intestinal ischemia?
Vascular occlusion
Bowel wall thickening
Intramural gas
Portal venous gas
Most common causes of visceral ischemia?
Embolic occlusion - 50%
Thrombotic occlusion - 25%
Nonocclusive - 15%
Venous thrombosis - 5%
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
Exposing the SMA
Divide ligament of Treitz
SMA is to teh right of the near the base of the transverse colon mesentary
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
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
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
Griffith’s watershed area
Splenic flexure
Sudak’s watershed area
Upper rectum
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
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
Arc of Riolan
Collateral that forms between the SMA and celiac
MCC of aneurysm above inguinal ligament
Rupture
MCC of aneurysm below inguinal ligament
Thrombosis and emboli
Risk factors for visceral artery aneurysm
Medial fibrodysplasia
Portal HTN
Arterial disruption secondary to inflammatory disease (i.e. pancreatitis)
Indications for repair of visceral artery aneurysms
> 2cm (except splenic)
Tx: covered stent; exclusion with bypass if that fails
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
Renal artery aneurysm
Treat if >1.5cm
Tx: Covered stent
Iliac artery aneurysm
Treat if >3.0cm
Tx: covered stent
Femoral artery aneurysm
Treat if >2.5cm
Tx: covered stent
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)
MC visceral artery aneurysm
Splenic artery aneurysm
MC peripheral artery aneurysm
Popliteal artery aneurysm
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
MC location for pseudoaneurysm
Femoral artery
Pseudoaneurysm that occurs at suture lines late after surgery (month to years)
Suggests graft infection
Course of the greater saphenous veins
Joins femoral vein near groin
Runs medially
Can you clamp the IVC?
NO - will tear
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
Most common failure of AV grafts for dialysis?
Venous obstruction secondary to intimal hyperplasia
Cimino AVF
Radial artery to cephalic vein
Wait 6 weeks to use - allows vein to mature
Interposition graft
Brachiocephalic loop graft
Wait 6 weeks to use - allows for fibrous scar formation
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
Varicose veins
Smoking, obesity, low activity
Tx: sclerotherapy
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
Fibromuscular dysplasia
Young women, HTN (renal), headaches, stroke (carotid)
String of bead apperance
Medial fibrodysplasia
Tx: PTA, bypass if that fails
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
Marfan’s disease
Fibrillin defect (connective tissue elastic fibers)
Marfanoid habitus
Retinal detachment
Aortic root dilation
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
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
Polyarteritis nodosa
Medium artery Weight loss, rash, arthralgias, HTN, kidney dysfunction Aneurysms that thrombose or rupture Most common renal arteries Tx: Steroids
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
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
Early radiation arteritis
Sloughing and thrombosis
Obliterative endarteritis
Late radiation arteritis
1-10 years
FIbrosis, scar, stenosis
Late late radiation arteritis
3-30 years
Advanced atherosclerosis
Raynaud’s disease
Young women
Pallor > cyanosis > rubor
Tx: CCB, warmth
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)
Superficial thrombophlebitis
Nonbacterial inflammation
Tx: NSAIDs, warm packs, ambulation
Suppurative thrombophlebitis
Pus filled vein
Fever, increased WBC, erythema, fluctuance
Following infected peripheral IV
Tx: resect entire vein
Migrating thrombophlebitis
Trousseau syndrome
Pancreatic CA
Normal findings on doppler US
Augmentaton of flow with distal compression or release of proximal compression
Benefit of sequential compression devices
Prevent blood clots
Decreases venous stasis
Increased tPA release
Why are DVTs more common in the left leg?
Longer iliac vein gets compressed by right iliac artery
Virchow’s triad
Venous stasis
Hypercoagulability
Venous wall injury
Phlegmasia alba dolens
Tenderness, pallor (whiteness), edema
Tx: heparin
Phlegmasia cerulea dolens
Tenderness, cyanosis (blueness), massive dedma
Tx: heparin, rarely surgical intervention
DVT treatment
Heparin, coumadin
Indications for IVCF
Contraindications to anticoagulation
PE while on coumadin
Free-floating ileofemoral thrombi
After pulmonary embolectomy
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
Where do you NOT find lymphatics?
Bone, muscle, tendon, cartilage, brain, cornea
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
Lymphagiosarcoma
Raised blue/red coloring
Early metastases to lung
Lymphangiosarcoma associated with breast axillary dissection and chronic lymphedema
Stewart-Treves syndrome
Lymphocele following surgery
Dissection of groin
Leakage of clear fluid
Tx: Percutaneous drainage; resection if that fails
