AIOD Flashcards
What are symptoms of AI dz?
Claudication (calf, thigh, butt)
embolism (saddle or blue toe syndrome)
Erectile dysfunction
What collateral network supplies distal to AI dz?
why are the collaterals important?
lumbar and hypogastric feeding vessles connect to circumflex iliac, hypogastric, femoral and profunda recipients
in extreme, IMA to inferior epigastric and
SMA to IMA and
hemorrhoidal artery via arc of Riolan and meadering mesenteric artery
prevent CLI, main presentation in claudication
What are signs and symptoms of blue toe syndrome?
palpable pulses with patchy ischemia (livedo) but distal gangrene can occur
What is Leriche syndrome?
Terminal aortic occlusion
Thigh, hip, buttock claudication, atrophy of leg muscles, impotence, decreased femoral pulses
What is small aortic syndrome or hypoplastic aortic syndrome?
What is life expectancy?
Where is plaque?
Isolated AI in usually younger females, usually smokers
normal
posterior plaque prox or at bifurcation
What are pullback pressure in AI?
Pull back pressure 5-10mmhg at rest or change in systolic pressure greater then 15% indicates dz warranting revasc
What are indications for surgery?
disabling claudication
tissue loss
ischemic rest pain
What is natural history of claudicants in AI?
1%/year limb loss
5%/year mortality
20-30% require OR in 5 years
What % of AI have CAD?
nearly 50%
What are repair techniques for AI?
endarterectomy
Aorto-bifem
Fem-Fem
Ax-fem
Obturator bypass
throaci/supra-celiac- fem bypass
When is endarterectomy best suited?
Small arteries
Want to avoid prosthetic graft
Erectile dysfunction as may improved hypogastric perfusion
Best for focal stenosis otherwise not usually done
Advantages to End-end in aortobifem?
Possible better hemodynamics, less flow turbulence
Less rate of pseudoaneurysm
Close peritoneum over graft
With concomitant aneurismal disease should to end-end
Advantages to end-side in aortobifem?
Preserve IMA
Preserve flow hypogastrics
Less erectile dysfunction, paraplegia secondary to cauda equina syndrome
Good if heavily calcified aorta
What is cauda equina?
what are symptoms?
damage to the cauda equina causes acute loss of function of the lumbar plexus, (nerve roots) of the spinal canal below the termination of the spinal cord. CES is a lower motor neuron lesion.
Urinary retention
decreased anal tone and consequent fecal incontinence;
sexual dysfunction;
saddle anesthesia;
bilateral (or unilateral) sciatic leg pain and weakness;
and absence of ankle reflex.
What dose of heparin do you give before clamping?
target ACT?
70-100units/kg
250-350 secs
Is there benefit of adjunctive profundoplasty in aortobifem?
May Improve long-term patency in AI bypasses
5year patency 88%
Advantages/disadvantages for external iliac anastomosis in AI bypass?
Good for hostile groin, obese, DM with intertriginous rash
More technically difficult and possible lower patency rates then to fem
when to consider inflow and outflow bypass?
tissue loss (appears no increase m&m)
how many patients have improvement of symptoms after ABF for AI?
80%
2/3 still have symptoms
When do you do concomittant SMA or Renal bypass?
what is mortality with ABF and ABF with SMA/renal recons?
what is symptom response rate?
If associated with the lesion repair
If thought to have reaversible on refractory hypertension or ischemic nephropathy
mortality 1-2% 5-6%(renal/SMA).
Favorable response to HTN 60-70%,
improvement in renal function 30%
what is 5 year patency for endart and ABFG in AI?
10 year patency?
moratlity rates?
10 survival?
95% and 85-90%
85-90% and 75-85% (older 95%, but <50yo 66%)
1%, 1-4%
isolated normal life expectency, multilevel disease 50%
patency difference between trans vs retro approach ABF?
PTFE vs Dacron
No
No
What are early complications and percentages ABF?
Sexual dysfunction <5%
bowl ischemia 2%
MI 1-5%
death 1-4%
ALI 1-3%
bleeding 1-2%
where is bowel ischemia usually found after Bypass for AI?
how to avoid?
recto-sigmoid
preserve IMA, keep up perfusion
what are features of neurogenic claudication?
diffues deep aching,burning possible paresthesias from buttock to feet. relieved by sitting or beding over while walking. occurs with walking
What are common causes of IC?
SFA stenosis, athersclerosis, pop entrapment, ACD, chronic compartement syndrom, arteriris, thrombosis, FMD, coarctation
what are RF for claudication?
HTN, DM, metabolic syndrome, smoking, male, age, DLP, hyperhomocystenemia
What is natural history of IC?
10% deteriorate within one year then 2-3% per year to CLI
1% risk of major amputation per year
2-5% risk of cardiac death per year
70% angioplasty rates for 5 years
What is the natural history for CLI patients?
30% will lose leg in one year
if unconstructable 40% limb loss at 6 months
25% dead in one year
25% CLI resolved
What is included in hypercoag workup?
thrombin/prothrombin times
activated partial thromboplastin time
protein S, protein C assays
factove V leidan asay
lupus anticoagulant assay
heparin induced plt antibodies
fibrinogen, plasminogen levels
ATIII activity
anticardiolipin antibody assay
How does hyperhomocysteine cause athero?
high level toxic to endothelium and reduce NO release, promote mSMC proliferation and arterial wall inflammation leading to athero
What is risk of surgery for PAD?
5% risk MI, CHF, death
What test to perfomr if has IC but palpable pulses?
exercise stress test
ABI at rest then walks 3.5km/hr on treadmill with 12% incline
if >20% decrease in ankle pressure for >3 minutes indicates vascular dz
What is the rutherford classification?
0 asympto normal
1 mild claudication completes treadmill test, but ankle pressure >50mmhg but at least 20mmhg lower then resting value
2 moderate caludication b/w catergories 1 and 3
3 severe claudication cannot complete standard teradmill exercise. AP after exercise <30
4 rest pain
5 ulcerations not exceeding digits
6 major tissue loss
what are features of a walking exercise for PAD?
treadmill or track walking, 35 mins porgressing to 50mins 35 times per week. treadmill incline should elicits IC within 3-5 mins
What drugs have evidence in IC?
cilostazol
naftidrofuryl
statin (supporting evidence)
what is cilastozol?
what is the evidence
phosphodeisterase inhibitor
RCT, 50% increase in walking distance
imporve QoL
CI in CHF
15% AE
What is the evidence for pentoxifylline?
MA questionable benefit
What was the BASIL trial?
what were findings of the trial?
RCT, angio vs open for severe limb ischemia
AFS primary end point
at 2 years surivival and AFS better in surgical arm, no difference at six months
if patient life expectancy >2 years then open
if attempt endo first then durability of subsequent open worse
What is the mortality with LE bypass?
wha are some complications?
2%
graft stenosis 20% in 1 year
major amp 5-10%
graft infection 1-3%
What are some scoring models for survival with LE intervention?
LEGES
Finnvasc
Prevent III
Basil
What are some indications for extra-anatomic bypass?
high-risk laparotomy
hostile abdo
infected graft
AE fistula
groin sepsis
When is axem or fem-fem best suited?
when is obturator bypass best suited?
no endo option, high risk lap, hostile abdo or acute presentation
hostile groins
what is better unilat ilio fem or fem-fem for patency?
what about aorta-fem vs ilio fem?
unilat ilio-fem at ten years
no difference at ten years
where is fem-fem tunneled?
prefascial plane
pre-peritoneal if thin or too fat, previsou surgery, radiation damage to skin
What is the mortality periop, 3 yr survival, 5 yr patency for fem-fem?
<5%
70%
65%
What features on duplex are concerning for graft failure?
peak systolic >300cm/sec inflow or <60cm/sec midgraft
What size better for fem-fem? what amterial?
no difference
what % have steal with fem-fem
3%
45% exercise induced
Which side axillary artery to choose for ax-fem?
consider non-dominant
if will need future left chest surgery
if 10mmhg discrepency
what is 3 year survival for ax-fem?
5 year patency?
3 yr limb salvage
35%
75% better in claudicants then CLI
70%
What is normal resting flow in ax fem?
what flow indicates impending graft failure?
600-900 ml/min
300-400 ml.min each limb
<240ml.min in 6mm
describe obturator bypass?
donor artery exposed retroperitoneal via oblique lower quadrant incision (or trasnperitoneal) dissect medial to external iliac vein and posterior to pubic ramus obturator nerve (may injure) and artery perforate postolaterally membrane must be opened sharply
What are the 3 and 5 yr patency for obturator bypass?
75 and 60%
What does the obturator nerve innervate?
sensory to medial thigh
motor of adductor muscles of LE
What are features of throaco-fem surgery?
7-8th rib incision
tunnel graft retroperitoneally behind or anterior to kidney
What are TASC A lesions for AI?
ui/bilat CIA
uni/bilat short <3cm EIA
Waht are TASC B lesions for AI?
short infrarenal aorta
uni CIA occlusion
single or multiple (3-10 cm) isolated EIA
uni isolated EIA occlusion
What are TASC C lesions for AI?
bilat CIA occlusion
bilat isolated EIA stenosis (3-10cm)
unilat EIA stenosis into CFA
unilat EIA occlusion origin of CFA or iliac
heavily calcified uni EIA
What are type D TASC lesions for AI?
infrarenal aortic occlusion
diffuse aort-iliac dz
diffuse stenosis of uni CIA, EIA, and CFA
bilat occlusion of EIA
iliac leasion in AAA that requires open surgery
When should you consider preventative measure for constrast enduced nephropathy? what are they?
GFR <45ml/min if IV
volume
bicarb to alkalinize urine (MA shows benefit)
metformin can increase risk of AKI
What is a significant pullback gradient?
10mmhg
>15% with papaverine
what are re-entry devices?
outback
pioneer
What are mechanical properties of balloon expandable vs self-expanding stents?
balloon
better precision
high radio-opacity
high hoop strength
less flexible, premanently defromed, can become dislodged from balloon
self-expanding
greater felxibility
what is the difference between selective stenting and angioplasty in AI?
RCT no difference with selective placement
20% will get stent reintervention and 20% in plasty alone will get reintervention
MA
better patency with primary stenting
reduces long term failure by 40% then plasty alone
What are patency rates for TASC lesions for endo in AI dz?
for open?
10 yr A or B 70%
5 yr C or D 70%
5 yr 80% patency with 30% comps
What are predictors of endovascular failure for AI dz?
what can improve patency?
EI dz (PPR 1 year 50%)
female
RI
CLI
covered grafts
What is the definition of CLI?
persistent, recurring ischemic rest pain requiring opiate >2 weeks
AP <50mmhg
What size vein for LE bypass?
3mm
whats a linton patch?
when bypass comes of CFA endart anastomoses
what is the patency of isolated popliteal target?
situational perfusion enhancement
5 yr patency 50%, secondary 75%
What are graft options for LE bypass?
SVG
LSV
superficial FV
arm vein
endarterectomized seg of SFA
cryopreserved vein
PTFE
ePTFE
contr vein
What % of contra vein is used for future surgery?
20-25%
What is the advantage of a vein cuff for LE bypass
may improve patency by 2-3 years
with cuff and PTFE 2 yr patency 50% vs 30%
What is the difference between miller, taylor, st marys boot?
miller—rim of vein circum, then ptfe sewed to rim
taylor patch–patch on toe of anastomosis (half artery, half ptfe)
sta mary boot–rim of vei nthat folds around on itself vein then comes off the top
What are correction rates for intra-op imaging for LE bypass?
arteriography 27%–may not see incomplete valve lysis
DUS 12% (psv >250)
What are patency rates of dacron vs ptfe for AK bypass?
HUV vs PTFE for AK?
PTFE cuff vs no cuff?
AK pop vein vs prothetic?
BK pop vein vs prosthetic?
infrapop vein vs prothetic?
1 yr 70% for both, 5 yr 50%
5 year 70 vs 40 (but some studies show not difference)
AK no diff, 1 yr 80%
BK 80 vs 65% 1 yr
60 vs 40% no signif
75 vs 55
70 vs 15%
What is the benefit of warfarin therapy for infr-inguinal bypass?
insitu vs reversed?
warfarin benefited prothetic graft patency but at double bleeding complications
no difference
what is a schedule for post-op graft surveillance?
what is the benefit of graft surveillance
4week
3 month x 1 year
6month x 2 yr
then yearly
improves patency by 15%
what are duplex criteria for impending infrainguinal graft failure?
velocity >300cm/s
velocity ratio >3.5-4
drop in ABI 0.15
prophylactic repair
what are causes of early graft failure?
early
anastomotic, clamp defect, valve defect, poor quality conduit, inadequate outflow
What are techniques for treating stenosis or late occlusion?
patch, interposition, valve excision, plasty, anastomotic translocation
thrombectomy, lysis, redo with vein or prosthetic
What are TASC A lesion for fempop?
single O <5cm
single s <10
What are TASC B for fempop?
multiple stenosis or collusion each <5cm
SS/O SFA <15
S/M lesions with no continuous runoff
Heavily calcified occlusion <5
single pop stenosis
What are TASC C lesions for fempop?
multiple stenosis or occlusions total >15cm
recurrent stenosis or occlusion after 2 endo attempts
what are Tasc D lesions for fem pop?
CTO of CFA/SFA
CTO of pop and prox trifurcation
What are TASC A lesion for infrapop?
singel stenosis <1cm in tibials
What are TASC B lesions for infrapop?
multiple stenosis of tibials each <1cm at trifurcation
short tibial stenosis with fempop PTA
What are TASC C lesions for infrapop?
stenosis 1-4cm
occlusions 1.2 cm of tibials
extensive stenosis of trifurcation
What are TASC D lesions for infrapop?
tibial occlusion >2cm
diffusely dz tibials
What are determinants of succes in endovascular?
improvement in at leas one rutherford and ABI increase >0.15
absence of stenosis <200
What are favorable characteristics for endovascular therapy?
proximal location
stenosis
short stenosis length
focal stenosis
single level dz
normal runoff
male
low comorbidities
IC
primary attemot
no residual stenosis or dissection
robust hemodyn response
What is patency difference for lesion > or < then 2 cm?
focal vs multifocal?
good vs poor runoff?
5 yr 75% vs 50%
70% vs 20%
50 vs 30%
What are 1,2,3 year success rates for endo in LE for endo vs open?
40, 20, 10 endo
85, 70, 70 open
How successful is angioplasty for fempop dz?
angio vs bypass?
angio vs stenting?
DES?
DCB vs POBA?
3 yr PP for stenosis in IC 60%
occlusion in IC 50%
stenosis in CLI 45%
occlusion in CLI 30%
BASIL, if lives >2 years open better
lesion greater then 5cm benefit from primary stenting
sirocco II failed to show improvement with DES for restenosis
DCB better at 6 months
What is patency of angio for infrapop?
difference in angio vs stenting?
1yr 75%
3yr 60%
no difference
wha is patency for laser atherrectomy?
1 yr 75%
What is benefit of DES in infrapop endo?
3 yrs everolimus had higher PP then BMS 30 vs 20
What is plasty/stenting surveillance?
ABI, PVR, Duplex
1,3,6,9,12 months then yearly
what is patency of CFA steting?
3 yr patency 80%, surgery recommended
What is endo not indicated for PFA?
usually not suitable because of ostial, bifurcation and diffuse
What are cholesterol targets for PAD?
BP?
HbgA1C
sympto/asympto PAd LDL 100mg/dL
PAD and vascular dz in other beds 70mg/dL
<7%
What medications should PAD patients be on, TASC?
ASA
beta-blocker peri-op
cilostazol first line for relief of claudication
What is an alternative way to test for IC if ABI unreliable?
treadmill test
active pedal flexion
inflate cuff for 3-5 minutes, this produces reactive hyperaemia, measure pressure 30sec after deflating cuff
What is critical TcPO2 level?
<30mmhg
What are the principles of ulcer management?
restoration of perfusion
local ulcer and pressure relief
treatment of infection
diabetic control
What are the treatment of choice for different TASC lesions for AI or fempop?
TASC A endo
TASC D open
TASC B endo preferred
TASC C open preferred if good risk
What is 5 yr latency for ABF?
is it better then endo?
70% in CLI
80% in IC
better ing term latency but higher risk
What is the Crawford Classification?
Type I LSCA to diaphragm
Type II LSCA to bifurcation
Type III T6 to to bifurcation
Type IV T6 to renals
Type V T6 to above renals
Things to ask when imaging aorta?
Location of abnormal
Max diameter
If genetic syndrome, av sinus, STJ, asc aorta diam
Filling defects
Presence if IMH, PAU, calcification
Extension into branches end organ injury
Presence of rupture hematoma
Previous imaging
What are the indications for surgical treatment for ascending aorta?
Class I
Asympto aneurysm, asc, root, IMH, PAU, mycoric pseudo >5.5 cm
Asympto growth rate >o.5 cm per year
Asympto plus cv sx >4.5 cm
Sympto
Modified David if possible for marfans LD, EHD
What is risk for asc/thoracic repair?
MI 1-5%
Infection 1-5%
Stroke. 1-2%
Reop 1-6%
Resp failure 5-15%
Paralysis 2-4% increase in extent II
What are causes of TAAA?
Degenerative 82%
Dissection 17%
CTD
What are the Indications for desc aneurysm/TAAA?
Class I
If chronic dissection >5.5cm
If defen/traumatic >5.5cm or saccular or pseudo EVAR recommend
If EVAR not commended and TAAA then 6.0 cm
What inflamm dz are associated with TAA and dissection?
Takayasau. T cell mediated para arteritis
Giant cell arteritis- elastic vessel vasculitis
Behcet
Ank spon
Infective
What bacteria are common in infected aorta?
S. Aureus, salmonella most common
Pneumococcus and E. coli most common gram negative
Treponema pallidum
Candida/aspergillus
Before stenting defending what do you need to confirm before covering LSCA?
What conditions increas risk of paraplegia when stenting?
Contra r subclavian and verts are patent
Verts communicate via basilar artery
Previous AAA 10% vs 2%
What is the endoderm classification?
Type I leak at attachment site
Ia proximal, Ib distal, Ic iliac occluder
Type II branch vessel, IIa single vessel, IIb 2 or more
Type III defect in great
IIIa junction of component, IIIb wint graft defect
Type IV. Graft porosity
Type V
Continued expansion without demonstrating leak endotension
Which endoleak is most common?
Which endoleak considered unresolved? What percentage are these?
How to deal with type II?
Does type IV require tx?
II 80%
I 10%
Can resolve spon or add occluder
NO
What are indications for definitive management for acute aortic disease?
Asc urgent repair
Desc
Medical management unless complicated
What is medical management of acute aortic disease?
Class I
IV BB HR 60 SBP<120
If BB CI then CCB
If SBP >120 with adequate HR use second vasod or ACEi
In what condition should BB and AoD be administered cautiously?
AI with AoD
Will block compensatory tachy
What is natural he of type A dissection?
Surgical mortality?
Survival?
50% die immediately then 1% per hour
10%
50-70% alive at 5years
What is natural history of type B?
What is mortality of treated?
50% mort untreated
9% hospital mortality
What are indications for arch replacement?
Class IIa
Entire arch if dissected or leaking
Low operative risk and asympto >5.5cm
Growth rate >0.5 cm per year
What is operative mortality for arch aneurysm?
Stroke rate?
Ten year survival?
Mort 9%
Stroke 7%
60-70%
How do you treat arch/thoracic atheroma embolic dz?
What is natural hx?
IIa
Warfarin or anti PLT in stroke patients with atheroma >4mm
1/3 progress
10% regress
What are bindi cations for BP management for thoracic aneurysmal dz?
And cholesterol?
Class I
BP <140/90 or 130/80 if diabetic/CRD
BB to all marfans
IIa
BB to decrease SBP as low as tolerated
IIb
LDL <70 mg/dl for atherosclerosis dz, aneurysm CAD or high risk for CAD
What mutations are associated with
Marfans
Loeys dietz
Ehlers danlos type IV
Turners
Familial thoracic aneurysm
FBN1. Fibrillin, increase penetrate with variable penetration
TGBFR1, TGBFR2, autosomal dom
COL3AI, type III collagen, autosomal dom
45X
ACTS2 14%, TGBFR2 4%, MYH11 1%
What are surgical I medications for marfans, loeys dietz and ED for asc and root?
Marfans
>5.0 cm unless fam hx rupture <5.0 cm, growth rate >0.5cm year, signif AI
LD
>= 4.2cm by TEE internal, 4.4-4.6 by ct MRI external,
ED UV not recommended for prophylaxis
What are main clinical findings in marfans?
Ocular skeletal cardiovascular
At what size can offer elective repair for root in marfans before conception?
If becomes pregnant what to do ?
When is guest risk?
4.5cm
Abort
Third trimester for dissection rupture
What is natural hx of TRA?
How to tx?
Mortality with tx?
20% MVA at autopsy
10-15% of them arrive to hospital alive
2% survive
Stent 1.5% mortality
What are features of TRA on CXR?
Widened mediastinum 8-8.5cm
Deviation of the esophagus
Trachea >1-2cm to the right of spinous process
When is thoracotomy indicate in penetrating mediastinal wound?
>1500-2000ml blood loss within first four hours
200-300ml per hour for 4-5 hours
Chest greater then half full despite chest tube
Positive arteriography for vessel injury
What % of blunt trauma have pericardial tear?
What are common injuries to heart with blunt trauma?
37%
Tear RA at junction of IVC/SVC, VS, ASD (Rare), AI
What percent of trauma have myocardial contusion?
What are the most frequent sites?
Comps of contusion?
TX of contusion?
90%
Ant right ventricular wall then and intervention septum and LV apex
Arrhytmia and myocardial contractility
10-20%
EKG 12-24 hours, serial troponins, TTE, monitored bed
What is the Crawford Classification?
Type I LSCA to diaphragm
Type II LSCA to bifurcation
Type III T6 to to bifurcation
Type IV T6 to renals
Type V T6 to above renals
Things to ask when imaging aorta?
Location of abnormal
Max diameter
If genetic syndrome, av sinus, STJ, asc aorta diam
Filling defects
Presence if IMH, PAU, calcification
Extension into branches end organ injury
Presence of rupture hematoma
Previous imaging
What are the indications for surgical treatment for ascending aorta?
Class I
Asympto aneurysm, asc, root, IMH, PAU, mycoric pseudo >5.5 cm
Asympto growth rate >o.5 cm per year
Asympto plus cv sx >4.5 cm
Sympto
Modified David if possible for marfans LD, EHD
What is risk for asc/thoracic repair?
MI 1-5%
Infection 1-5%
Stroke. 1-2%
Reop 1-6%
Resp failure 5-15%
Paralysis 2-4% increase in extent II
What are causes of TAAA?
Degenerative 82%
Dissection 17%
CTD
What are the Indications for desc aneurysm/TAAA?
Class I
If chronic dissection >5.5cm
If defen/traumatic >5.5cm or saccular or pseudo EVAR recommend
If EVAR not commended and TAAA then 6.0 cm
What inflamm dz are associated with TAA and dissection?
Takayasau. T cell mediated para arteritis
Giant cell arteritis- elastic vessel vasculitis
Behcet
Ank spon
Infective
What bacteria are common in infected aorta?
S. Aureus, salmonella most common
Pneumococcus and E. coli most common gram negative
Treponema pallidum
Candida/aspergillus
Before stenting defending what do you need to confirm before covering LSCA?
What conditions increas risk of paraplegia when stenting?
Contra r subclavian and verts are patent
Verts communicate via basilar artery
Previous AAA 10% vs 2%
What is the endoderm classification?
Type I leak at attachment site
Ia proximal, Ib distal, Ic iliac occluder
Type II branch vessel, IIa single vessel, IIb 2 or more
Type III defect in great
IIIa junction of component, IIIb wint graft defect
Type IV. Graft porosity
Type V
Continued expansion without demonstrating leak endotension
Which endoleak is most common?
Which endoleak considered unresolved? What percentage are these?
How to deal with type II?
Does type IV require tx?
II 80%
I 10%
Can resolve spon or add occluder
NO
What are indications for definitive management for acute aortic disease?
Asc urgent repair
Desc
Medical management unless complicated
What is medical management of acute aortic disease?
Class I
IV BB HR 60 SBP<120
If BB CI then CCB
If SBP >120 with adequate HR use second vasod or ACEi
In what condition should BB and AoD be administered cautiously?
AI with AoD
Will block compensatory tachy
What is natural he of type A dissection?
Surgical mortality?
Survival?
50% die immediately then 1% per hour
10%
50-70% alive at 5years
What is natural history of type B?
What is mortality of treated?
50% mort untreated
9% hospital mortality
What are indications for arch replacement?
Class IIa
Entire arch if dissected or leaking
Low operative risk and asympto >5.5cm
Growth rate >0.5 cm per year
What is operative mortality for arch aneurysm?
Stroke rate?
Ten year survival?
Mort 9%
Stroke 7%
60-70%
How do you treat arch/thoracic atheroma embolic dz?
What is natural hx?
IIa
Warfarin or anti PLT in stroke patients with atheroma >4mm
1/3 progress
10% regress
What are bindi cations for BP management for thoracic aneurysmal dz?
And cholesterol?
Class I
BP <140/90 or 130/80 if diabetic/CRD
BB to all marfans
IIa
BB to decrease SBP as low as tolerated
IIb
LDL <70 mg/dl for atherosclerosis dz, aneurysm CAD or high risk for CAD
What mutations are associated with
Marfans
Loeys dietz
Ehlers danlos type IV
Turners
Familial thoracic aneurysm
FBN1. Fibrillin, increase penetrate with variable penetration
TGBFR1, TGBFR2, autosomal dom
COL3AI, type III collagen, autosomal dom
45X
ACTS2 14%, TGBFR2 4%, MYH11 1%
What are surgical I medications for marfans, loeys dietz and ED for asc and root?
Marfans
>5.0 cm unless fam hx rupture <5.0 cm, growth rate >0.5cm year, signif AI
LD
>= 4.2cm by TEE internal, 4.4-4.6 by ct MRI external,
ED UV not recommended for prophylaxis
What are main clinical findings in marfans?
Ocular skeletal cardiovascular
At what size can offer elective repair for root in marfans before conception?
If becomes pregnant what to do ?
When is guest risk?
4.5cm
Abort
Third trimester for dissection rupture
What is natural hx of TRA?
How to tx?
Mortality with tx?
20% MVA at autopsy
10-15% of them arrive to hospital alive
2% survive
Stent 1.5% mortality
What are features of TRA on CXR?
Widened mediastinum 8-8.5cm
Deviation of the esophagus
Trachea >1-2cm to the right of spinous process
When is thoracotomy indicate in penetrating mediastinal wound?
>1500-2000ml blood loss within first four hours
200-300ml per hour for 4-5 hours
Chest greater then half full despite chest tube
Positive arteriography for vessel injury
What % of blunt trauma have pericardial tear?
What are common injuries to heart with blunt trauma?
37%
Tear RA at junction of IVC/SVC, VS, ASD (Rare), AI
What percent of trauma have myocardial contusion?
What are the most frequent sites?
Comps of contusion?
TX of contusion?
90%
Ant right ventricular wall then and intervention septum and LV apex
Arrhytmia and myocardial contractility
10-20%
EKG 12-24 hours, serial troponins, TTE, monitored bed
How does the normal aortic doppler signal appear superior and inferior to the renal arteries?
monophasic/biphasic flow
triphasic flow
What are normal size measurements of the visceral vessels?
aorta 2-2.5
celiac 0.7
SMA 0.6
IMA 0.3
Renal 0.4-0.5
What is normal length of the kidneys?
what is the normal size of the parenchyma?
which kidney is usually bigger?
>9cm >13 large
>1 cm
L>R
What are velocities for aorta and renals?
aorta 60-120cm/s
renal artery 160-180
What criteria suggest stenosis in the renal artery?
RA/Aorta velocity (RAR)> 3.5 suggest >60% stenosis
need to correct for angle
What doppler criteria suggest RAS?
Main renal artery: RAR >3.5
dampening of doppler waveform in segmental arteries
acceleration index 70m/s
What are the RAS criteria?
% stenosis RAR PSV PSturbu
N 180 no
>60% >3.5 >180 yes
occluded N/A N/A N/A
What indicates portal hypertension?
MPV >13mm
absent variation in portal/splenic vein
deminished portal flow
hepato-fugal flow
varices
ascites/splenomeg
PVobstruction
turbulent hepatic artery flow
How do you know if a TIPS is malfunctioning?
no flow
shunt PSV 190 cm/s
change in shunt PSV by decrease of >40cm.s or increase in >60cm/s
MPV PSV <30cm/s
reversal of flow in hepatic veins
hepatopedal intrahepatic portal venous flow
what is the resistive index? and waht is abnormal?
RI=PSV-EDV/PSV
0.6 (with 0.7 upper limit of normal)
what is abnormal MPV size?
>13mm
what is abnormal spleen size?
>15mm
