All Things Vascular Flashcards
Rutherford stage of ischemia: not immediately threatened; intact motor and sensory function with audible arterial and venous signals
rutherford stage 1
Rutherford stage of ischemia: marginally threatened and salvageable limb (intact motor function and sensory deficit in the toes with inaudible arterial signal)
rutherford stage 2a
Rutherford stage of ischemia: immediately threatened and salvageable only with emergent revascularization (mild to moderate neurodeficit)
rutherford stage 2b
Rutherford stage of ischemia: irreversibly damaged limb with major tissue loss or nerve damage (paralysis)
rutherford stage 3
what major nerve is transected during an AKA?
sciatic nerve
Most commonly implicated muscle in popliteal entrapment syndrome:
gastrocnemius
waterhammer pulse is indicative of ischemia from what: example, bounding femoral pulses with absent distal pulses
indicative of acute embolism at a bifurcation (femoral bifurcation)
True or false. Angioplasty alone is generally sufficient in treating fibromuscular dysplasia
true
most common etiology of SMA aneurysm
infectious etiology; risk factors are IV drug use, bacteremia, and infective endocarditis
which type of bypass has the highest patency rate?
aortobifemoral bypass
threshold for compartment syndrome
intracompartmental pressure >30mm Hg; difference of less than 40mm Hg between MAP and intracompartmental pressure; difference of <10mm Hg between DBP and intracompartmental pressure
management of pseudoaneurysms <2cm in diameter without complications:
observation
contraindications to nonoperative management of pseudoaneurysms:
peripheral or cutaneous ischemia, infection, prosthetic graft, large suprainguinal, rapid enlargement, skin necrosis, distal embolization, rupture
True or False. Calcaneous osteomyelitis is simple to heal and flaps usually do well
false
true or false. cause of graft failure depends on the time since surgery at which it occurs
true
most common cause of early graft failure:
(within 30 days) technical error or inadequate inflow/outflow
most common cause of intermediate graft failure:
(30-2 years) intimal hyperplasia
most common cause of late graft failure:
(>2years) progression or recurrence of atherosclerotic disease
effects of nitric oxide on vascular tissue:
inhibits proliferation of vascular smooth muscle by downregulating endothelin 1 and platelet derived growth factor b; inhibits adhesion and aggregation of platelets to the endothelium
symptoms of vertebrobasilar insufficiency:
ataxia, bilateral or alternating weakness, dizziness, vertigo
True or false. A TIA by definition lasts 48 hours.
false (less than 24 hrs)
treatment of asymptomatic moderate carotid disease in setting of CAD:
manage medically until coronary artery disease is addressed (CABG before CEA)
True or false. Skin of lipodermatosclerosis is highly suggestive of venous insufficiency/stasis
True
disorder characterized by nonpitting edema, thickening of the skin, woody edema, and hyperkeratotic papillomatous plaques
lymphedema
True or false. Observation is appropriate for aneurysms <2cm
true
complex coagulation process that involves activation of teh coagulation system with deposition of fibrin in the microvasculature
DIC
treatment of DIC
treat the underlying cause
characterized by thickening of the vessel media and collagen formation
fibromuscular dysplasia
vascular disease characterized by artery wall thickening as a result of invasion and accumulation of white blood cells and proliferation of intimal smooth muscle cells
atherosclerosis
causes arterial thrombosis as a result of rupture of fat rich deposit in the blood vessel wall
atheroma
small tear that forms in the innermost lining of the arterial wall called the tunica intima
arterial dissection
what is the initial treatment for intermittent claudication?
medical management; smoking cessation, antiplatelet therapy, statin therapy, exercise
True or false. revascularization is only recommended in severe cases of claudication that have failed medical therapy
true
treatment of asymptomatic FMD of the carotid artery
antiplatelet therapy
treatment of symptomatic FMD of the carotid artery
open arteriotomy with serial dilation or balloon dilation (angioplasty)
True or false. superficial venous thrombosis (SVT) in teh trunks of the GSV or SSV have highest risk of extension into the deep venous system
true
treatment of SVT within 3 cm of the saphenofemoral junction:
fondaparinux for 45 days; patients with risk for DVT should be considered for chemoprophylaxis
surgical patients are at increased risk of DVT due to transient release of large amounts of ____
tissue factor (a potent procoagulant)
true or false. patients with chronic renal disease and nephrotic syndrome are at decreased risk of DVT
false
how long should clopidogrel be held for elective surgery reversal?
5-7 days
amaurosis fugax: caused by isolated embolism where?
retinal or ophthalmic artery
most common complication of untreated jugular vein suppurative thrombophlebitis:
septic emboli to the lungs that can infiltrate, cavitate and form empyemas
therapeutic anticoagulation regimen for acute limb ischemia:
heparin bolus of 80 units/kg and then heparin drip at 18units/kg with goal aPTT of 60-90 seconds
types of thoracic outlet syndromes (TOS)
neurogenic, arterial, venous
most common type of TOS
neurogenic
initial treatment of neurogenic TOS
physical therapy; if this fails treat with rib resection, scalenectomy, and dissection of brachial plexus
presentation of neurogenic TOS:
pain over posterior and lateral neck that radiates down the upper extremity to the medial aspect of the hand and arm with associated paresthesia
venous TO treatment:
catheter directed thrombolysis of subclavian vein; if stenosis is present on venogram afterwards, need surgical decompression as in neurogenic type
cause of arterial TOS
subclavian artery thrombosis or aneurysm; occurs exclusively in patients with a cervical rib or elongated TP of C7 vertebrae
treatment of arterial TOS
resection of C7 bone abnormality, the first rib, and subclavian artery with graft reconstruction
branches of external iliac artery
deep circumflex iliac (provides collateral circulation to lower leg in patients with femoral occlusions); inferior epigastric
hypervascular tumor derived from neural crest cells located at carotid bifurcation
carotid body tumor
treatment and presentation of carotid body tumors:
asymptomatic in many; also may present with neck pain, dysphonia, hoarseness, stridor, dysphagia, sore throat; treat with resection
failure of AV access is mainly due to ____
outflow stenosis from intimal hyperplasia; occurs anywhere in vein of AVF and at the anastomosis of the AVF graft
where do peripheral arterial emboli typically lodge?
bifurcations
most common site of embolic lodgement
common femoral bifurcation
What is a DRIL (distal revascularization and interval ligation)?
procedure of choice for steal; artery is ligated distal to the origin of the fistula and a bypass is done between proximal and distal portions of the artery
physiologic effect of unilateral renal artery stenosis:
compensatory response by unaffected kidney to maintain euvolemia by creating a renin dependent euvolemic HTN (high serum renin)
physiologic effect of bilateral renal artery stenosis:
no compensation to maintain euvolemia, creating a volume-dependent or hypervolemic hypertensive state through negative feedback resulting in normal/low serum renin
treatment of an iliofemoral DVT
chemical and mechanical thrombolysis (superior to anticoagulation)
True or False. Late access thrombosis of a fistula or graft usually occurs 1-2 years after placement, most commonly from intimal hyperplasia.
true
first line operative therapy for FMD of the carotid artery
balloon angioplasty
what nerve is at highest risk of injury during 4 compartment fasciotomy
superficial peroneal nerve, courses around the neck of the fibula in the lateral compartment
Mickey Mouse sign on duplex US:
Mickey’s ears are the GSV (more superficial ear) and CFA; common femoral vein is the head (middle)
What is May Thurner Syndrome:
compression of the left common iliac vein by the right common iliac artery, resulting in mechanical obstruction of the venous outflow tract from the LLE
where do individuals who smoke tend to develop arterial disease?
SFA disease
where do diabetics and renal disease patients tend to develop arterial disease?
infrapopliteal disease
US findings of significant reflux in the saphenous, tibial, & deep femoral veins:
> 0.5 seconds of reflux
US findings of significant reflux in femoral and popliteal veins:
> 1 second of reflux
signs of superficial venous disease
pain and swelling that is least apparent in the morning before standing and ambulation; swelling limited to leg and ankle (spares foot); pain is nonspecific
pancreaticoduodenal artery provides a vital collateral pathway between ___ and ____
celiac and SMA
NASCET and ECST trial findings:
there is significant risk reduction in stroke for patients with symptomatic high grade stenosis (70-90%) undergoing CEA when compared to medical therapy alone; for patients with moderate stenosis (50-69%) the benefit is less but still favorable when compared to medical therapy alone
bypass options for SMA occlusion:
supraceliac aorto to SMA; common iliac to SMA
transperitoneal approach to aortic repairs advantage:
provides better access to the right side of the aorta (renal and iliac arteries)
retroperitoneal approach to aortic repairs advantages:
less blood loss, less ileus, less pain, less infeciton, more proximal exposure of aorta
earliest sign of compartment syndrome
pain
minimum size of cephalic vein used for AVF
2.5-3mm
what energy increase is required for a below knee amputation to ambulate
10-40%
first line tx for mesenteric venous thrombosis
anticoagulation
what accounts for most cases of renovascular HTN
renal artery occlusive disease due to atherosclerosis
treatment of fibromuscular dysplasia
percutaneous transluminal angioplasty
first step in management of suspected acute limb ischemia
IV anticoagulation
most common microorganism in suppurative thrombophlebitis
Staph aureus
treatment of suppurative thrombophlebitis
catheter removal, blood culture, expression of pus, antibiotics
when is surgery required for a pseudoaneursysm?
acutely expanding, compressing adjacent nerves, or compromising overlying skin
True or false. renal artery angioplasty with stent placement has been shown to be more effective in the treatment of atherosclerotic renal artery stenosis when compared with angioplasty alone
true
mechanism and presentation of heparin induced thrombocytopenia:
heparin antibody complex binds to platelets to cause their activation and thrombocytopenia
presents 3-14 days after initial heparin exposure with arterial or venous thrombosis, platelet drop below 100,000 or by half
testing and treatment of HIT
test for with ELISA test initially, confirm dx with serotonin release assay for confirmation; treat by stopping all heparin products (including lovenox) and starting direct thrombin inhibitor
presentation of acute aortic occlusion from saddle embolus
acute bilateral leg ischemia and sudden paraplegia from spinal cord ischemia/cauda equina syndrome (loss of bowel and bladder control)
treatment of saddle embolus aortic occlusion
immediate operative thrombectomy/embolectomy, preferably through bilateral femoral exposures of the aorta and both legs
presentation of popliteal entrapment
claudication with active ankle plantar flexion and passive ankle dorsiflexion; seen in young runners
most specific test for the presence of a DVT
venous duplex ultrasound
management of acutely thrombosed popliteal artery aneurysm with acute ischemia:
anticoagulate with heparin
perform leg angiography to identify runoff vessel
if runoff vessel identified, perform a bypass
if no runoff, perform thrombolysis to identify a potential distal target for bypass
classic appearance of FMD on imaging
string of beads appearance
because of its location deep in the compartment of the lower leg, the _____ artery is the most likely artery to remain patent in diabetic patients with vascular disease
peroneal
True or false. Thrombolysis for acute limb ischemia leads to fewer number of subsequent open surgical procedures, equivalent amputation free survival, and higher major hemorrhage rates than upfront open surgery
true
True or false. accessing the supraceliac aorta requires mobilizing the left lobe of the liver and dividing the triangular ligament
true
Where should the final location of the catheter tip be for a tunneled dialysis catheter
right atrium - because they require higher flow rates than a standard CVC
medially located venous ulcers are connected to an incompetent ____
GSV
laterally located venous ulcers are connected to an incompetent ____
small saphenous vein (SSV)
At what ABI does rest pain begin?
0.5
constellation of symptoms of aortoiliac occlusive disease (Leriche syndrome):
diminished or absent femoral pulse, buttock claudication; impotence
presentation and treatment of venous TOS (Paget Schroetter Syndrome)
young, healthy people with hx of repetitive exercise (e.g. swimming, pitching); present with arm fatigue and heaviness that progresses to swelling; treat with thrombolysis (anticoagulation alone is associated with high morbidity)
first line therapy for renovascular HTN
ACE inhibitor and beta blocker
True or False. There is significant benefit in stenting over only medical therapy for patients with renovascular HTN
false (ASTRAL trial)
what is post thrombotic syndrome?
development of chronic venous stasis symptoms after a LE DVT
treatment of a severely symptomatic iliofemoral DVT:
catheter directed thrombolysis to improve morbidity and long term function (reduce posthrombotic sydrome)
True or false. Short term complications are higher for open AAA repair but long term complications are higher with EVAR
true
what is a type 1 endoleak?
incomplete seal between stent-graft device and native vessel; occurs typically in early postprocedure period and has a continued risk of rupture
treatment of type 1 endoleak:
treat with balloon angioplasty +/- placemetn of additional component
what is a type 2 endoleak?
persistent retrograde flow into the aneurysm from branch vessels/collaterals of infrarenal aorta
treatment of type 2 endoleak:
controversial; may resolve spontaneously; persistent ones treated with embolization or open ligation of involved vessel
what is a type 3 endoleak?
tear or rupture of fabric of graft; requires intervention
treatment of a type 3 endoleak:
place a cuff or reline with a new stent within the stent graft to cover the tear
what is a type 4 endoleak?
passage of blood through graft due to graft porosity; very rare with modern grafts
treatment of type 4 endoleak?
anticoagulation
what is a type 5 endoleak/endotension?
persistently elevated intraaneurysmal sac pressure in absence of obvious endoleak on CT
treatment of type 5 endoleak?
observation
Treatment of thrombus after EVLA at the saphenofemoral or saphenopopliteal junction:
aspirin
Treatment of thrombus after EVLA with extension into the common femoral or popliteal veins with <50% surface area involvement:
aspirin
Treatment of thrombus after EVLA with extension into the common femoral or popliteal veins with >50% surface area involvement or total occlusion:
anticoagulation
Most common site of aortoenteric fistulas
duodenum
What is nutcracker syndrome?
compression of left renal vein between SMA and aorta
Symptoms of nutcracker syndrome:
left flank and abdominal pain
associated with varicocele in men
gross or microscopic hematuria
What is May Thurner syndrome:
compression of left common iliac vein between right common iliac artery and sacral promontory/5th lumbar vertebra causing acute ileofemoral dvt and left leg swelling
Treatment of nutcracker syndrome:
left adrenal vein transposition and stenting
Treatment of May Thurner syndrome:
anticoagulation and compression stockings
may improve with catheter directed thrombolysis with placement of self-expanding stent
Symptoms of popliteal vein compression:
varicose veins below knee or DVT
True or false. Thrombolysis is equivalent to anticoagulation in treatment of iliofemoral DVT.
False. Thrombolysis is superior
Atherosclerotic plaques often form on the _____ aspect of sclerotic vessels.
posterior
Classic Ehler Danlos syndrome is due to a defect in production of ____
type V collagen
Vascular Ehler Danlos syndrome is due to a defect in production of ____
type III collagen
Common complication of suppurative thrombophlebitis of the jugular vein
septic emboli to the lungs causing empyema
Management of uncomplicated pseudoaneursym <3cm
observation
management of uncomplicated pseudoaneursym >3cm
US guided thrombin injection or compression
Most common operation for SMA syndrome
duodenojejunostomy: bypasses compression caused by the abdominal aorta and SMA
Treatment of spontaneous/primary superficial venous thrombosis within 3 cm of the saphenofemoral junction
fondaparinux for 45 days
Peak systolic velocity for the ICA in normal anatomy
<125 cm/sec
Peak systolic velocity for the ICA in 50% stenosis
125 cm/sec
Peak systolic velocity for 50-69% stenosis
125-230 cm/sec
Peak systolic velocity of ICA for >70% stenosis
> 230 cm/sec
Management of uncomplicated femoral pseudoaneurysm <3cm
observation; if still not resolved after 6 weeks, US-guided thrombin injection
Management of uncomplicated femoral pseudoaneurysm >3cm
US guided thrombin injection
Features of complicated pseudoaneursym that requires surgical repair
infected pseudoaneurysm hemodynamic instability active bleeding skin necrosis or cellulitis distal limb ischemia neurologic deficit failure of US guided treatment large aneurysm with wide neck
The diagnostic test of choice to confirm lymphedema
lymphoscintigraphy
What is Paget-von Schroetter syndrome
venous thoracic outlet syndrome; severe narrowing or thrombosis of the subclavian-axillary vein secondary to chronic extrinsic mechanical compression
Initial treatment of venous TOS
catheter directed thrombolytics (no longer anticoagulation alone); perform first rib resection after reestablishing venous patency
Strongest risk factor for abdominal aortic aneursym:
smoking
Basic pathophysiologic process of AAA:
degradation of the tunica media by proteolytic processes such as matrix metalloproteinases that least to decreased elastic and smooth muscle fibers
