cardiac, thoracic and vascular

Question 1

thoracic anatomy1) where does the azygous vein run2) where does the thoracic duct run3) where does the phrenic nerve run4) where does the vagus nerve run5) what are the volumes of each lung and and lobes6) what muscles are responsible for quiet inspiration7) what are accessory muscles?8) role of type I and II pneumocytes9) role of pores of Kahn

Answer 1

1) runs along the right side and dumps into superior vena cava2) runs along the right side, crosses midline at T4-5 and dumps into left subclavian vein at junction with internal jugular vein3) runs anterior to hilum4) runs posterior to hilum5) right lung, 3 lobes is 55% volume and left (2 lobes + lingula) is 45%6) diaphragm (80%), intercostals (20%)7)sternocleidomastoid muscle, levators, serratus posterior, scalenes8) Type I pneumocytes-gas exchangeType II pneumocytes- surfactant production9) direct air exchange bw alveoli

Question 2

Pulmonary Function tests1) what predicted postop FEV1 do you need to be able to resect?-what if it is close, what diagnostic test should you get2) What is DLCO, what does it measure/represent and what does the value depend on3) what predicted postop DLCO is needed for lung resection4) what preop pCO2, pO2 and VO2max are contraindications for lung resection

Answer 2

1) predicted postop FEV1>0.8 needed for resection–if close, get qualitative V/Q scan to see contribution of that portion of lung to overall FEV1. if low may still be able to resect.2) Diffusion capacity of lung for CO-measures carbon monoxide diffusion and represents O2 exchange capacity-value is dependent on capillary surface area, hemoglobin content and alveolar architecture3) >10mL/min/mm HgCO (or >40% predicted postop value)4) pCO2>50, PO2

Question 3

What is the most common lung surgery that causes1) persistent air leak2) atelectasis3) Arrhythmias

Answer 3

1) wedge/secmentectomy2) lobectomy3) pneumonectomy

Question 4

Lung Cancer1) T/F: MCC of cancer-related death in US2) what factor has strongest influence on survival3) what is MC site of metastasis (and other met sites)4)T/F: recurrence usually appears as single metastasis5) what disease stages are resectable6) possible surgeries7) prognosis8) MC type of lung CA9) Most malignant Lung CA

Answer 4

1) True2) node involvement3) Brain (liver, other lung, supraclavicular nodes, adrenals)4) False- usually disseminated metastases5) Stage I and II are resectable, T3N1M0 (stage IIIa) may be resectable6) lobectomy or pneumonectomy MC, sample suspicious nodes7) poor. 10% 5-year overall survival. 30% with resection for cure8) non-small cell carcinoma, adenocarcinoma is MC overall type9) mesothelioma

Question 5

Non-small cell carcinoma of lung1) what % of all lung CA2) what type is more centrally located3) what type is more peripherally located4) chemo- when to use and which drugs

Answer 5

1)80%2) squamous cell CA3) adenocarcinoma (MC)4) Stage II or higher- carboplatin, Taxol (can also do XRT)

Question 6

Small cell lung CA1) what % of lung CA2) prognosis3) 5-year survival rate for T1N0M04) rx5) cell origin

Answer 6

1) 20%2) poor, <5% 5-year survival3) 50%4) most just get chemo-XRT (cisplatin, etoposide)5) neuroendocrine

Question 7

TNM staging for lung CA1) difference bw T1-T42) difference bw N1-N3 and significance for treatment3) difference bw stage 1-IV4) single best test to determine T and N status5) single best test to determine M status

Answer 7

1) T1 is 3cm but >2cm from carina; T3-invades chest wall, pericardium, diaphragm or

Question 8

Paraneoplastic syndromes associated with1) squamous cell CA2) small cell lung CA3) which paraneoplastic syndrome is MC

Answer 8

1) PTH-related peptide2) ACTH and ADH3) ACTH

Question 9

Mesothelioma1) prognosis2) risk factor

Answer 9

1) most malignant lung CA–> aggressive local invasion, nodal invasion and distant mets common at diagnosis2) asbestos exposure

Question 10

Mediastinoscopy1) what lung tumors should you use it for?2) what does it not assess3) where are you looking with it?a-right-side structuresb- left-side structuresc-anterior structures

Answer 10

1) centrally located tumors and pts with suspicious adenopathy2) aorto-pulmonary window nodes (L-lung drainage)3) middle mediastinuma-azygous vein and SVCb- Recurent laryngeal nerve, esophagus, aorta, main pulmonary arteryc-innominate artery and vein, right pulm artery

Question 11

What is the Chamberlain procedure and what does it assess

Answer 11

goes through left 2nd rib cartilage (anterior thoracotomy or parasternal mediastinotomy) to assess the AP window nodes (L-lung drainage)

Question 12

What is Bronchoscopy used to assess for lung CA

Answer 12

needed for centrally located tumors to check for airway invasion

Question 13

2 criteria needed for operative resection of lung CA

Answer 13

pts must be 1) operable (appropriate FEV1 and DLCO values)2) resectable (no T4, N2, N3 or M disease)

Question 14

Pancoast tumor1) where is it?2) related symptoms/syndromes

Answer 14

1) invades apex of chest wall–>2) Horner’s syndrome (invasion of sympathetic chain-> ptosis, miosis, anhidrosis) or ulnar nerve compression

Question 15

Coin lesion on CXR1) how many are malignant overall and by age2) what findings suggest benign disease3) If suspicious what is next step

Answer 15

1) 10% malignant overall (<5% in pts younger than 50yo but 50% in pts older than 50yo)2) no growth in 2 years, smooth contour3) guided bx or wedge resection

Question 16

1) Asbestos exposure increases lung CA risk by what %2) appearance of bronchoalveolar CA3) treatment of lung metastasis from other primary

Answer 16

1) 90%2) can look like pneumonia, grows along alveolar walls, multifocal3) can resect if isolated and not associated with any other systemic disease for colon, renal cell, sarcoma, melanoma, ovarian and endometrial CA

Question 17

Carcinoids of lung1) cell type and location2) % with mets, % with symptoms3) pronosis for typical and atypical carcinoid4) rx5) tumor characteristics that result in increased recurrence

Answer 17

1) Neuroendocrine tumor, centrally located usually2) 5% have mets and 50% have sx at time of dx3) typical has 90% 5-yr survival, atypical is only 60%4) resection, treat like CA5) recurrence increased with positive nodes or tumors>3cm (outcome closely linked to histology)

Question 18

Bronchial Adenomas1) types and malignant potential2) which types are slow growing and don’t metastasize3) which types spread along perineural lymphatics4) which types are very XRT sensitive5) rx for each type6) which type can have 10-yr survival with unresectable disease

Answer 18

1) mucoepidermoid adenoma, mucous gland adenoma and adenoid cystic adenoma (all are malignant)2, 5) Mucoepidermoid adenoma and mucous gland adenoma (rx-resection)3, 4, 5) Adenoid cystic adenoma-slow growing (rx- resection, if unresectable, XRT is good palliation). Can get 10-yr survival with unresectable disease

Question 19

Hamartomas1) malignant potential2) CT appearance3) dx and rx

Answer 19

1) benign (MC benign adult lung tumor)2) calcifications and appear as popcorn lesion3) dx made with CT- repeat chest CT in 6 months to confirm, no resection needed

Question 20

Mediastinal tumors in adults1) MC presentation/sx2) MC type in adults and children3) what % of symptomatic mediastinal masses are malignant4) what % of asymptomatic mediastinal masses are benign5) MC site for mediastinal tumor6) Anterior tumors7) Middle mediastinal tumors8) posterior tumors

Answer 20

1) asx. however, can have CP, cough, dyspnea2) neurogenic tumors (usually posterior)3) 50%; 4) 90%5) thymus (anterior)6) Thymus- thymoma (#1 anterior mediastinal mass in adults), thyroid CA and goiters, T-cell lymphoma, Teratoma (and other germ-cell tumors), paraThyroid adenomas7) heart, trachea, ascending aorta- bronchogenic, paricardial and enteric cysts, lymphoma8) esophagus and descending aorta-enteric cysts, neurogenic tumors, lymphoma

Question 21

Thymoma1) rx2) 50% rule3) what % of pts with Myasthenia gravis have thymoma

Answer 21

1) resect (also resect thymus if too big or refractory M.G.)2) 50% have symptoms, 50% have M.G., 50% are malignant3) 10%

Question 22

Myasthenia Gravis1) sx and cause2) rx

Answer 22

1) fatigue, weakness, diplopia, ptosis, caused by antibodies to acetylcholine receptors2) anticholinesterase inhibitors (neostigmine), steroids, plasmapheresis. 80% get improvement with thymectomy (including those who don’t have a thymoma)

Question 23

Mediastinal Germ Cell Tumors1) how to dx2) MC one in mediastinum3) MC malignant one in mediastinum4) Teratoma-a) benign or malignant?b) rx5) Seminomaa) tumor markersb) rx6) Non-seminomaa) tumor markersb) rx

Answer 23

1) biopsy (often with mediastinoscopy)2) Teratoma3) Seminoma4) a- can be eitherb- resection, possible chemo5) a-10% are beta-HCG positive. should NOT have AFPb-XRT (extremely sensitive) , chemo only if mets or bulky nodal disease, surgery for residual dz after that6)a-90% have AFP and beta-HCG elevationb-chemo (cisplatin, bleomycin, VP-16), surgery for residual disease

Question 24

Mediastinal cysts1) Bronchiogenica-locationb-rx2) Pericardiala-locationb-rx

Answer 24

1)a-posterior to carina; b-resect2) a-right costophrenic angle; b-leave alone (benign)

Question 25

Neurogenic Mediastinal tumors1) sx2) rx3) what % have intraspinal involvement requiring simultaneous spinal surgery4) what type is MC5) what type produces catecholamines and is associated with von Recklinghausen’s disease6) 2 other types of tumors

Answer 25

1) pain, neurologic deficit2) resection3) 10%4) Schwannoma (Neurolemmoma)5) Paraglanglioma6) Neurofibroma, neuroblastoma

Question 26

Trachea1) benign tumor in adults2) benign tumor in children3) malignant tumor4) MC early complication after tracheal surgery and rx5) MC late complication after tracheal surgery

Answer 26

1) papilloma2) hemangioma3) squamous cell carcinoma4) laryngeal edema. rx- intubate, recemic epi and steroids5) granulation tissue formation

Question 27

Trachea1) post-intubation stenosisa- where does it occur with tracheostomy and ET tubeb- rx2) Tracheo-innominate artery fistula- a-when does it occurb- rxc- how to avoid this complication3) Tracheoesophageal fistulaa-when does it occurb- temporary treatmentc- permanent treatment

Answer 27

1) a-at stoma site with tracheostomy and at cuff site with ET tubeb- if minor- serial dilation, bronchoscopic resection or laser ablationif severe or recurring- tracheal resection with end-to-end anastamosis2) a- with tracheostomy-> can have rapid exsanguinationb-place finger in trach hole and hold pressure–> median sternotomy with ligation and resection of innominate arteryc- keep tracheostomy above 3rd tracheal ring3) a-with prolonged intubationb- place large-volume cuff endotracheal tube below fistula, attempt repair after vent weanc-tracheal resection and reanastamosis; close hole in esophagus; sternohyoid flap between esophagus and trachea

Question 28

Lung Abscess1) MC cause and location2) rx3) how to differentiate from empyema

Answer 28

1) aspiration, superior segment of RLL2) abx alone (95% success); if that fails- CT-guided drainage. Surgery if above fails or can’t r/o CA (>6cm, doesn’t resolve within 6month)3) can get CT scan

Question 29

Empyema1) MC cause2) symptoms3) characteristics of pleural fluid labs4) empyema phases- time when it is seen and rxa)exudative phaseb) Fibro-proliferative phasec) organized phase

Answer 29

1) pneumonia and subsequent paraneumonic effusion (staph or strep) is MC. but also can be 2/2 esophageal, pulm or mediastinal surgery2) pleuritic CP, fever, cough, SOB3) WBCs >500cells/cc, bacteria and + gm stain4) a)1st week. rx- abx, CTb) 2nd week. rx- CT, abx; possible VATS deloculation (=video-assisted thoracoscopic surgery)c) 3rd week. rx- decrotication (fibrous peel occurs around lung). some use intra-pleural tPA to dissolve the peel. May need Eloesser flap (open thoracic windo direct to external environment) to frail/elderly

Question 30

Chylothorax1) fluid appearance and lab findings and special stain2) infection risk3) MC causes4) causes of L-sided chylothorax vs right-sided chylothorax5) rx

Answer 30

1) white, milky fluid. has inc lymphocytes and TAGs (triglycerides >110ml/uL). Sudan red stains fat2) resistant to infection= no risk3) trauma or iatrogenic injury 50%malignancy (ie-lymphoma 2/2 tumor burden in lymphatics) 50%4) Injury above T5/6-> left-sided chylothoraxInjury below-> right sided chylothorax5) 2-3 wks conservative rx (Chest tube, octreotide, low-fat diet/TPN)-if fails and cause is trauma-> ligation of thoracic duct on right side in low mediastinum-if fails and cause is malignant-> need talc pleurodesis and possible chemo &/or XRT

Question 31

Massive Hemoptysis1) quantity that defines it2) MC site of bleed3) MC cause4) MCC of death5) rx

Answer 31

1) >600cc/24hr2) high pressure bronchial arteries3) 2/2 infection4) asphyxiation5) place bleeding side down; mainstem intubation to opposite side of bleed. rigid bronchoscopy to identify site and possible control of beed. May need lobectomy/pneumonectomy or bronchial artery embolization if not suitable for surgery

Question 32

Spontaneous pneumothorax1) classic patient description2) MC side3) recurrence risk4) rx for all5) when to operate and what operation

Answer 32

1) thin, tall, healthy young male2) right side MC3) after 1st pneumo-20%, after 2nd-60%, after 3rd-80%4) Chest tube5) if recurrence, air leak >7 days, non-reexpansion, high-risk profession (airline pilot, diver, mountain climber) or pt living in remote area– do thoracoscopy, apical blebectomy and mechanical pleurodesis

Question 33

Other lung conditions1) MCC of arrest after blunt trauma2) occurs in temporal relation to menstruation 2/2 to endometrial implants in visceral lung pleura3) rx of residual hemothorax despite 2 good chest tubes4) when to surgically drain clotted pneumothorax5) cause of broncholiths6) MCC of mediastinitis

Answer 33

1) tension pneumo 2/2 impaired venous return2) Catamenial pneumothorax3) OR for thorascopic drainage4) if >25% of lung, air-fluid levels or signs of infection (fever, inc WBCs). do surgery in 1st week to avoid peel5) infection6) usually occurs after cardiac surgery

Question 34

Management of whiteout on CXR if1) midline shift toward whiteout2) midline shift away from whiteout3) no shift

Answer 34

1) most likely collapse-> need bronchoscopy to remove plug2) most likely effusion-> place CT3) CT scan to figure out

Question 35

Bronchiectasis1) causes2) surgical management

Answer 35

1) acquired from infection, tumor or cystic fibrosis2) too diffuse for surgery

Question 36

TB1) MC location in lungs2) typical pathology3) what is a Ghon complex4) Rx5) difference between path in sarcoidosis and TB

Answer 36

1) apical2) calcifications and caseating granulomas3) parenchymal lesion + enlarged hilar LNs4) INH, rifampin, pyrazinamide5) has non-caseating granulomas

Question 37

1) Rx of recurrent pleural effusions2) rx of airway fires3) MC benign Chest wall tumor4) MC malignant chest wall tumor

Answer 37

1) mechanical pleurodesis (Talc powder for malignancies)2) usually from laser. 3) osteochondroma4) chondrosarcoma

Question 38

Lung AVMS1) vasculature involved2) MC location3) what syndrome can they occur with4) rx5) sx

Answer 38

1) cnxn bw pulm artery and veins2) lower lobes3) osler-Weber-rendu disease4) embolization5) hemoptysis, SOB, neurologic events

Question 39

Congenital Heart disease1) a)what kind of shunt results in cyanosisb) why does squatting relive symptoms in these ptsc) what is Eisenmenger’s syndrome and why does it occurd) complications of cyanosis2) what kind of shunt causes CHF3) 3 causes of L-> R shunts and how do they present4) 1 cause of R->L shunt

Answer 39

1) a) R->L shuntb) squatting-> increased SVR and decrease R->L shuntc) shift from L-> R to R->L shunt. 2/2 increased pulmonary vascular resistance (PVR) and pulmonary HTN, generally irreversibled)polycythemia, strokes, brain abscess, endocarditis2) L-> R shunt3) VSD, ASD, PDA. manifest as failure to thrive, inc HR, tachypnea, hepatomegaly (1st sign of CHF in children)4) tetralogy of fallot

Question 40

Congenital Heart disease1) what is the ductus arterios2) What is the ductus venosum3) what provides fetal circulation to placenta (supply deoxygenated blood from fetus to placenta)4) what provides fetal circulation away from placenta (supplies oxygenated blood to fetus)5) MC congenital heart defect6) MC congenital heart defect that results in cyanosis

Answer 40

1) connection bw left PA and descending aorta (blood shunted away from lungs in utero)2) Cnxn bw portal vein and IVC (blood shunted away from liver in utero)3) 2 x umbilical arteries4) umbilical vein (only 1 vein, but 2 arteries)5) VSD6) tetrology of fallot

Question 41

Ventricular Septal Defect1) direction of shunt2) what % close spontaneously and by what age3) when do they cause symptoms and physiology of why4) consequent symptoms/effects5) Medical rx6) when to repaira)large VSD (Shunt >2.5)b) medium VSD (Shunt 2-2.5)c) what is MC reason for earlier repair

Answer 41

1) L->R2) 80% spontaneously close by 6mo3) large VSDs cause symptoms at 4-6weeks bc of PVR decreasing and shunt increasing4) CHF (tachypnea, tachycardia) and failure to thrive5) diuretics and digoxin6) a- at 1 year old; b-at 5 years old; c- failure to thrive

Question 42

Atrial Septal Defect1) shunt direction2) what is MC type and location3) what type can have mitral valve and tricuspid valve problems and what syndrome do you see this type with4) when do symptoms occur and what are they5) medical rx6) when to repair

Answer 42

1) L->R2) Ostium secundum, centrally located, 80%3) ostium primum (or Atrioventricular defects or endocardial cushion defects) seen with DOwn’s syndrome4) when shunt >2-> CHF (SOB, recurrent infections). In adults can get paradoxical emboli5) diuretics and digoxin6) 1-2years of age. If canal defects 3-6mo.

Question 43

Tetrology of Fallot1) shunt direction2) what defects are part of this3) medical rx4) usual timing of repair5) how is repair done

Answer 43

1) R->L2) anterior superior displacement of infundibular septim->pulm artery stenosis and VSD, over-riding aorta, and RV hypertrophy (secondary occurance)3) B-blockers4) 3-6months5) removal of RV outflow tract obstruction (RVOT) and RVOT enlargement + VSD repair

Question 44

Patent Ductus Arteriosus1) direction of shunt2) what drug causes the PDA to close, and during what timeframe is this successful3) repair of persistent PDA through what type of incision

Answer 44

1) L-> R2) indomethacin, rarely effective beyond the neonatal period3) requires surgical repair through left thoracotomy

Question 45

Adult Cardiac Disease: Coronary Artery disease1) risk factors2) medical treatment3) branches of Left Main coronary artery4) where are most stherosclerotic lesions5) what is the restenosis rate of drug-eluting stent at 1 year6) what is saphenous vein graft 5-year patency rate7) what is the best conduit for CABG- name the artery, where it branches off of and what it collateralizes with8) Indictions for CABG9) high mortality risk factors for CABG

Answer 45

1) smoking, HTN, male, family hx, hyperlipidemia, diabetes2) nitrates, smoking cessation, weight loss, statins, ASA3) Left anterior descending and Left circumflex arteries4) proximal5) 20% restenosis at 1-year6) 80% patency at 5-years7) internal mammary (branch of subclavian artery) collateralizes with superior epigastric artery8) >70% stenosis for most areas except >50% stenosis for Left main disease is considered significant.CABG for:-Left main >50% stenosis-3-vessel disease (LAD, Cx, and Right Coronary Artery)-2-vessel disease involving LAD-lesions not amenable to stenting9) pre-op cardiogenic shock is #1 risk factor, emergency operations, age, low EF

Question 46

Complications of MI1) Ventricular Septal Rupturea-symptomsb-timeframe in which occursc- shunt direction and consequent O2 content effectd-how to dxe- rx2) Papillary muscle rupturea- syptomsb-when it occursc-dxd-rx

Answer 46

1)a- hypotension, pansystolic murmurb-usually 3-7d after MIc- L-> R shunt-> increase in pulmonary artery and right atrium O2 contentd- echoe- temporize with intra-aortic balloon pump, patch over septum2) a- hypotension and severe mitral regurgb- 3-7 days after MIc-echod- temporize with IABP, valve replacement

Question 47

Adult Cardiac disease1) what is MC cause of death in US2) MC valve lesion3) MC benign tumor of the heart and where are they located4) MC malignant heart tumor5) MC metastatic tumor to the heart6) which veins have lowest O2 tension of any tissue in the body and why7) what is the treatment for coming off cardiopulmonary bypass and aortic root vent when blood is dark and aortic perfusion cannula blood is red8) with mediastinal bleeding after a cardiac procedure when do you need to re-explore9) risk-factors for mediastinitis and rx

Answer 47

1) Coronary Artery disease2) aortic stenosis3) myxoma- 75% in LA4) Angiosarcoma5) lung CA6) coronary veins 2/2 O2 extraction by myocardium7) ventilate the lungs8) >500cc for 1st hour, or >250cc/h for 4 hours-> need to re-explore9) obesity, use of bilateral internal mammary arteries, DM. rx- debridement with pectoralis flaps (can also use omentum)

Question 48

Superior Vena Cava symdrome1) sx2) MC cause and rx

Answer 48

1) upper extremity and face swelling2) MC 2/2 to lung CA invading SVC-> emergent XRT

Question 49

Post-pericardiotomy syndrome1) sx2) EKG findings3) rx

Answer 49

1) pericardial friction rub, fever, chest pain, SOB2) diffuse ST-segment elevation in mult leads3) NSAIDS, steroids*basically like pericarditis

Question 50

Endocarditis1) sx2) MC site of prosthetic valve infections3) MC site of native valve infections4) MC organism responsible5) what is MC side except for in which pts6) MC organism in IVDA7) Rx and indications for surgery (how often is medical rx successful)

Answer 50

1) fever, chills, sweats2) Aortic valve3) Mitral Valve4) staph aureus responsible for 50%5) Left side MC (mitral valve) except in IVDA (tricuspid valve)6) pseudomonas7) medical therapy 1st- sucessful in 75%, sterilizes valve in 50%surgery if- failure of abx, severe valve failure or perivalvular abscesses, pericarditis

Question 51

Cardiac Valve disease1) MC valve to become stenosed and cause2) what type of valves don’t require anticoagulation3) Bioprosthetic tissue valvesa-how long to give ACb-when to usec-life of tissue valvesd-what pts is it c/i in4) Aortic Stenoisa- cardinal symptoms and mean survival for each (Dyspnea, Angina, Syncope)b- indications for operation and peak gradient/valve area at the time5) Mitral regurgea-key index of disease progression in pts with MRb- common associated arrhythmiac- indications for surgery6) Mitral stenosisa- MC causeb-symptomsc- indications for surgery and 1st operation to try

Answer 51

1) Aorta (degenerative calcification)2) bioprosthetic tissue valves3) a- not neededb- pts who want pregnancy, C/I to anticoagulation, >65yo and unlikely to require another valve, or frequent fallsc- last 10-15 years (not as durable as mechanical valves) d- children and young pts bc of rapid calcification4) a) dyspnea on exertion (mean survival 5yr), angina (4years), syncope (3 years)b) symptomatic (usually peak gradient >50mmHg and valve area LV function key index of dz progressionb- a-fib. In end-stage dz pulmonary congestion occursc- symptoms or severe mitral regurge6)a- rare- MC cause rheumatic feverb- dyspnea and pulmonary edemac- symptoms (usually valve area

Question 52

Vascular1) MC congenital hypercoagulable disorder2) MC acquired hypercoagulable disorder

Answer 52

1) resistance to activated protein C (Leiden factor)= factor 5 leiden d/o2) smoking

Question 53

Stages of atherosclerosis1) 1st stage- cells that are present2) 2nd stage- proliferation of what cells? and what is it mediated by and what is the result3) 3rd phase- what happens and result4) risk factors5) vessel layers from inside to out

Answer 53

1) foam cells= macrophages that have absorbed fats and lipids in the vessel wall2) smooth muscle cell proliferation caused by growth factors released from macrophages-> wall injury3) intimal disruption (From SM cell proliferation)-> exposure of collagen in vessel wall-> thrombus formation-> fibrous plaques form in these areas with underlying atheromas4) smoking, HTN, hypercholesterolemia, DM, hereditary factors5) Endothelium-> Intima-> media-> adventitia

Question 54

Cerbrovascular disease1) Most important risk factor for stroke?2) where does stroke rank in MC causes of death in US?3) what artery supplies 85% of blood flow to brain4) MC site of stenosis5) Type of flow in normal internal carotid artery? and 1st branch of internal carotid artery?6) Type of flow in normal external carotid artery and first branch?7) how does communication bw ICA and ECA occur8) MC diseased intracranial artery9) MC cause of cerebral ischemic events

Answer 54

1) HTN2) 3rd MC cause of death3) carotid artery (vertebral artery supplies the rest)4) at carotid bifurcation5) continuous forward flow. Ophthalmic artery is 1st branch6) triphasic flow, superior thyroid artery is 1st branch7) ophthalmic artery (off ICA) and internal maxillary artery (off ECA)8) middle cerebral artery9) arterial embolization from ICA (not thrombosis), heart is 2nd MC source of emboli. Can also occur via low-flow state through severely stenotic lesion

Question 55

Cerebrovascular disease1) symptoms of a- anterior cerebral artery eventsb-middle cerebral artery eventsc- posterior cerebral artery events2) what is amaurosis fugax (cause and sx) and what do you see on ophthalmologic exam3) what allows for antergrade perfusion when proximal occlusion develops in carotid or vertebral arteries4) what allows for retrograde flow through the ophthalmic artery to internal carotid artery in presence of cervical internal carotid artery occlusion.

Answer 55

1) a- slowing, AMSb- contralateral motor and speech (if dominant side), contralateral facial droopc- vertigo, tinnitus, drop attacks, incoordination2) occlusion of the ophthalmic branch of the ICA (visual changes like shade coming down over eyes)- changes are transient. See Hollenhorst plaques on ophthalamic exam3) extensive collaterals bw vertebral and carotids4) periorbital collaterals

Question 56

Cerebraovascular disease1) Carotid traumatic Injury with major fixed deficit- when do you repair and why don’t you always repair it2) Carotid endarterectomya- indications for surgeryb- what if recent completed stroke, when to operatec- when is emergent CEA of benefitd- when to use a shunt during CEAe-which side do you repair first3) when should you do carotid stenting instead of CEA

Answer 56

1) repair if not occluded with carotid stent or open procedure. Don’t repair if occluded bc can exacerbate injury with bleeding2) a- syptomatic and >70% stenosis or asymptomatic and >80% stenosis.b- wait 4-6 weeks, then perform CEA if meets criteria (earlier operation has bleeding risk)c-with fluctuating neuro symptoms or crescendo/evolving TIAsd- for stump pressures

Question 57

Complications from carotid endarterectomy1) MC cranial nerve injury with CEA, sx and cause2) hypoglossal nerve injury- exam findings and sx3) glossopharyngeal nerve injury- when does it occur and sx4) Ansa cervicalis injury- what does it innervate and sx from damage5) Mandibular branch of facial nerve injury effects6) management of acute event immediately after CEA7) symptoms and management of pseudoaneurysm after CEA8) HTN after CEA- % that have it, cause and rx9) MC cause of non-stroke morbidity and mortality following CEA10) restonisis rate

Answer 57

1) Vagus nerve injury-secondary to vascular clamping during endarterectomy. Pts get hoarseness (recurrent laryngeal comes off vagus)2) tongue deviates to the side of injury-> speech and mastication difficulty3) difficulty swallowing. seen with really high carotid dissection4) strap muscles- no sx5) corner of mouth (smile)6) back to OR to check for flap or thrombus7) pulsatile bleeding mass after CEA. drape and prep before intubation, intubate, then repair.8) 20% have it caused by injury to carotid body. rx- nipride to avoid bleeding9) MI10) 15%

Question 58

Vertebrobasilar artery disease1) what do vertebral arteries arise from?2) what do they combine to form?3) what does the basilar artery split into4) T/F: usually need basilar artery or bilateral vertebral artery disease to have symptoms5) causes of vertebrobasilar insufficiency6) symptoms of vertebrobasilar insufficiency7) rx

Answer 58

1) subclavian arteries-> 2 vertebral arteries2) 2 vertebral arteries -> basilar artery3) basilary artery-> 2 posterior cerebral arteries4) True5) atherosclerosis, spurs, bands6) diplopia, vertigo, tinnitus, drop attacks, incoordination7) Percutaneous transluminal angioplasty (PTA) with stent

Question 59

Carotid body tumors1) presentation (sx)2) where are they MC3) Cell type4) rx

Answer 59

1) painless neck mass. 2) near bifurcation3) neural crest cells, extremely vascular4) resection

Question 60

Thoracic Aortic disease1) anatomya- what are the aortic arch vessels and branches2) ascending aortic aneurysma- symptoms and dxb- indications for repair (how does this change in pts with Marfan’s)3) descending aortic aneurysma-indications for repairb-risk of mortality or paraplegia with endovascular vs open repairc- where should you reimplant intercostal arteries with an open repair and why?

Answer 60

1) a- innominate (branches into right subclavian and right common carotid arteries), left common carotid artery and left subclavian artery2) a-often asx and found via CXR. Other possible sx include- compression of: vertebra-> back pain, RLN-> voice changes, bronchi-> dyspnea or PNA, esophagus-> dysphagiab-repair if acutely symptomatic or 5.5+cm (5cm or more in Marfans) or rapid increase in size (>0.5cm/year)3)a- if endovascular repair possible- >5.5cm, if open repair needed- >6.5cmb- risk is 2-3% with endovascular and 20% with open repairc-below T8 to help prevent paraplegia with open repair

Question 61

Aortic dissections1) What is stanford classification based on? describe class A and B2) What is DeBakey classification based on? Describe Types I-III3) where do most dissections start4) sx5) what % of pts have severe HTN at presentation6) risk factors7) dx8) what layer of the blood vessel wall does the dissection occur in?9) what % have aortic inssufficiency and cause?

Answer 61

1) based on presence or absence of involvement of ascending aorta.Stanford Class A= any ascending aorta involvementClass B= descending aorta involvement only2) based on site of tear and extent of dissectionDeBakey Class I= ascending and descendingClass II= ascending onlyClass III=descending only3) in the ascending aorta4) tearing chest pain, unequal pulses or BP in upper extremitiy5) 95%6) Marfan’s, previous aneurysm, atherosclerosis7) Chest CT with contrast (CXR may be normal or may have wide mediastinum)8) medial layer9) 70% 2/2 annular dilatation or when valve cuff is sheared off

Question 62

Thoracic Aortic Dissections1) what arteries can become occluded?2) MC causes of death after dissection3) Initial medical rx4) definitive rx- when to operate and how to repair5) followup post-dissection6) postop complications for thoracic aortic surgery7) cause of paraplegia with descending thoracic aortic surgery

Answer 62

1) coronary arteries and major aortic branches2) Cardiac failure from aortic insufficiency, cardiac tamponade, or rupture3) BP control with b-blockers (ie- esmolol) and Nipride4) Operate on ALL ASCENDING aortic dissections- need open repair with graft placed to eliminate flow to false lumanONLY operate on descending aortic dissections with visceral or extremity ischemia, or if contained rupture- rx- endograft or open repair or can just place fenestrations in the dissection flap to restore blood flow to viscera or extremity if ischemia is the prbm5) pts need lifetime serial scans (MRI to decrease radiation exposure) bc 30% get aneurysm formation and need surgery6) MI, renal failure, paraplegia (descending thoracic aortic surgery)7) spinal cord ischemia 2/2 occlusion of intercostal arteries and artery of Adamkiewicz that occurs with descending thoracic aortic surgery

Question 63

Abdominal Aortic Disease1) AAAa- normal size of aortab- what layer degeneratesc- risk factorsd- MC presentatione-leading cause of death2) branches of aorta in order from cephalad down

Answer 63

1) a- 2-3cmb- medial layer degenerationc- smoking, male, age, family hxd- incidental finding. Other presentations include rupture, distal embolization or compression of adjacent organse- rupture without operation2) 1st- celiac trunk (branches to splenic and common hepatic and left gastric). Common hepatic branches include Right Gastric, gastroduodenal and proper hepatic. Gastroepiploics come off of R and L gastric. Superior Pancreaticoduodenal artery comes from Right gastric2nd- L and R renal artery3rd- SMA4th- IMA5th- splits into 2 common iliacs which -> internal and external iliac (external iliac-> common femoral which branches into superficial and deep femorals)

Question 64

Abdominal Aortic Disease1) AAA rupturea- sxb- dxc- most likely site of ruptured- comorbidities that increase risk of rupturee- mortality2) AAA treatmenta- when to repairb- type of graft to usec- when do you need to reimplant the IMAd- what should you do for bleeding lumbar arteriese- what must your check if you are doing an aorto-bifemoral repair instead of a straight graft and why

Answer 64

1) a- back or abdominal pain, profound hypotensionb- US or CT (showes fluid in retroperitoneal space and extraluminal contrast with rupture)c- left posterolateral wall, 2-4cm below renalsd- COPD and HTN (predictors of expansion)e- 50% mortality if reach hospital alive2) a- if symptomatic, >5.5cm or growth >0.5cm/yrb- if backpressure

Question 65

Abdominal Aortic Aneurysm1) Complications of surgery for AAA repaira- what is the major vein injury with proximal cross-clampb- cause of impotencec- mortality of elective repaird- MCC of acute death after surgerye- MCC of late death after surgeryf- Risk factors for mortality2) Graft infection rate3) rate of pseudoaneurysm after graft placement4) MC Late complication after aortic graft placement5) what should you worry about if pt presents with diarrhea (esp if bloody) after AAA repair and whya- how to dx and what parts of rectum are spared?b- rx

Answer 65

1) a- retro-aortic left renal veinb- 1/3 get 2/2 disruption of autonomic nerves and blood flow to the pelvisc-5%d-MIe- renal failuref-Cr>1.8 is #1 RF. Others are CHF, EKG ischemia, pulmonary dysfunction, older age, females2) 1%3) 1%4) atherosclerotic occlusion5) ischemic colitis bc IMA often sacrificed with AAA repair and can cause ischemia of L colona- dx- endoscopy or abdominal CT. middle and distal rectum are spared from ischemia (supplied by middle and inferior rectal arteries which are branches of internal iliac artery)b-if peritoneal signs, mucosa is black on endoscopy or part of colon looks dead on CT-> OR for colectomy and colostomy placement.

Question 66

Criteria for AAA endovascular repair1) Neck length > than?2) neck diameter3) neck angulation than?5) common iliac artery diameter6) other criteria that must be met

Answer 66

1) >15mm2) 20-30mm3)10mm5) 8-18mm6) non-tortuous, noncalcified iliac arteries, lack of neck thrombus

Question 67

Treatment for AAA endovascualr repair leak type for the following failure sites:1) Type 1- proximal or distal graft attachment sites2) Type II- collaterals (patent lumbar, IMA, intercostals, accessory renal)3) Type III- overlap sites when using multiple grafts or fabric tear4) Type IV- Graft wall porosity or suture holes5) Type V- Expansion of aneurysm without evidence of leak

Answer 67

1) Extension cuffs2) Observe most. Perc coil embolization if pressurizing aneurysm3) secondary endograft to cover overlap site or tear4) observe. nonporous stent if that fails.5) repeat EVAR or open repair.

Question 68

AAA1) inflammatory aneurysmsa- % of AAAb-T/F- secondary to infectionc-where can it cause adhesions?d- what can become entrapped?e-symptoms and lab and CT findingsf- when does inflammatory process resolve2) Mycotic aneurysmsa- top 2 causesb- pathophysiologyc- sx and lab resultsd-rx

Answer 68

1) a- 10%b- falsec- 3rd and 4th parts of duodenumd- ureteral entrapment in 25%e- weight loss, inc ESR, thickened rim above calcifications on CTf- after aortic graft placement (may need to place preoperative ureteral stents2) a-Salmonella is #1, Staph is #2b- bacteria infect atherosclerotic plaque, can cause aneurysmc- pain, fever, 50% have positive blood cultures, periarotic fluid, gas, retroperitoneal soft tissue edema, lymphadenopathyd- extra-anatomic bypass (axillary-femoral with femoral-to-femoral crossover) and resection of infrarenal abdominal aorta to clear infection

Question 69

Aortic graft infection1) MC causes2) CT findings3) T/F- many pts have negative blood cx4) rx5) what graft site is infected most

Answer 69

1) Staph #1, E. Coli #22) fluid, gas, thickening around graft3) true4) bypass through non-contaminated field (ie- axillary femoral bypass with femoral-to-femoral crossover) and then resect infected graft5) groin grafts (aorto-bifemoral grafts)

Question 70

Aortoenteric fistulas1) time frame for occurance after abdominal aortic surgery2) sx3) MC site of fistula4) rx

Answer 70

1) >6mo after abdominal aortic surgery2) herald bleed with hematemesis, then blood per rectum.3) graft erodes into 3rd or 4th portion of duodenum near proximal suture line4) bypass through non-communicating field (axillary-femoral bypass with femoral-to-femoral crossover), resect graft and close hole in duodenum

Question 71

Peripheral Arterial Disease (PAD)1) anatomy- branches of external iliac artery from cephalad down2) Leg compartments- name the nerves (and what they innervate) and arteries for each compartmenta- Anterior compartmentb- Lateralc- deep posteriord- superficial posterior3) symptoms and MC cause of PAD

Answer 71

1) external iliac-> common femoral-> deep femoral (perforator arteries branch off) and superficial femoral artery-> popliteal artery (branches include anterior tibial, peroneal then posterial tibial artery. Dorsal pedis artery comes from anterior tibial.2) a- anterior-deep peroneal nerve (dorsiflexion, sensation bw 1st and 2nd toes) and anterior tibial arteryb-lateral-superficial peroneal nerve (eversion, lateral foot sensationc- deep posterior- tibital nerve (plantar flexion), posterior tibial artery and peroneal arteryd-superficial posterior- sural nerve3) pallor, dependent rubor, hair loss, slow capillary refill. MC 2/2 atherosclerosis

Question 72

Atherosclerosis1) #1 preventative agent2) effect of homocystinuria on atherosclerosis and rx

Answer 72

1) statins2) increased risk of atherosclerosis rx- Folate and B12

Question 73

Peripheral Arterial disease1) Claudication treatment2) symptoms- where do they occur3) name the level of occlusion for the following symptomsa- buttock claudiationb- mid-thigh claudicationc- calf claudicationd- Foot claudication4) what disease can mimic claudication5) what disease can mimic rest pain

Answer 73

1) medical rx first-> ASA, smoking cessation, exercise until pain occurs to improve collaterals2) at one level below occlusiona- aortoiliac diseaseb- external iliac diseasec- common femoral artery or proximal superficial femoral diseased- popliteal disease or superficial femoral artery3) lumbar stenosis4) diabetic neuropathy

Question 74

Leriche syndrome1- signs/sx2- level of lesion3- rx

Answer 74

1) no femoral pulses, buttock or thigh claudication, impotence (from decreased flow in the internal iliacs2) level of aortic bifurcation or above3) aorto-bifemoral bypass graft

Question 75

Peripheral artery disease (PAD)1) MC atherosclerotic occlusion in lower extremities- location and muscle that covers it2) what causes collateral artery formation and where do collaterals form3) ABI- at what ankle-brachial index do you a- start to get claudicationb- start to get rest painc- start to get ulcersd- see gangrene4) in what pts can ABIs be inaccurate and why5) T/F: in pts with claudication ABI drops with exercise

Answer 75

1) Hunter’s Canal (distal superficial femoral artery exits here); the sartorius muscle covers hunter’s canal2) abdominal pressure gradients->-circumflex iliacs to subcostals-circumflex femoral arteries to gluteal arteries-Geniculate arteries around knees3) a- ABI

Question 76

Peripheral Arterial Disease1) Postnatal angiogenesis- what is it and what stimulates it2) Pulse Volume Recordings- what are they used for3) When is arteriogram indicated

Answer 76

1) budding from preexisting vessels. Angiogenin involved2) used to find significant occlusion and at what level3) indicated if pulse-volume recordings suggest significant disease, Also used to treat pt with percutaneous intervention. Gold standard for vascular imaging.

Question 77

Surgical Indications for PAD (Periph. arterial dz)1) indications2) when to use PTFE (polytetrafloroethylene)= Gortex grafts. Otherwise what should you use.3) when to use Dacron grafts4) repair of aortoiliac occlusive disease and how to prevent vasculogenic impotence/pelvic ischemia5) rx of isolated iliac lesion6) Femoropopliteal graftsa- 5-yr patencyb-what are the muscles surrounding the popliteal artery in the knee that you must identify for exposure

Answer 77

1) rest pain, ulceration or gangrene, lifestyle limitation, atheromatous embolization2) only for bypasses above the knee. Need to use saphenous vein for below the knee bypasses3) good for aorta and large vessels4) aorto-bifemoral repair MC. ensure flow to at least 1 internal iliac artery (hypogastric with good back-bleeding) to prevent vasculogenic impotence and pelvic ischemia, otherwise need bypass to internal iliac.5) PTA (percutaneous transluminal angioplasty) with stent 1st choice. if that fails, consider femoral-femoral crossover6) a- 75%b- gastrocnemius is posterior and popliteus is anterior

Question 78

Surgery for PAD (periph art dz)1) Femoral-Distal grafts (peroneal, anterior tibial or posterior tibial arterya-5-yr patencyb- T/F- patency influenced by level of distal anastamosisc- T/F- distal lesions more limb threatening bc of lack of collateralsd- when are bypasses to distal vessels used and what is needed for them to be successful2) when to use extra-anatomic grafts3) complication of femoral-to-femoral crossover graft

Answer 78

1) a- 50%b-false. not influenced by levelc- trued- for limb-salvage only. bypass vessel needs to have run-off below the ankle for it to be successful2) to avoid hostile conditions in the abdomen (multiple previous operations in a frail patient3) doubles blood flow to donor artery-> can get vascular steal in donor leg.

Question 79

Lower extremity bypass complications1) Swellinga- if early causes and complications and rxb- if late cause2) complications of reperfusion of ischemic tissue3) #1 cause of early failure of reversed saphenous vein graft4) #1 cause of late failure

Answer 79

1) a- reperfusion injury and compartment syndrome. rx- fasciotomyb- DVTs- dx- US, rx- heparin, coumadin2) compartment syndrome, lactic acidosis, hyperkalemia, myoglobinuria3) technical prbm4) atherosclerosis

Question 80

Peripheral Arterial Disease1) rx of heal ulceration to bone2) What is difference bw dry and wet gangrene3) rx of dry gangrene4) rx of wet gangrene5) Mal perforans ulcera- locationb- risk factorc- what may be present at time of dx at site of ulcerd-rx

Answer 80

1) amputation2) wet gangrene is infectious nd need to remove infected necrotic matl and give abx. Dry gangrene is noninfectious and can allow to autoamputate if small or just toes3) amputate large lesions, see if pt has correctable vascular lesion4) can be surgical emergency if extensive infection or systemic complications (ie- sepsis). May need emergency amputation. Otherwise debridement and abx5) a- at metatarsal heads- 2nd MTP joint MCb-DM. c- osteomyelitis. d-non-weightbearing, debridement of metatarsal head (remove cartilage), abx. assess need for revascularization

Question 81

Percutaneous Transluminal angioplasty (PTA)1) when to use2) how it works

Answer 81

1) use for short stenoses. excellent for common iliac artery stenosis2) intima usually ruptured and media stretched, pushes the plaque out (requires passage of a wire first)

Question 82

Compartment syndrome1) caused by what after PAD intervention2) cell type responsible3) which compartment is it most likely to occur in and sx4) rx

Answer 82

1) reperfusion injury-> swelling-> compartment syndrome2) PMNs3) anterior compartment-> foot drop4) fasciotomies (get all 4 compartements in lower leg) and leave open 5-10days

Question 83

Popliteal entrapment syndrome1) presentation/ what pts and sx2) anatomic abnormality3) rx

Answer 83

1) men, 40s, loss of pulses with plantar flexion, present with mild intermittent claudication2) medial deviation of artery around medial head of gastrocnemius3) resection of medial head of gastrocnemius muscle. may need arterial reconstruction

Question 84

Adventitial Cystic Disease1) who gets it2) where is MC area to have it3) sx4) dx5) rx

Answer 84

1) Men, 40s2) popliteal fossa, often bilateral (gnaglia originate from adjacent joint capsule or tendon sheath)3) intermittent claudication, change in sx with knee flexion/extension.4) angiogram5) cyst resection. vein graft if vessel is occluded

Question 85

WHat are the arterial autografts used in CABG

Answer 85

radial artery grafts and IMA

Question 86

Amputations1) indications2) Mortality for leg amputation3) How many heal, walk again, mortality fora-BKAb-AKA4) when to do emergency amputation

Answer 86

1) gangrene, large non-healing ulcers or unrelenting rest pain not amenable to surgery2) 50% in 3 years3) a- 80% heal/70% walk/ 5% mortalityb- 90% heal/ 30% walk again/ 10% mortality4) systemic complication or extensive infection

Question 87

Acute arterial emboli1) clinical distinction bw acute arterial embolism and acute arterial thrombosis-which is associated witha-arrhythmiab- claudication or rest painc- absence of contralateral pulsesd-no physical findings of chronic limb ischemiae- collaterals2) symptoms3) MCC4) MC site of peripheral obstruction5) rx

Answer 87

1) a and d-emboli, b, c and e-thrombosis2) Pain, pallor, poikliothermia, pulselessness, parasthesia, paralysisleg goes from white (pallor)-> cyanotic-> marbling3) a-fib #1. Others- recent MI with LV thrombus, myxoma, aorto-iliac disease4) common femoral artery5) embolectomy, need to get pulses back, postop angiogram-consider fasciotomy if ischemia>4-6hr-aortoiliac emboli can be treated with bilateral femoral artery cutdowns and bilateral embolectomies

Question 88

Atheroma embolism1) cause2) MC site of atheroma embolization3) Blue toe syndrome- source of emboli, PE findings4) dx5) rx

Answer 88

1) cholesterol clefts that can lodge in small arteries2) renals3) flaking atherosclerotic emboli off abdominal aorta or branches. pts typically have good distal pulses. Aortoiliac dz MC source4) chest/abd/pelvis CT to look for aneurysma source and echo to look for clot or myxoma in heart5) may need aneurysm repair or arterial exclusion with bypass

Question 89

Acute arterial Thrombosis treatment

Answer 89

for threatened limb (loss of sensation or motor fnc)-> give heparin and go to OR for thrombectomy#if limb not threatened->angiography for thrombolytics#if thrombosis of PTFE (Gortex) graft-> thrombolytics and AC. if limb threatened go to OR for thrombectomy

Question 90

Renal vascular disease1) where does right renal artery run2) % of pts with accessory renal arteries3) signs of renovascular HTN (renal artery stenosis)4) Renal atherosclerosis- location and sex affected5) fibromuscular dysplasia- location and sex6) Dx7) rx8) indications for nephrectomy with renal HTN

Answer 90

1) posterior to IVC2) 25%3) bruits, diastolic BP>115, HTN, in kids or premenoausal women HTN resistant to drug rx4) left side, proximal 1/3, men5) right side, distal 1/3, women6) angiogram7) PTA with stent placement if due to atheroscerotic disease8) atrophic kidney

Question 91

Upper extremity vascular disease1) Occlusive diseasea- why are proximal lesions usually asymptomaticb- MC site of UE stenosisc-rx2) Subclavian steal syndromea- what is it/causeb-when to operatec-rx3) Thoracic outlet syndromea- where does the subclavian vein runb- where do the brachial plexus and subclavian artery runc-symptomsd-dxe- MCC of anatomic abnormalityf- MCC of pain

Answer 91

1) a- collaterals; b-subclavian arteryc-PTA with stent. common carotid to subclavian bypass if that fails2) a-proximal subclavian artery stenosis-> reversal of flow through ipsilateral vertebral artery into the subclavian arteryb- if limb or neuro sx (vertebrobasilar symptoms)c- PTA with stent to subclavian artery. common carotid to subclavian bypass if that fails3) a- over the 1st rib anterior to anterior scalene muscle, then behind the clavicalb- over the 1st rib, posterior to anterior scalene and anterior to middle scalenec- back, neck and/or arm pain/weakness/tingling (often worse with palpation/manipulationd- cervical spine and chest MRI, duplex US (vascular etiology), electromyelogram (EMG, neurologic etiology). Neuro involvement MC than vasculare- cervical ribf- brachial plexus irritation

Question 92

THoracic outlet syndrome1) If brachial plexus irritation causea-how to reproduce symptomsb-MC nerve distribution and effectsc-rx2) if subclavian vein cuasea- presentationb-is venous or arterial thrombus MCc- dxd-rx3) if subclavian artery cause of sxa- MCC of compressionb-sxc-what is Adson’s testd- dxe-rx

Answer 92

1) a- tapping (tinsel’s test)b- ulnar nerve-> tricep muscle weakness and atrophy, weakness of intrinsic muscles of hand, weak risk flexionc- cervical rib and 1st rib resection, divide anterior scalene muscle2) a- effort-induced thrombosis of subclavian vein (Paget-Von-Schrotter disease, baseball pitchers)- acutely painful, swollen, blue limbb- venous MCc- venography gold standard, but Duplex US fined- thrombolytics initially, repair at that admission (cervical rib and 1st rib resection, divide anterior scalene)3)a- compression 2/2 anterior scalene hypertrophy. lease common cause of TOS.b-hand pain from ischemiac- absent radial pulses with head turned to ipsilateral sided-duplex US or angiographye-surgery- cervical rib and 1st rib resection, divide anterior scalene muscle. possible bypass graft if artery damaged or aneurysmal

Question 93

Why can motor fnc remain in digits after prolonged hand ischemia

Answer 93

bc motor groups are in proximal forearm

Question 94

Mesenteric ischemia1) mortality2) MC artery involved3) CT findings4) MC causes of visceral ischemia

Answer 94

1) 60%; 2) SMA; 3) bowel wall thickening, vascular occlusion, intramural gas, portal venous gas4) embolic- 50%, thrombotic-25%, non-occlusive-15%, venous thrombosis- 5%

Question 95

Mesneteric ischemia 2/21) SMA embolisma- MC location; b- MC source; c- sxd-PMH/risk factors; e-dx; f-rxg- how to get SMA exposure2) SMA thrombosisa- sxb-dxc-rx3) mesenteric vein thrombosisa- presentation/ PMHb-dxc- rx

Answer 95

1) a-near origin of SMA; b- heart (a-fib); c-pain out of proportion to exam, sudden onset, hematochezia and peritoneal signs are late findingsd- a-fib/endocarditis/recent MI, recent angiographye- angiogram or CT abd with IV contrastf-embolectomy, resect infarcted bowel if presentg-divide ligament of treitz, SMA is to the right of this near the base of the transverse colon mesentery2) a-h/o food fear, weight loss, vasculitis or hypercoaguable state. sx similar to embolismb- angiogram or CT abd with IV contrastc- thrombectomy. May need PTA with stent or open bypass. Resection of infarcted bowel3) a- short segments of intestine involved-> bloody diarrhea, crampy abdominal pain, PMH- vasculitis, hypercoagulable state, portal HTNb- abd CT or angio with venous phasec- heparin + resection of infarcted bowel if present

Question 96

Non-occlusive mesenteric ischemia1) causes2) risk factors3) sx4) what areas are most vulnerable5) rx

Answer 96

1) spasm, low-flow, hypovolemia, hemoconcentration, digoxin-> final common pathway is low cardiac output to visceral vessels2) prolonged shock, CHF, prolonged cardiopulmonary bypass3) blood diarrhea, pain4) watershed areas (Griffith’s - splenic flexure; Sudak’s- upper rectom5) volume resuscitation, catheter directed nitroglycerin can inc visceral blood flow. may also need to inc cardiac output (dobutamine). also resect infarcted bowel.

Question 97

Median arcuate ligament syndrome1) what does it cause2) symptoms/signs3) rx

Answer 97

1) celiac artery compression2) bruit near epigastrium, chronic pain, weight loss, diarrhea3) transect median arcuate ligament; may need arterial recon

Question 98

Chronic Mesenteric angina1) sx2) dx3) rx

Answer 98

1) weight loss 2/2 food fear (visceral angina 30min after meals)2) lateral visceral vessel aortography to see origins of celiac and SMA3) PTA and stent. Bypass if that fails

Question 99

What is Arc of Riolan

Answer 99

collateral bw SMA and celiac

Question 100

Visceral and peripheral aneurysms1) MC complication of aneurysms above inguinal ligament2) MC complication of aneurysms below inguinal ligament3) Visceral artery aneurysmsa- risk factorsb-MC visceral aneurysmc- rx- when to repair splanchnic aneurysms, what about splenic and type of repair

Answer 100

1) rupture2) thrombosis/emboli3) a-medial fibrodysplasia, portal HTN, arterial disruption 2/2 inflammation (ie- pancreatitis)b-splenic artery aneurysm (women, 2% risk of rupture)c- Repair all splanchnic artery aneurysms >2cm when diagnosed (50% rupture risk) except splenic-Repair splenic after aneurysms if sx, pregnant (high rate of pregnancy-related rupture MC in 3rd trimester), childbearing age or >3-4 cmrx- PTA and stent. bypass if fails. Splenic artery aneurysms can be ligated bc good collaterals

Question 101

Visceral and peripheral aneurysms1) Renal artery aneurysm- size to rx and rx2) Iliac and femoral artery aneurysms- size to rx and rx3) MC peripheral aneurysm4) Most likely type to get thrombosis or emboli with limb ischemia

Answer 101

1) >1.5cm. rx- covered stent2) Iliac >3cm or femoral >2.5 cm. rx- covered stent3) Popliteal artery aneurysm4) Popliteal artery aneurysm

Question 102

Visceral and peripheral aneurysms1) Popliteal artery aneurysma-findings on leg examb- what % are BL or have another aneurysm elsewherec-dxd-indications for surgerye-rx

Answer 102

1) a- prominent popliteal pulsesb-50%; c-ultrasound; d-sx, >2cm or mycotice- exclusion and bypass, 25% have complication that requires amputation if not treated. DO NOT USE covered stent for these

Question 103

visceral and peripheral Pseudoaneurysm1) MC location2) cause3) rx4) what does a pseudoaneurysm that occurs at a suture line late (months to years) after surgery imply

Answer 103

1) femoral artery2) percutaneous interventions or disruption of a suture line bw graft and artery3) if sp percutaneous intervention-> US-guided compression with thrombin injectionif at suture line early after surgery-> surgical repair4) suggests graft infection

Question 104

Fibromuscular dyspasia1) who gets it and sx2) MC involved vessel3) MC variant4) Rx

Answer 104

1) women, HTN if renal involved. HA or stroke if carotids involved2) renal artery, then carotid and iliac3) medial fibrodysplasia (85%)4) PTA (best), bypass if that fails

Question 105

Buerger’s Disease1) who gets it/risk factors2) sx3) angiogram findings4) rx

Answer 105

1) young men, smokers2) severe rest pain with B/L ulceration, gangrene of digits esp fingers3) corkscrew collaterals and severe distal disease. normal arteries proximal to popliteal and brachial vessels (it’s a SMALL VESSEL DISEASE)4) quit smoking. otherwise will require serial amputations

Question 106

Cystic Medial Necrosis syndromes1) Marfan’s diseasea- defectb- sx2) Ehlers-Danlos syndromea-defectb-sxc-can you do angiogramd-rx

Answer 106

1) a- fibrillin (connective tissue elastic fibers)b- marfinoid habitus, retinal detachment, aortic root dilatation2) a- collagen defectsb- easy bruising, hypermobile joints, tendacy for arterial rupture (esp abdominal vessels)c- NO!-> risk of vessel lacerationd- repair too difficult. must ligate vessels to control hemorrhage

Question 107

immune arteritis1) Temporal arteritisa-size of artery affected; b- sx and who gets it; c) dx; d)- path; e-rx2) Polyarteritis nodosaa-size of artery affectedb- what does it cause; c- MC artery involved; d-rx3) Kawasaki’s diseasea-size of artery affected; b- who gets it and sxc- MC cause of death; d-rx4) hypersensitivity angiitisa-size of artery affected; b- cause; c- sx; d-rx

Answer 107

1) a- large artery; b-women >55yo. HA, fever, blurred vision (risk of blindness); c-temporal artery bx; d- giant cell arteritis, granulomas, inflammation of large vessels, long segments of smooth stenosis alternating with segments of large diameter; e- steroids, bypass of large vessel if needed.2) a- medium sized; b- aneurysms that thrombose or rupture; c-renal; d-steroids3) a- medium; b) kids, febrile viral illness with erythematous mucosa and epidermis, get aneurysms of coronary arteries and brachiocephalic vessels; c-arrhythmia; d- steroids, possible CABG4) a- small artery dz; b- 2/2 drug/tumor antigens; c- rash (palpable purpura), fever, symptoms of end-organ dysfnc. d-Ca-channel blockers, pentoxifylline, stop offending agent

Question 108

Radiation arteritis1) Early changes2) Late changes (1-10yr)3) Late late (3-30yr)

Answer 108

1) sloghing and thrombosis (Obliterative endarteritis)2) fibrosis, scar, stenosis3) advanced atherosclerosis

Question 109

Raynaud’s disease1) who gets it and sx2) rx

Answer 109

1) young women, pallor-> cyabosis-> rubor2) Ca-channel blockers and warmth

Question 110

Venous Disease1) what vein does greater saphenous vein drain to and where does it run2) can you clamp the IVC3) which renal vein can be ligated near the IVC in emergencies bc of collaterals

Answer 110

1)runs medially and joins femoral vein near groin2)NO-> it will tear3) the left renal vein can be ligated near the IVC bc of collaterals (L gonadal vein and L adrenal vein). The R renal vein doesn’t have these collaterals

Question 111

Dialysis access grafts1) MC reason of failure of AV grafts for dialysis2) Crimino graft- artery and vein used. when can you start to use for dialysis3) Interposition graft- vein involved and when you can use

Answer 111

1) venous obstruction 2/2 intimal hyperplasia2) radial artery to cephalic vein. Wait 6wks to use to allow the vein to mature3) brachiocephalic loop graft. wait 6 wk to allow fibrous scar to form

Question 112

Aquired AV fistula1) MC cause2) symptoms3) how to repair

Answer 112

1) trauma2) peripheral arterial insuffciency, CHF, aneurysm, limb-length discrepancy3) lateral venous suture arterial side may need a patch or bypass graft, interpose tissue so it doesn’t recur

Question 113

Varicose veins1) risk factors2) rx

Answer 113

1) smoking, obesity, low activity2) sclerotherapy

Question 114

Venous ulcers1) cause2) where do they occur3) what size ulcers will heal without surgery4) rx

Answer 114

1) venous valve incompetence2) above and posterior to malleoli3) t need surgery4) Unna boot compression cures 90%, may need to ligate perforators or have vein stripping of greater saphenous vein

Question 115

Venous insufficiency1) sx2) rx

Answer 115

1) aching, swelling, night cramps, brawny edema, venous ulcers. edema 2/2 to incompetent perforators and/or valves2) elevate, leg wrap, ambulation with avoidance of long standing-greater saphenous vein stripping for saphenofemoral valve incompetence or removal of perforators if just perforator valves invompetent (stab avulsion technique) if sx are severe or recurrent ulceration despite medical rx

Question 116

Superficial thrombophlebitis1) cause2) rx

Answer 116

1) nonbacterial inflammation2) NSAIDs, warm packs, ambulation

Question 117

Suppurative thrombophlepitis1) signs/sx2)rx

Answer 117

1) pus fills vein; fever, inc WBC, erythema, fluctuance, usually associated with infection following peripheral IV2) resect entire vein

Question 118

Migrating thrombophelbitis- what is this a sign of

Answer 118

pancreatic cancer

Question 119

what is seen on a normal venous doppler US

Answer 119

augmentation of flow with distal compression or release of proximal compression

Question 120

how do SCDs work

Answer 120

decrease venous stasis and increase tPA release

Question 121

DVTs1) which leg is MC involved and why2) Virchow’s Triad3) IVC filter indications4) how does a pt get a PE with IVC filter in place5) Phlegmasia cerulea dolens- sx and rx

Answer 121

1) Left 2x more than right bc longer left iliac vein compressed by right iliac artery2) venous stasis, hypercoagulability, venous wall injury3) C/I to anticoagulation; PE while on coumadin, free-floating ileofemoral thrombi; after pulmonary embolectomy4) comes from ovarian veins, inferior vena cava superior to filter, or from upper extremity via SVC5) tenderness, cyanosis, massive edema. rx- heparin, rarely need surgery

Question 122

Management of venous thrombosis with central line

Answer 122

pull out central line if not needed, then heparin. can try to rx with systemic heparin or TPA down line if access site is important

Question 123

Lymphatics1) T/F: do not contain basement membrane2) T/F: are found in bone, muscle, tendon, cartilage, brain and cornea3) MC infection in Lymphedema4) rx of lymphedema5) MC side for congenital lymphedema

Answer 123

1) true2) false- not found in these3) strep4) leg elevation, compression, abx for infection5) L>R

Question 124

Lymphangiosarcoma1) symptoms2) early mets to where3) what is Stewart-Treves syndrome

Answer 124

1) raised blue/red coloring2) lung3) lymphangiosarcoma associated with breast axillary dissection and chronic lymphedema

Question 125

Lymphocele following surgery1) usually after what type of operation2) signs3) dx and rx

Answer 125

1) groin dissection2) leakage of clear fluid3) perc drain. resection if that fails- can inject isosulfan blue dye into foot to identify the lymphatic channels supplying the lymphocele