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Vascular surgery - Rutherford's 9th ed > Chap 108-109 Aorto-iliac Dz > Flashcards

Chap 108-109 Aorto-iliac Dz Flashcards

2
Q

What are symptoms of AI dz?

A

Claudication (calf, thigh, butt)
embolism (saddle or blue toe syndrome)
Erectile dysfunction

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3
Q

What collateral network supplies distal to AI dz?

why are the collaterals important?

A

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

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4
Q

What are signs and symptoms of blue toe syndrome?

A

palpable pulses with patchy ischemia (livedo) but distal gangrene can occur

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5
Q

What is Leriche syndrome?

A

Terminal aortic occlusion

Thigh, hip, buttock claudication, atrophy of leg muscles, impotence, decreased femoral pulses

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6
Q

What is small aortic syndrome or hypoplastic aortic syndrome?
What is life expectancy?
Where is plaque?

A

Isolated AI in usually younger females, usually smokers
normal
posterior plaque prox or at bifurcation

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7
Q

What are pullback pressure in AI?

A

Pull back pressure 5-10mmhg at rest or change in systolic pressure greater then 15% indicates dz warranting revasc

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8
Q

What are indications for surgery?

A

disabling claudication
tissue loss
ischemic rest pain

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9
Q

What is natural history of claudicants in AI?

A

1%/year limb loss
5%/year mortality
20-30% require OR in 5 years

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10
Q

What % of AI have CAD?

A

nearly 50%

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11
Q

What are repair techniques for AI?

A 
endarterectomy
Aorto-bifem
Fem-Fem
Ax-fem
Obturator bypass
throaci/supra-celiac- fem bypass
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12
Q

When is endarterectomy best suited?

A

Small arteries
Want to avoid prosthetic graft
Erectile dysfunction as may improved hypogastric perfusion
Best for focal stenosis otherwise not usually done

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13
Q

Advantages to End-end in aortobifem?

A

Possible better hemodynamics, less flow turbulence
Less rate of pseudoaneurysm
Close peritoneum over graft
With concomitant aneurismal disease should to end-end

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14
Q

Advantages to end-side in aortobifem?

A

Preserve IMA
Preserve flow hypogastrics
Less erectile dysfunction, paraplegia secondary to cauda equina syndrome
Good if heavily calcified aorta

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15
Q

What is cauda equina?

what are symptoms?

A

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.

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16
Q

What dose of heparin do you give before clamping?

target ACT?

A

70-100units/kg

250-350 secs

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17
Q

Is there benefit of adjunctive profundoplasty in aortobifem?

A

May Improve long-term patency in AI bypasses

5year patency 88%

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18
Q

Advantages/disadvantages for external iliac anastomosis in AI bypass?

A

Good for hostile groin, obese, DM with intertriginous rash

More technically difficult and possible lower patency rates then to fem

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19
Q

when to consider inflow and outflow bypass?

A

tissue loss (appears no increase m&m)

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20
Q

how many patients have improvement of symptoms after ABF for AI?

A

80%

2/3 still have symptoms

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21
Q

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?

A

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%

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22
Q

what is 5 year patency for endart and ABFG in AI?
10 year patency?
moratlity rates?
10 survival?

A

95% and 85-90%
85-90% and 75-85% (older 95%, but <50yo 66%)
1%, 1-4%
isolated normal life expectency, multilevel disease 50%

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23
Q

patency difference between trans vs retro approach ABF?

PTFE vs Dacron

A

No

No

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24
Q

What are early complications and percentages ABF?

A 
Sexual dysfunction <5%
bowl ischemia 2%
MI 1-5%
death 1-4%
ALI 1-3%
bleeding 1-2%
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25
Q

where is bowel ischemia usually found after Bypass for AI?

how to avoid?

A

recto-sigmoid

preserve IMA, keep up perfusion

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26
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
27
What are common causes of IC?
SFA stenosis, athersclerosis, pop entrapment, ACD, chronic compartement syndrom, arteriris, thrombosis, FMD, coarctation
28
what are RF for claudication?
HTN, DM, metabolic syndrome, smoking, male, age, DLP, hyperhomocystenemia
29
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
30
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
31
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 ```
32
How does hyperhomocysteine cause athero?
high level toxic to endothelium and reduce NO release, promote mSMC proliferation and arterial wall inflammation leading to athero
33
What is risk of surgery for PAD?
5% risk MI, CHF, death
34
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
35
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
36
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
37
What drugs have evidence in IC?
cilostazol naftidrofuryl statin (supporting evidence)
38
what is cilastozol? | what is the evidence
``` phosphodeisterase inhibitor RCT, 50% increase in walking distance imporve QoL CI in CHF 15% AE ```
39
What is the evidence for pentoxifylline?
MA questionable benefit
40
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
41
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%
42
What are some scoring models for survival with LE intervention?
LEGES Finnvasc Prevent III Basil
43
What are some indications for extra-anatomic bypass?
``` high-risk laparotomy hostile abdo infected graft AE fistula groin sepsis ```
44
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
45
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
46
where is fem-fem tunneled?
prefascial plane | pre-peritoneal if thin or too fat, previsou surgery, radiation damage to skin
47
What is the mortality periop, 3 yr survival, 5 yr patency for fem-fem?
<5% 70% 65%
48
What features on duplex are concerning for graft failure?
peak systolic >300cm/sec inflow or <60cm/sec midgraft
49
What size better for fem-fem? what amterial?
no difference
50
what % have steal with fem-fem
3% | 45% exercise induced
51
Which side axillary artery to choose for ax-fem?
consider non-dominant if will need future left chest surgery if 10mmhg discrepency
52
what is 3 year survival for ax-fem? 5 year patency? 3 yr limb salvage
35% 75% better in claudicants then CLI 70%
53
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
54
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 ```
55
What are the 3 and 5 yr patency for obturator bypass?
75 and 60%
56
What does the obturator nerve innervate?
sensory to medial thigh | motor of adductor muscles of LE
57
What are features of throaco-fem surgery?
7-8th rib incision | tunnel graft retroperitoneally behind or anterior to kidney
58
What are TASC A lesions for AI?
ui/bilat CIA | uni/bilat short <3cm EIA
59
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
60
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 ```
61
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
62
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
63
What is a significant pullback gradient?
10mmhg | >15% with papaverine
64
what are re-entry devices?
outback | pioneer
65
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
66
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
67
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
68
What are predictors of endovascular failure for AI dz? | what can improve patency?
EI dz (PPR 1 year 50%) female RI CLI covered grafts
69
What is the definition of CLI?
persistent, recurring ischemic rest pain requiring opiate >2 weeks AP <50mmhg
70
What size vein for LE bypass?
3mm
71
whats a linton patch?
when bypass comes of CFA endart anastomoses
72
what is the patency of isolated popliteal target?
situational perfusion enhancement | 5 yr patency 50%, secondary 75%
73
What are graft options for LE bypass?
``` SVG LSV superficial FV arm vein endarterectomized seg of SFA cryopreserved vein PTFE ePTFE contr vein ```
74
What % of contra vein is used for future surgery?
20-25%
75
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%
76
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
77
What are correction rates for intra-op imaging for LE bypass?
arteriography 27%--may not see incomplete valve lysis | DUS 12% (psv >250)
78
``` 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%
79
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
80
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%
81
what are duplex criteria for impending infrainguinal graft failure?
velocity >300cm/s velocity ratio >3.5-4 drop in ABI 0.15 prophylactic repair
82
what are causes of early graft failure?
early | anastomotic, clamp defect, valve defect, poor quality conduit, inadequate outflow
83
What are techniques for treating stenosis or late occlusion?
patch, interposition, valve excision, plasty, anastomotic translocation thrombectomy, lysis, redo with vein or prosthetic
84
What are TASC A lesion for fempop?
single O <5cm | single s <10
85
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 ```
86
What are TASC C lesions for fempop?
multiple stenosis or occlusions total >15cm | recurrent stenosis or occlusion after 2 endo attempts
87
what are Tasc D lesions for fem pop?
CTO of CFA/SFA | CTO of pop and prox trifurcation
88
What are TASC A lesion for infrapop?
singel stenosis <1cm in tibials
89
What are TASC B lesions for infrapop?
multiple stenosis of tibials each <1cm at trifurcation | short tibial stenosis with fempop PTA
90
What are TASC C lesions for infrapop?
stenosis 1-4cm occlusions 1.2 cm of tibials extensive stenosis of trifurcation
91
What are TASC D lesions for infrapop?
tibial occlusion >2cm | diffusely dz tibials
92
What are determinants of succes in endovascular?
improvement in at leas one rutherford and ABI increase >0.15 | absence of stenosis <200
93
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
94
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%
95
What are 1,2,3 year success rates for endo in LE for endo vs open?
40, 20, 10 endo | 85, 70, 70 open
96
``` 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
97
What is patency of angio for infrapop? | difference in angio vs stenting?
1yr 75% 3yr 60% no difference
98
wha is patency for laser atherrectomy?
1 yr 75%
99
What is benefit of DES in infrapop endo?
3 yrs everolimus had higher PP then BMS 30 vs 20
100
What is plasty/stenting surveillance?
ABI, PVR, Duplex | 1,3,6,9,12 months then yearly
101
what is patency of CFA steting?
3 yr patency 80%, surgery recommended
102
What is endo not indicated for PFA?
usually not suitable because of ostial, bifurcation and diffuse
103
What are cholesterol targets for PAD? BP? HbgA1C
sympto/asympto PAd LDL 100mg/dL PAD and vascular dz in other beds 70mg/dL <7%
104
What medications should PAD patients be on, TASC?
ASA beta-blocker peri-op cilostazol first line for relief of claudication
105
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
106
What is critical TcPO2 level?
<30mmhg
107
What are the principles of ulcer management?
restoration of perfusion local ulcer and pressure relief treatment of infection diabetic control
108
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
109
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

Vascular surgery - Rutherford's 9th ed (16 decks)

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