Chap 43-46 Anastomotic aneurysm, AEF, Graft Thrombosis and Endovascular Flashcards by Christine Herman

List local factors associated with development of anastomotic aneurysm.

Arterial wall degen
Suture line disruption
Prosthetic graft failure
Infection/inflammation
Technical factors
Mechanical stress

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List systemic factors associated with anastomotic aneurysm.

Smoking
DLP
HTN
Anticoagulation
Vasculitides
Generalized arterial weakness

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What are indications for treatment for anastomotic aneurysm?

> 2.5cm

symptomatic

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Is endovascular better then open repair for anastomotic aneurysms?

endo can offer lower mortality and morbidity rates with high success rates in certain patients

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What are the causes of primary AEF?

aneurismal aorta (most common)
foreign body
tumor
radiation
infection
GI dz

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What portion of the duodenum is involved in AEF?

3rd or 4th

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Where do secondary AEF and AEE occurs?

AEF suture line

AEE on graft

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What are the causes of secondary AEF?

infection
pulsatile pressure (graft non compliant)
technical error (injury to bowel)

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what is the classic triad for secondary AEF?

GI bleeding
abdo pain
pulsatile mass
11%

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What is the classic feature of a secondary AEF?

herald bleed

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What are findings on CT scan that indicate AEF?

Effacement of fat planes around aorta
Perigraft fluid and soft tissue thickening,
ectopic gas,
tethering of adjacent thickened bowel loops toward aortic graft, rarely extrav

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What are signs of AEF on endoscopy?

need to see 3-4th portions
visualization of graft
ulcer
erosion with adherent clot
extrinsic pulsatile mass

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What are the most common bacteria for primary AEF?

salmonella

klebsiella

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What are the most common bacteria for secondary AEF?

s.aureus

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What are repair options?

graft excision without replacement if enough ollaterals

insitu graft replacement

neo-aortoiliac procedure

extra-anatomic revasc

endovascular (as bridge)

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What grafts can be used for replacement?

allograft
synthetic graft
silver coated dacron
antibiotic impregnated grafts

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What are the result of operative repair for AEF?

mortality 30%
amputation 10%
3 yr survival 50%

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What are most common complications after PCI?

bleeding/hematoma
PSA
AVF
dissection
thrombosis

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What are RF for complications after endo procedure?

larger sheath
interventional procedures
previous cath
small BMI
female
uncontrolled HTN
GIIbIIIa
increased age

What are indications for intervention for femoral hematoma?

hemo instability
persistent anemia
skin necrosis
nerve compression 
severe pain

What nerves can be affected in the retroperitoneal space (4)?

lateral cutaneous nerve of the thigh
genitofemoral nerve
femoral nerve
nerve to cremaster muscle

What does the lateral cutaneous nerve of the thigh innervate?

innervates skin on lateral thigh

What does the genitofermoral nerve innervate?

sensation upper anterior thigh

sensation anterior scrotum/mons

What does the femoral nerve innervate?

sensation ant/medial thigh/medial chin/arch of foot

extends knee

What does the nerve of the cremaster muscle innervate?

cremasteric reflex

What are signs/symptoms of RPB?

``` non-specific groin/back pain oliguria numbness weakness LE ecchymosis flank (grey turner) ecchymosis umbilicus (cullens) ```

What is natural hx of AVF from endovascular procedure?

30-80% resolve spontaneously within 1 year (most within 1 month)

What are treatment strategies for PSA?

US compression US guided thrombin observation surgical Endovascular

what is success of thrombin injection for PSA? describe procedure.

95-100% Anesthetize skin Fill sac with 0.1-0.2ml of thrombine Direct needle away from inflow of the PSA If perist then another dose Check distal pulses and repeat US in 24-48 hours Recurrence 3%

What are indications for surgical intervention on PSA?

``` Infected Hemo instability Skin necrosis Distal limb ischemia Neurologic defecit Failure of US treatment Large aneurysm >5cm with wide necks ```

What causes thrombosis after endovasclar procedure?

large sheath aggressive compression closure device failure

What are methods of nerve injury in brachial access?

hematoma direct damage schema from arterial thrombosis

What are different types of closure devices and give an e.g.?

``` collagen based (angioseal) suture based (per close) metal/disk based (star close) ```

What is the evidence for closure devices?

MA | no difference in complication rate then with compression alone

What are active and passive closure devices?

active suture/clip extravascular prothrombotic matrix passive (faciliatate compression) external patches with prothrombotic coating assisted compression

What were the rates of life threatening hemorrhage in TOPAS and STILE trial?

13% | 6%

At what fibrinogen levels do you alter thrombolysis management?

<100 stop

List ways to assess graft latency intra-operatively.

``` inspection palpation arteriography doppler duplex angioscopy IVUS ```

What b/w to send off before initiating heparin in thromboses grafts?

``` Plt Functional activated protein C resistance Anticardiolipin antibodies ATIII Protein S HITT assay ```

What are RF for graft thrombosis?

``` Single vessel runoff high rate of graft failure Below knee target DM Preop tissue loss BMI >35 Early revision African American smoking failure to go to surveillance ```

What are the critical elements for sustained flow in bypass graft?

``` Inflow Outflow Conduit Operative technique Coagulation profile ```

What are 30 day causes of graft thrombosis?

technical error graft thrombogenicity poor runoff obstructive venous disease

What are 18 month causes of graft failure?

neointimal hyperplasia | vein graft structural abnormalities

What are 5 year causes of graft failure?

vein or prosthetic graft structural abnormalities | progressive athero

What are indications for angioplasty for intimal hyperplasia?

Post CTD to bridge to OR High risk for OR Difficult to approach surgically