Chap 43-46 Anastomotic aneurysm, AEF, Graft Thrombosis and Endovascular Flashcards
List local factors associated with development of anastomotic aneurysm.
Arterial wall degen Suture line disruption Prosthetic graft failure Infection/inflammation Technical factors Mechanical stress
List systemic factors associated with anastomotic aneurysm.
Smoking DLP HTN Anticoagulation Vasculitides Generalized arterial weakness
What are indications for treatment for anastomotic aneurysm?
> 2.5cm
symptomatic
Is endovascular better then open repair for anastomotic aneurysms?
endo can offer lower mortality and morbidity rates with high success rates in certain patients
What are the causes of primary AEF?
aneurismal aorta (most common) foreign body tumor radiation infection GI dz
What portion of the duodenum is involved in AEF?
3rd or 4th
Where do secondary AEF and AEE occurs?
AEF suture line
AEE on graft
What are the causes of secondary AEF?
infection pulsatile pressure (graft non compliant) technical error (injury to bowel)
what is the classic triad for secondary AEF?
GI bleeding
abdo pain
pulsatile mass
11%
What is the classic feature of a secondary AEF?
herald bleed
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
What are signs of AEF on endoscopy?
need to see 3-4th portions visualization of graft ulcer erosion with adherent clot extrinsic pulsatile mass
What are the most common bacteria for primary AEF?
salmonella
klebsiella
What are the most common bacteria for secondary AEF?
s.aureus
What are repair options?
graft excision without replacement if enough ollaterals
insitu graft replacement
neo-aortoiliac procedure
extra-anatomic revasc
endovascular (as bridge)
What grafts can be used for replacement?
allograft
synthetic graft
silver coated dacron
antibiotic impregnated grafts
What are the result of operative repair for AEF?
mortality 30%
amputation 10%
3 yr survival 50%
What are most common complications after PCI?
bleeding/hematoma PSA AVF dissection thrombosis
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
