Chapter 14

Question 1

what is a arteriovenous fistulae?

Answer 1

abnormal connection between high pressure arterial system and low pressure venous system. marked anatomic and hemodynamic changes

Question 2

T/F AVF is congenital or traumatic

Answer 2

true

Question 3

what can happen if a fistula is close to the heart?

Answer 3

potential for cardiac failure increases

Question 4

fistulas located peripherally more likely to cause?

Answer 4

ischemia

Question 5

what may avfs involve?

Answer 5

proximal and distal arteries/ veins as well as collateral arteries/veins. diameter and length predicts resistance it offers

Question 6

what will the arterial waveform look like proximal to an AVF?

Answer 6

increased diastolic flow b/c fistula reduces resistance

low resistance

Question 7

what will arterial waveform be distal to an AVF?

Answer 7

resumes its normal triphasic pattern or may be somewhat reduced

Question 8

what is the flow at the AVF?

Answer 8

high velocities. lower resistant flow

turbulent flow

Question 9

what will venous outflow waveform look like at an AVF?

Answer 9

takes on the flow quality of the fistulas low resistant more pulsatile flow

Question 10

how should the neck of a pseudoansym be compressed?

Answer 10

b/w native artery and pseudoane can be uniformly and completely compressed
compressions can last 10-15min
distal monitoring of the great toe

Question 11

what is pop a entrapment syndrome?

Answer 11

pop a possibly compressed by medial head of gastrocnemius muscle (anomalous origin) or fibrous bands

Question 12

who is more likely to get pop a entrapment syndrome?

Answer 12

found in young men,

Question 13

repeated trauma to the pop cause?

Answer 13

aneurysm, thrombosis, emboli

Question 14

what are patients symptoms with pop a entrapment?

Answer 14

symptomatic arterial occlusion or intermittent claudication

Question 15

what is the testing for pop a entrapment?

Answer 15

flow to great toe is monitored with an end point detector such as PPG
diminished pulsations considered abnormal

Question 16

what will confirm pop a entrapment?

Answer 16

with knee extended and active plantar flexion of the foot (or with passive dorsiflexion of the foot) against resistance, PPG pulsations may diminish or obliterate, which could be suggestive of pop a entrapement

Question 17

which vessels can they look at for preoperative arterial mapping?

Answer 17

epigastric EA

internal mammary artery/ internal thoracic artery

Question 18

what is a terminal branch of the internal mammary artery?

Answer 18

deep superior EA

Question 19

what does the EA fed?

Answer 19

both arteries and perforators take blood to the rectus abdominis muscle, long strap muscle vertically ordiented, each side of midline

Question 20

what is part of the transverse recuts abdominus myocuaneous flap (TRAM)

Answer 20

rectus abdominis muscle, subq fat, arteries, perforators, overlying skin

Question 21

what is the reason for mapping the EA?

Answer 21

surgeon wants to use the best arterially supplied muscle section for TRAM flap for autogenous breast reconstruction

Question 22

where is another name for internal mammary artery?

Answer 22

internal thoracic artery

Question 23

where does the internal thoracic artery arise from?

Answer 23

subclavian artery

Question 24

where does the internal mammary artery descendes from?

Answer 24

posterior side of cartilage of upper 6 ribs, about 1 cm from sternum

Question 25

reasons for mapping the internal thoracic artery?

Answer 25

utilzed as a recipient side for free flaps in breast reconstruction second important use for this artery is as a graft to the left anterior descending (LAD) coronary artery

Question 26

reasons for mapping the radial artery

Answer 26

determine suitability for use as graft for coronary artery bypass

Question 27

what is the technique for assessing the radial artery?

Answer 27

assess patency of palmar arch with modified Allen test

Question 28

what will a positive allen test for radial artery do?

Answer 28

do not proceed. | removal of radial artery will compromise the hand

Question 29

what freq transducer will you use on radial artery?

Answer 29

7.5 or 5MHz

Question 30

what abnormalities should you be on the look out for with radial artery mapping?

Answer 30

focal elevated PSV, abnormal doppler quality, | intimal thickening, aneurysm, calcification

Question 31

what should you measure of the radial artery?

Answer 31

diameter prox, mid, distal

Question 32

what are some limitations of radial artery study?

Answer 32

wall calcification

Question 33

what are indications for preoperative vein mapping?

Answer 33

determine suitability for use as extremity or coronary bypass determine suitability of veins for use in dialysis access. graft

Question 34

what is the technique for vein mapping LE?

Answer 34

7.5 MHz or higher GSV sometimes LSV mapped (prox-dist) high, mid, dist thigh, knee, BK, prox, mid, distal calf, ankle

Question 35

what is the technique for vein mapping UE?

Answer 35

cephalic and basilic veins are mapped | measure at prox, biceps, above elbow, forearm. (prox mid distal,) wrist

Question 36

what will proximal tourniquet do?

Answer 36

assists with expansion of the vein size

Question 37

what is evaluated with vein mapping?

Answer 37

vein wall coaptation (compressibility)

Question 38

how is the criteria for measuring vessels for vein mapping?

Answer 38

``` outer edge to outer edge diameter measurements (mm) vein length (cm) obtained ```

Question 39

what are normal findings with vein mappings?

Answer 39

compressilbilty of veins without evidence of thrombosis

Question 40

what is the acceptable diameter measurement for vein mapping?

Answer 40

at least 2-3mm. basilic vein is often larger than cephalic

Question 41

what findings may prevent use of vein for bypass graft?

Answer 41

presence of vein wall thickening or mural calcifications

Question 42

what is thoracic outlet syndrome?

Answer 42

occurs with neurovascular bundle compression by should structures (cervical rib, clavicle, scalene muscle) occurs in certain arm positions

Question 43

why do most symptoms occur with TOS?

Answer 43

due to neurogenic compression of the brachial plexus and a small percentage due to subclavian vein or artery compression

Question 44

what are symptoms of TOS?

Answer 44

numbness/ tingling of arm pain/aching of shoulder/forearm exercise/upward positions increase discomfort/symptoms 25-30% have asymptomic compression

Question 45

what is used to diagnosis TOS?

Answer 45

PPG and or doppler waveform

Question 46

what is the technique for PPG / doppler for TOS?

Answer 46

PPG attached to index finger. or CW doppler on radial artery resting waveform obtained patients arm placed in various positions while arterial pulsations monitored

Question 47

what is normal for TOS PPG/ Doppler?

Answer 47

resting waveforms maintained

Question 48

what is abnormal for TOS PPG / doppler?

Answer 48

attenuation or flattening of the waveforms in one or more of the positions

Question 49

what are some arm positions for TOS?

Answer 49

``` resting position- hand in lap arm at 90 degrees arm at 180 degress exaggerated military stance adson maneuver causative position/ hand where symptoms arise ```

Question 50

what is Adson maneuver?

Answer 50

arm extended 180 degress with head turned sharply right and then left

Question 51

what kind of surgery can help with TOS?

Answer 51

rib resection with or without scalene splitting

Question 52

where can arterial injuries result from?

Answer 52

blunt trauma e.g long bone fractures which injure vessels or penetrating trauma (e.g stabbing wounds)

Question 53

what is a clinical presentation of a trauma?

Answer 53

open wound, hemorrage, hematoma | may or may not have distal pulses