Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

My Absite > Chapter 27: Vascular > Flashcards

Chapter 27: Vascular Flashcards

1
Q

Most common congenital hyper coagulable disorder

A

Resistance to activated protein C (Leiden factor)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Most common acquired hyper coagulable disorder

A

Smoking

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Atherosclerotic stages

  • 1st
  • 2nd
  • 3rd
A

1) Foam cells (macrophages have absorbed fat and lipids in the vessel wall)
2) Smooth muscle cell proliferation (caused by growth factors released from macrophages; results in wall injury)
3) Intimal disruption (from smooth muscle cell proliferation)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What stage of athersclerosis causes thrombus formation?

A

Third - intimal disruption: leads to exposure of collagen in vessel wall and eventual thrombus formation -> fibrous plaques then form in these areas with underlying atheromas

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Risk factors for atherosclerosis

A

Smoking, HTN, hypercholesterolemia, DM, hereditary factors

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

3rd most common cause of death in the United States

A

Stroke

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Most important risk factor for stroke

A

HTN

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Supple 85% of blood supply to the brain

A

Carotids

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Most common site of stenosis in cerebrovascular disease

A

Carotid bifurcation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Type of flow from normal internal carotid artery

A

Continuous forward flow

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

1st branch off the internal carotid artery

A

Ophthalmic artery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Type of flow from external carotid artery

A

Triphasic flow

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

1st branch of the external carotid artery

A

Superior thyroid artery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Communication between the ICA and ECA

A

Ophthalmic artery (off ICA) and internal maxillary artery (off ECA)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Most commonly diseased intracranial artery

A

Middle cerebral artery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

cerebral ischemic events

MCC?

A

embolization to ICA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

2nd most common source of cerebral emboli

A

Heart

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Which cerebral artery?

Lesion: mental status changes, release, slowing

A

Anterior cerebral artery events

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Which cerebral artery?

Lesion: contralateral motor and speech (if dominant side); contralateral facial droop

A

Middle cerebral artery events

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Which cerebral artery?

Lesion: vertigo, tinnitus, drop attacks, incoordination

A

Posterior cerebral artery events

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Amaurosis fugax - which artery?

A

Occlusion of the ophthalmic branch of the ICA (visual changes -> shade coming down over eyes); visual changes are transient

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What do you see on ophthalmologic exam in amaurosis fugax?

A

Hollenhorst plaques

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Treatment: carotid traumatic injury with major fixed deficit:

  • Occlusion
  • Nonocclusion
A
  • If occluded, do not repair -> can exacerbate injury with bleeding
  • If not occluded -> repair with carotid stent or open procedure
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Indications for CEA

A

Symptomatic > 50%, asymptomatic > 70%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

When do you consider CEA in a recent completed stroke?

A

Wait 4-6 weeks and then perform CEA if it meets criteria (bleeding risk if performed earlier)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Indications for emergenct CEA

A

May be of benefit with fluctuating neurologic symptoms or crescendo / evolving TIAs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

When do you use a shunt during CEA?

1 answer relates to stump pressure

A

Use a shunt during CEA if:
1) stump pressures < 50, or

2) contralateral side is tight

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

What side do you repair in bilateral stenosis during CEA?

A

Repair the tightest side first if the patient has bilateral stenosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

What side do you repair if the patient has equally tight carotid stenosis bilaterally during CEA?

A

Repair the dominant side first if the patient has equally tight carotid stenosis bilaterally

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Complications from repair during CEA

- which 5 nerves can be injured?

A
  • Vagus nerve injury
  • Hypoglossal nerve injury
  • Glossopharyngeal nerve injury
  • Ansa cervicalis
  • Mandibular branch of facial nerve
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Most common cranial nerve injury with CEA?

mech?

A

Vagus nerve: secondary to vascular clamping during endarterectomy; patients get hoarseness (recurrent laryngeal nerve comes off vagus)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

CEA complication: tongue deviates to the side of injury-> speech and mastication difficulty

A

Hypoglossal nerve injury

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

CEA complication: rare, occurs with really high carotid dissection -> causes difficulty swallowing

A

Glossopharyngeal nerve injury

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

CEA complication: innervation to strap muscles; no serious deficits

A

Ansa cervicalis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

CEA complication: affects corner of mouth (smile)

A

Mandibular branch of facial nerve

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Stroke sx immediately aft CEA - mgt?

A

Back to OR to check for flap or thrombosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Pulsatile, bleeding mass after CEA

- Treatment?

A

Pseudoaneurysm

Tx: drape and prep before intubation, intubate, then repair

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Why do 20% have hypertension following CEA?

A

Caused by injury to the carotid body

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

Tx: HTN following CEA

A

Nipride to avoid bleeding

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Most common cause of non-stroke morbidity and mortality following CEA

A

Myocardial infarction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Restonosis rate after CEA

A

15%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

Indications for carotid stenting

A

For high-risk patients (e.g. patients with previous CEA and restenosis, multiple medical comorbidities, previous neck XRT)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

Pathway of the vertebrobasilar artery

A

Two vertebral arteries arise from the subclavian arteries and combine to form a single basilar artery; the basilar then splits into two posterior cerebral arteries

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

When do you see symptoms in vertebrobasilar artery disease?

A

Usually need basilar artery or bilateral vertebral artery disease to have symptoms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

Tx: vertebrobasilar artery disease

A

PTA with stent

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

What causes vertebrobasilar artery disease?

A

Caused by atherosclerosis, spurs, band; get vertebrobasilar insufficiency

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

Symptoms: diplopia, vertigo, tinnitus, drop attacks, incoordination

A

Vertebrobasilar artery disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

Tx: vertebrobasilar artery disease

A

PTA with stent

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

Present as a painless neck mass, usually near bifurcation, neural crest cells; are extremely vascular

A

Carotid body tumors

Tx: resection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

What are the aortic arch vessels?

A

Innominate artery (which branches into the right subclavian and right common carotid arteries), the left common carotid artery, and the left subclavian artery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

delete

  • Often asymptotic and picked up on routine CXR
  • Can get compression of vertebra (back pain), RLN (voice changes), bronchi (dyspnea or PNA), or esophagus (dysphagia)
A

Ascending aortic aneurysm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

Indications for repair in ascending aortic aneurysm

A

Acutely symptomatic, > 5.5 cm (with Marfan’s > 5.0cm), or rapid increase in size ( > 0.5 cm/yr)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

Indications for endovascular vs open repair of descending aortic aneurysm (also thoracoabdominal aneurysms)

A

If endovascular repair possible > 5.5 cm.

If open repair needed > 6.5cm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

Risk of mortality or paraplegia endovascular repair vs open repair

A

Less with endovascular repair (2-3%) compared to open repair (20%)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

How can you help prevent paraplegia with open repair of TAAA (thoracoabdominal aortic aneurysms)?

A

Reimplant intercostal arteries below T8 to help prevent paraplegia with open repair

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

Classifications of Aortic Dissection

A

Stanford classification

DeBakey classification

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

What is the difference between the Stanford classification and the DeBakey Classification?

A
  • Stanford: based on presence or absence of involvement of ascending aorta
  • DeBakey: based on the site of tear and extent of dissection
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

Stanford classification: Class A

A

any ascending aortic involvement

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

Stanford classification: class B

A

Descending aortic involvement only

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

Type I DeBakey

A

Ascending and descending

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

Type II DeBakey

A

Ascending only

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

Type III DeBakey

A

Descending only

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
63
Q

Where do most dissections start?

A

In the ascending aorta

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
64
Q

What can aortic dissection mimic?

A

Myocardial infarction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
65
Q

Symptoms: tearing like chest pain, can have unequal pulses (or BP) in upper extremities

A

Aortic dissection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
66
Q

What is present in 95% of patients with aortic dissection?

A

95% of patients have severe HTN at presentation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
67
Q

Risk factors for aortic dissection

A

Marfan’s syndrome, previous aneurysm, atherosclerosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
68
Q

Dx: aortic dissection

A

Chest CT with contrast

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
69
Q

Aortic dissection involves which layer of the blood vessel wall?

A

Dissection occurs in the medial layer of blood vessel wall

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
70
Q

Incidence of aortic insufficiency in aortic dissection

A

Aortic insufficiency: occurs in 70%, caused by annular dilatation or when aortic valve cusp is sheared off

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
71
Q

What arteries are at risk in aortic dissection?

A

Can also have occlusion of the coronary arteries and major aortic branches

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
72
Q

What is usually the cause of death in aortic dissection?

A

Death with ascending aortic dissections usually secondary to cardiac failure from aortic insufficiency, cardiac tamponade or rupture

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
73
Q

Medical treatment initially for aortic dissections

A

Control BP with IV beta-blockers (e.g. esmolol) and Nipride

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
74
Q

When to operate on ascending aortic dissections?

Open or endovascular?

A

Operate on all ascending aortic dissections.

- Tx: need open repair; graft is placed to eliminate flow to the false lumen

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
75
Q

When to operate on descending aortic dissections?

A

Only operate on descending aortic dissections with visceral or extremity ischemia or if contained rupture
- Tx: Endograft or open repair; can also just place fenestrations in the dissection flap to restore blood flow to viscera or extremity if ischemia is the problem.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
76
Q

Follow up for surgery for aortic dissection

A

Follow these patients with lifetime serial scans (MRI to decrease radiation exposure)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
77
Q

Why do people status post aortic dissection repair need lifetime follow up?

A

30% eventually get aneurysm formation requiring surgery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
78
Q

Post op complications for thoracic aortic surgery

A

MI, renal failure, paraplegia (descending thoracic aortic surgery)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
79
Q

Why is paraplegia a risk in aortic dissection repair?

A

Paraplegia is caused by spinal cord ischemia due to occlusion of intercostal arteries and artery of Adamkiewicz that occurs with descending thoracic aortic surgery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
80
Q

Normal aorta size

A

2-3cm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
81
Q

What causes AAA?

A

Results from degeneration of the medial layer

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
82
Q

Risk factors for AAA

A

males, age, smoking, family history

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
83
Q

How do AAA usually present?

A
  • Usually found incidentally.

- Can present with rupture, distal embolization, or compression of adjacent organs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
84
Q

Leading cause of death in AAA

A

Rupture: leading cause of death without an operation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
85
Q

delete

Symptoms: back or abdominal pain, can have profound hypotension

A

Rupture

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
86
Q

Dx: Ruptured AAA

A

Ultrasound or abdominal CT

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
87
Q

CT findings in ruptured AAA

A

CT shows fluid in the retroperitoneal space and extraluminal contrast with rupture

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
88
Q

Where is AAA most likely to rupture?

relationship to renals

A

Most likely to rupture on left posterolateral wall, 2-4 cm below renals

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
89
Q

When is AAA more likely to rupture? (2 conditions)

A

More likely to rupture in the presence of diastolic HTN or COPD (thought to be predictors of expansion)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
90
Q

Rate of mortality with rupture of AAA if patient reaches hospital alive

A

50% mortality rate with rupture if patient reaches hospital alive

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
91
Q

Indications for surgical repair of AAA (3)

A

Repair if symptomatic, > 5.5 cm in males, or growth > 0.5 cm/yr

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
92
Q

When do you reimplant the inferior mesenteric artery in surgical repair of ruptured AAA?

A

Reimplant IMA if back pressures

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
93
Q

What arteries need ligation in ruptured AAA repair?

A

Ligate bleeding lumbar arteries

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
94
Q

What artery needs ensured flow in aorto-bifemoral repair instead of straight tube graft in ruptured AAA repair?

A

If performing an aorto-bifemoral repair: ensure flow to at least one internal iliac artery (hypogastric artery) to avoid vasculogenic impotence

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
95
Q

Graft used for repair of AAAs

A

Usually use a straight tube Dacron graft for repair of AAAs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
96
Q

Complications of AAA repair

A

Major vein injury with proximal cross-clamp. Impotence. MI. Renal failure. Graft infection. Pseudo aneurysm. Atherosclerotic occlusion. Diarrhea.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
97
Q

AAA complication: major vein injury with proximal cross-clamp

A

Retro-aortic left renal vein

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
98
Q

AAA complication: impotence

A

In 1/3 secondary to disruption of autonomic nerves and blood flow to the pelvis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
99
Q

Rate of mortality with elective AAA repair

A

5% mortality with elective repair

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
100
Q

1 cause of acute death after surgery

A

MI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
101
Q

1 cause of late death after surgery

A

Renal failure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
102
Q

Risk factors for mortality in AAA repair

A

Creatinine > 1.8 (#1), CHF, EKG ischemia, pulmonary dysfunction, older age, females

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
103
Q

1 risk factor for mortality after AAA repair

A

Creatinine > 1.8

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
104
Q

Graft infection rate s/p AAA repair

A

1%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
105
Q

Pseudoaneurysm formation s/p graft placement for AAA repair

A

1%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
106
Q

Most common later complication after aortic graft placement

A

Atherosclerotic occlusion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
107
Q

What is diarrhea (especially bloody) worrisome for after AAA repair?

A

Ischemic colitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
108
Q

Why is ischemic colitis a possible complication in AAA repair?

A

Inferior mesenteric artery is often sacrificed with AAA repair and can cause ischemia (most commonly left colon)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
109
Q

Dx: ischemic colitis s/p AAA repair

A

Endoscopy or abdominal CT: middle and distal rectum are spared from ischemia (middle and inferior rectal arteries are branches off the internal iliac artery)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
110
Q

When do you go to OR for ischemic colitis s/p AAA repair?

A

If patient has peritoneal signs, mucosa is black on endoscopy, or part of the colon looks dead on CT scan -> take to OR for colectomy and colostomy placement

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
111
Q

AAA: ideal criteria for endovascular repair:

  • Neck length
  • Neck diameter
  • Neck angulation
  • Common iliac artery length
  • Common iliac artery diameter
  • Other
A
  • Neck length: > 15mm
  • Neck diameter: 20-30mm
  • Neck angulation: 10mm
  • Common iliac artery diameter: 8-18mm
  • Other: non-tortuous, noncalcified iliac arteries, lack of neck thrombus
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
112
Q

AAA repair: failure site -> Type 1 endoleak

A

Proximal or distal graft attachment sites

Tx: extension cuffs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
113
Q

AAA repair: failure site -> Type 2 endoleak

A

Collaterals (eg patent lumbar, IMA, intercostals, accessory renal)

Tx: observe most, percutaneous coil embolization if pressurizing aneurysm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
114
Q

AAA repair: failure site -> Type 3 endoleak

A

Overlap sites when using multiple grafts or fabric tear

Tx: Secondary endograft to cover overlap site or tear

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
115
Q

AAA repair: failure site -> Type 4 endoleak

A

Graft wall porosity or suture holes

Tx: Observe, can place nonporous stent if that fails

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
116
Q

AAA repair: failure site -> Type 5 endoleak (endotension)

A

Expansion of aneurysm without evidence of leak

Tx: repeat EVAR or open repair

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
117
Q
  • Occurs in 10% of patients with AAA; males

- Weight loss, increased ESR, thickened rim above calcifications on CT scan

A

Inflammatory aneurysms

  • Not secondary to infection: just an inflammatory process
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
118
Q

Anatomical problems to consider in inflammatory aneurysms

A
  • Can get adhesions to the 3rd and 4th portion of the duodenum
  • Ureteral entrapment in 25%
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
119
Q

How do you prevent ureteral injury (25%) in repair of inflammatory aneurysms?

A

May need to place preoperative ureteral stents to help avoid injury.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
120
Q

Treatment: inflammatory aneurysm

A

Inflammatory process resolves after aortic graft placement

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
121
Q

Cause of mycotic aneurysms

A 
#1 Salmonella
#2 Staphylococcus
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
122
Q

How do bacteria cause mycotic aneurysms?

A

Bacteria infect atherosclerotic plaque, cause aneurysm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
123
Q
  • Pain, fevers, positive blood cultures in 50%

- Periaortic fluid, gas, retroperitoneal soft tissue edema, lymphadenopathy

A

Mycotic aneurysms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
124
Q

Treatment: mycotic aneurysms

A

Usually need extra-anatomic bypass (axillary-femoral with femoral-to-femoral crossover) and resection of infrarenal abdominal aorta to clear infection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
125
Q

Causes of aortic graft infections

A 
#1 Staphylococcus
#2 E. coli
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
126
Q
  • Cause: 1) Staph 2) Ecoli
  • See fluid, gas, thickening around graft
  • Blood cultures negative in many patients
A

Aortic graft infections

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
127
Q

What are aortic graft infections most common in?

A

More common with grafts going to the groin (e.g., aorto-bifemoral grafts)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
128
Q

Treatment: aortic graft infections

A

Bypass thru non-contaminated field (e.g. axillary-femoral bypass with femoral-to-femoral crossover) and then resect the infected graft

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
129
Q
  • Usually occurs > 6 months after abdominal aortic surgery

- Herald bleed with hematemesis, then blood per rectum

A

Aortoenteric fistula

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
130
Q

Where does the graft erode in aortoenteric fistula?

A

Graft erodes into 3rd or 4th portion of duodenum near proximal suture line

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
131
Q

Treatment: aortoenteric fistula

A

Bypass through non-contaminated field (e.g. axillary-femoral bypass with femoral-to-femoral crossover), resect graft, and then close hole in the duodenum

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
132
Q

Standard treatment for an infected aortic valvular prosthesis

A

An axillobifemoral bypass is performed first. This is followed a few days later by removal of the infected aortic prosthesis and careful oversewing of the aortic stump as illustrated

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
133
Q

Components of leg compartments

A

Anterior: deep peroneal nerve (dorsiflexion, sensation between 1st and 2nd toes), anterior tibial artery

  • Lateral: superficial peroneal nerve (eversion, lateral foot sensation)
  • Deep posterior: tibial nerve (plantar flexion), posterior tibial artery, peroneal artery
  • Superficial posterior: sural nerve
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
134
Q

Components of anterior leg compartment

A

Deep peroneal nerve (dorsiflexion, sensation between 1st and 2nd toes), anterior tibial artery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
135
Q

Components of lateral leg compartment

A

Superficial peroneal nerve (eversion, lateral foot sensation)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
136
Q

Components of deep posterior leg compartment

A

Tibial nerve (plantar flexion), posterior tibial artery, peroneal artery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
137
Q

Components of superficial posterior leg compartment

A

Sural nerve

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
138
Q

Signs of PAD

A

Pallor, dependent rubor, hair loss, slow capillary refill

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
139
Q

MCC PAD

A

Atherosclerosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
140
Q

1 preventative agent for atherosclerosis

A

Statin drugs (lovastatin)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
141
Q

Can increase risk of atherosclerosis.

- Tx: folate and B12

A

Homocystinuria

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
142
Q

Treatment of claudication

A

Medical therapy first: ASA, smoking cessation, exercise until pain occurs to improve collaterals

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
143
Q

Level of occlusion: buttock claudication

A

Aortoiliac disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
144
Q

Level of occlusion: mid-thigh claudication

A

External iliac

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
145
Q

Level of occlusion: calf claudication

A

Common femoral artery or proximal superficial femoral artery disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
146
Q

Level of occlusion: foot claudication

A

Distal superficial artery or popliteal disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
147
Q

How can you remember the symptoms associated with the level of occlusion in PAD?

A

Symptoms occur one level below occlusion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
148
Q

What can mimic claudication?

A

Lumbar stenosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
149
Q

What can mimic rest pain in PAD?

A

Diabetic neuropathy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
150
Q
  • No femoral pulses
  • Buttock or thigh claudication
  • Impotence (from decreased flow in the internal iliacs)
A

Leriche syndrome

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
151
Q

Where is the lesion in Leriche syndrome?

A

Lesion at aortic bifurcation or above

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
152
Q

Treatment: Leriche syndrome

A

Aorto-bifemoral bypass graft

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
153
Q

Most common atherosclerotic occlusion in the lower extremities

A

Hunter’s canal (distal superficial femoral artery exits here)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
154
Q

What muscle covers Hunter’s canal?

A

Sartorius muscle

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
155
Q

What forms collateral circulation?

A

Forms form abnormal pressure gradients

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
156
Q

Collateral circulation of circumflex iliacs

A

Circumflex iliacs to subcostals

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
157
Q

Collateral circulation of circumflex femoral arteries

A

Circumflex femoral arteries to gluteal arteries

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
158
Q

Collateral circulation around the knee

A

Geniculate arteries

159
Q

Budding from preexisting vessels; angiogenin involved

A

Postnatal angiogenesis

160
Q

ABI

A

Start to get claudication (typically occurs at same distance each time)

161
Q

ABI

A

Start to get rest pain (usually across the distal arch and foot)

162
Q

ABI

A

Ulcers (Usually starts in toes)

163
Q

ABI

A

Gangrene

164
Q

Why can ABIs be very inaccurate in patients with diabetes?

A

Secondary to incompressibility of vessels; often have to go off Doppler waveforms in these patients

165
Q

How does walking affect the ABI?

A

In patients with claudication, the ABI in the extremity drops with walking (i.e. resting ABI may be 0.9 but can drop to

166
Q

Used to find significant occlusion and at what level

A

Pulse volume recordings (PVRs)

167
Q

When is arteriogram indicated in PAD?

A

If PVRs suggest significant disease - can also at times treat the patient with percutaneous intervention; gold standard for vascular imaging.

168
Q

Gold standard for vascular imaging

A

Arteriogram

169
Q

Surgical indications for PAD

A

Rest pain, ulceration or gangrene, lifestyle limitation, atheromatous embolization

170
Q

Only for bypasses above the knee; need to use vein for below the knee bypasses

A

PTFE (Gortex)

171
Q

Good for aorta and large vessels

A

Dacron

172
Q

Most get aorto-bifemoral repair

A

Aortoiliac occlusive disease

173
Q

How do you prevent vasculogenic impotence and pelvic ischemia during repair of aortoiliac occlusive disease?

A

Need to ensure flow to at least 1 internal iliac artery (hypogastric artery; want to see good back-bleeding from at least 1 of the arteries, otherwise need a bypass to an internal iliac artery) when performing aorto-bifemoral repair

174
Q

Treatment for isolated iliac lesions

A

PTA with stent 1st choice; if that fails, consider femoral-to-femoral crossover

175
Q
  • 75% 5-year potency

- improved patency with surgery for claudication as opposed to limb salvage

A

Femoropopliteal grafts

176
Q

Popliteal artery exposure below the knee:

  • Posterior muscle
  • Anterior muscle
A

Posterior muscle: gastrocnemius

Anterior muscle: popliteus

177
Q

Arteries useful in femoral-distal grafts

A

Peroneal, anterior tibial, or posterior tibial artery

178
Q

Rate of potency of femoral-distal grafts

A

50% 5-year potency; potency not influenced by level of distal anastomosis

179
Q

Why are distal lesions more limb threatening?

A

Because of lack of collaterals

180
Q

When are bypasses to distal vessels usually performed?

A

Usually used only for limb salvage

181
Q

If you are going to perform distal bypass on the leg, what do you need to ensure?

A

Bypassed vessel needs to have run-off below the ankle for this to be successful

182
Q

Why use saphenous vein for bypass below the knee?

A

Synethetic grafts have decreased patency below the knee -> need to use saphenous vein.

183
Q

When to consider extra-anatomic grafts?

A

Can be used to avoid hostile conditions in the abdomen (multiple previous operations in a frail patients_

184
Q

Doubles blood flow to donor artery; can get vascular steal in donor leg

A

Femoral-to-femoral crossover graft

185
Q

Dx: early swelling following lower extremity bypass

A

Reperfusion injury and compartment syndrome

Tx: fasciotomies

186
Q

Dx: late swelling following lower extremity bypass

A

DVT

Dx: US
Tx: heparin, coumadin

187
Q

Complications of reperfusion of ischemic tissue

A

Compartment syndrome, lactic acidosis, hyperkalemia, myoglobinuria

188
Q

1 cause of early failure of reversed saphenous vein grafts

A

Technical problem

189
Q

1 cause of late failure of reversed saphenous vein grafts

A

Atherosclerosis

190
Q

Noninfectious, can allow to autoamputate if small or just toes.

A

Dry gangrene

191
Q

Management of dry gangrene

A
  • Large lesions should be amputated

- See if patient has a correctable vascular lesion

192
Q

Infectious, need to remove infected necrotic material ; antibiotics

A

Wet gangrene

193
Q

When is wet gangrene considered a surgical emergency?

A

If extensive infection (Eg swollen red toe with pus coming out and red streaks up leg) or systemic complication occur (e.g. septic) -> may need emergency amputation

194
Q
  • At metatarsal heads

- Diabetics, can have osteomyelitis

A

Mal perforans ulcer

195
Q

MC’ly involved joint in mal performs ulcer

A

2nd MTP joint most common

196
Q

Tx: mal perforans ulcer

A

Non-weightbearing, debridement of metatarsal head (need to remove cartilage), antibiotics; assess need for revascularization

197
Q
  • Excellent for common iliac artery stenosis

- Best for short stenoses

A

Percutaneous transluminal angioplasty (PTA)

198
Q

How does percutaneous transluminal angioplasty (PTA) work?

A

Intimal usually ruptured and media stretched, pushes the plaque out.
- Requires passage of wire first.

199
Q

What causes compartment syndrome?

A

Is caused by repercussion injury to the extremity (mediated by PMNs; occurs with cessation of blood flow to extremity and repercussion > 4-6 hours later).

200
Q

What causes increased compartment pressures in compartment syndrome?

A

Reperfusion injury leads to swelling of the muscle compartments -> raising compartment pressures, which can lead to ischemia

201
Q

Symptoms of compartment syndrome

A

Pain with passive motion; extremity feels tight and swollen

202
Q

Where is compartment syndrome most likely to occur?

A

Most likely to occur in the anterior compartment of leg (get foot drop)

203
Q

Dx / Tx: compartment syndrome

A

Dx: often based on clinical suspicion; compartment pressure > 20 - 30 mmHg abnormal

Tx: fasciotomies (get all 4 compartments if in lower leg) -> leave open 5-10 days

204
Q
  • Most present with mild intermittent claudication

- Men, 40s, loss of pulses with plantar flexion

A

Popliteal entrapment syndrome

205
Q

What leads to popliteal entrapment syndrome?

A

Have medial deviation of artery around medial head of gastrocnemius muscle

206
Q

Tx: popliteal entrapment syndrome

A

Resection of medial head of gastrocnemius muscle; may need arterial reconstruction

207
Q
  • Men, 40s, popliteral fossa most common area

- Symptoms: intermittent claudication, changes in symptoms with knee flexion / extension

A

Adventitial cystic disease

208
Q

Why is adventitial cystic disease most often bilateral?

A

Ganglia originate from adjacent joint capsule or tendon sheath

209
Q

Dx / Tx: adventitial cystic disease

A

Dx: angiogram

Tx: resection of cyst; vein graft if the vessel is occluded

210
Q

What are arterial autografts?

A

Radial artery grafts for CABG, IMA from CABG

211
Q

When do you amputate?

A

For gangrene, large non-healing ulcers or unrelenting rest pain not amenable to surgery.

212
Q

Rate of mortality within 3 years for leg amputation

A

50% mortality

213
Q

BKA:

  • ___% heal
  • ___% walk again
  • ___% mortality
A

80% heal
70% walk again
5% mortality

214
Q

AKA:

  • ___% heal
  • ___% walk again
  • ___% mortality
A

90% heal
30% walk again
10% mortality

215
Q

Indications for emergency amputation

A

Systemic complications or extensive infection

216
Q

Embolism or Thrombosis?

  • Arrhythmia
  • No prior claudication or rest pain
  • Normal contralateral pulses
  • No physical findings of chronic limb ischemia
A

Embolism

217
Q

Embolism or thrombosis?

  • No arrhythmia
  • History of claudication or rest pain
  • Contralateral pulses absent
  • Physical findings of chronic limb ischemia
A

Thrombosis

218
Q
  • Usually do not have collaterals, signs of chronic limb ischemia, or history of claudication with emboli (do have collaterals with thrombosis)
A

Acute arterial emboli

219
Q

Contralateral leg in acute arterial emboli

A

Contralateral leg usually has no chronic signs of ischemia and pulses are usually normal

220
Q

Symptoms: pain, paresthesia, poikilothermia, paralysis

A

Acute arterial emboli

221
Q

Extremity ischemia evolution in acute arterial emboli

A

Pallor (white) -> cyanosis (blue) -> marbling

222
Q

MCC acute arterial emboli

A

Atrial fibrillaiton

223
Q

Common causes of acute arterial emboli

A

A fib (MCC), recent MI with LV thrombus, myxoma, aorto-iliac disease

224
Q

MC site of peripheral obstruction from emboli

A

Common femoral artery

225
Q

Tx: acute arterial emboli

A

Embolectomy usual; need to get pulses back; post op angiogram
- Consider fasciotomy is ischemia > 4-6 hours

226
Q

When do you consider fasciotomy in acute arterial emboli?

A

If ischemia > 4-6 hours

227
Q

Treatment possibility in aortoiliac emboli (loss of both femoral pulses)

A

Can be treated with bilateral femoral artery cutdown and bilateral embolectomies

228
Q

Cholesterol clefts that can lodge in small arteries

A

Atheroma embolism

229
Q

Most common site of atheroma embolization

A

Renals

230
Q

Flaking atherosclerotic emboli off abdominal aorta or branches
- Patients typically have good distal pules

A

Blue toe syndrome

231
Q

MC source of blue toe syndrome

A

Aortoiliac disease

232
Q

Dx: atheroma embolism

A

Chest/abdomen/pelvis CT scan (look for aneurysmal source) and ECHO (clot or myxoma in heart)

233
Q

Tx: atheroma embolism

A

May need aneurysm repair or arterial exclusion with bypass

234
Q

Do patients with acute arterial thrombosis usually have arrhythmia?

A

No. These patients usually do not have arrhythmias.

235
Q

What is the usually history in acute arterial thrombosis?

A

Do have a history of claudication and have signs of chronic limb ischemia and poor pulses in the contralateral leg.

236
Q

Tx: acute arterial thrombosis

A

Threatened limb (loss of sensation or motor function) -> give heparin and go to OR for thrombectomy

If limb is not threatened: angiography for thrombolytics

237
Q

Treatment: thrombosis of PTFE graft

A

Thrombolytics and anticoagulation; if limb threatened -> OR for thrombectomy

238
Q

Where does the right renal artery run?

A

Posterior to IVC

239
Q

Rate of accessory renal arteries in humans

A

Accessory renal arteries in 25%

240
Q

Bruits. Diastolic blood pressure > 115, HTN, in children or premenopausal women, HTN resistant to drug therapy.

A

Renovascular HTN (renal artery stenosis)

241
Q

Renovascular HTN:

  • Left side
  • Proximal 1/3
  • Men
A

Renal atherosclerosis

242
Q

Renovascular HTN:

  • Right side
  • Distal 1/3
  • Women
A

Fibromuscular dysplasia

243
Q

Dx: renovascular HTN (renal atherosclerosis, fibromuscular dysplasia)

A

Angiogram

244
Q

Tx: renovascular HTN (renal atherosclerosis, fibromuscular dysplasia)

A

PTA (percutaneous transluminal angioplasty); place stent if due to atherosclerotic disease

245
Q

Indications for nephrectomy with renal HTN

A

Atrophic kidney

246
Q

Occlusive disease in the upper extremity: why are proximal lesions usually asymptomatic?

A

Secondary to increased collaterals

247
Q

Most common site of upper extremity stenosis

A

Subclavian artery

248
Q

Tx: occlusive disease of the upper extremity

A

PTA with stent; common carotid to subclavian artery bypass if that fails.

249
Q

Proximal subclavian artery stenosis resulting in reversal of flow through ipsilateral vertebral artery into the subclavian artery

A

Subclavian steal syndrome

250
Q

When do you operate in subclavian steal syndrome?

A

Operate with limb or neurologic symptoms (usually vertebrabasilar symptoms)

251
Q

Tx: subclavian steal syndrome

A

PTA with stent to subclavian artery, common carotid to subclavian artery bypass if that fails.

252
Q

Passes over the first rib anterior to the anterior scalene muscle, then behind clavicle

A

Subclavian vein

253
Q

Passes over the first rib posterior to the anterior scalene muscle and anterior to the middle scalene muscle

A

Brachial plexus and subclavian artery

254
Q

General symptoms: back, neck, and/or arm pain / weakness / tingling (often worse with palpation / manipulation)

A

Thoracic outlet syndrome

255
Q

Dx: thoracic outlet syndrome

A

Cervical spine and chest MRI, duplex US (vascular etiology), electromyelogram (EMG; neurologic etiology)

256
Q

If neurologic or vascular involvement more common in thoracic outlet syndrome?

A

Neurologic involvement - much more common than vascular

257
Q

1 anatomic abnormality in thoracic outlet syndrome

A

Cervical rib

258
Q

1 cause of pain in thoracic outlet syndrome

A

Brachial plexus irritation

259
Q

How does the exam look in thoracic outlet syndrome?

A

Usually have normal neurologic exam; tapping can reproduce symptoms (Tinsel’s test)

260
Q

Most common nerve distribution causing pain in thoracic outlet syndrome

A

Ulnar nerve distribution (C8-T1) - inferior portion of brachial plexus

261
Q

Symptoms of ulnar nerve distribution involvement in thoracic outlet syndrome

A

Tricep muscle weakness and atrophy, weakness of intrinsic muscles of hand, weak wrist flexion.

262
Q

Tx: thoracic outlet syndrome

A

Cervical rib and 1st rib resection, divide anterior scalene muscle

263
Q

Usually presents as effort-induced thrombosis of subclavian vein (Paget-von Schrotter disease; baseball pitchers) - acutely painful, swollen, blue limb

A

Subclavian vein TOS

264
Q

What type of thrombosis is involved in subclavian vein TOS

A

Venous thrombosis is much more common than arterial

265
Q

Dx: subclavian vein causing TOS

A

Venography is the gold standard for diagnosis, but duplex US makes the diagnosis and is quicker to get.

266
Q

Rate of thoracic outlet problem in subclavian vein problem causing TOS

A

80% have associated thoracic outlet problem.

267
Q

Tx: subclavian vein TOS

A

Thrombolytics initially; repair at that admission (Cervical rib and 1st rib resection, divide anterior scalene)

268
Q

Least common cause of TOS

A

Subclavian artery

269
Q

What is the cause of subclavian artery involvement in TOS?

A

Compression usually secondary to anterior scalene hypertrophy (weight lifters)

270
Q

Symptoms: subclavian artery TOS

A

Hand pain from ischemia

271
Q

Test used to confirm subclavian artery TOS

A

Adson’s test: absent radial pulse with head turned to ipsilateral side

272
Q

Dx / Tx: subclavian artery TOS

A

Dx: duplex US or angiogram (gold standard)

Tx: surgery -> cervical rib and 1st rib resection, divide anterior scalene muscle; possible bypass graft if artery is too damaged or aneursymal

273
Q

Why can motor function be preserved in digits after prolonged hand ischemia?

A

Motor function can remain in digits after prolonged hand ischemia because motor groups are in the proximal forearm.

274
Q
  • Overall mortality 60%
  • Usually involve SMA
  • CT findings: vascular occlusion, bowel wall thickening, intramural gas, portal venous gas
A

Mesenteric ischemia

275
Q

MCC of visceral ischemia

A
  • Embolic occlusion: 50%
  • Thrombotic occlusion: 25%
  • Nonocclusive: 15%
  • Venous thrombosis: 5%
276
Q

MC location of SMA embolism

A

Most commonly occurs near origin of SMA

277
Q

1 source of SMA embolism

A

Heart (atrial fibrillation)

278
Q
  • Pain out of proportion to exam; pain usually of sudden onset; hematochezia and peritoneal signs are late findings
  • May have h/o a fib, endocarditis, recent MI, recent angiography
A

SMA embolism

279
Q

Dx / Tx: SMA embolism

A

Dx: angiogram or abdominal CT with IV contrast

Tx: embolectomy, resect infarcted bowel if present

280
Q

How do you expose the SMA?

A

Divide ligament of Treitz, SMA is to the right of this near the base of the transverse colon mesentery

281
Q
  • Often history of chronic problems (food fear, weight loss)
  • Possible history of vasculitis or hyper coagulable state
  • Symptoms: similar to embolism, may have developed some collaterals
A

SMA thrombosis

282
Q

Dx / Tx SMA thrombosis

A

Dx: angiogram or abdominal CT with IV contrast

Tx: thrombectomy (open or catheter directed; thrombolytics may have a role) ; may need PTA with stent or open bypass after the vessel is opened for any residual stenosis; resection of infarcted bowel

283
Q

Dx: SMA thrombosis

A

Angiogram or abdominal CT with IV contrast

284
Q

Tx: SMA thrombosis

A

thrombectomy (open or catheter directed; thrombolytics may have a role) ; may need PTA with stent or open bypass after the vessel is opened for any residual stenosis; resection of infarcted bowel

285
Q
  • Usually short segments of intestine involved; bloody diarrhea, crampy abdominal pain
  • May have a history of vasculitis, hyper coagulable state, portal HTN
A

Mesenteric vein thrombosis

286
Q

Dx: mesenteric vein thrombosis

A

Abdominal CT scan or angiogram with venous phase

287
Q

Tx: mesenteric vein thrombosis

A

Heparin usual; resection of infarcted bowel if present

288
Q

Dx / Tx: mesenteric vein thrombosis

A

Dx: abdominal CT scan or angiogram with venous phase

Tx: heparin usual; resection of infarcted bowel if present

289
Q
  • Spasm, low-flow states, hypovolemia, hemoconcentration, digoxin -> final common pathway is low cardiac output to visceral vessels
  • Symptoms: bloody diarrhea, pain
A

Nonocclusive mesenteric ischemia

290
Q

Final common pathway of nonocclusive mesenteric ischemia

A

Low cardiac output to visceral vessels

291
Q

Risk factors of nonocclusive mesenteric ischemia

A

Prolonged shock, CHF, prolonged cardiopulmonary bypass

292
Q

What areas are most vulnerable to nonocclusive mesenteric ischemia?

A

Watershed areas (Griffith’s - splenic flexure and Sudak’s - upper rectum)

293
Q

Watershed area: splenic flexure

A

Griffith’s

294
Q

Watershed area: upper rectum

A

Sudak’s

295
Q

Tx: nonocclusive mesenteric ischemia

A

Volume resuscitation, catheter-directed nitroglycerin can increase visceral blood flow; also need to increase cardiac output (dobutamine); resection of infarcted bowel if present

296
Q
  • Causes celiac artery compression

- Bruit near epigastrium, chronic pain, weight loss, diarrhea

A

Median arcuate ligament syndrome

297
Q

Tx: median arcuate ligament syndrome

A

Transect median arcuate ligament; may need arterial reconstruction

298
Q

Weight loss secondary to food fear (visceral angina 30 minutes after meals)

A

Chronic mesenteric ischemia

299
Q

Dx: chronic mesenteric ischemia

A

Get lateral visceral vessel aortography to see origins of celiac and SMA

300
Q

Tx: chronic mesenteric ischemia

A

PTA and stent; bypass if that fails

301
Q

Important collateral between the SMA and celiac

A

Arc of Riolan

302
Q

Most common complication of aneurysms above the inguinal ligament

A

Rupture

303
Q

Most common complications of aneurysms below inguinal ligament

A

Thrombosis and emoli

304
Q

Risk factors for visceral artery aneurysms

A

Medial fibrodysplasia, portal HTN, arterial disruption secondary to inflammatory disease (eg, pancreatitis)

305
Q

Repair guidelines for visceral artery aneursyms

A

Repair all splanchnic artery aneurysms (>2cm) when diagnosed (50% risk for rupture) except splenic

306
Q

MC visceral aneurysm

  • More common in women
  • 2% risk of rupture
A

Splenic artery aneurysm

307
Q

When do you repair splenic artery aneurysms?

A

If symptomatic, if patient is pregnant, if occurs in women of childbearing age, or is > 3-4 cm

308
Q

Splenic artery aneurysm: what is concerning in pregnants?

A

High rate of pregnancy-related rupture -> usually in 3rd trimester

309
Q

Tx: visceral artery aneurysm

A

Covered stent (best); exclusion with bypass if that fails

310
Q

Treatment splenic artery aneurysms

A

Splenic artery aneurysms can just be ligated if open procedure is required (have good collaterals)

311
Q

When do you treat renal artery aneurysms?

A

> 1.5 cm

Tx: covered stent

312
Q

When do you treat iliac and femoral artery aneurysms?

A

Iliac: > 3.0 cm
Femoral: > 2.5 cm

Tx: covered stent

313
Q

Most common peripheral aneurysm

A

Popliteal artery aneurysm

314
Q
  • Leg exam reveals prominent popliteal pulses
  • 1/2 are bilateral
  • 1/2 have another aneurysm elsewhere (AAA, femoral, etc)
  • Most likely to get thrombosis or emboli with limb ischemia
  • Can also get leg pain from compression of adjacent structures
A

Popliteal artery aneurysm

315
Q

Dx: popliteal artery aneurysm

A

Ultrasound

316
Q

Surgical indications for repair of popliteal artery aneurysm

A

Symptomatic, > 2cm, or mycotic

317
Q

TX: popliteal artery aneurysm

A

Exclusion and bypass of all popliteal aneurysms; 25% have complication that requires amputation if not treated; covered stent not recommended for these

318
Q

Collection of blood in continuity with the arterial system but not enclosed by all 3 layers of the arterial wall

A

Pseudoaneurysm

319
Q

Most common location of pseudoaneurysm

A

Femoral artery

320
Q

What can cause pseudo aneurysm?

A

Can result from percutaneous interventions or from disruption of a suture line between graft and artery

321
Q

Treatment pseudo aneurysm if it occurs after percutaneous intervention

A

Ultrasound-guided compression with thrombin injection (surgical repair if flow remains in the pseudo aneurysm after thrombin injection)

322
Q

Treatment pseudo aneurysm if it occurs at a suture line early after surgery

A

Need surgical repair

323
Q

What do pseudo aneurysms that occur at suture lines late after surgery (months to years) suggest?

A

Suggests graft infection

324
Q
  • Young women; HTN if renal involved; headaches or stroke if carotids involved
  • String of beads appearance
A

Fibromuscular dysplasia

325
Q

Most commonly involved vessel in fibromuscular dysplasia

A

Renal artery, followed by carotid and iliac

326
Q

Most common variant of fibromuscular dysplasia

A

Medial fibrodysplasia

327
Q
  • young men, smokers

- severe rest pain with bilateral ulceration; gangrene of digits, especially fingers

A

Buerger’s disease

328
Q

What do you see on arteriogram of Buerger’s disease?

A

Corkscrew collaterals on angiogram and severe distal disease; normal arterial tree proximal to popliteal and brachial vessels (i.e., a small vessel disease)

329
Q

Treatment: Buerger’s disease

A

Stop smoking of will require continued amputations

330
Q

Cystic medial necrosis syndromes

A

Marfan’s, Ehlers-Danlos syndrome

331
Q

Fibrillin defect (connective tissue elastic fibers); marfanoid habitus, retinal detachment, aortic root dilatation

A

Marfan’s disease

332
Q
  • Many types of collagen defects are identified
  • Easy bruising, hypermobile joints; tendency for arterial rupture, especially abdominal vessels
  • Get aneurysms and dissections
A

Ehlers-Danlos syndrome

333
Q

Angiogram protocol for Ehlers Danlos syndrome

A

No angiograms -> risk of laceration to vessel

334
Q

What is important to consider in Ehlers Danlos syndrome cystic medial necrosis?

A

Often too difficult to repair and need ligation of vessels to control hemorrhage

335
Q
  • Women, age > 55, headache, fever, blurred vision (risk of blindness)
  • Inflammation of large vessels (aorta and branches)
  • Long segments of smooth stenosis alternating with segments of larger diameter
A

Temporal arteritis (large artery)

336
Q

What do you see on temporal artery biopsy in temporal arteritis?

A

Giant cell arteritis, granuloma

337
Q

What do you see on temporal artery biopsy in temporal arteritis?

A

Giant cell arteritis, granuloma

338
Q

Tx: temporal arteritis (large artery)

A

Steroids, bypass of large vessels if needed; no endarterectomy

339
Q
  • Weight loss, rash, arthralgias, HTN, kidney dysfunction
  • Get aneurysms that thromboses or rupture
  • Renals most commonly involved
A

Polarteritis nodosa (medium artery)

340
Q

What organ is most commonly involved in polyarteritis nods?

A

Renals

341
Q

Tx: polyarteritis nodosa (medium artery)

A

Steroids

342
Q
  • Children; febrile viral illness with erythematous mucosa and epidermis
  • Get aneurysms of coronary arteries and brachiocephalic vessels
  • Die from arrhythmias
A

Kawasaki’s disease (medium artery)

343
Q

What do peeps with Kawasaki’s die from?

A

Arrhythmias

344
Q

Tx: kawasaki disease

A

Steroids, possible CABG

345
Q
  • Often secondary to drug / tumor antigens

- Symptoms: rash (palpable purpura), fever, symptoms of end-organ dysfunction

A

Hypersensitivity angiitis (small artery)

346
Q

Tx: hypersensitivity angiitis (small artery)

A

Calcium channel blockers, pentoxifylline, stop offending agent

347
Q

Radiation arteritis:

  • Early
  • Late
  • Late late
A
  • Early: sloughing and thrombosis (obliterative endarteritis)
  • Late: (1-10 years) - fibrosis, scar, stenosis
  • Late late (3-30 years) - advanced atherosclerosis
348
Q
  • Young women

- Pallor -> cyanosis -> rubor

A

Raynaud’s disease

349
Q

Tx: raynaud’s disease

A

Calcium channel blockers, warmth

350
Q

Joins femoral vein near groin; runs medially

A

Greater saphenous vein

351
Q

Why no clamps on the IVC?

A

Will tear

352
Q

Can be ligated near the IVC in emergencies because of collaterals (left gonadal vein, left adrenal vein); right renal vein does not have these collaterals

A

Left renal vein

353
Q

Most common failure of AV grafts for dialysis

A

Venous obstruction secondary to intimal hyperplasia

354
Q

Dialysis access grafts:

  • Radial artery to cephalic vein
  • Wait 6 weeks to use -> allows vein to mature
A

Cimino

355
Q

Dialysis access grafts

  • eg brachiocephalic loop graft
  • wait 6 weeks to allow fibrous scar to form
A

Interposition graft

356
Q

Two types of dialysis access graft

A

Cimino, interposition graft

357
Q
  • Usually secondary to trauma; can get peripheral arterial insufficiency, CHF, aneurysm, limb-length discrepancy
  • Most need repair -> lateral venous suture; arterial side may need patch or bypass graft; try to place interposing tissue so it does not recure
A

Acquired AV fistula

358
Q
  • Causes: smoking, obesity, low activity

- Tx: sclerotherapy

A

Varicose veins

359
Q
  • Secondary to venous valve incompetence (90%)

- Ulceration occurs above and posterior to malleoli

A

Venous ulcers

360
Q

Venous ulcers: size that often heal without surgery

A

Ulcers > 3cm often heal without surgery

361
Q

Tx: venous ulcers

A

Unna boot compression cures 90%

362
Q

What do you need to consider in the treatment of venous ulcers?

A

May need to ligate perforators or have vein stripping of greater saphenous vein

363
Q
  • Aching, swelling, night cramps, brawny edema, venous ulcers
  • Elevation brings relief
A

Venous insufficiency

364
Q

What causes edema in venous insufficiency?

A

Secondary to incompetent perforators and/or valves

365
Q

Tx: venous insufficiency

A

Leg wraps, ambulation with avoidance of long standing

366
Q

Treatment of venous ulcers: for severe symptoms or recurrent ulceration despite medical treatment

A

Greater saphenous vein stripping (for saphenofemoral valve incompetence) or removal or perforators (if just perforator valves are incompetent; stab avulsion technique)

367
Q

Nonbacterial inflammation

- Tx: NSAIDs, warm packs, ambulation

A

Superficial thrombophlebitis

368
Q
  • Pus fills vein; fever, increased WBCs, erythema, fluctuant; usually associated with infection following a peripheral IV
  • Tx: resect entire vein
A

Suppurative thrombophlebitis

369
Q

What is associated with migrating thrombophlebitis?

A

Pancreatic CA

370
Q

Augmentation of flow with distal compression or release of proximal compression

A

Normal venous Doppler ultrasound

371
Q

Help prevent blood clots by decreasing venous stasis and increasing tPA release

A

Sequential compression devices (SCDs)

372
Q
  • Most common in calf
  • Pain, tenderness, calf swelling
  • Risk factors: Virchow’s triad (venous stasis, hypercoaguability, venous wall injury)
A

DVT

373
Q

Why is the left leg 2x more involved than right in DVT?

A

Longer left iliac vein compressed by right iliac artery

374
Q

DVT: minimal swelling

A

Calf DVT

375
Q

DVT: ankle and calf swelling

A

Femoral DVT

376
Q

DVT: leg swelling

A

Iliofemoral DVT

377
Q

Tenderness, pallor (whiteness), edema

- Tx: heparin

A

Phlegmasia alba dolens

378
Q

Tenderness, cyanosis (blueness), massive edema

- Tx: heparin, rarely need surgery

A

Phlegmasia alba dolens

379
Q

DVT treatment

A

Heparin, coumadin

380
Q

IVC filter indications

A

Contraindication to anticoagulation; PE while on coumadin; free-floating ileofemoral thrombi; after pulmonary embolectomy

381
Q

Etiology of pulmonary embolism with filter in place

A

Comes from ovarian veins, inferior vena cava superior to filter, or from upper extremity via the superior vena cava

382
Q

Treatment: venous thrombosis with central line

A

Pull out central line if not needed, then heparin; can try to treat with systemic heparin or TPA down line if the access site is important

383
Q
  • Do not contain a basement membrane

- Not found in bone, muscle, tendon, cartilage, brain, or cornea

A

Lymphatics

384
Q

Are lymphatics valveless?

A

Deep lymphatics have valves

385
Q
  • Occurs when lymphatics are obstructed, too few in number, or nonfunctional
  • Leads to woody edema secondary to fibrosis in subcutaneous tissue (toes, feet, ankle, leg)
A

Lymphedema

386
Q

What are big problems in lymphedema?

A

Cellulitis and lymphangitis secondary to minor trauma are big problems

387
Q

Most common infection in lymphedema

A

Strep

388
Q

Laterality of congenital lymphedema

A

L > R

389
Q

Tx: lymphedema

A

Leg elevation, compression, antibiotics for infections

390
Q

Raised blue/red coloring; early metastases to lung

A

Lymphangiosarcoma

391
Q

Lymphangiosarcoma associated with breast axillary dissection and chronic lymphedema

A

Stewart-Treves syndrome

392
Q
  • Usually after dissection in the groin (e.g. after femoral to popliteal bypass)
  • Leakage of clear fluid
A

Lymphocele

393
Q

Tx: lymphocele

A

Percutaneous drainage (can try a couple of times); resection if that fails

394
Q

How can you identify the lymphatic channels supplying a lymphocele?

A

Can inject isosulfan blue dye into foot to identify the lymphatic channels supplying the lymphocele if having trouble locating.

My Absite (40 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions