Chapter 27 - Vascular II

Question 1

What is the patency of femoral distal grafts?

Answer 1

50% five-year patency; not influenced by level of distal anastomosis. Distal lesions More limb threatening because of what lack of collaterals.
Bypasses distal to me usually used only for limb salvage

Question 2

What is a complication of femoral femoral crossover graft?

Answer 2

Vascular steal in donor leg

Question 3

Swelling following lower extremity bypass caused by what?

Answer 3

One: DVT; two edema from reperfusion injury

Question 4

What are the complications of reperfusion of ischemic tissue?

Answer 4

Lactic acidosis, hyperkalemia, myoglobinuria, compartment syndrome

Question 5

What is the number one cause of late failure of reverse saphenous Vein grafts?

Answer 5

Atherosclerosis

Question 6

What is the number one cause of early failure of reverse saphenous vein grafts?

Answer 6

Technical problem

Question 7

What do you do with a patient with a heel ulceration to the bone?

Answer 7

Chop chop

Question 8

What is dry gangrene?

Answer 8

Noninfectious; can allow to auto amputate it just toes

Amputate if a large lesion, see if patient has correctable vascular lesion

Question 9

What is wet gangrene?

Answer 9

Infectious; amputation to remove infected necrotic material, antibiotics, surgical emergency

Question 10

What is a malperforans ulcer?

Answer 10

At metatarsal heads-second MTP most common. Diabetics; can have osteomyelitis

Question 11

When do you use percutaneous transluminal angioplasty?

Answer 11

Excellent for common iliac lesions. Best for short stenoses. Intima usually ruptured and media stretched, pushes the plaque out. Requires passage of wire first

Question 12

What do you do with a pseudoaneurysm after arteriography?

Answer 12

Thrombin injection with ultrasound guidance. Ultrasound duplex best first test.

Question 13

In what part of the leg is compartment syndrome most likely to occur?

Answer 13

Anterior compartment. Get footdrop. Pressures greater than 20 to 30 abnormal; consider fasciotomy-leave open for 5 to 10 days.

Question 14

What is popliteal entrapment syndrome?

Answer 14

Most present with mild intermittent claudication
Loss of pulses with plantarflexion
Usually have medial deviation of artery around the medial head of gastrocnemius muscle
Treatment is resection of medial head of gastrocnemius muscle. May need arterial reconstruction

Question 15

What is adventitial cystic disease?

Answer 15

Popliteal most common area
Often bilateral-ganglia originate from adjacent joint capsule or tendon sheath
Intermittent claudication; changes in symptoms with knee flexion extension
Treat with vein graft if Vestle occluded; otherwise just for section of cyst

Question 16

What is the three-year mortality of an AKA or BKA?

Answer 16

50%

Question 17

With a BKA, what percentage heal, what percentage walk again, what is the mortality?

Answer 17

80% heal, 70% walk again, 5% mortality

Question 18

With an AKA, what percentage heal, what percent walk again, what is the mortality?

Answer 18

90% heal, 30% to walk again, 10% mortality

Question 19

What are the signs of an acute arterial emboli?

Answer 19

No signs of chronic ischemia. contralateral leg usually pulses are normal. First pallor, then cyanosis, then marbling. Symptoms include pain, pallor, pulselessness, parasthesia, poillothermia, paralysis.

Question 20

What is the most common cause of arterial emboli?

Answer 20

A fib

Question 21

What are other causes of arterial emboli?

Answer 21

LV aneurysm with thrombus, prosthetic heart valve, myxoma, paradoxical embolus from patent foramen ovale, peripheral arterial or aortic atherosclerotic plaque embolism

Question 22

Where is the most common site of peripheral obstruction from emboli?

Answer 22

Common femoral artery

Question 23

When do you do a fasciotomy after an embolectomy?

Answer 23

If ischemia is greater than 4 to 6 hours. Aorto iliac emboli can be treated with bilateral femoral artery cutdowns and bilateral embolectomies

Question 24

What site is most commonly involved with at herons embolism?

Answer 24

Renals

Question 25

What are the indications for nephrectomy with real hypertension?

Answer 25

Atrophic kidney less than 6 cm and minimal collaterals with persistently increased renin levels

Question 26

Acute arterial thrombosis?

Answer 26

Usually do not have arrhythmias. Have a history of claudication and chronic ischemia. If limb is threatened, give heparin and go to OR for thrombectomy. If limb not threatened can go to angiography for thrombolytics. If it is from thrombosis of PTFE graft give thrombolytics and anticoagulation.

Question 27

Where is the right renal artery run in relationship to the IVC?

Answer 27

Posterior to the IVC

Question 28

What percentage of patients have accessory renal arteries?

Answer 28

25%

Question 29

Where do most renal emboli come from?

Answer 29

The heart

Question 30

In what patients does renal atherosclerosis occur, and in what part of the artery

Answer 30

Men, proximal one third of artery, left side. Treat with PTA and stent.

Question 31

Fibromuscular dysplasia, what patients what part of artery?

Answer 31

Women, right side, distal one third of artery. Treat with pta

Question 32

So what symptoms are suggestive of renovascular hypertension?

Answer 32

Bruits, diastolic blood pressure greater than 115, worsening hypertension, rapid onset after age 50, hypertension resistant to drug therapy

Question 33

What is the most common site of upper extremity stenosis?

Answer 33

Subclavian. Proximal lesions usually asymptomatic secondary to collaterals. Treat with stent; can also perform common carotid to subclavian bypass

Question 34

What is subclavian steel syndrome?

Answer 34

Proximal subclavian artery stenosis resulting in reversal of flow through ipsilateral vertebral artery into subclavian. Operate with limb or neurologic symptoms. Treat with carotid to subclavian bypass or PTA

Question 35

Where is the normal subclavian vein?

Answer 35

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

Question 36

Where is the normal brachial plexus and subclavian artery?

Answer 36

Pass over the first rib posterior to the anterior scalene muscle, and anterior to the middle scalene muscle

Question 37

What is Adson’s test?

Answer 37

Decreased radial pulse with head turned ipsilateral side. Subclavian artery compression.

Question 38

What is tinsel’s test?

Answer 38

Tapping reproduces symptoms of thoracic outlet syndrome

Question 39

In thoracic outlet syndrome what is more common neurologic or vascular involvement?

Answer 39

Neurologic is more common. The number one abnormality is the cervical rib. The number one cause of pain is brachioplexus irritation

Question 40

With thoracic outlet syndrome what are the neurologic symptoms?

Answer 40

Increased back and neck symptoms. Older nerve distribution C8 T1 is most common can get triceps weakness and atrophy, weakness of intrinsic muscles of the hand, weak wrist flexion.