Chapter 27 - Vascular III Flashcards
What is Paget-von-Schrotter disease?
effort induced thrombosis of subclabian vein
Venography gold standard for evaluation
men, pain swelling with activity
80% have thoracic outlet problem
thrombolytics, heparin, warfarin. Repair.
What is mortality from mesenteric ischemia?
50-70%
What are fintings of mesenteric ischemia on CT?
bowel thickening, intrabural gas, portal venous gas, vascular occlusion
Wat are causes of visceral ischemia?
Acute embolic occlusion 50%
Thrombotic occlusion 25%
low-flow state 15%
Venous thrombosis 5%
Superior mesenteric embolism occurs in what area of SMA?
origin of SMA pain out of proportion sudden onset hematochezia peritoneal signs late finding Tx: volume resusc. antibiotics, embolectomy, resect infarcted bowe, heparin
What are signs of mesenteric artery thrombosis?
food fear
wt loss
Thrombectomy, SMA bypass, resect infarcted bowe
What are signs of mesenteric vein thrombosis?
short segments of intestine involved
bloody diarrhea, crampy abdominal pain
Heparin, thrombolytics, can try mesenteric vein thrombectomy if dx early, resect bowel
Non-occlusive mesenteric ischemia happens when?
Spasm low flow states hypovolemia hemoconcentration Digoxin Water shed areas most common Tx volume resuscitation, glucagon, papaverine, nitrates, increase CO, resect bowel
What is Median arcuate ligament syndrome?
celiac compression bruit near epigastrium chronic pain weight loss diarrhea Tx: transect median arcuate ligament, may need arterial reconstruction
Chronic mesenteric angina?
food fear
30 minutes after meals
may need PTA, bypass, endarterectomy
What is the collateral between SMA and celiac?
arc of riolan
What is the most common complication of aneurysms above inguinal ligament?
Rupture
What is the most common complication of aneurysms below inguinal ligament?
thrombosis and emboli
What do you do with splanchnic aneurysms?
repair, 50% rupture rate
What do you do with splenic artery aneurysms?
most common visceral aneurysm.
more common in women
Repair if symptomatic, pregnant, women of childbearing age
What dilatation of visceral arteries is considered aneurysmal?
> 2cm
What can you do with splenic and common hepatic aneurysms?
can exclude- have good collaterals
What are the surgical indications for iliac a aneurysms?
symptomatic- thrombosis, emboli, compression, >3.0cm, mycotic
bypass with exclusion
What are surgical indications for femoral a aneurysm?
symptomatic, >2.5cm
What are the surgical indications for popliteal aneurysms?
exclusion and bypass of >2cm, mycotic, symptomatic
1/2 bilateral, 1/2 have another aneurysm elsewhere
thrombosis and emboli with limb ischemia most common with these
What do you do with a femoral pseudoaneurysm?
if acter percutaneous intervention need US guided compression with thrombin injection. May need surgical repair if this fails
-collection of blood in continuity with the arterial system but unenclosed by all 3 layers of the wall
What are the surgical indications for renal A aneurysms?
symptomatic, expansion, >1.5 com, women who want to get knocked up.
reconstruction with vein patch; nephrectomy with rupture
Fibromuscular dysplasia?
young women, HTN if involves renals
renal most commonly involved vessel (right), carotid next, iliac next
string of (anal) beads
medial fibrodysplasia most common variant
PTA or bypass
What is Buerger’s disease?
you men, smokers, corkscrew collateral on angiogram and severe distal disease
severe rest pain
gangrene of digits
normal arterial tree proximal to popliteal and brachial
stop smoking or amputate
What diseases cause cystic medial necrosis?
marfan’s- type I collagen
Ehlers-danlos - tendency for arterial rupture
Can’t do angiogram- risk of laceration of vessel
What is temporal arteritis?
giant cell arteritis- granulomatous disease
inflammation of large vessels
long segments of smooth stenosis alternating with segments of larger diameter
fever, arthralgia, myalgia, anorexia
Steroids, bypass, no endarterectomy
What is takayasu’s?
same path, syx, and treatment of temporal artheritis
What is polyarteritis Nodos?
Get aneurysms that thrombose or rupture
renals most common
steroids
What is Kawasaki’s disease?
affects douchebags in affliction T’s on lime green motorcycles
children- get dilated coronaries and brachiocephalic vessels
die from arrhythmias
steroids, possible CABG
What is hypersensitivity angiitis?
secondary to drug/tumor antigens
rash, fever, end-organ dysfunction
Ca+ channel blockers, pentoxifylline
What happens with radiation arteritis?
sloughing and thrmobosis early
fibrosis, scar, stenosis 1-10 years
Advanced atherosclerosis 3-30 years
Raynaud’s disease?
young women, pallor, cyanosis, rubor
Ca2+ blockers, warmth
Where is the great saphenous vein?
joins femoral vein near groin- runs medially
Where is the lesser saphenous vein?
joins popliteal in lower leg- runs lateral at first
Can you clamp the IVC?
No- will tear
Can you ligate left renal vein?
yes- gonadal/adrenal vein collaterals
What is the most common cause of failure of AV grafts?
venous obstruction secondary to intimal hyperplasia
What is a Cimino graft?
radial artery to cephalic vein- wait 6 weeks
How long before an interposition graft can be used?
6 weeks to allow fibrous scar to form
How do you get an acquired AV fistula
Trauma
can get peripheral insufficiency, CHF, aneurysm, limb length problems
-repair with lateral venous suture, may need bypass of arterial side
Varicose veins
smoking, obesity, low activity
tx with stockings, elevation, exercise, sclerotherapy
Venous ulcers
secondary to venous valve incompitence
-unna boot cures 90%
Venous insufficiency symptoms?
aching, swelling, night cramps, brawny edema
ulceration above and posterior to malleoli
edema secondary to incompetent perforators
How do you perform a trendelenburg test?
elevate leg, occlude greater saphenofemoral vein junction, lower leg, rapid filling of greater saphenous vein suggests incompetent perforators
2 if first part did not fill, release pressure on saphenofemoral jxn- rapid filling suggests incompetent valves in greater saphenous
What is superficial thrombophlebitis?
nonbacterial inflammation
NSAIDS, warm packs, ambulation
What is suppurtive thrombophlebitis?
fever, increased WBC, erythema, fluctuance- resect vein
What is migrating thrombophlebitis a sign of?
pancreatic CA
what is Mondor’s Disease?
self limiting thrombophlebitis of the breast
How do SCD’s work?
help prevent blood clots by decreasing venous stasis, increasing AT-III, tPA, increased fibrinolysis
Where is DVT most common?
calf
what is Virchow’s triad?
stasis, hypercoagulability, vessel wall injury
what do you get with calf DVT?
minimal swelling
What do you get with femoral DVT?
ankle and calf swelling
what do you get with iliofemoral DVT?
severe leg swelling
What is phlegmasia alba dolens?
tenderness, pallor, edema with DVT
What is phelgmasia cerulea dolens
tenderness, cyanosis, massive edema
Treatment for long term DVT?
1st- coumadin for 6 months
2nd- coumadin for 1 year
3rd or PE- coumadin for life
when do you put in a greenfield filter?
contraindication for anticoagulation
PE on coumadin
free floating ileofemoral thrombi
after pulmonary embolectomy
what can you get a PE with filter in place?
ovarian veins, inferior vena cava, upper extremity
what do you do with venous thrombosis with a central line?
pull out if not needed, try to tx with heparin or TPA down line
what do you see with PE?
decreased paO2, decreased PaCO2, increased RR, alkalosis
most arise from above knee
if in shock- OR for pulmonary artery thrombectomy
do lymphatics have a basement membrane?
no
Where are lymphatics not found?
bone, muscle, tendon, cartilage, brain, cornea
When does lymphedema occur?
obstruction, too few in number, nonfunctional
woody edema secondary to fibrous tissue in subcutaneous tissue
cellulitis aand lymphantitis secondary to minor trauma
-strep most common infection
What side is congenital lymphedema most common?
Left
What do you see with lymphangiosarcoma?
raised blue/red coloring
early mets to lung
What is stewart treves syndrome?
lymphangiosarcoma associated with breast axillary dissection
what is lymphangiectasia?
dilation of preexisting lymphatic channels
dx with lymphangiography
tx with resection
When do you get lymphocele?
after surgery- usually groun
rule out infectious source first
How do you identify lymphatic channels going to a lymphocele?
inject isosulfan blue into foot to id channels
resect lymphocele and ligate supplying channel
