Chapter 7: Vascular Surgery Flashcards
Subclavian steal syndrome, what is it?
- arteriosclerotic stenotic plaque at origin of the subclavian
before vertebral
a. allows enough blood to reach arm for normal activity, but doesn’t allow enough to meet exercise demands
b. during exercise, arm sucks blood away from brain by reversing flow in vertebral artery
Subclavian steal sx?
- claudication of arm (coldness, tingling, muscle pain)
- posterior neurologic signs (visual sx, equilibrium problems))
- vascular + neurologic sx = subclavian steal
How do you diagnose subclavian steal?
duplex scanning (can show reversal of flow)
How to Tx subclavian steal?
bypass surgery cures it
What imaging do you use to determine size of abdominal aortic aneurysm?
sonogram or CT scan
Management of AAA?
- if smaller than 4 cm –> safely watch and almost 0 chance of rupture
- if 5-6cm or larger-> pt should have elective repair bc chance or rupture is very high
- if grows 1cm per year or faster then need elective repair also
Surgery for ruptured AAA
- very high morbidity and mortality
- most of time use endovascular stents percutaneously
- neck of AAA should be 2.5cm
Prognosis of a tender AAA
is going to rupture w/i a day or two
immediate repair is indicated
Excruciating back pain in pt w large AAA?
- means aneurysm is already leaking
- retroperitoneal hematoma is already forming
- blowout into the peritoneal cavity is only mins-hrs away
- emergency surgery required
Arteriosclerotic occlusive disease of the lower extremities?
- unpredictable natural history so no “prophylactic” surgery
- surgery done only to relieve disabling sx or save extremity from necrosis
- first sign is: intermittent claudication
Tx of arteriosclerotic occlusive disease of lower extremity?
- stop smoking
- exercise program
- cilostazol
Workup for disabling intermittent claudication?
- doppler studies looking for pressure gradient
a. if there isn’t one–> disease is in small vessels and not amenable to surgery - if there’s a signif. gradient–> ct angio or mri angio done to identify specific areas of stenosis or complex obstruction & look for good distal vessels where a graft can be hooked
Tx of intermittent claudication?
- short stenotic segments–> angioplasy and stunting
2. extensive stenosis-> require bypass grafts, sequential stents, or longer stents
In intermittent claudication when there are multiple stenotic lesions, do you treat proximal or distal lesions first?
do proximal repair before distal
What material are grafts originating at the aorta (i.e. aortobifemoral) made from?
prosthetic material
What material are bypasses between more distal vessels (femoropopliteal, etc) made of?
reversed saphenous vein grafts
Order of severity of arteriosclerotic occlusive disease of the lower extremity?
- intermittent claudication
- resting pain
- ulceration or gangrene
presentation of resting claudication in occlusive disease of LE
- “can’t sleep”
- learn that sitting up and dangling leg helps pain
- leg that was very pale becomes deep purple
- shiny, atrophic skin w/o hair on physical
- no peripheral pulses
Within how many hours should evaluation and treatment of arterial embolization of LE artery occur?
wi 6 hrs
What do you use to find the point of obstruction in LE artery embolization?
Doppler
Tx for early incomplete occlusion of LE artery embolization?
clot busters
Tx for complete obstruction in LE artery emboli?
Embelectomy w Fogarty catheter
+ Fasciotomy (if several hours have passed before revascularization)
Definitive diagnosis of dissecting aneurysm of aorta
- avoid high pressure injection needed for aortogram
- do MRI angiogram
- TEE (transesophageal echo)
- spiral CT scan (the best)
Treatment of dissections?
- ascending aorta dissection: surgery
2. descending aorta: medical management (control of htn in ICU)
