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ABSITE > Fiser Chapter 27 VASCULAR > Flashcards

Fiser Chapter 27 VASCULAR Flashcards

1
Q

Lymphedema tx

A

Leg elevation, compression, antibiotics for infection

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2
Q

How do you expose the SMA?

A

Divide the LOT. SMA is to the right of this near the base of the transverse colon mesentery.

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3
Q

Swollen red toe with pus coming out and red streaks up leg, sepsis

A

Wet gangrene, surgical emergency, may need amputation

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4
Q

Inflammatory aneurysms complications

A

Just inflammation (not infection), occurs in 10% of AAA patients; weight loss, high ESR, thickened rim above calcifications on CT; resolves after aortic graft placement

  • Adhesions to 3rd and 4th duodenum
  • Ureteral entrapment
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5
Q

Watershed areas

A

Griffith’s: splenic flexure

Sudak’s: upper rectum

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6
Q

Mal perforans ulcer

A 
Metatarsal heads
2nd MTP joint most common
Possible OM (Diabetics)
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7
Q

Leakage of clear fluid after groin surgery

A

Lymphocele

Tx: percutaneous drainage; resection of that fails

Can inject isosulfan blue dye into foot to identify lymphatic channels supplying lymphocele

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8
Q

Indication for repair of descending aortic aneurysms

A

> 5.5 cm if endovascular repair possible

> 6.5cm if open repair needed

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9
Q

Risk factors for visceral artery aneurysms

A

Medial fibrodysplasia
Portal HTN
Inflammation (pancreatitis causing arterial disruption)

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10
Q

Swelling right after lower extremity bypass

A

Reperfusion injury

can lead to compartment syndrome, lactic acidosis, hyperkalemia, myoglobinuria

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11
Q

Tx of acute arterial embolism

A

Embolectomy
Fasciotomy if ischemia > 4-6 hours
Aortoiliac emboli (loss of both femoral pulses): bilateral femoral artery cutdowns and bilateral embolectomies

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12
Q

Atheroma embolism diagnosis and treatment

A

Dx: CT CAP (look for aneurysmal source) and ECHO

Tx: aneurysm repair or arterial exclusion with bypass

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13
Q

Most common congenital hypercoagulable disorder

A

Leiden factor: resistance to activated protein C

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14
Q

Indication for repair of ascending aortic aneurysm

A

Acutely symptomatic
>/= 5.5 cm (> 5cm with Marfan’s)
Rapid increase in size (>0.5 cm/yr)

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15
Q

Most common cause of acute death after AAA repair

A

MI

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16
Q

Major vein injured with prximal cross-clamp in AAA repair

A

Retro-aortic left renal vein

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17
Q

Most common visceral aneurysm, and indication for repair

A

Splenic artery aneurysm

High rate of rupture in 3rd trim pregnancy

Repair if symptomatic, if pregnant, if childbearing age, or is >3-4cm

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18
Q

Indications for shunt during CEA

A

Stump pressures < 50, or

Contralateral side is tight

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19
Q

Signs of PAD

A
  • Pallor
  • Dependent rubor
  • Hair loss
  • Slow capillary refill
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20
Q

Most common location of pseudoaneurysm

A

femoral artery

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21
Q

Risk factors for AAA

A

Males
Age
Smoking
Family history

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22
Q

Atherosclerosis risk factors

A

-Smoking
-HTN
-Hypercholesterolemia
-DM
0Hereditary factors

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23
Q

Femoropopliteal graft 5-year patency

A

75%

Improved if for claudication rather than limb salvage

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24
Q

Carotid endarterectomy indications

A

> 70% stenosis and symptoms, or

> 80% stenosis

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25
Q

HTN in young women, string of beads appearance

A

FMD: Most commonly renal artery followed by carotid and iliac
If carotids involved, HA or stroke

Tx: PTA best, bypass if fails

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26
Q

Postnatal angiogenesis mechanism

A

Budding from preexisting vessels

Involved angiogenin

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27
Q

Most complication of aneurysms above versus below inguinal ligament

A

Rupture above

Thrombosis and emboli below

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28
Q

Dacron graft use

A

Aorta and large vessels

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29
Q

Treatment of pseudoaneurysm after percutaneous interention

A

US-guided compression with thrombin injection

Surgical repair if flow remains afterward

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30
Q

Pain, paresthesia, poikilothermia, paralysis

A

acute arterial embolus

pallor -> cyanosis -> marbling

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31
Q

Popliteal artery exposure below knee

A

Gastrocnemius is posterior

Popliteus muscle is anterior

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32
Q

TOS most common cause of pain

A

brachial plexus irritation

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33
Q

Blood flow to brain

A

Carotids supply 85%

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34
Q

Thoracic aortic surgery complications

A

MI
Renal failure
Paraplegia (descending thoracic aortic surgery)

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35
Q

Patient with AAA develops back or abdominal pain and has hypotension

A

AAA rupture

Dx: US or abdominal CT

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36
Q

Postop aortic dissection repair monitoring

A

Lifetime MRIs

30% eventually get aneurysm formation requiring surgery

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37
Q

TOS most common anatomic abnormality

A

cervical rib

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38
Q

Wet gangrene management

A

Need to remove infected necrotic material, antibiotics

Can be surgical emergency if extensive infection

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39
Q

What layer of vessel wall does aortic dissection occur in?

A

Medial layer

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40
Q

Early and late swelling following lower extremity bypass

A

Early: reperfusion injury and compartment syndrome (fasciotomy)

Late: DVT

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41
Q

Raised red/blue scarring where prior lymphedema was

A

Lymphangiosarcoma

Early mets to lung

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42
Q

Mid-thigh claudication means occlusion is where

A

External iliac

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43
Q

Pseudoaneurysm definition

A

Collection of blood in continuity with artery but not enclosed by all 3 layers of wall

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44
Q

Patient with heel ulceration to bone: treatment?

A

Amputation

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45
Q

most common peripheral aneurysm

A

popliteal
prominent pop pulses on exam
50% have aneurysm elsewhere

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46
Q

TOS tx

A

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

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47
Q

Problems with smiling/corner of mouth after CEA

A

Mandibular branch of facial nerve injury

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48
Q

BKA versus AKA prognosis

A

BKA: 80% heal, 70% walk again, 5% mortality
AKA: 90% heal, 30% walk again, 10% mortality

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49
Q

Mycotic aneurysm treatment

A

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

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50
Q

Risk factors for aortic dissection

A

Marfan’s
Previous aneurysm
Atherosclerosis

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51
Q

Communication between ICA and ECA

A

Ophthalmic artery and internal maxillary artery

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52
Q

Dx compartment syndrome

A

Clinical

Compt pressure >20-30 mm Hg

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53
Q

Leg amputation 3 year mortality

A

50%

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54
Q

Aortic graft infection organisms

A
  1. Staphylococcus

2. E coli

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55
Q

Emergent CEA indications

A

Fluctuating neurologic symptoms or crescendo/evolving TIAs

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56
Q

Most common cause of non-stroke M&M after CEA

A

MI

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57
Q

Type III endoleak

A

OVERLAP sites failure when using multiple grafts or fabric tear
Tx: Secondary endograft to cover overlap site or tear

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58
Q

Superficial posterior leg compartment nerve

A

Sural nerve

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59
Q

Older woman with headache, fever, blurred vision

A

Temporal arteritis
Risk of blindness

Dx: Temproal artery bx shows giant cell arteritis, granulomas. Long segments of smooth stenosis

Tx: Steroids, bypass of large vessels if needed; NO endarterectomy

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60
Q

Where do most dissections start?

A

Ascending aorta

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61
Q

Greater saphenous vein stripping

A

tx for saphenofemoral valve incompetence

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62
Q

Isolated iliac disease tx

A
  1. PTA with stent

2. Consider fem-fem crossover

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63
Q

MCC early failure of RSVG

A

Technical problem

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64
Q

Lymphatics

A

No basement membrane

Not in bone/muscle/tendon/cartilage/brain/cornea

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65
Q

Radiation arteritis early/late/very late

A

Early: obliterative endarteritis (sloughing and thrombosis)

Late 1-10 years: fibrosis, scar, stenosis

Very late 3-30 years: advanced atherosclerosis

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66
Q

MCC of PAD

A

Atherosclerosis

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67
Q

Treatment of Mal perforans ulcer

A

Non-weightbearing, metatarsal head debridement (remove cartilage), antibiotics, assess need for revasc

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68
Q

Percutaneous transluminal angioplasty indication

A

Common iliac artery stenosis, best for short stenosis

Mech: intima usually rupture, media stretched, plaque pushed out, requires passage of wire first

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69
Q

Patient with tearing-like chest pain, unequal pulses or BP in upper extremities

A

Aortic dissection

95% have HTN at presentation

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70
Q

Most common cause of cerebral ischemic events

A
  • Arterial embolization from the ICA (not thrombosis)
  • Can also occur from low-flow state through stenotic lesion
  • Heart is 2nd most common source of cerebral emboli
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71
Q

Anterior cerebral artery events symptoms

A

AMS, release, slowing

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72
Q

Most common atherosclerotic occlusion in lower extremities

A

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

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73
Q

What causes death in aortic dissection?

A

Cardiac failure from aortic insufficiency, cardiac tamponade, or rupture

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74
Q

Popliteal artery aneurysm dx and tx

A

Dx: US

Tx: exclusion and bypass (not stent)

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75
Q

Lateral leg compartment nerve

A

Superficial peroneal nerve: eversion, lateral foot sensation

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76
Q

Rate or restenosis after CEA

A

15%

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77
Q

Leg compartments

A
  1. Anterior: deep peroneal nerve (dorsiflexion and web sensation), AT artery
  2. Lateral: superficial peroneal nerve (eversion, lateral foot sensation)
  3. Deep posterior: tibial nerve (plantar flexion), PT artery, peroneal artery
  4. Superficial posterior: sural nerve
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78
Q

Tenderness, cyanosis, massive edema

A

Phlegmasia cerulean dolens

Tx: heparin, rarely surgery

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79
Q

Venous ulcer cause and location

A
  • venous valve incompetence 90%

- above and posterior to malleoli

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80
Q

Lymphedema mechanism

A

Obstructed, too few, or nonfunctional lymphatics

  • > fibrosis in subcutaneous tissue -> woody edema
  • > cellulitis and lymphangitis after minor trauma
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81
Q

1 preventive agent for atherosclerosis

A

Statins

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82
Q

Next step if pulse volume recordings suggest significant disease

A

Arteriogram

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83
Q

Buttock or thigh claudication, impotence, no femoral pulses

A

Leriche syndrome: lesion at aortic bifurcation or above

Tx: Aorto-bifemoral bypass graft

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84
Q

Surgical repair of aortic dissections

A

Ascending: open repair with graft

Descending: endograft or open or fenestrations

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85
Q

Posterior cerebral artery events symptoms

A

Vertigo, tinnitus, drop attacks, incoordination

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86
Q

Tongue deviates to L after CEA, speech and mastication difficult

A

Left hypoglossal nerve injury

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87
Q

Premenopausal woman with resistant HTN, DBP > 115, bruits

A

Renal artery stenosis
FMD: R side, distal 1/3, women
Renal atherosclerosis: L side, proximal 1/3, men

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88
Q

TOS diagnosis

A

cervical spine and chest MRI
duplex US
EMG

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89
Q

Most common acquired hypercoagulable disorder

A

Smoking

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90
Q

Acute arterial thrombosis treatment

A

Threatened limb (loss of motor or neuro): heparin and OR for thrombectomy

Otherwise: angiography for thrombolytics

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91
Q

Virchow’s triad

A

Venous stasis
Hypercoagulability
Venous wall injury

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92
Q

Type IV endoleak

A

graft WALL porosity or suture holes

Tx: observe; can place nonporous stent if that fails

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93
Q

Indications for IVC filter

A

AC contraindication
PE while on Coumadin
Free-floating ileofemoral thrombi
After pulmonary embolectomy

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94
Q

Mortality after elective AAA repair

95
Q

Aortic graft infection treatment

A

Bypass through non-contaminated field (eg axillary-femoral bypass with fem-fem crossover) and then resect infected graft

96
Q

Most likely leg compartment to get compartment syndrome

A

Anterior compartment, get foot drop

97
Q

Acute arterial embolism versus acute arterial thrombosis

A

Embolism: Arrhythmia, no prior claudication or rest pain, normal contralateral pulses, no physical findings of chronic limb ischemia; no collaterals

Thrombosis: No arrhythmia; history of claudication or rest pain, contralateral pulses absent, physical findings of chronic limb ischemia; collaterals present

98
Q

Suppurative thrombophlebitis

A

Pus fills vein; fever, leukocytosis, erythema, fluctuance, usually associated with infection after PIV

Tx: resect entire vein

99
Q

Collateral circulation

A

Circumflex iliacs to subcostals
Circumflex femoral to gluteals
Geniculate around the knee

100
Q

Most common cause of AV graft failure

A

Intimal hyperplasia -> venous obstruction

101
Q

Indications for operative repair of aortic dissections

A 
-All ascending (class A or type I/II)
     Open repair, graft to eliminate flow to false lumen

-Descending aortic dissection (class B or type III) if visceral or extremity ischemia, or if contained rupture
     Endograft or open repair; or just place fenestrations in dissection flap to restore blood flow to viscera or extremity
102
Q

Painless neck mass

A

Carotid body tumor: painless neck mass, usually near bifurcation, neural crest cells, EXTREMELY VASCULAR
Tx: resection

103
Q

Type II endoleak

A 
COLLATERALS failure (eg patent lymbar, IMA, intercostals, accessory renal)
Tx: Observe; percutaneous coil embolization if pressurizing aneurysm
104
Q

Claudication management

A

ASA, stop smoking, exercise until pain occurs to improve collaterals

105
Q

Diagnosis of AAA rupture

A

CT: fluid in retroperitoneal space and extraluminal contrast with rupture
-Most likely in Left posterolateral wall, 203 cm below renals

106
Q

Aortic dissection Stanford classification

A

A: any ascending aortic involvement

B: descending aortic involvement only

107
Q

Rest pain mimicker

A

DM neuropathy

108
Q

Cimino fistula

A

Radial artery to cephalic vein

Wait 6 weeks for vein to mature

109
Q

Type I endoleak

A

Proximal or distal ATTACHMENT SITES of graft failure

Tx: extension cuffs

110
Q

Young male smoker with severe rest pain and bilateral ulceration, gangrene of digits especially fingers

A

Buerger’s disease

Corkscrew collaterals on angiogram and severe distal disease; normal

111
Q

Abdominal pain out of proportion, sudden onset, hematochezia and peritonitis

A

Mesenteric ischemia from SMA embolism

112
Q

Vertebrobasilar symptoms and subclavian artery stenosis

A

Subclavian steal syndrome: proximal subclavian artery stenosis resulting in reversal of flow through ipsilateral vertebral artery into subclavian artery

Operate if limb or neuro symtpms
Tx: PTA with stent to subclavian artery; common carotid to subclavian artery bypass if fails

113
Q

Effort-induced thrombosis of subclavian vein with acutely painful, swollen, blue limb

A

Paget-von-Schrotter disease, baseball pitchers

Venous thrombosis much more common than arterial

Dx: venography gold standard; also duplex US quicker

80% have associated thoracic outlet problem

Tx: Thrombolytics initially, repair at that admission (cervical rib and 1st rib resection, divide anterior scalene muscle)

114
Q

Gold standard for vascular imaging

A

Arteriogram

115
Q

CEA complications

A
  1. Vagus nerve injury is most common cranial nerve injury, and is secondary to vascular clamping, manifests as hoarseness (d/t RLN branch)
  2. Hypoglossal nerve injury: tongue deviates toward injury, speech and mastication difficult
  3. Glossopharyngeal nerve injury: rare, with really high carotid dissection, difficulty swallowing
  4. Ansa cervicalis: innervation to strap muscles, no serious deficits
  5. Mandibular branch of facial nerve: affects corner of mouth, smile
  6. Stroke: OR to check for flap or thrombosis
  7. Pseudoaneurysm: pulsatile, bleeding mass; tx drape and prep, intubate, repair
  8. HTN: in 20%, caused by carotid body injury, tx Nipride to avoid bleeding
  9. MI: MCC of non-stroke m & m after CEA
  10. Restenosis: 15 % rate
116
Q

ECA branches

A
  1. Superior thyroid artery
  2. Ascending pharyngeal
  3. Lingual
  4. Facial
  5. Occipital
  6. Postauricular
  7. Maxillary
  8. Superficial temporal

Some Anatomists Like Freaking Out Poor Medical Students

117
Q

History of food fear, weight loss, vasculitis, hypercoagulable state, presents with abdominal pain

A

Mesenteric ischemia from SMA thrombosis

118
Q

Prolonged hand ischemia, why does motor function remain in digits?

A

Motor groups are in proximal forearm

119
Q

Stewart-Treves syndrome

A

Lymphangiosarcoma associated with breast axillary dissection and chronic lymphedema

120
Q

Graft infection rate after AAA repair

121
Q

Claudication mimicker

A

Lumbar stenosis

122
Q

Foot claudication means occlusion is where

A

Distal superficial femoral or popliteal

123
Q

Most common site of upper extremity stenosis

A

subclavian artery

tx: Perc transluminal angioplasty with stent; common carotid to subclavian artery bypass if fails

124
Q

Atheroma embolism mechanism

A

Cholesterol clefts that can lodge in small arteries

125
Q

Child with fever, viral illness with erythematous mucosa and epidermis

A

Kawasaki’s disease (medium artery): aneurysms of coronary arteries and brachiocephalic vessels, die from arrhythmias

Tx: Steroids, possible CABG

126
Q

DVT most common where

A

Calf

Left leg 2x more common (longer left iliac vein compressed by right iliac artery)

127
Q

Varicose vein risk factors and tx

A

Smoking, obesity, sedentary

Tx: Sclerotherapy

128
Q

Aortic insufficiency incidence in aortic dissection

A

70%

  • Caused by annular dilatation or when aortic valve cusp is sheared off
  • Can also have occlusion of coronary arteries and major aortic branches
129
Q

PAD surgical indications

A
  • Rest pain
  • Ulceration or gangrene
  • Lifestyle limitation
  • Atheromatous embolization
130
Q

40yo man with mild intermittent claudication, loss of pulses with plantar flexion

A

Popliteal entrapment syndrome: medial deviation of artery around medial head of gastrocnemius muscle

Tx: resect medial head of gastroc, may need arterial reconstruction

131
Q

Pulse volume recordings use

A

To find significant occlusion and at what level

132
Q

Diarrhea after AAA repair

A

Concern for ischemic colitis, especially if bloody

  • IMA often sacrificed -> left colon ischemia
  • Dx: endoscopy or abdominal CT; middle and distal rectum spared (middle and inferior rectal arteries come off internal iliac artery)
  • If peritonitis or black mucosa on endoscopy or dead colon on CT -> OR for colectomy and colostomy
133
Q

PTFE graft thrombosis tx

A

Thrombolytics and AC

If limb threatened (loss of motor or neuro): OR for thrombectomy

134
Q

Amputation indications

A

Gangrene, Large non-healing ulcers, Unrelenting rest pain not amenable to surgery

Emergency amp for systemic complication or extensive infection

135
Q

Weight loss, visceral angina 30 min after meals

A

Chronic mesenteric angina

Dx: Lateral visceral vessel aortography to see celiac and SMA origins

Tx: PTA and stent, bypass if fails

136
Q

Anterior leg compartment nerve

A

Deep peroneal nerve: dorsiflexion and web sensation, also AT artery

137
Q

Indications to reimplant the IMA after AAA repair?

A
  • Backpressure < 40 (poor backbleeding)
  • Previous colonic surgery
  • Stenosis at SMA
  • Flow to left colon appears inadequate
138
Q

Most common site of peripheral obstruction from emboli

A

Common femoral artery

139
Q

Treatment of pseudoaneurysm early after surgery at a suture line

A

Surgical repair

140
Q

HTN after CEA

A

Carotid body injury, occurs in 20%, tx Nipride to avoid bleeding

141
Q

Superficial thrombophlebitis

A

Nonbacterial inflammation

Tx: NSAIDs, warm packs, ambulation

142
Q

AAA definition and mechanism

A

Degeneration of medial layer -> AAA

Normal aorta 2-3 cm

143
Q

Hoarseness after CEA

A

Vagus nerve injury (RLN branch too)

144
Q

Indication for carotid stent instead of CEA

A

High-risk patients (previous CEA and restenosis, multiple comorbidities, prior neck XRT)

145
Q

Type V endoleak

A

Endotension: expansion of aneurysm without e/o leak
Tx: Repeat EVAR or open repair

146
Q

Increased risk of atherosclerosis

A

Homocystinuria (tx folate and B12)

147
Q

Palpable purpura rash, fever, end-organ dysfunction

A

Hypersensitivity angiitis (small artery) 2/2 drug or tumor antigens

Tx: CCB, pentoxifylline, stop offending agent

148
Q

Atherosclerosis stages

A
  1. Foam cells: macrophages with absorbed fat and lipids in vessel wall
  2. Smooth muscle cell proliferation: from growth factors released by macrophages, causing wall injury
  3. Intimal disruption: exposure of collagen in vessel wall and eventual thrombus formation -> fibrous plaques in areas with underlying atheromas
149
Q

Ideal criteria for AAA endovascular repair

A
  • Neck length > 15 mm
  • Neck diameter 20-30 mm
  • Neck angulation < 60 degrees
  • Common iliac artery length > 10 mm
  • Common iliac artery diameter 8-18 mm
  • Non-tortuous, non-calcified iliac arteries
  • Lack of neck thrombus
150
Q

Tenderness, pallor, edema

A

Phlegmasia alba dolens

Tx: heparin

151
Q

Upper extremity occlusive disease symptoms

A

Proximal lesions usually asymptomatic d/t collaterals

152
Q

SCDs mech

A

Decrease venous stasis and increase tPA release

153
Q

Below knee graft type

A

Saphenous vein, as synthetic grafts have decreased patency below the knee

154
Q

How do you prevent vasculogenic impotence and pelvic ischemia in aorto-bifemoral repair?

A

Ensure flow to at least 1 internal iliac (hypogastric) artery, by seeing good back-bleeding, otherwise need bypass to an internal iliac artery

155
Q

PE with IVC filter in place comes from where?

A

Ovarian veins,
IVC superior to filter, or
Upper extremity via SVC

156
Q

Stroke risk factors

A

HTN most important

157
Q

Middle cerebral artery events symptoms

A

Contralateral motor, speech (if dominant side), contralateral facial droop sparing forehead

158
Q

Vertebrobasilar artery disease mechanism

A

Need either bilateral vertebral artery or basilar artery disease to have symptoms

Symptoms: Diplopia, vertigo, tinnitus, drop attacks, incoordination
Tx: PTA with stent

159
Q

Risk factors for mortality after AAA repair

A

-Cr > 1.8

  • CHF
  • ECG ischemia
  • Pulmonary dysfunction
  • Older age
  • Females
160
Q

Renal artery stenosis dx and tx

A

Angiogram

Tx: Percutaneous transluminal angioplasty; place stent if due to atherosclerotic disease

Nephrectomy if atrophic kidney with persistently high renin levels

161
Q

Migrating thrombophlebitis

A

Pancreatic Ca

162
Q

Most common late complication after aortic graft placement

A

Atherosclerotic occlusion

163
Q

Normal venous Doppler US

A

Augmented flow with distal compression or proximal release

164
Q

Chronic pain, weight loss, diarrhea, bruit near epigastrium

A

Median arcuate ligament syndrome: celiac artery compression

Tx: Transect median arcuate ligament, may need arterial reconstruction

165
Q

Can IVC be clamped?

A

No, will tear

166
Q

6 months after AAA repair, herald bleed with hematemesis and then blood per rectum

A

Aortoenteric fistula

Graft erodes into 3rd or 4th duodenum near proximal suture line
Tx: bypass through noncontaminated field (ax-fem bypass with fem-fem crossover), resect graft, then close hole in duodenum

167
Q

Stroke after CEA

A

OR to check for flap or thrombosis

168
Q

Which side do you repair first in bilateral carotid stenosis?

A

Tighter side first

If equal, dominant side first

169
Q

Tinsel’s test positive and ulnar nerve (C8-T1) symptoms (tricep weakness, intrinsic hand weakness, wrist flexion weakness)

A

Brachial plexus irritation from TOS

170
Q

ABI levels and symptoms

A

< 0.9 claudication
< 0.5 rest pain (distal arch and foot)
< 0.4 ulcers (toes first)
< 0.3 gangrene

171
Q

Venous thrombosis with central line, management

A

Pull central line
Heparin
If need line, try heparin or tPA down line

172
Q

ABI inaccurate in who?

A

DM patients 2/2 incompressiblity of vessels

Go off Doppler waveforms instead

173
Q

Most common site of stenosis causing stroke

A

Carotid bifurcation

174
Q

Deep posterior leg compartment nerve

A

Tibial nerve: plantar flexion

also PT artery and peroneal artery

175
Q

Stroke with diplopia, vertigo, tinnitus, drop attacks, incoordination. What vessels cut off?

A

Vertebrobasilar

Tx: PTA with stent

176
Q

Mechanism of paraplegia after descending thoracic aortic surgery

A

Occlusion of intercostal arteries and artery of Adamkiewicz -> spinal cord ischemia

Less risk with endovascular repair

Less risk when reimplant intercostal arteries below T8 in open repair

177
Q

SMA embolism dx and tx

A

Angiogram or CTAP with IV contrast

Embolectomy, resect infarcted bowel

178
Q

Mycotic aneurysm organisms

A
  1. Salmonella

2. Staphylococcus

179
Q

Aortic graft infection presentation

A

Fluid, gas, thickening around graft

Often cultures are negative

More common with grafts going to groin (aorto-bifem grafts)

180
Q

Treatment of aortic dissection

A

Medical initially: BP control with esmolol and nipride

181
Q

Leading cause of death in AAA without surgery

A

Rupture, 50% mortality if patient reaches hospital alive

182
Q

Pseudoaneurysm rate after AAA repair

183
Q

Mesenteric ischemia cause

A 
SMA disease
    Embolic 50% (heart a fib most common source)
    Thrombotic 25%
    Nonocclusive 15%
    Venous thrombosis 5%
60% mortality
184
Q

Aortic dissection DeBakey classification

A

“DeBakey is BAD (both, ascending, descending)

based on site of tear and extent of dissection

Type I: Ascending and descending
Type II: Ascending only
Type III: Descending only

185
Q

Splenic, renal, iliac, femoral artery aneurysm tx

A

covered stent

186
Q

Fem-fem crossover graft effects on blood flow in donor leg

A

Doubles blood flow to donor artery

Can get vascular steal in donor leg

187
Q

Aching, swelling, night cramps, brawny edema, venous ulcers

A

Venous insufficiency

Tx: leg wraps, ambulation with avoidance of long standing

188
Q

Carotid traumatic injury with major fixed deficit, treatment

A

If occluded, do not repair as can exacerbate injury with bleeding

If not occluded, repair with carotid stent or open procedure

189
Q

Young woman with hand pallor -> cyanosis -> rubor

A

Reynaud’s disease

Tx: CCB, warmth

190
Q

Most commonly diseased intracranial artery

A

Middle cerebral artery

191
Q

Tall, retinal detachment, aortic root dilatation

A

Marfan’s (fibrillin defect), a cystic medial necrosis syndrome

192
Q

Nonocclusive mesenteric ischemia dx and tx

A

Recent prolonged shock/CHF/Cardiopulm bypass -> low cardiac output to visceral vessels -> watershed areas ischemia

Tx: volume resuscitation, catheter-directed nitroglycerin can increase visceral blood flow; also need to increased CO (dobutamine); resect infarcted bowel if present

193
Q

Venous ulcer tx

A

Unna booth compression cures 90%

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

194
Q

Femoral-distal graft 5-year patency (peroneal, AT, PT)

A

50%

  • Usually used only for limb salvage
  • Bypassed vessel needs to have run-off below ankle to be successful
  • Not influenced by level of distal anastomosis
  • Distal lesions more limb threatening because lack of collaterals
195
Q

SMA thrombosis dx and tx

A

Angiogram or CTAP with IV contrast

Thrombectomy (open or catheter; thrombolytics), possible PTA with stent, possible open bypass, resection of infarcted bowel

196
Q

Dry gangrene management

A

Can allow autoamputation if small or just toes

But large lesions should be amputated

See if patient has correctable vascular lesion

197
Q

CT findings of intestinal ischemia

A
  • Vascular occlusion
  • Bowel wall thickening
  • Intramural gas
  • Portal venous gas
198
Q

Easy bruising, mobile joints, arterial rupture especially abdominal vessels

A

Ehler-Danlos syndrome, collagen problems, a cystic medial necrosis: aneurysms, dissections
No angiograms (risk of lac to vessel)
Often too difficult to repair and must ligate to control hemorrhage

199
Q

PTFE Gortex use

A

Bypasses above knee ONLY

200
Q

Endoleak types

A

ACOWE, observe 2&4

Type I: Attachment sites

Type II: Collaterals

Type III: Overlap sites

Type IV: graft Wall porosity

Type V: Expansion or aneurysm without leak

201
Q

Pseudoaneurysms that occur at suture lines months-years after surgery, worrisome for what?

A

Graft infection

202
Q

Back, neck, arm pain/weakness/tingling, worse with palpation or manipulation

A

Thoracic outlet syndrome
Subclavian vein passes over 1st rib ANTERIOR to anterior scalene muscle, then behind clavicle
Brachial plexus and subclavian artery pass over 1st rib POSTERIOR to anterior scalene muscle and anterior to middle scalene muscle (traverse narrow triangle formed by anterior and middle scalene muscles and first rib)

Dx: cervical spine and chest MRI, duplex US, EMG

Neuro involvement much more common than vascular

203
Q

Pulsatile, bleeding mass after CEA

A

Pseudoaneurysm: drape and prep, intubate, repair

204
Q

Symptoms of PAD occur at what level relative to occlusion

A

One level below

205
Q

Indications for repair of splanchnic artery aneurysm (>2 cm)

A

Repair all when diagnosed, as there is 50% risk of rupture, except splenic

206
Q

Amaurosis fugax

A

Occlusion of ophthalmic branch of ICA -> shade coming down over eyes; transient

-Hollenhorst plaques on ophthalmic exam

207
Q

Endovascular versus open repair of descending aortic aneurysms

A

-Less mortality, less paraplegia (2-3% versus 20%)

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

208
Q

Most common cause of LATE death after AAA repair

A

Renal failure

209
Q

40yo man with intermittent claudication, changes in symptoms with knee flexion/extension

A

Adventitial cystic disease: often bilateral ganglia originating from adjacent joint capsule or tendon sheath, most commonly in popliteal fossa

Dx: angiogram
Tx: Cyst resection, vein graft if vessel occluded

210
Q

Complications of AAA

A

Rupture
Distal embolization
Compression of adjacent organs

211
Q

Hand pain from ischemia in a weight lifter, absent radial pulse with head turned to ipsilateral side (Adson’s test)

A

Anterior scalene hypertrophy causing compression and TOS

Dx: angiogram gold standard or duplex US

Tx: cervical rib and 1st rib resection, divide anterior scalene muscle, possible bypass graft if artery too damaged or aneurysmal

212
Q

Tx compartment syndrome

A

Fasciotomy of all 4 compartments if in lower leg

Leave open 5-10 days

213
Q

Mycotic aneurysm mechanism and presentation

A

Bacteria infect atherosclerotic plaque and cause aneurysm (Salmonella, staphylococcus)

  • Pain, fevers, bacteremia
  • Periaortic fluid, gas, retroperitoneal soft tissue edema, lymphadenopathy
214
Q

Predictors of AAA rupture

A

diastolic HTN

COPD

215
Q

Calf claudication means occlusion is where

A

Common femoral or proximal superficial femoral artery

216
Q

Aorto-bifemoral repair complication

A

Vasculogenic impotence
-Ensure flow to at least one internal iliac artery (hypogastric) to avoid this

-Impotence in 1/3 d/t disruption of autonomic nerves and blood flow

217
Q

CEA contraindications

A

Recent completed stroke: wait 4-6 weeks, otherwise bleeding risk

218
Q

Swelling location and DVT location

A

Calf DVT - minimal swelling
Femoral DVT - ankle and calf swelling
Iliofemoral DVT - leg swelling

219
Q

Can renal veins by ligated?

A

Left can, has collaterals (gonadal, adrenal)

220
Q

MCC late failure of RSVG

A

Atherosclerosis

221
Q

SMA and celiac collateral

A

Arc of Riolan

222
Q

Indications for AAA repair

A

Symptomatic
Size > 5.5 cm
Growth > 0.5 cm/yr

223
Q

Diagnosis of aortic dissection

A

Chest CT with contrast

CXR normal or widened mediastinum

224
Q

Buttock claudication means occlusion is where

A

Aortoiliac disease

225
Q

Traumatic AV fistula management

A

Most need repair: lateral venous suture

Can get peripheral arterial insufficiency, CHF, aneurysm, limb-length discrepancy

226
Q

Most common site of atheroma embolization

A

Renal arteries

227
Q

ICA first branch

A

Ophthalmic artery

228
Q

Difficulty swallowing after CEA

A

Glossopharyngeal nerve injury (high carotid dissections)

229
Q

MCC acute arterial embolus

A

A fib
Recent MI with LV thrombus
Myxoma
Aorto-iliac disease

230
Q

Flaking atherosclerotic emboli off abdominal aorta or branches

A

Blue toe syndrome
Typically good distal pulses
Aortoiliac disease most common source

231
Q

Pain with passive motion, extremity feels tigh and swollen

A

Compartment syndrome from reperfusion injury (PMNs mediate it, occurs after > 4-6 hours of cessation of blood flow and then reperfusion)

232
Q

Weight loss, rash, arthralgias, HTN, kidney dysfunction

A

Polyarteritis nodosa (medium artery): aneurysms that thrombose or rupture, renals most commonly involved

Tx: steroids

233
Q

Mesenteric vein thrombosis dx and tx

A

CTAP or angiogram with venous phase. Usually short segments of intestinve involved.

Tx: heparin usual, resection of infarcted bowel if present

ABSITE (34 decks)

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