Fiser Chapter 27 VASCULAR Flashcards
1
Q
Lymphedema tx
A
Leg elevation, compression, antibiotics for infection
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.
3
Q
Swollen red toe with pus coming out and red streaks up leg, sepsis
A
Wet gangrene, surgical emergency, may need amputation
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
5
Q
Watershed areas
A
Griffith’s: splenic flexure
Sudak’s: upper rectum
6
Q
Mal perforans ulcer
A
Metatarsal heads 2nd MTP joint most common Possible OM (Diabetics)
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
8
Q
Indication for repair of descending aortic aneurysms
A
> 5.5 cm if endovascular repair possible
> 6.5cm if open repair needed
9
Q
Risk factors for visceral artery aneurysms
A
Medial fibrodysplasia
Portal HTN
Inflammation (pancreatitis causing arterial disruption)
10
Q
Swelling right after lower extremity bypass
A
Reperfusion injury
can lead to compartment syndrome, lactic acidosis, hyperkalemia, myoglobinuria
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
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
13
Q
Most common congenital hypercoagulable disorder
A
Leiden factor: resistance to activated protein C
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)
15
Q
Most common cause of acute death after AAA repair
A
MI
16
Q
Major vein injured with prximal cross-clamp in AAA repair
A
Retro-aortic left renal vein
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
18
Q
Indications for shunt during CEA
A
Stump pressures < 50, or
Contralateral side is tight
19
Q
Signs of PAD
A
- Pallor
- Dependent rubor
- Hair loss
- Slow capillary refill
20
Q
Most common location of pseudoaneurysm
A
femoral artery
21
Q
Risk factors for AAA
A
Males
Age
Smoking
Family history
22
Q
Atherosclerosis risk factors
A
-Smoking
-HTN
-Hypercholesterolemia
-DM
0Hereditary factors
23
Q
Femoropopliteal graft 5-year patency
A
75%
Improved if for claudication rather than limb salvage
24
Q
Carotid endarterectomy indications
A
> 70% stenosis and symptoms, or
> 80% stenosis
25
HTN in young women, string of beads appearance
FMD: Most commonly renal artery followed by carotid and iliac
If carotids involved, HA or stroke
Tx: PTA best, bypass if fails
26
Postnatal angiogenesis mechanism
Budding from preexisting vessels
| Involved angiogenin
27
Most complication of aneurysms above versus below inguinal ligament
Rupture above
Thrombosis and emboli below
28
Dacron graft use
Aorta and large vessels
29
Treatment of pseudoaneurysm after percutaneous interention
US-guided compression with thrombin injection
| Surgical repair if flow remains afterward
30
Pain, paresthesia, poikilothermia, paralysis
acute arterial embolus
pallor -> cyanosis -> marbling
31
Popliteal artery exposure below knee
Gastrocnemius is posterior
| Popliteus muscle is anterior
32
TOS most common cause of pain
brachial plexus irritation
33
Blood flow to brain
Carotids supply 85%
34
Thoracic aortic surgery complications
MI
Renal failure
Paraplegia (descending thoracic aortic surgery)
35
Patient with AAA develops back or abdominal pain and has hypotension
AAA rupture
Dx: US or abdominal CT
36
Postop aortic dissection repair monitoring
Lifetime MRIs
| 30% eventually get aneurysm formation requiring surgery
37
TOS most common anatomic abnormality
cervical rib
38
Wet gangrene management
Need to remove infected necrotic material, antibiotics
Can be surgical emergency if extensive infection
39
What layer of vessel wall does aortic dissection occur in?
Medial layer
40
Early and late swelling following lower extremity bypass
Early: reperfusion injury and compartment syndrome (fasciotomy)
Late: DVT
41
Raised red/blue scarring where prior lymphedema was
Lymphangiosarcoma
| Early mets to lung
42
Mid-thigh claudication means occlusion is where
External iliac
43
Pseudoaneurysm definition
Collection of blood in continuity with artery but not enclosed by all 3 layers of wall
44
Patient with heel ulceration to bone: treatment?
Amputation
45
most common peripheral aneurysm
popliteal
prominent pop pulses on exam
50% have aneurysm elsewhere
46
TOS tx
Cervical rib and 1st rib resection, divide anterior scalene muscle
47
Problems with smiling/corner of mouth after CEA
Mandibular branch of facial nerve injury
48
BKA versus AKA prognosis
BKA: 80% heal, 70% walk again, 5% mortality
AKA: 90% heal, 30% walk again, 10% mortality
49
Mycotic aneurysm treatment
Usually need extra-anatomic bypass (axillary-femoral with fem-fem crossover) and resection of infrarenal aorta to clear infection
50
Risk factors for aortic dissection
Marfan's
Previous aneurysm
Atherosclerosis
51
Communication between ICA and ECA
Ophthalmic artery and internal maxillary artery
52
Dx compartment syndrome
Clinical
| Compt pressure >20-30 mm Hg
53
Leg amputation 3 year mortality
50%
54
Aortic graft infection organisms
1. Staphylococcus
| 2. E coli
55
Emergent CEA indications
Fluctuating neurologic symptoms or crescendo/evolving TIAs
56
Most common cause of non-stroke M&M after CEA
MI
57
Type III endoleak
OVERLAP sites failure when using multiple grafts or fabric tear
Tx: Secondary endograft to cover overlap site or tear
58
Superficial posterior leg compartment nerve
Sural nerve
59
Older woman with headache, fever, blurred vision
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
60
Where do most dissections start?
Ascending aorta
61
Greater saphenous vein stripping
tx for saphenofemoral valve incompetence
62
Isolated iliac disease tx
1. PTA with stent
| 2. Consider fem-fem crossover
63
MCC early failure of RSVG
Technical problem
64
Lymphatics
No basement membrane
| Not in bone/muscle/tendon/cartilage/brain/cornea
65
Radiation arteritis early/late/very late
Early: obliterative endarteritis (sloughing and thrombosis)
Late 1-10 years: fibrosis, scar, stenosis
Very late 3-30 years: advanced atherosclerosis
66
MCC of PAD
Atherosclerosis
67
Treatment of Mal perforans ulcer
Non-weightbearing, metatarsal head debridement (remove cartilage), antibiotics, assess need for revasc
68
Percutaneous transluminal angioplasty indication
Common iliac artery stenosis, best for short stenosis
Mech: intima usually rupture, media stretched, plaque pushed out, requires passage of wire first
69
Patient with tearing-like chest pain, unequal pulses or BP in upper extremities
Aortic dissection
95% have HTN at presentation
70
Most common cause of cerebral ischemic events
- 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
71
Anterior cerebral artery events symptoms
AMS, release, slowing
72
Most common atherosclerotic occlusion in lower extremities
Hunter's canal (distal superficial femoral artery exits here)
Sartorius muscle covers Hunter's canal
73
What causes death in aortic dissection?
Cardiac failure from aortic insufficiency, cardiac tamponade, or rupture
74
Popliteal artery aneurysm dx and tx
Dx: US
Tx: exclusion and bypass (not stent)
75
Lateral leg compartment nerve
Superficial peroneal nerve: eversion, lateral foot sensation
76
Rate or restenosis after CEA
15%
77
Leg compartments
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
78
Tenderness, cyanosis, massive edema
Phlegmasia cerulean dolens
Tx: heparin, rarely surgery
79
Venous ulcer cause and location
- venous valve incompetence 90%
| - above and posterior to malleoli
80
Lymphedema mechanism
Obstructed, too few, or nonfunctional lymphatics
- > fibrosis in subcutaneous tissue -> woody edema
- > cellulitis and lymphangitis after minor trauma
81
#1 preventive agent for atherosclerosis
Statins
82
Next step if pulse volume recordings suggest significant disease
Arteriogram
83
Buttock or thigh claudication, impotence, no femoral pulses
Leriche syndrome: lesion at aortic bifurcation or above
Tx: Aorto-bifemoral bypass graft
84
Surgical repair of aortic dissections
Ascending: open repair with graft
Descending: endograft or open or fenestrations
85
Posterior cerebral artery events symptoms
Vertigo, tinnitus, drop attacks, incoordination
86
Tongue deviates to L after CEA, speech and mastication difficult
Left hypoglossal nerve injury
87
Premenopausal woman with resistant HTN, DBP > 115, bruits
Renal artery stenosis
FMD: R side, distal 1/3, women
Renal atherosclerosis: L side, proximal 1/3, men
88
TOS diagnosis
cervical spine and chest MRI
duplex US
EMG
89
Most common acquired hypercoagulable disorder
Smoking
90
Acute arterial thrombosis treatment
Threatened limb (loss of motor or neuro): heparin and OR for thrombectomy
Otherwise: angiography for thrombolytics
91
Virchow's triad
Venous stasis
Hypercoagulability
Venous wall injury
92
Type IV endoleak
graft WALL porosity or suture holes
| Tx: observe; can place nonporous stent if that fails
93
Indications for IVC filter
AC contraindication
PE while on Coumadin
Free-floating ileofemoral thrombi
After pulmonary embolectomy
94
Mortality after elective AAA repair
5%
95
Aortic graft infection treatment
Bypass through non-contaminated field (eg axillary-femoral bypass with fem-fem crossover) and then resect infected graft
96
Most likely leg compartment to get compartment syndrome
Anterior compartment, get foot drop
97
Acute arterial embolism versus acute arterial thrombosis
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
Suppurative thrombophlebitis
Pus fills vein; fever, leukocytosis, erythema, fluctuance, usually associated with infection after PIV
Tx: resect entire vein
99
Collateral circulation
Circumflex iliacs to subcostals
Circumflex femoral to gluteals
Geniculate around the knee
100
Most common cause of AV graft failure
Intimal hyperplasia -> venous obstruction
101
Indications for operative repair of aortic dissections
```
-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
Painless neck mass
Carotid body tumor: painless neck mass, usually near bifurcation, neural crest cells, EXTREMELY VASCULAR
Tx: resection
103
Type II endoleak
```
COLLATERALS failure (eg patent lymbar, IMA, intercostals, accessory renal)
Tx: Observe; percutaneous coil embolization if pressurizing aneurysm
```
104
Claudication management
ASA, stop smoking, exercise until pain occurs to improve collaterals
105
Diagnosis of AAA rupture
CT: fluid in retroperitoneal space and extraluminal contrast with rupture
-Most likely in Left posterolateral wall, 203 cm below renals
106
Aortic dissection Stanford classification
A: any ascending aortic involvement
B: descending aortic involvement only
107
Rest pain mimicker
DM neuropathy
108
Cimino fistula
Radial artery to cephalic vein
Wait 6 weeks for vein to mature
109
Type I endoleak
Proximal or distal ATTACHMENT SITES of graft failure
| Tx: extension cuffs
110
Young male smoker with severe rest pain and bilateral ulceration, gangrene of digits especially fingers
Buerger's disease
Corkscrew collaterals on angiogram and severe distal disease; normal
111
Abdominal pain out of proportion, sudden onset, hematochezia and peritonitis
Mesenteric ischemia from SMA embolism
112
Vertebrobasilar symptoms and subclavian artery stenosis
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
Effort-induced thrombosis of subclavian vein with acutely painful, swollen, blue limb
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
Gold standard for vascular imaging
Arteriogram
115
CEA complications
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
ECA branches
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
History of food fear, weight loss, vasculitis, hypercoagulable state, presents with abdominal pain
Mesenteric ischemia from SMA thrombosis
118
Prolonged hand ischemia, why does motor function remain in digits?
Motor groups are in proximal forearm
119
Stewart-Treves syndrome
Lymphangiosarcoma associated with breast axillary dissection and chronic lymphedema
120
Graft infection rate after AAA repair
1%
121
Claudication mimicker
Lumbar stenosis
122
Foot claudication means occlusion is where
Distal superficial femoral or popliteal
123
Most common site of upper extremity stenosis
subclavian artery
tx: Perc transluminal angioplasty with stent; common carotid to subclavian artery bypass if fails
124
Atheroma embolism mechanism
Cholesterol clefts that can lodge in small arteries
125
Child with fever, viral illness with erythematous mucosa and epidermis
Kawasaki's disease (medium artery): aneurysms of coronary arteries and brachiocephalic vessels, die from arrhythmias
Tx: Steroids, possible CABG
126
DVT most common where
Calf
| Left leg 2x more common (longer left iliac vein compressed by right iliac artery)
127
Varicose vein risk factors and tx
Smoking, obesity, sedentary
| Tx: Sclerotherapy
128
Aortic insufficiency incidence in aortic dissection
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
PAD surgical indications
- Rest pain
- Ulceration or gangrene
- Lifestyle limitation
- Atheromatous embolization
130
40yo man with mild intermittent claudication, loss of pulses with plantar flexion
Popliteal entrapment syndrome: medial deviation of artery around medial head of gastrocnemius muscle
Tx: resect medial head of gastroc, may need arterial reconstruction
131
Pulse volume recordings use
To find significant occlusion and at what level
132
Diarrhea after AAA repair
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
PTFE graft thrombosis tx
Thrombolytics and AC
| If limb threatened (loss of motor or neuro): OR for thrombectomy
134
Amputation indications
Gangrene, Large non-healing ulcers, Unrelenting rest pain not amenable to surgery
Emergency amp for systemic complication or extensive infection
135
Weight loss, visceral angina 30 min after meals
Chronic mesenteric angina
Dx: Lateral visceral vessel aortography to see celiac and SMA origins
Tx: PTA and stent, bypass if fails
136
Anterior leg compartment nerve
Deep peroneal nerve: dorsiflexion and web sensation, also AT artery
137
Indications to reimplant the IMA after AAA repair?
- Backpressure < 40 (poor backbleeding)
- Previous colonic surgery
- Stenosis at SMA
- Flow to left colon appears inadequate
138
Most common site of peripheral obstruction from emboli
Common femoral artery
139
Treatment of pseudoaneurysm early after surgery at a suture line
Surgical repair
140
HTN after CEA
Carotid body injury, occurs in 20%, tx Nipride to avoid bleeding
141
Superficial thrombophlebitis
Nonbacterial inflammation
Tx: NSAIDs, warm packs, ambulation
142
AAA definition and mechanism
Degeneration of medial layer -> AAA
| Normal aorta 2-3 cm
143
Hoarseness after CEA
Vagus nerve injury (RLN branch too)
144
Indication for carotid stent instead of CEA
High-risk patients (previous CEA and restenosis, multiple comorbidities, prior neck XRT)
145
Type V endoleak
Endotension: expansion of aneurysm without e/o leak
Tx: Repeat EVAR or open repair
146
Increased risk of atherosclerosis
Homocystinuria (tx folate and B12)
147
Palpable purpura rash, fever, end-organ dysfunction
Hypersensitivity angiitis (small artery) 2/2 drug or tumor antigens
Tx: CCB, pentoxifylline, stop offending agent
148
Atherosclerosis stages
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
Ideal criteria for AAA endovascular repair
- 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
Tenderness, pallor, edema
Phlegmasia alba dolens
Tx: heparin
151
Upper extremity occlusive disease symptoms
Proximal lesions usually asymptomatic d/t collaterals
152
SCDs mech
Decrease venous stasis and increase tPA release
153
Below knee graft type
Saphenous vein, as synthetic grafts have decreased patency below the knee
154
How do you prevent vasculogenic impotence and pelvic ischemia in aorto-bifemoral repair?
Ensure flow to at least 1 internal iliac (hypogastric) artery, by seeing good back-bleeding, otherwise need bypass to an internal iliac artery
155
PE with IVC filter in place comes from where?
Ovarian veins,
IVC superior to filter, or
Upper extremity via SVC
156
Stroke risk factors
HTN most important
157
Middle cerebral artery events symptoms
Contralateral motor, speech (if dominant side), contralateral facial droop sparing forehead
158
Vertebrobasilar artery disease mechanism
Need either bilateral vertebral artery or basilar artery disease to have symptoms
Symptoms: Diplopia, vertigo, tinnitus, drop attacks, incoordination
Tx: PTA with stent
159
Risk factors for mortality after AAA repair
-Cr > 1.8
- CHF
- ECG ischemia
- Pulmonary dysfunction
- Older age
- Females
160
Renal artery stenosis dx and tx
Angiogram
Tx: Percutaneous transluminal angioplasty; place stent if due to atherosclerotic disease
Nephrectomy if atrophic kidney with persistently high renin levels
161
Migrating thrombophlebitis
Pancreatic Ca
162
Most common late complication after aortic graft placement
Atherosclerotic occlusion
163
Normal venous Doppler US
Augmented flow with distal compression or proximal release
164
Chronic pain, weight loss, diarrhea, bruit near epigastrium
Median arcuate ligament syndrome: celiac artery compression
Tx: Transect median arcuate ligament, may need arterial reconstruction
165
Can IVC be clamped?
No, will tear
166
6 months after AAA repair, herald bleed with hematemesis and then blood per rectum
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
Stroke after CEA
OR to check for flap or thrombosis
168
Which side do you repair first in bilateral carotid stenosis?
Tighter side first
| If equal, dominant side first
169
Tinsel's test positive and ulnar nerve (C8-T1) symptoms (tricep weakness, intrinsic hand weakness, wrist flexion weakness)
Brachial plexus irritation from TOS
170
ABI levels and symptoms
< 0.9 claudication
< 0.5 rest pain (distal arch and foot)
< 0.4 ulcers (toes first)
< 0.3 gangrene
171
Venous thrombosis with central line, management
Pull central line
Heparin
If need line, try heparin or tPA down line
172
ABI inaccurate in who?
DM patients 2/2 incompressiblity of vessels
| Go off Doppler waveforms instead
173
Most common site of stenosis causing stroke
Carotid bifurcation
174
Deep posterior leg compartment nerve
Tibial nerve: plantar flexion
| also PT artery and peroneal artery
175
Stroke with diplopia, vertigo, tinnitus, drop attacks, incoordination. What vessels cut off?
Vertebrobasilar
| Tx: PTA with stent
176
Mechanism of paraplegia after descending thoracic aortic surgery
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
SMA embolism dx and tx
Angiogram or CTAP with IV contrast
Embolectomy, resect infarcted bowel
178
Mycotic aneurysm organisms
1. Salmonella
| 2. Staphylococcus
179
Aortic graft infection presentation
Fluid, gas, thickening around graft
Often cultures are negative
More common with grafts going to groin (aorto-bifem grafts)
180
Treatment of aortic dissection
Medical initially: BP control with esmolol and nipride
181
Leading cause of death in AAA without surgery
Rupture, 50% mortality if patient reaches hospital alive
182
Pseudoaneurysm rate after AAA repair
1%
183
Mesenteric ischemia cause
```
SMA disease
Embolic 50% (heart a fib most common source)
Thrombotic 25%
Nonocclusive 15%
Venous thrombosis 5%
60% mortality
```
184
Aortic dissection DeBakey classification
"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
Splenic, renal, iliac, femoral artery aneurysm tx
covered stent
186
Fem-fem crossover graft effects on blood flow in donor leg
Doubles blood flow to donor artery
| Can get vascular steal in donor leg
187
Aching, swelling, night cramps, brawny edema, venous ulcers
Venous insufficiency
Tx: leg wraps, ambulation with avoidance of long standing
188
Carotid traumatic injury with major fixed deficit, treatment
If occluded, do not repair as can exacerbate injury with bleeding
If not occluded, repair with carotid stent or open procedure
189
Young woman with hand pallor -> cyanosis -> rubor
Reynaud's disease
Tx: CCB, warmth
190
Most commonly diseased intracranial artery
Middle cerebral artery
191
Tall, retinal detachment, aortic root dilatation
Marfan's (fibrillin defect), a cystic medial necrosis syndrome
192
Nonocclusive mesenteric ischemia dx and tx
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
Venous ulcer tx
Unna booth compression cures 90%
| May need to ligate perforators or have vein stripping of greater saphenous vein
194
Femoral-distal graft 5-year patency (peroneal, AT, PT)
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
SMA thrombosis dx and tx
Angiogram or CTAP with IV contrast
Thrombectomy (open or catheter; thrombolytics), possible PTA with stent, possible open bypass, resection of infarcted bowel
196
Dry gangrene management
Can allow autoamputation if small or just toes
But large lesions should be amputated
See if patient has correctable vascular lesion
197
CT findings of intestinal ischemia
- Vascular occlusion
- Bowel wall thickening
- Intramural gas
- Portal venous gas
198
Easy bruising, mobile joints, arterial rupture especially abdominal vessels
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
PTFE Gortex use
Bypasses above knee ONLY
200
Endoleak types
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
Pseudoaneurysms that occur at suture lines months-years after surgery, worrisome for what?
Graft infection
202
Back, neck, arm pain/weakness/tingling, worse with palpation or manipulation
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
Pulsatile, bleeding mass after CEA
Pseudoaneurysm: drape and prep, intubate, repair
204
Symptoms of PAD occur at what level relative to occlusion
One level below
205
Indications for repair of splanchnic artery aneurysm (>2 cm)
Repair all when diagnosed, as there is 50% risk of rupture, except splenic
206
Amaurosis fugax
Occlusion of ophthalmic branch of ICA -> shade coming down over eyes; transient
-Hollenhorst plaques on ophthalmic exam
207
Endovascular versus open repair of descending aortic aneurysms
-Less mortality, less paraplegia (2-3% versus 20%)
Reimplant intercostal arteries below T8 to help prevent paraplegia with open repair
208
Most common cause of LATE death after AAA repair
Renal failure
209
40yo man with intermittent claudication, changes in symptoms with knee flexion/extension
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
Complications of AAA
Rupture
Distal embolization
Compression of adjacent organs
211
Hand pain from ischemia in a weight lifter, absent radial pulse with head turned to ipsilateral side (Adson's test)
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
Tx compartment syndrome
Fasciotomy of all 4 compartments if in lower leg
| Leave open 5-10 days
213
Mycotic aneurysm mechanism and presentation
Bacteria infect atherosclerotic plaque and cause aneurysm (Salmonella, staphylococcus)
- Pain, fevers, bacteremia
- Periaortic fluid, gas, retroperitoneal soft tissue edema, lymphadenopathy
214
Predictors of AAA rupture
diastolic HTN
| COPD
215
Calf claudication means occlusion is where
Common femoral or proximal superficial femoral artery
216
Aorto-bifemoral repair complication
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
CEA contraindications
Recent completed stroke: wait 4-6 weeks, otherwise bleeding risk
218
Swelling location and DVT location
Calf DVT - minimal swelling
Femoral DVT - ankle and calf swelling
Iliofemoral DVT - leg swelling
219
Can renal veins by ligated?
Left can, has collaterals (gonadal, adrenal)
220
MCC late failure of RSVG
Atherosclerosis
221
SMA and celiac collateral
Arc of Riolan
222
Indications for AAA repair
Symptomatic
Size > 5.5 cm
Growth > 0.5 cm/yr
223
Diagnosis of aortic dissection
Chest CT with contrast
| CXR normal or widened mediastinum
224
Buttock claudication means occlusion is where
Aortoiliac disease
225
Traumatic AV fistula management
Most need repair: lateral venous suture
Can get peripheral arterial insufficiency, CHF, aneurysm, limb-length discrepancy
226
Most common site of atheroma embolization
Renal arteries
227
ICA first branch
Ophthalmic artery
228
Difficulty swallowing after CEA
Glossopharyngeal nerve injury (high carotid dissections)
229
MCC acute arterial embolus
A fib
Recent MI with LV thrombus
Myxoma
Aorto-iliac disease
230
Flaking atherosclerotic emboli off abdominal aorta or branches
Blue toe syndrome
Typically good distal pulses
Aortoiliac disease most common source
231
Pain with passive motion, extremity feels tigh and swollen
Compartment syndrome from reperfusion injury (PMNs mediate it, occurs after > 4-6 hours of cessation of blood flow and then reperfusion)
232
Weight loss, rash, arthralgias, HTN, kidney dysfunction
Polyarteritis nodosa (medium artery): aneurysms that thrombose or rupture, renals most commonly involved
Tx: steroids
233
Mesenteric vein thrombosis dx and tx
CTAP or angiogram with venous phase. Usually short segments of intestinve involved.
Tx: heparin usual, resection of infarcted bowel if present
