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Vascular Surgery by Emi > Mesenteric vessels > Flashcards

Mesenteric vessels Flashcards

1
Q

normal celiac duplex

A

<200 cm/sec PSV normal

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2
Q

normal SMA duplex

A

<275 cm/sec PSV normal

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3
Q

normal renal duplex

A

<180 cm/sec PSV normal
<3.5 RAR
<0.75 RI

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4
Q

celiac artery >75% stenosis

A

> 200 PSV

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5
Q

celiac artery >50%

A

EDV >55`

delayed upstroke in splenic and hepatic

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6
Q

SMA >75% stenosis

A

> 275 PSV

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7
Q

SMA >50% stenosis

A

> 45 EDV

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8
Q

normal TIPS duplex criteria

A

portal flow 30-40
velocities in shunt 90-200
PSV down with inspiration

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9
Q

TIPS obstruction duplex criteria

A

PSV<90 or >200,
PSV down by 50 or more comparing to shunt
point to point increase in PSV by more or equal to 50
portal vein velocity <30
hepatofugal flow in portal vein
absence of doppler signal or color flow in TIPS

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10
Q

hepatofugal flow

A

away from the liver

abnormal in portal vein, normal in hepatic veins

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11
Q

how do you calculate resistive index in the kidney

A

(PSV - EDV)/PSV

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12
Q

what is a normal resistive index in the kidney

A

<0.6

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13
Q

what is an abnormal resistive index in the kidney

A

> 0.7

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14
Q

What is the definition of parenchymal diastolic / systolic ratio?

A

EDV/PSV

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15
Q

what is the abnormal parenchymal diastolic / systolic radio in kidney

A

<0.2

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16
Q

what is the definition of RAR for the kidney?

A

PSV renal artery / PSV aorta

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17
Q

what is the normal RAR for the kidney?

A

<3.5

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18
Q

normal renal artery PSV

A

<180-200cm/sec

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19
Q

what are the normal characteristics of renal artery duplex

A

short systolic upstroke
rapid deceleration
diastolic forward flow
early compliance peak

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20
Q

In stent SMA restenosis

A

> 445cm/s

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21
Q

In stent celiar artery restenosis

A

> 289cm/s

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22
Q

Goldblatt experiment - unilateral disease

A

1 clip 2 kidneys
RENIN DRIVEN: continued renin release from bad kidney, but good kidney can excrete excess volume. Angiotensin II derives renovwwcular HTN
Initial decline in GFR with ACE-I but long term recovery

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23
Q

renal artery size

A

5mm

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24
Q

criteria for >60% renal artery stenosis?

A

PSV >180mm/s
renal artery/aortic PVS ratio>3.5
resistive index >0.8

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25
Q

renal stenting trials

A

STAR
ASTRAL
CORAL

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26
Q

What does STAR trial say

A

140 patients criteria: >=50% stenosis plus impaired renal function
only patients with medically controlled BP
no difference in primary endpoints of 20% or more decline in renal function

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27
Q

What does ASTRAL trial say

A

806 patients
stenting rendered small improvement of renal function but no change in BP
23 patients had serious complications after procedure
no protocolized medical therapy
mild CKD and HTN - 40% of patient’s without severe RAS
Patients who definitely needed a stent were excluded

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28
Q

What does CORAl trial say

A

prospective, 947 patients
Endpoints: major CV events and renal failure
RAS >80% or 60% with pressure gradient >20 and HTN on 2 or more meds
stenting showed no benefit

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29
Q

Technique of stenting renal artery

A

sized to normal artery segment
length: lesion +1-3mm on each side
if ostial: 2mm in the aorta
Use BES to provide radial force

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30
Q

what are the duplex changes in median arquate ligament

A

celiac artery velocities are ELEVATED with EXPIRATION (artery is compressed on Expiration)

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31
Q

what’s the other name of kidney resistive index?

A

Pourcelot’s index

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32
Q

criteria for <60% renal artery stenosis?

A

PSV>200 but RAR <3.5

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33
Q

duplex characteristics of hepatic vein flow

A

bidirectional
hepatofugal
pulsatile
similar to proximal IVC

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34
Q

what are the peaks and valleys of hepatic vein flow on duplex?

A

A peak - RA contractility
S valley - filling of RA during ventricular systole
V small peak- RA overfilling just before tricuspid valve opens
D valley - filling of RA during ventricular diastole

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35
Q

what is the characteristics of cirrhosis on duplex

A

loss of hepatic vein variability

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36
Q

what are the duplex characteristics of distal IVC

A 
reciprophasic flow
(continuous cephalad flow with respiratory variation)
37
Q

what vessels have reciprophasic flow

A 
distal IVC
portal
splenic
renal
SMV
38
Q

normal aortic velocity

A

40 - 100 cm/s

39
Q

what size discrepancy indicates arterial lesions in kidney

40
Q

normal portal vein size

41
Q

what does pulsatile portal vein flow indicate

A

tricuspid regurgitation

right heart failure

42
Q

Goldblatt experiment

A
  1. decreased arterial flow to one kidney (by narrowing the artery) activated RAA system. circulating angiotensin II increases blood pressure and total systemic vascular resistance. It has negative feedback on the non-malperfused kidney and decreases renal production there. Renin production increased in malperfused kidney causes hypertension due to high levels of angiotensin II (to maintain blood flow to the affected kidney) and causes pressure diuresis (mounted by the non-malperfused kidney)
  2. solitary malperfused kidney is unable to achieve the pressure diuresis required to handle aldosterone - induced Na and H20 retension –> volume expansion
43
Q

Winslow pathway

A

Internal thoracic artery –> superior epigastric –> inferior epigastric –> external iliac

44
Q

Visceral pathway

A

superior rectal –> obturator artery or internal pudendal artery –> medial circumflex artery

45
Q

collateral pathway between celiac and SMA

A

arch of Bueller

46
Q

SMA syndrome

A

compression of duodenum between SMA and aorta

acute angle between SMA and aorta (normal 45* –> less than 30* indicates the syndrome)

47
Q

Quincke’s triad

A

bleeding into biliary tree: upper abdominal pain, upper GI bleed and jaundice

48
Q

zones of SMA

A
  1. aorta to IPDA
  2. IPDA to mesocolic
  3. mesocolic to distal branches
  4. distal branches
49
Q

Integrated injury hypothesis in acute mesenteric ischemia

A
  1. Hypoxia - injury reflects time and severity of hypoperfusion. Central mechanism is disruption of intercellular tight junction with increased capillary permeability
  2. reperfusion - cytokines and ROS upregulate cell adhesion molecules. Accentuate neutrophil aggregation and secondary injury
50
Q

Mortality in acute mesenteric ischemia

51
Q

Source and site of embolic AMI

A

Cardiac source

SMA preferred site - 15% Ostia and 50% distal

52
Q

Which side incision for SMA embolectomy

A

Transverse

53
Q

What is the most common site for In site thrombosis as a cause of AMI

A

Origin of SMA

54
Q

Causes of mesenteric venous thrombosis

A 
Prothrombic state
Hematologist disorder
Abdominal inflammatory disorder
Cirrhosis and portal hypertension
Trauma, dehydration, and decompression sickness
55
Q

What vasodilators can be used as an infusion for NOMI

A 
Tolazoline bolus (25mg) 
Papaverine infusion (60mg/hr)
56
Q

Operative indications for NOMI

A

Pneumoperitoneum
Peritoneal signs that persist despite vasodilators
Leukocytosis
Ihemorrhagic shock

57
Q

What’s the bimodal presentation of chronic mesenteric ischemia

A
  1. elder patients with advanced atherosclerosis and high OR risk. Mean age 75, no gender difference
  2. younger patients with strong tobacco history and better poerative risk, mean age 55, female > male
58
Q

When is open surgery indicated for mesenteric occlusive disease

A 
Acute ischemia with peritoneal signs
Unfavorable lesion (flush occlusion, long stenosis, problematic angulation)
Aortic disease requiring operation
Young patient (<50)
After railed angioplasty
59
Q

Right rental artery exposure

A

Medial to IVC (graft posteromedial to IVC) or distal exposure with ascending colon medial rotation and mobilization of duodenum (graft anterior to IVC)

60
Q

Left renal artery exposure

A

Proximal exposure by ligation of IMV, gonadal, adrenal vein wit mobilization of 3rd and 4th portion of duodenum; distal exposure by ,mobilization of splenic flexure and medial rotation of descending colon

61
Q

In stent restenosis >70% in SMA

62
Q

In stent restenosis >70% in celiac

63
Q

Rental duplex technique

A

Obtain aortic PSV proximal to visceral segment
Locate main renal landmarks
Examine main renal artery from origin to renal parenchyma with recording of waveforms
Examine inteapsrenchymal renal arteriole flow
Document kidney length

64
Q

Celiac artery detailed exposure

A

Midline or chevron incision
Enter through gatrohepatic ligament
Retract left lobe of the liver cephalon and esophagus to the left
Body of the pancreas lies along the inferior border

65
Q

How to access SMA open?

A
  1. Lift the mesocolon and identify middle colic artwru
    Go down to the SMA
    As it travels over the fourth portion of the duodenum
  2. Elevate the transverse mesocolon
    Mobilize the fourth portion of thenduodenum
    Cephalon retraction of the inferior border of the pancreas
66
Q

Where do you tunnel the obturator bypass

A

ANTERO MEDIAL!!! Through the obturator canal

67
Q

Exposure of PT

A

Media incision 1 cm from the tibia
Bend the knee to relax the gastrocnemius muscle
Take down tibial insertion of the soleus

68
Q

Proximal peroneal artery approach

A

Medial leg, just like PT

69
Q

Middle third peroneal approach

A

Latest approach with partial fobulectomy

70
Q

Goldblatt experiment - bilateral disease

A

1 clip 1 kidney or 2 clips 2 kidneys
VOLUME DRIVEN - neither kidney can excrete excess volume; body settles down to a volume overloaded homeostatic state (diuretics)
Aldosterone mediated renovawcular HTN
Significant incidence of neuropathy as overall GFR drops
Acute renal failure after starting ACE I concerning for bilateral renal involvement

71
Q

Who should get a rental PTA or stent

A
  1. FMD/pediatric - early intervention, best outcomes of creatinine and kidney size normal, and HTN <8 years
  2. Severe hypertension not medically controlled
  3. Flash pulmonary edema (early intervention)
  4. Ischemic nephropathy - documented proteinuria, larger pole length and resistive index less than or equal to 0.8
72
Q

Treatment of pediatric renal congenital hypoplastic syndrome

A

Endovascular has a very high recurrence rates
Direct Surgical reconstruction best option - medialization of kidney with direct reimplantation or bypass with hypogastric artery

73
Q

Griffiths point

A

SMA and IMA

splenic flesher

74
Q

Sudeks point

A

Between IMA and hypogasteic branches

Rectosigmoid

75
Q

Do you explore midline supramesocolic blunt hematoma

76
Q

Do you explore midline supramesocolic penetrating hematoma

77
Q

Do you explore midline inframesocolic blunt hematoma

78
Q

Do you explore midline inframesocolic penetrating hematoma

79
Q

Do you explore lateral perinephric hematoma blunt

80
Q

Do you explore lateral perinephric hematoma penetrating

81
Q

Do you explore blunt pelvic hematoma

82
Q

Do you explore penetrating pelvic hematoma

83
Q

Zones of SMA

A
  1. Between the aortic origin and inferior PDA
  2. Between inferior PDA and middle colic artsy
  3. Distal to the middle colic artery
  4. Segmental intestinal branches
84
Q

How many splanchnjc aneurysms present as emergencies

85
Q

Incidence of splenic artery aneurysm

A

60% of all mesenteric aneurysms
F:m 4:1
Medial degeneration, inflammation pancreatitis related, trauma, atherosclerosis

86
Q

What’s the incidence of different splanchnjc aneurysms types

A 
Splenic 60%
Hepatic 20%
SMA 5.5%
Celiac 4%
Gastric and gastroepiploic 4%
Jejunal, ileal and colic 3%
GDA 1.5%
PDA 2%
Renal 0.1%
87
Q

Best study to diagnose MVT

88
Q

Segmental arterial mediolysis

A

Rare, acute, often self limiting
Mean age 60, no gender difference
Visceral arteries at the adventitial- medial junction
Arterial dilatation, aneurysm, hematoma, stenosis and occlusion
Overstimulation is Alfa-1 receptors May lead to vasoconstriction

89
Q

Most common location of hepatic aneurysm

A

80% extrahepatic in common hepatic artery

Vascular Surgery by Emi (15 decks)

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