Miscellaneous1

Question 1

Preop workup prior to vascular access

Answer 1

eval veins and arteries with duplex, arteriograms and venograms

Question 2

Should vascular access start more distally or proximally

Answer 2

distally

Question 3

What is the most distal fistula

Answer 3

radio-cephalic (Bescia-Cimino-Appel fistula)

Question 4

What fistula can be created if a radio-cephalic fails

Answer 4

brachial-cephalic or brachial-basilic

Question 5

What should be used if a patient does not have an autologous vein to use in a fistula

Answer 5

use a graft

Question 6

What type of graft is best placed in the lower arm

Answer 6

loop-graft from brachial artery to cephalic vein

Question 7

MC complication of vascular access

Answer 7

thrombosis

Question 8

If thrombosis occurs post op from a fistula where is it MC found

Answer 8

proximal vein

Question 9

Tx for post op thrombosis in new fistula

Answer 9

endovascular repair, angioplasty or stent

Question 10

Organisms MC cultured from vascular access

Answer 10

Staph aureus, MRSA

Question 11

Complications of vascular access

Answer 11

infection, seroma, aneurysms, pseudoaneurysms, proximal vein occlusion due to central vein stenosis, bleeding

Question 12

What syndrome can iliac vein obstruction lead to

Answer 12

May-Thurner syndrome

Question 13

Primary tx for VTE

Answer 13

systemic anticoagulation

Question 14

Why is systemic VTE important

Answer 14

reduces risk of PE, extension of thrombosis and recurrence of thrombosis

Question 15

What is the recommendation after a second episode of VTE or unprovoked VTE

Answer 15

prolonged warfarin

Question 16

When is catheter directed thrombolysis accepted when used for VTE

Answer 16

axillary and subclavian VTE�s

Question 17

What does May-Thurner syndrome put a patient at risk for

Answer 17

VTE

Question 18

Descrive May Thurner syndrome

Answer 18

iliac vein obstruction leading to leg edema

Question 19

Name 2 classes of agents for VTE treatment for oral therapy

Answer 19

direct thrombin inhibitors and direct factor Xa inhibitors

Question 20

How is Rivaroxiban (anti-factor Xa) excreted

Answer 20

renally

Question 21

Primary indications for IVC filter

Answer 21

complication of anticoagulation, contraindication to anticoagulation and or failure of anticoagulation

Question 22

Indications for suprarenal IVC filter placement

Answer 22

IVC clot, pregnancy, women of childbearing age, previous filter clotted, previous filter that failed

Question 23

Complications of IVC filter

Answer 23

migration, device failure: recurrent PE, fracture

Question 24

How is an IVC with acute thrombus treated

Answer 24

full anticoagulation with heparin followed by catheter directed thrombolysis

Question 25

Common tx for uncomplicated VTE

Answer 25

LMWH with transition to vitamin K antagonist for 3 months

Question 26

When is aggressive thrombus removal considered in VTE

Answer 26

iliofemoral DVT and effort thrombosis and for those with PE and significant right heart strain

Question 27

Etiology of sx�s of a PE

Answer 27

1. obstruction of pulmonary arteries leading to decreased oxygenation and right heart strain 2. platelet activation the pulmonary circulation, with inherent release of vasospastic and bronchospastic substances

Question 28

Initial workup of a PE

Answer 28

ECG, ABG, CXR

Question 29

What are the findings on EKG for PE

Answer 29

right heart strain, S wave in lead I, Q wave in lead III and T waves in leads III VI and V3

Question 30

3 occasional findings on CXR to indicate PE

Answer 30

Hampton hump and Westermark sign and Fleischer knuckle sign

Question 31

Define Hamptons hump

Answer 31

CXR finding indicative of PE: : peripheral wedge shaped opacity at the costophrenic angle representing a pulmonary infract

Question 32

Define Westermark sign

Answer 32

CXR finding indicative of PE: an area of focal ishcemia

Question 33

Define Fleischer knuckle sign

Answer 33

CXR finding indicative of PE: enlargement of the central pulmonary artery

Question 34

What does a positive VQ scan show with PE

Answer 34

wedge shaped perfusion defect with normal ventilation

Question 35

What does a negative VQ scan mean with PE

Answer 35

exclude the diagnosis of PE

Question 36

Modality of choice for detecting a DVT

Answer 36

venous duplex US

Question 37

Describe a patient at low risk for DVT

Answer 37

minor surgery under 40yo, no additional risk factors

Question 38

Describe a patient at moderate risk for DVT

Answer 38

minor surgery, 40-60yo, no additional risk factors

Question 39

Describe a patient at high risk for DVT

Answer 39

patients older than 60, 40-60yo with additional risk factors (prior DVT, prior PE, cancer, hypercoagulability)

Question 40

What stops propagation of the thrombus

Answer 40

anticoagulation

Question 41

Indication for Vena Cava Filters

Answer 41

venous thromboembolism with contraindication to or failure of therapeutic anticoagulation, free floating thrombus in the IVC or iliac veins, critically ill patients with limited cardiopulmonary reserves

Question 42

When should suprarenal IVC filters be considered

Answer 42

women of childbearing age, those with an inadequate �landing zone� in the infrarenal position

Question 43

Criteria vena cava filter retrieval

Answer 43

PE has returned to an acceptably low level or that the patient can be therapeutically anticoagulated, life expectancy more than 6 months, any filter that has migrated, fractured or tilted

Question 44

What causes lymphedema

Answer 44

lymphatic dysfunction that results in accumulation of protein rich fluid in the interstitium of extremities or other regions

Question 45

What reactions occur secondary to protein stasis

Answer 45

inflammatory response with macrophages and fibroblasts replacing elastic interstitium with fibrosclerotic thickened congested tissue

Question 46

What condition can arise from chronic lymphedema

Answer 46

Stewart-Treves syndrome: aggressive lymphangiosarcoma

Question 47

Name primary etiologies of lymphedema (congenital)

Answer 47

Milroy disease, Meigs disease, Tarda

Question 48

Describe Milroy disease

Answer 48

lymphedema that presents within the first 2 years of life: affects females moreso, bilateral LE edema, not progressive and may spontaneously resolve

Question 49

Describe lymphedema praecox or Meigs disease

Answer 49

presents at puberty (before at 35), affects females, unilateral lower extremity involvement

Question 50

Describe lymphedema tarda

Answer 50

presents spontaneously after the age of 35, rarest form

Question 51

What are causes of secondary lymphedema

Answer 51

Wuchereria bancrofti, post-operatively

Question 52

How is lymphedema diagnosed

Answer 52

lymphangioscintigraphy

Question 53

Describe conservative management of lymphedema

Answer 53

hygiene, compression, elevation, physical therapy and diuretics

Question 54

Name the surgical treatments for lymphedema

Answer 54

debulking, liposuction, shunt, Charles or Sistrunk procedure

Question 55

Describe the Charles procedure

Answer 55

remove the tissue to the fascia and then perform a skin gift

Question 56

Describe the Sistrunk procedure

Answer 56

staged excision of sub-Q tissues with incorporation of dermal and skin flaps