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SURGERY CARDS > NMS Vascular > Flashcards

NMS Vascular Flashcards

1
Q

definition of TIA, how do you manage it

A

transient neuro findings < 24 h usually 2/2 embolus from carotid bifurcation;
mgmt: need to do duplex u/s of carotids, followed by carotid endarterectomy if >70% stenosis; may need echo if heart murmur

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2
Q

when is Carotid endarterectomy indicated

A

if > 70% stenosis in symptomatic patient; in asymptomatic patient, less well-defined; definitely carotid endarterectomy if >80% stenosis, maybe if >60% stenosis

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3
Q

what precautions needed to prevent stroke during carotid endarterectomy procedure

A

intraop EEG monitoring , bp control

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4
Q

what possible complications with carotid endarterectomy (3)

A

1) hypoglossal nerve injury
2) mandibular branch of facial nerve injury
3) vagus nerve injury

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5
Q

tx of amaurosis fugax

A

same as carotid endarterectomy: carotid duplex –> carotid endarterectomy if >70% stenosis

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6
Q

what to do if amaurosis fugax or TIA with PERSISTENT neuro findings (ie, stroke)

A

OBSERVE for 2-4 wks, then carotid endarterectomy when stable

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7
Q

what are 6 P’s of acute arterial occlusion

A 
Pain
Pallor
Pulselessness
Poikilothermia
Paralysis*
Paresthesias*
(these last 2 steps happen first; nerves most sensitive to anoxia)
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8
Q

how does acute arterial occlusion happen? how do you tx it

A

embolus from heart (70%) or artery/aneurysm (30%); treatment is revascularization in OR for balloon catheter embolectomy

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9
Q

what is dangerous finding postop with balloon catheter embolectomy for acute arterial occlusion

A

COMPARTMENT SYNDROME resulting from ischemia-reperfusion injury –> edema

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10
Q

what are 3 classifications of acute arterial occlusion? how do you know if limb is not salvagable

A

1) viable
2) threatened
3) irreversible (no dopplerable venous pulses, paralyzed, insensate)

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11
Q

what is most common site of acute arterial occlusion

A

lower extremity, specifically common femoral artery

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12
Q

how do you work up intermittent claudication

A

look for ulcers, skin changes, neuro deficits; TESTS include ABI (ankle brachial index, determines severity) and DOPPLER waveforms (normally triphasic)

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13
Q

most common site and findings with intermittent claudication

A

superficial femoral artery at adductor hiatus –> loss of popliteal and pedal pulses

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14
Q

when to do angiogram in claudication

A

ONLY as preop test (ie if you dont plan to operate, dont do an angiogram)

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15
Q

what is normal ABI

A

> 1 ( i saw >0.9, but >1.2 can be pathologic/sign of severe hardened arteries 2/2 atherosclerosis)

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16
Q

how to treat patients with intermittent claudication

A

operate only if grossly disturbing patients lifestyle; if with activity and mildly aggravating, treatment is EXERCISE + lifestyle modification

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17
Q

what does claudication + absent femoral pulses suggest? how does that change mgmt

A

suggests AORTOILIAC DISEASE; more progressive than distal disease, so SURGERY should be considered if symptoms progress

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18
Q

what are the tx options for aortoiliac dz? when do you pursue each (2)

A

1) BYPASS: if multiple or long segments of disease

2) PTA (angioplasty): if single, short segment

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19
Q

how do you work up pt with PVD and ULCER? when to tx? what options

A

key is adequacy of blood supply; if SBP > 65 (or 90 in DM), supply should be adequate for healing; if NOT, tx surgically; ANGIOGRAM to define anatomy (remember this is preop test) –> graft vs. angioplasty/stent

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20
Q

what longterm tx do most pts with PVD receive

A

ASA

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21
Q

what is a “trash foot” (complication of PVD repair)? how is it managed

A

ischemic digit 2/2 atheroembolization –> blue, painful toe; TREATMENT is heparin and long term antiplatelet therapy

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22
Q

what major risk associated with surgery in pt with vascular disease? how to work up preop

A

CARDIAC dz often a/w vascular dz (MI risk during op) –> need CARDIAC WORKUP: stress test/thallium –> angiogram if positive treat with CABG/PTCA if dz; if testing negative, do operation with intraop monitoring if pt has other risk factors (sick, old)

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23
Q

mgmt of AAA

A

elective repair if > 5 cm; observe if < 5 cm

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24
Q

three big complications associated with AAA repair

A

1) ISCHEMIC BOWEL: presents with diarrhea +/- blood in first 3d, 2/2 sigmoid ischemia from IMA occlusion
2) VASCULAR GRAFT INFECTION: from graft seeding with skin flora, but may not present for months-years
3) AORTOENTERIC FISTULA: grossly bloody stool, usually from fistula between aorta and duodenum

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25
Q

treatment of three big complications of AAA repair

A

1) ISCHEMIC BOWEL: need sigmoidoscopy to determine depth of ischemia; if superficial treat with bowel rest; full thickness, resect + colostomy
2) VASCULAR GRAFT REPAIR: remove graft, debride tissue, extra anatomic bypass, long-term abx
3) AORTOENTERIC FISTULA: 3 steps:
I) remove graft
II) repair GI
III) extra anatomic aortic graft

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26
Q

Presentation, workup and tx of chronic mesenteric ischemia

A

PRESENTS: with post-prandial pain and resultant weight loss; WORKUP: with angiogram (b/c of intent to operate); TREAT: with surgical bypass (aorta –> vessel)

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27
Q

types of aortic dissection and management (3)

A

TYPE 1: ascending only (OPERATE)
TYPE 2: ascending + descending (OPERATE)
TYPE 3: descending only (MED MGMT); control htn with all types

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28
Q

tx for DVT? how long

A

anticoagulation (heparin –> warfarin) x 3-6 m

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29
Q

what is low dose heparin (LDH) therapy

A

prophylactic heparin for high risk pts: 5000 U subq heparin q8-12 hrs post-op

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30
Q

ABG findings in PE

A

decreased PCO2 due to hyperventilation

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31
Q

what is tx of PE

A

SAME AS DVT (anticoagulation x 3-6m)

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32
Q

what is phlegmasia cerulea dolens? how to tx

A

acute obstruction of venous outflow –> DANGEROUS (can cause sensorimotor loss and eventually gangrene) –> URGENT TX (anticoagulation, leg elevation); VENOUS THROMBECTOMY RARELY INDICATED

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33
Q

if TIA untreated what are chances of recurrences

A

40% chance of another TIA or stroke in 2 yrs

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34
Q

tests to eval TIA

A

carotid bruits, neuro exam, murmurs, echocardiogram, Duplex ultrasound of carotids

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35
Q

what % stenosis of carotids does better with surgery

A

70% stenosis 3x more effective than aspirin in preventing strokes

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36
Q

additional preop for carotid endarterectomy

A

bp control, cardiac eval

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37
Q

perioperative risk for major stroke for carotid endarterectomy

A

1-3%

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38
Q

nerves to avoid during carotid endarterectomy

A

hypoglossal, vagus, marginal branch of facial nerve

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39
Q

what imaging do you do to make sure carotid endarterectomy is perfect

A

on table angiogram or duplex ultrasound

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40
Q

what is risk % for carotid narrowing on operated side

A

13% over 5 years

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41
Q

what drug to take post op for carotid endarterectomy

A

asa

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42
Q

what are carotid endarterectomy pts most likely to die from

A

MI bc TIA is a sign of atherosclerosis. should take up exercise regimen, lifestyle changes, lipid control

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43
Q

name of ophthalmic finding with amaurosis fugax

A

Hollenhorst Plaque

44
Q

what eval do you do if a person has a stroke and it’s not a TIA

A

carotid duplex, observation for improvement, operate after patient stable; usually 2-4 weeks post stroke or when neuro status stabilizes

45
Q

at what % carotid stenosis should asymptomatic pts get surgery ?

A

65%; in a 2 yr period, 2.5% of pts had stroke compared to 11% of ASA pts.

46
Q

6 Ps for acute arterial occlusion of extremity

A

pain, pallor, paresthesia, paralysis, pulselessness, poikilothermia

47
Q

when do you operate on acute occlusion of leg? what do you give them immediately

A

ASAP. within 6 hrs. give heparin

48
Q

what is surgical procedure for acute occlusion

A

Fogarty catheter embolectomy (balloon catheter)

49
Q

complications of acute reperfusion

A

compartment syndrome

50
Q

at what pressure can compartment syndrome get dangerous

A

20-40 mm Hg: ischemic injury of muscles and nerves

51
Q

3 most common sites for lower limb embolus

A

femoral, then iliac, then aortic saddle, then popliteal

52
Q

long term care for post fasciotomy

A

coumadin, ECHO, CT to search for embolic source

53
Q

2 common causes for acute arterial ischemia

A
  1. femoral arterial puncture: raise intimal flaps, dislodge emboli, cause local thrombosis
  2. aortic dissection where false lumen extends to femoral artery
54
Q

workup for claudication

A

pulses, bruits, thrills, skin exam for ulcerations, sensory and motor function exam, dependent rubor, history of DM, cardiovascular dz

55
Q

where in superficial femoral artery is there most likely to be occlusion

A

at adductor hiatus

56
Q

if you dont get pulses in some places, what test do you do

A

ABI with Doppler tracing

57
Q

what are worrisome signs with claudication

A

rest pain, ischemic ulceration

58
Q

what are ranges of normal and abnormal ABI values

A

normal: 0.9-1.1
mild claudication: 0.6-0.8
severe claudication: < 0.3

59
Q

in what type of patients can ABI be artificially high

A

diabetics (bc they have calcified vessels)

60
Q

what happens to Doppler waveforms with claudication

A

triphasic –> biphasic –> monophasic

61
Q

why wouldn’t you operate on claudication

A

risk-benefit. dangers of arteriogram, possibility of thrombosis, infection, amputation, unfavorable medical condition such as CAD. exercise seems to help

62
Q

how many claudicators get better

A

1/3 get better, 1/3 same, 1/3 deteriorate

63
Q

why would you operate quicker on aortoiliac dz than just a plain old claudication

A

progresses faster!

64
Q

how can you tell if a diabetic foot ulcer is likely to heal or not

A

ankle systolic BPs in torr; nondiabetics probable healing 55-65. diabetics probable healing 80-90.

65
Q

why would we do non-preop arteriogram for diabetics with claudication

A

bc it changes our strategy for operation or not

66
Q

which arteries are given preference when doing femorodistal bypass

A

popliteal, anterior and posterior tibial, then peroneal (fibular artery)

67
Q

what f/u procedures after a bypass

A

frequent duplex of graft for patency, ASA, lipid control, foot care

68
Q

what is Leriche syndrome

A

aortoiliac dz; claudication + atrophy + impotence (occlusion of internal iliac that gives rise to pudendal)

69
Q

treatment for short segment iliac stenosis

A

percutaneous transluminal angioplasty

70
Q

surgery for b/l aortoiliac dz

A

aortobifemoral bypass. if at risk for complications or poor general health, ax-fem-fem may be better

–> i dont fully know what this is?

71
Q

surgery for unilateral aortoiliac dz

A

fem-fem

72
Q

what part of aortobifem bypass graft surgery has greatest risk?

A

anesthesia induction and during hemorrhage/stress; during clamping: high afterload, must manage bp; during unclamping sudden decrease of afterload possible hypotension and decreased CO.

Unclamping flushes blood from lower body that could have become acidotic and hyperkalemic, causing arrhythmia

73
Q

what is trash foot

A

microvessel occlusion following revascularization from fibrin, platelets, atherosclerotic debris that travels down to toes. with good pulses, it should heal!

74
Q

post op for aortoiliac dz

A

heparin bridge to coumadin, assess toes for necrosis, watch for evidence of infection, ASA

75
Q

cardiac morbidity perioperatively in major vessel reconstruction

A

up to 10%

76
Q

cardiac mortality post operatively in major vessel reconsturction

A

2-3%

77
Q

substance used for stress echo

A

regadenosone or dobutamine

78
Q

how to use Eagle’s criteria

A

for prediction of perioperative cardiac morbidity:

age>70, angina, diabetes, DTS redistribution, ventricular arrhythmia, Q waves on EKG.

0 risk factors: 3% risk of MI. operate
1-2 risk factors: 15% risk of MI. do DTS testing.
3 risk factors: 50% risk of MI. do coronary angiography and revascularize heart if necessary.

DTS= dipyrimadole thallium scanning (scintigraphy; imaging with radioisotopes)

79
Q

AAA imaging modalities

A

US or CT

80
Q

AAA more common in who

A

4:1 males, 11x first degree relatives, 50% pts with popliteal aneurysms

81
Q

When should AAA be repaired

A

> 0.5 cm growth per year or > 5 cm in size

82
Q

Post-op complications of AAA

A
  1. third spacing of fluids. increase fluid requirements

2. third day mobilization of fluids, need diuresis and fluid restriction or else pulmonary edema

83
Q

why might a AAA pt get impotence after surgery

A

damage to hypogastric circulation or autonomic nerves on anterior surface of aorta near IMA

84
Q

what % ruptured AAA die

A

more than half

85
Q

What are 5 yr rupture rates for AAA

A

7 cm: 95%

86
Q

should the ER resuscitate fluids in ruptured AAA

A

no, do it after you’ve clamped the aorta in the OR

87
Q

complications of aortic replacement

A
  • ischemic colitis in rectosigmoid due to interruption of IMA flow: do sigmoidoscopy, bowel rest, NPO, GI decompression, abx, frequent reexamination, fill thickness involvement requires resection and colostomy;
  • vascular graft infection due to S.epidermidis or S.aureus; remove, debride, do extra anatomic bypass, long term abx
  • upper GI bleed from aortoenteric fistula in 3rd or 4th part of duodenum. remove, repair, GI tract, extraanatomic bypass
88
Q

how to manage mesenteric ischemia

A

mesenteric angiogram, bypass graft from aorta to distal obstruction, could be obstruction of celiac axis or SMA (usually)

89
Q

symptoms of aortic dissection

A

tearing chest pain, back pain, severe htn, tachycardia, diaphoresis

90
Q

imaging for aortic dissection

A

TEE, MRI, CT, arteriography

91
Q

Types of dissections and treatments

A

Type A: ascending involvement. operate

Type B: descending only. BP control with beta blockers.

92
Q

sx of lower extremity DVT

A

pain with movement esp dorsiflexion (Homan’s sign), leg swelling, palpable cord (thrombosed superficial vein)

93
Q

how to dx a DVT

A

Duplex ultrasound

94
Q

how to treat DVT

A

Heparin 70-100 U/kg bolus then maintenance of 15-25 U/kg/hr for 5-7 days. bridge to warfarin within first few days, continue 3-6 months.

95
Q

heparin mxn

A

activates antithrombin which inactivates II, VII, IX, X

96
Q

goals of heparin tx for DVT

A

PTT 1.5 to 2x normal and INR 2-3, follow platelet counts for HIT

97
Q

why do we bridge to coumadin

A

because warfarin inhibits protein C and S synthesis, a relatively hypercoagulable state. gotta wait till the effects kick in.

98
Q

what is post-thrombotic syndrome and how do we treat

A

after DVT treatment: 10% get edema, skin ulceration, venous claudication for chronic venous HTN. treat with support hose

99
Q

Virchow triad

A

venous stasis, hypercoagulable state, endothelial injury

100
Q

some dvt risk factors

A

over 40, recent surgery, obesity, smoking, previous hx, cancer, PV, MM, MI, CHF, COPD, pregnancy, DIC, HIT, SLE

101
Q

what is preventive heparin

A

5000 U subQ preop and every 8-12 hours postop until ambulatory. dont forget to raise legs and give pneumatic compression devices.

102
Q

workup for suspected PE

A

abg, ekg, cxr, pulse ox, v/q scan, CT if necessary (CTA), DVT hx

103
Q

how to treat PE

A

same as treating DVT. heparin bolus and drip and bridge to coumadin

104
Q

how to treat recurrent PE

A

IVC filter with heparin failure or complications such as HIT

105
Q

what to do if someone has GI bleeding with heparin

A

d/c, put in IVC (greefield) filter, antiulcer tx

106
Q

suspected dx with severe DVT and advanced pelvic ca? tx?

A

Phlegmasia Cerulea Dolens.

acute interruption of venous outflow due to malignancy. anticoagulate and elevate leg. duplex and CT afterward

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