Pestana Vascular Surgery

Question 1

Patient comes in complaining of sudden onset of visual changes and dizziness and arm claudication when he is bench pressing

Answer 1

subclavian steal syndrome - arteriosclerotic plaque at the origin of the subclavian (right before the vertebral artery branches off) causes reversal of flow in the ipsilateral vertebral artery to supply the exercising arm -> results in posterior neurologic sx (visual ∆, equilibrium problems) + arm claudication since there is insufficient blood flow to the arm

Question 2

What condition predisposes one to the subclavian steal syndrome?

Answer 2

arteriosclerotic plaque at the origin of the subclavian (right before the vertebral artery branches off)

Question 3

Diagnosis and treatment of subclavian steal syndrome?

Answer 3

diagnosis: duplex scanning
treatment: bypass surgery

Question 4

asymptomatic, pulsatile abdominal mass in a 65 yo M

Answer 4

AAA

Question 5

management of an asymptomatic, pulsatile abdominal mass in a 65 yo M <4 cm

Answer 5

AAA - observe - chances of rupture is almost 0

Question 6

management of an asymptomatic, pulsatile abdominal mass in a 65 yo M >5 cm

Answer 6

AAA - elective repair (endovascular stent) because chances of rupture is very high

Question 7

management of an asymptomatic, pulsatile abdominal mass in a 65 yo M that has increased from 1cm -> 3cm in the last year

Answer 7

AAA - elective repair (endovascular stent) because chances of rupture is very high

Question 8

management of a tender, pulsatile abdominal mass in a 65 yo M

Answer 8

AAA - immediate repair indicated since the pain indicates an imminent rupture

Question 9

management a patient with excruciating back pain in a patient with a known pulsatile abdominal mass

Answer 9

Leaky AAA resulting in a retroperitoneal hematoma is an indication that a blowout into the peritoneum is imminent - emergency surgery

Question 10

management of intermittent claudication that does not interfere with patient’s lifestyle

management of intermittent claudication that is disabling

Answer 10

not disabling: no workup indicated

disabling: surgery - relieves disabling symptoms and/or saves the extremity from impending necrosis

Question 11

long-term management of patients with intermittent claudication 3

Answer 11

1) stop smoking
2) regular exercise program
3) cilostazol

Question 12

w/u of patient is disabling intermittent claudication 2

Answer 12

1) doppler to look for pressure gradient; if there is a significant gradient, then proceed to
2) CTA or MRA to identify specific stenotic or obstructed areas and to look for good distal vessels to which a graft can be hooked

Question 13

management of a patient with intermittent claudication that is found to have a short stenotic segment

Answer 13

angioplasty + stenting

Question 14

management of a patient with intermittent claudication that is found to have extensive disease

Answer 14

bypass grafting, sequential stents, or longer stents

Question 15

managmenet of symptomatic atherosclerotic occlusive disease at the aortobifemoral junction

Answer 15

bypass with synthetic grafts

Question 16

managmenet of symptomatic atherosclerotic occlusive disease of vessels distal to the aortobifemoral junction

Answer 16

bypass with saphenous vein grafts

Question 17

Patient that complains of calf pain that is relieved by sitting up and dangling the feet off the bed. Physical exam shows shiny atrophic skin without hair and decreased peripheral pulses

Answer 17

peripheral vascular disease/rest pain

Question 18

management of a patient who suddenly developed painful, pale, cold, pulseless, paresthetic, and paralytic lower extremity

Answer 18

think arterial embolization (likely secondary to a-fib or recent MI). Get a doppler study immediately!

Question 19

management of a patient who suddenly developed painful, pale, cold, pulseless, paresthetic, and paralytic lower extremity; doppler study shows incomplete occlusion

Answer 19

treat with clot busters

Question 20

management of a patient who suddenly developed painful, pale, cold, pulseless, paresthetic, and paralytic lower extremity; doppler study shows complete occlusion

Answer 20

embolectomy with fogarty catheter

Question 21

management of a patient who developed painful, pale, cold, pulseless, paresthetic, and paralytic lower extremity several hours ago; doppler study shows complete occlusion

Answer 21

embolectomy using a fogarty catheter and fasciotomy
(catheter with balloon is inserted into the blood vessel through a clot. The balloon is then inflated to extract the clot from the vessel)

Question 22

risk of dissecting aortic aneurysms of the thoracic aorta is highest in which patient population

Answer 22

poorly controlled HTN

Question 23

XRay shows widened mediastinum

Answer 23

dissecting aortic aneurysm

Question 24

management of patient with suspected dissecting aortic aneurysm

Answer 24

EKG and cardiac enzymes to r/o MI

Spiral CT scan

Question 25

treatment of patient with definitive dissection of the ascending aorta

Answer 25

surgery

Question 26

treatment of patient with definitive dissection of the descending aorta

Answer 26

medical management to control HTN