Surgery

Question 1

What is the difference between the presentation of acute versus chronic arterial insufficiency.

Answer 1

Acute: 6 Ps\nChronic: Claudication or trophic changes

Question 2

Among patients with chronic arterial insufficiency, how can one identify a patient with critical ischemia?

Answer 2

Critical ischemia is characterized by pain at rest, ulceration, and trophic changes

Question 3

Describe the 5 trophic changes

Answer 3

Atrophic skin (thin shiny) \n Atrophic muscle \n Swollen feet \n Dependant rubor \n Pallor on elevation

Question 4

What is a duplex ultrasound

Answer 4

An ultrasound that contains both doppler and imaging

Question 5

How is perfusion pressure calculated?

Answer 5

=mean arterial pressure – mean venous pressure

Question 6

How is mean arterial pressure calculated?

Answer 6

=(2xDiastolicBP + SystolicBP)/3

Question 7

How is mean venous pressure calculated?

Answer 7

Mean venous pressure is not calculated, it is measured using a catheter in the right atrium attached to a manometer.

Question 8

What is the ABI? Why is it useful?

Answer 8

The ABI is the pressure at which the doppler pulse can once again be heard while deflating a cuff at the ankle relative to at the arm.\nIt suggests the severity of arterial occlusion, with normal ranging from 0.95 to 1.1. This value decreases as the severity of occlusion increases.

Question 9

What are the 6 Ps of acute arterial occlusion

Answer 9

Pallor\nPain\nPulseless\nParalysis\nParesthesia\nPoikilothermia (i.e., polar)

Question 10

Why is compartment syndrome a concern after revascularization of an acute arterial occlusion

Answer 10

Post–ischemic reperfusion triggers swelling which reduces perfusion pressure, leading to a second ischemia

Question 11

What medications have been shown to reduce CV events in peripheral artery disease?

Answer 11

Statins\nACE–i\nInsulin/ Oral Hypoglycemics\nASA or clopidogrel

Question 12

Aside from medications, what other management strategies exist for peripheral artery disease?

Answer 12

Reduce risk factors\nExercise\nEndovascular techniques (e.g., angioplasty)\nSurgery (i.e., bypass graft)

Question 13

Buerger’s disease

Answer 13

Disease of young men and related to smoking, found in distant vessels, can affect veins

Question 14

Takayasu disease

Answer 14

Middle aged, women, not related to smoking, central vessels coming off the aorta, doesn’t affect veins

Question 15

What is the biggest risk factor for atherosclerosis

Answer 15

Smoking

Question 16

How will a patient with one level of occlusive artery disease present?

Answer 16

ABI of 0.7\nPain/claudication below level of obstruction

Question 17

What causes Leriche syndrome? How does it present?

Answer 17

Caused by aorto–iliac occlusive disease. Presents with:\n\nreduced or absent femoral pulses\nbruit\nbuttock claudication\nED\n(no trophic changes)

Question 18

Critical Ischemia leads to ABI in what range?

Answer 18

0.5 or lower

Question 19

Go to this website for a high yield visual quiz reviewing the arteries of the body: https://www.getbodysmart.com/blood–vessels/major–arteries

Answer 19

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Question 20

What are the 7 rungs of the reconstructive ladder? Bottom to top.

Answer 20

Secondary intention\nPrimary intention\nDelayed primary closure\nSkin graft\nTissue expansion\nLocal tissue transfer\nFree tissue transfer

Question 21

Secondary intention means…

Answer 21

Allow the wound to heal on its own

Question 22

Primary intention means…

Answer 22

Close the wound by approximation and sutures

Question 23

Delayed primary closure

Answer 23

Wait to close it (sometimes called tertiary closure)

Question 24

Skin graft

Answer 24

Borrow skin from elsewhere

Question 25

Tissue expansion

Answer 25

stretch out nearby tissue, then use it to close

Question 26

Local tissue transfer

Answer 26

Local graft of dermis, epidermis and underlying tissue

Question 27

Free tissue transfer

Answer 27

Distal graft of dermis, epidermis and underlying tissue

Question 28

When is it better not to close a wound? List three of the five examples given in lecture.

Answer 28

When there is infection\nWhen the defect is small\nYou need to temporize a wound for future closure\nThere is demarcated necrotic tissue\nHealing by secondary intention will give a reasonable outcome

Question 29

What are dermal appendages, why are they important.

Answer 29

They are the sebaceous glands and dermal papillae associated with hair shafts. They are the units that allow wounds to heal in on their own and epithelialize.

Question 30

What is a split thickness skin graft

Answer 30

Graft made up of the epidermis and the top layer of the dermis. The remaining dermis allows donors site to heal in by secondary intention.

Question 31

Full thickness skin graft

Answer 31

Graft made of epidermis, dermis, and dermal appendages.

Question 32

How do you make a partial thickness skin graft larger?

Answer 32

Meshing – tiny holes allow the graft to expand over greater area, also promotes healing in new location and prevents seromas and hematomas.

Question 33

How do full thickness skin grafts close?

Answer 33

Must close through primary closure (no adnexal structures).

Question 34

What is the benefit of a full thickness skin graft?

Answer 34

It reduces the contracture of the graft (split thickness grafts “shrivel up” more after being harvested). Best for face or volar surface of hand

Question 35

What is a free flap?

Answer 35

The transfer of tissue with it’s artery and reconnecting it to the blood supply in a new location.