Surgery - Vascular Flashcards
Which cardiac symptom do we investigate in the case of arterial limb embolisation?
A) cardiac decompensation
B) angina pectoris
C) arrhythmia absoluta
D) rheumatic fever
E) cardiomyopathia
C) arrhythmia absoluta
EXPLANATION
The most common origin of embolisation is thrombus of the left atrium due to arrhythmia absoluta. Valvular vegetation, or the scar of the left ventriculum are possible, but less frequent causes.
The patophysiological cause of arterial thrombosis:
A) dilution of the blood
B) slow blood flow due to stenosis of the vessel
C) standing job
D) hormonal effects
E) diabetes mellitus
B) slow blood flow due to stenosis of the vessel
EXPLANATION
Arterial thrombosis typically formates between two plaques, where the blood flow is low. It developes most frequently in arterosclerosis obliterans. Endarteritis, entrapment, blunt traumatic injury, inflammation can also lead to arterial thrombosis, but these were not present in the possible answers.
The cause of transient ischemic attack (TIA) can be:
A) hypotonia
B) diabetes mellitus, hypoglycemia
C) anuria
D) poisoning
E) stenosis of the internal carotid artery
E) stenosis of the internal carotid artery
EXPLANATION
Transient ischemic attack (TIA) is a brief episode of neurological dysfunction, which resolves in a short period of time. Hypotension does not result focal neurologic deficit. TIA does not resolve by treating hypoglycemia. Symptoms of anuria and poisoning do not resolve without treatment. Only „stenosis of the internal carotid artery” is the right answer
Risk factors of arteriosclerosis, except:
A) smoking
B) genetic predisposition
C) diabetes mellitus
D) cirrhosis of the liver
E) hyperlipidemia
D) cirrhosis of the liver
EXPLANATION
The incidence of arteriosclerosis is statistically lower in patients with cirrhosis of the liver, than in the population with the same age. All the other answers listed are risk factors for arteriosclerosis.
Surgery of a patient with symptomatic abdominal aortic aneurysm, with a diameter of 6 cm:
A) it is only contraindicated if a severe concomittant risk factor is present
B) it is a high risk for surgery, so it is not indicated
C) conservative treatment is more effective
D) only with excellent ejection fraction, and intact coronary arteries
E) only indicated in patients younger than 70
A) it is only contraindicated if a severe concomittant risk factor is present
EXPLANATION
The risk of rupture in one year with an abdominal aortic aneurysm with the diameter of 6 cm is about 70%. The operative mortality is 4-7% with elective surgery, and 35-55 % with the urgent surgery of aortic rupture.
Typical dysbasia, intermittent claudication develops due to:
A) arthrosis of the hip or knee
B) pes planus
C) compression of the sciatic nerve
D) arterial occlusion, and reduced oxygen supply
E) deep vein thrombosis
D) arterial occlusion, and reduced oxygen supply
EXPLANATION
Dysbasia is the typical symptom of arterial occlusion. First time it was described as the disease of horses. Similar symptoms can occur in other diseases, but it is never parallel with walking. For these conditions terms dysbasia or claudication can not be used. Dysbasia referres to the pain due to loss of blood flow and oxygen.
Which definition corresponds to the concept of progressive stroke?
A) Fluctuating neurological symptoms, which worsen after every episode, but definitive stroke has not yet been developed.
B) A focal brain leison becomes more extensive
C) Hemiparesis turns into hemiplegia
D) Besides hemiplegia, or hemiparesis aphasia evolves
E) The current post-stroke neurological status worsenes
A) Fluctuating neurological symptoms, which worsen after every episode, but definitive stroke has not yet been developed.
EXPLANATION
Urgent intervention is needed. In a conscious patient with the stenosis of internal carotid artery, blood supply of the brain is on the border of decompensation. Remissions are the evidence of the possibility for reconstruction. In this case CT angiography does not demonstrate fresh ischemic lesion yet, and after the revascularisation, normal brain function can return. With definitive stroke (without remissions), it is late for revascularisation due to brain tissue loss.
Symptom of a right internal carotid artery stenosis or occlusion in a right-handed patient:
A) right hemiparesis
B) right hemiplegia
C) left hemiparesis
D) aphasia
E) vision loss of the left eye
C) left hemiparesis
EXPLANATION
The right internal carotid artery supplies the right cerebral hemispherie. Due to the crossing of the nerves, central hypoxia results contralateral symptoms. Vision loss on the ipsilateral side is possible, but it is not listed. Language representation of a right handed patient is usually in the right hemisphere.
Characteristics of subclavian steal syndrome:
A) The first part of subclavian artery is occluded, so the flow is reversal in the ipsilateral vertebral artery, resulting vertigo.
B) Exercise-induced contralateral neurological symptoms due to increased blood flow in the upper-limb, which results transient ischaemia in the affected hemispherium.
C) It results different blood pressure of the upper limbs, because the third part of subclavian artery is occluded, so the blood pressure must be lower on the affected side.
D) If the difference in blood pressure is big between the two sides, vertigo is more significant, and the upper limb complaints are moderate.
E) It results ipsilateral hemispherial symptoms.
A) The first part of subclavian artery is occluded, so the flow is reversal in the ipsilateral vertebral artery, resulting vertigo.
EXPLANATION
Answer ‘A’ is right. The vertebral artery supplies the brain stem and the cerebellum, so hemispherial ischemia can not occur. If the blood flow in the upper limb increases, the ‘steal’ from the vertebral artery rises. This can result a difference in the blood pressure of the two arms, which sometimes leads to neurologic symptoms due to vertebrobasilar ischemia.
What is the next step when noticing a subclavian steal syndrome?
A) Urgent hospitalisation and investigation, because circulatory disorders of the brain lead to severe brain damage.
B) In symptomatic cases carotid ultrasound, CT angiography should be performed, and endovascular treatment is recommended, if it is not feasable, surgery may be necessary. In asymptomatic cases only periodic check-ups are needed.
C) Operative reconstruction is recommended of the first part of subclavian artery from left thoracotomy.
D) It can be treated by control of the blood pressure.
E) No therapy, no observation is needed.
B) In symptomatic cases carotid ultrasound, CT angiography should be performed, and endovascular treatment is recommended, if it is not feasable, surgery may be necessary. In asymptomatic cases only periodic check-ups are needed.
EXPLANATION
Urgent intervention of subclavian steal syndrome is not frequently needed. The therapeutic choice depends on the severity of the symptoms. Treatment options are PTA (percutaneous transluminal angioplasty) of the first part of subclavian artery, or open surgery (carotid-subclavian transposition or bypass).
Embolisation should not be performed in:
A) aortic aneurysm
B) traumatic bleeding of a side brach
C) vascular malformation
D) gastrointestinal bleeding
E) kidney cancer
A) aortic aneurysm
EXPLANATION
Answers B, C, D, E are the main indications for catheter embolization. Aortic aneurysm can not be embolized. It would result critical limb ischaemia.
Which of the following is appropriate for the diagnosis of deep vein thrombosis?
1) phlebography
2) CT angiography
3) ultrasound
4) D-dimer test
A) the 1st, 2nd and 3rd answers are correct
B) the 1st and 3rd answers are correct
C) the 2nd and 4th answers are correct
D) only the 4th answer is correct
E) all of the answers are correct
E) all of the answers are correct
EXPLANATION
All the four diagnostic modalities can be used for the right diagnosis, but ultrasound gives the most valuable result.
A patient after aortobifemoral bypass presents with succulent fistula of the right groin. Management is the following:
1) waiting, these type of fistulas usually heal spontaneously
2) wound management, ambulantory care
3) looking for suture granuloma in the wound
4) admission to vascular surgical department, fistulography, CT angiography, surgery
A) the 1st, 2nd and 3rd answers are correct
B) the 1st and 3rd answers are correct
C) the 2nd and 4th answers are correct
D) only the 4th answer is correct
E) all of the answers are correct
D) only the 4th answer is correct
EXPLANATION
These symptoms are signs of potential vascular graft suppuration. It is a dangerous complication due to the risk of bleeding, propagation, sepsis. Waiting is not the right option. Searching for suture granulome in the wound can result bleeding. Until precise diagnosis we have to presume the infection of the graft.
A 65-year-old male patient presents with the history of aortobifemoral bypass 6 years ago. He noticed melaena and diarrhea lately and had no other complaints than general weakness until admission to the hospital. Which diagnosis is likely for this patient?
1) aorto-duodenal fistula
2) stress ulcer
3) aortojejunal fistula
4) colitis ulcerosa
A) the 1st, 2nd and 3rd answers are correct
B) the 1st and 3rd answers are correct
C) the 2nd and 4th answers are correct
D) only the 4th answer is correct
E) all of the answers are correct
B) the 1st and 3rd answers are correct
EXPLANATION
Melaena due to aortoenteric fistula is a possible late complication of aorto-bifemoral bypass with prosthetic graft. A patient with colitis ulcerosa would not have been asymptomatic for 6 years. Stress ulcer does not occur without previous damage.
Possibilities in the treatment of deep vein thrombosis:
1) angio VAC/Jet therapy
2) selective thrombolysis
3) per os medical treatment, which do not need monitoring
4) phlebography
A) the 1st, 2nd and 3rd answers are correct
B) the 1st and 3rd answers are correct
C) the 2nd and 4th answers are correct
D) only the 4th answer is correct
E) all of the answers are correct
A) the 1st, 2nd and 3rd answers are correct
EXPLANATION
Phlebography is a diagnostic modality, it is not used for therapy. The other answers are right.
