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DVS Part XVI Vascular > Surgical Recall - Ch. 66 Vascular Surgery > Flashcards

Surgical Recall - Ch. 66 Vascular Surgery Flashcards

1
Q

Atherosclerosis

  1. What is it?
  2. How is it initiated?
  3. Risk factors?
  4. Common sites of plaque formation in arteries?
  5. What must be present for a successful arterial bypass operation?
  6. What is the major principle of safe vascular surgery?
  7. Which arteries supply the blood vessel itself?
  8. What is “ENDOVASCULAR” repair?
A

Atherosclerosis

  1. What is it? Diffuse disease process in arteries; atheromas containing cholesterol and lipid form within the intima and inner media, often accompanied by ulcerations and smooth muscle hyperplasia
  2. How is it initiated? Endothelial injury –> damaged vessel walls release thrombin, ADP, cytokines –> platelets adhere –> growth factors released –> smooth muscle hyperplasia/plaque deposition
  3. Risk factors? HTN, SMOKING***, DM, family hx, hypercholesterolemia, high LDL, obesity, sedentary lifestyle
  4. Common sites of plaque formation in arteries? Branch points (carotid bifurcation)
  5. What must be present for a successful arterial bypass operation?
    1. Inflow (e.g., patent aorta)
    2. Outflow (e.g., open distal popliteal a.)
    3. Run off (e.g., patent trifurcation vessels down to the foot)
  6. What must be present for a successful arterial bypass operation? Get proximal and distal control of the vessel to be worked on!
  7. Vaso vasorum
  8. Endovascular repair: placement of a catheter in artery and then deployment of a graft intraluminally
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2
Q

Peripheral Vascular Disease

  1. ​What is peripheral vascular disease?
  2. What is the most common site of arterial atherosclerotic occlusion in the lower extremities?
  3. What are the symptoms of PVD?
  4. What is intermittent claudication?
  5. What is rest pain?
  6. What classically resolves rest pain?
  7. What is Buerger’s Sign?
A

Peripheral Vascular Disease

  1. ​What is peripheral vascular disease? Occlusive atherosclerotic disease in the lower extremities
  2. What is the most common site of arterial atherosclerotic occlusion in the lower extremities? Occlusion of the SFA in Hunter’s Canal
  3. What are the symptoms of PVD?
    1. Intermittent claudication
    2. Rest pain
    3. Erectile dysfunction
    4. Sensorimotor impairment
    5. Tissue loss
  4. What is intermittent claudication?
    1. Pain, cramping… usually the calf muscle, after walking a specific distance; then pain resolves after stopping
  5. What is rest pain? Sign of advanced PAD… Pain in the foot, usually over the distal metatarsals; this pain arises at rest (classically at night, awakening the pt) –> LIMB-THREATENING ISCHEMIA**
  6. What classically resolves rest pain? Hanging the foot over the side of the bed or standing; gravity affords some extra flow to ischemic areas
  7. Buerger’s Sign: Physical exam sign of advanced chronic ischemia… the affected foot turns pale after it is elevated (usually for 1-2 min). Once the pt sits up and dangles the foot down, it becomes ruborous (like a cooked lobster) due to marked arteriolar dilation from chronic severe ischemia that causes a reactive hyperemia… such pts will have low ABI <0.4
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3
Q

Peripheral Vascular Disease

  1. What is the differential diagnosis of lower extremity claudication?
  2. What are the signs of PVD?
  3. What is the site of a PVD ulcer vs. a venous stasis ulcer?
A

Peripheral Vascular Disease

  1. What is the differential diagnosis of lower extremity claudication?
    1. Neurogenic (e.g., nerve entrapment/discs)
    2. Arthritis
    3. Coarctation of the aorta
    4. Popliteal artery syndrome
    5. Chronic compartment syndrome
    6. Neuromas
    7. Diabetic neuropathy pain
    8. Anemia
  2. What are the signs of PVD?
    1. Absent pulses
    2. Bruits
    3. Muscular atrophy
    4. Decreased hair growth
    5. Thick toenails
    6. Tissue necrosis/ulcers/infections
  3. What is the site of a PVD ulcer vs. a venous stasis ulcer?
    1. PVD arterial insufficiency ulcer–usually on TOES, FOOT
    2. Venous stasis ulcer–MEDIAL MALLEOLUS (ankle)
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4
Q

Peripheral Vascular Disease

  1. What is the ABI?
  2. What ABIs are associated with normals, claudicators, and rest pain?
  3. Who gets false ABI readings?
A
  1. What is the ABI? Ankle to Brachial Index (ABI); ratio of systolic BP at ankle to systolic BP at arm (brachial a.)… taken with doppler
  2. Normal ABI > 1.0; Claudicator ABI < 0.6; Rest pain ABI < 0.4
  3. Pts with calcified arteries, esp. those with diabetes
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5
Q

Peripheral Vascular Disease

  1. Prior to surgery for chronic PVD, what diagnostic test will every pt receive?
  2. What are the indications for surgical tx in PVD?
  3. What is the tx of claudication?
A
  1. A-gram (arteriogram: dye in vessel and x-rays) map disease and allows for best tx option (i.e., angioplasty vs surgical bypass vs. endarterectomy)… GOLD STANDARD FOR DX PVD
  2. “STIR”
    1. ​Severe claudication refractory to conservative tx that affects quality of life/livelihood (e.g. can’t work b/c of claudication)
    2. Tissue necrosis
    3. Infection
    4. Rest Pain
  3. ​Tx: for vast majority, conservative tx:
    1. ​”PACE”
      1. ​Pentoxifylline (results in increased RBC deformity and flexibility)
      2. Aspirin (inhibits platelets aggregation)
      3. Cessation of smoking
      4. Exercise
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6
Q

Peripheral Vascular Disease

  1. What is the risk of limb loss with claudication?
  2. What is the risk of limb loss with rest pain?
  3. In the pt with PVD, what is the main post-op concern?
A

Peripheral Vascular Disease

  1. What is the risk of limb loss with claudication? 5% limb loss at 5 yrs (5 in 5, 10 in 10)
  2. What is the risk of limb loss with rest pain? >50% of pts will have amputation of limb at some point
  3. In the pt with PVD, what is the main post-op concern? Cardiac status b/c most pts with PVD have coronary artery disease (~20% have an AAA)
    1. ​MI = most common cause of post-op death after PVD operation
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7
Q

Peripheral Vascular Disease

  1. What is Leriche’s syndrome?
  2. What are the tx options for severe PVD?
A

Peripheral Vascular Disease

  1. What is Leriche’s syndrome?
    1. “CIA”
      1. ​Claudication of butt (not rest pain b/c gradual… so time for collaterals to help)
      2. Impotence (erectile dysfxn… dec. blood flow to internal iliacs –> internal pudendals)
      3. Atrophy (from occlusive disease of the iliacs/distal aorta)
  2. ​​Tx options:
    1. Surgical graft bypass
    2. Angioplasty–balloon dilation
    3. Endarterectomy–remove diseased intima and media
    4. Surgical patch angioplasty (place patch over stenosis)
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8
Q

Peripheral Vascular Disease

  1. What is a FEM-POP bypass?
  2. What is a FEM-DISTAL bypass?
  3. Dry vs. wet gangrene?
  4. What is blue toe syndrome?
A
  1. Bypass SFA occlusion with a graft from the femoral a. to the popliteal a.
  2. Bypass from femoral a. to distal a. (peroneal a., anterior tibial a., or posterior tibial a.)
  3. Dry: necrosis of tissue W/O signs of infection (“mummified tissue”)
  4. BTS: intermittent painful blue toes (or fingers) due to microemboli from a proximal arterial plaque
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9
Q

Acute Arterial Occlusion

  1. What is it?
  2. What are the classic signs & sx of AAO?
  3. What is the classic timing of pain with AAO from an embolus?
  4. What is the immediate pre-op mgmt?
  5. What are the sources of emboli?
  6. What is the most common cause of embolus from the heart?
  7. WHat is the most common site of arterial occlusion by an embolus?
  8. What diagnostic studies are in order?
  9. What is the tx?
  10. How is Fogarty catheter used? How many mm in diameter is a 12 French Fogarty catheter?
A

Acute Arterial Occlusion

  1. What is it? Acute occlusion of an artery, usually by embolization; other causes include acute thrombosis of an atheromatous lesion, vascular trauma
  2. What are the classic signs & sx of AAO?
    1. Pain
    2. Paralysis
    3. Pallor
    4. Paresthesia
    5. Polar (Poikilothermia)
    6. Pulselessness
  3. What is the classic timing of pain with AAO from an embolus? Acute onset; pt can tell you exactly when and where it happened
  4. What is the immediate pre-op mgmt?
    1. Anticoagulate w/ IV heparin (bolus followed by constant infusion)
    2. A-gram
  5. What are the sources of emboli?
    1. Heart–85% (e.g., clot from AFib, clot forming on dead muscle after MI, endocarditis, myxoma)
    2. Aneurysms
    3. Atheromatous plaque (atheroembolism)
  6. What is the most common cause of embolus from the heart? Afib
  7. What is the most common site of arterial occlusion by an embolus? Common femoral artery (SFA = most common site of arterial occlusion from atherosclerosis)
  8. What diagnostic studies are in order?
    1. A-gram
    2. ECG (looking for MI, Afib)
    3. Echo (looking for clot, MI, valve vegetation)
  9. What is the tx? Surgical embolectomy via cutdown and Fogarty balloon (bypass is reserved for embolectomy failure)
  10. Insinuate the catheter with balloon deflated past the embolus and then inflate the balloon and pull the catheter out; the balloon brings the embolus with it / To get mm from French measurements, divide the French number by pi (3.14); thus a 12 French catheter is 12/3 = 4 mm in diameter
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10
Q

Acute Arterial Occlusion

  1. What must be looked for post-op after reperfusion of a limb?
  2. What is compartment syndrome?
  3. What are the signs/sx of compartment syndrome?
  4. Can a patient have a pulse and compartment syndrome?
  5. Tx?
A

Acute Arterial Occlusion

  1. What must be looked for post-op after reperfusion of a limb?
    1. Compartment syndrome
    2. Hyperkalemia
    3. Renal failure from myoglobinuria
    4. MI
  2. What is compartment syndrome? Leg (claf) is separated into compartments by very unyielding fascia; tissue swelling from reperfusion can inc. intracompartmental pressure, resulting in dec. capillary flow, ischemia, and myonecrosis –> myonecrosis may occur after intracompartment P reaches only 30 mm Hg
  3. What are the signs/sx of compartment syndrome?
    1. Pain, especially after passive flexing/extension of foot
    2. Paralysis
    3. Paresthesias
    4. Pallor
    5. PULSES ARE PRESENT b/c systolic pressure is MUCH higher than minimal 30 mm Hg needed for syndrome
  4. Can a patient have a pulse and compartment syndrome? NO
  5. Tx: open compartments via bilateral calf-incision fasciotomies of all four compartments in the calf
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11
Q

AAA

  1. What is it?
  2. What is the M:F ratio and who is at the highest risk?
  3. Most common site?
  4. Classically, what do testicular pain and AAA signify?
  5. What are the signs of rupture?
  6. How can AAA typically be seen initially on imaging?
  7. What is the mean abdominal aortic diameter?
  8. What are the indications for surgical repair?
  9. Why is colonic ischemia a concern in the repair of AAAs?
  10. What are the signs of colonic ischemia?
  11. What is the study of choice to dx colonic ischemia?
  12. When is colonic ischemia seen post-op?
A

AAA

  1. What is it? Abnormal dilation of abdominal aorta (>1.5-2x normal) forming a true aneurysm
  2. What is the M:F ratio and who is at the highest risk? 6:1, white males
  3. Most common site? Infrarenal (95%)
  4. Classically, what do testicular pain and AAA signify? Retroperitoneal rupture with ureteral stretch and referred pain to testicle
  5. What are the signs of rupture? (prior to rupture.. typically asymptomatic)
    1. Abdominal pain
    2. Pulsatile abdominal mass
    3. Hypotension
  6. ​Abdominal plain x-ray - you will see the calcification outline… esp on lateral film so that calcification will not overlap with lumbar spine
  7. ​2 cm
  8. >5.5 cm in diameter
  9. Often the IMA is sacrificed during surgery and collaterals can be inadequate
  10. BRBPR, diarrhea, abdominal pain
  11. Colonoscopy
  12. Usually in the first week
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12
Q

AAA

  1. What is the possible long-term complication that often presents with both upper and lower GI bleeding?
  2. What are other possible post-op complications?
  3. What is ASA?
  4. What artery is involved in anterior spinal cord syndrome?
  5. What are the most common bacteria involved in aortic graft infections?
  6. How is a graft infection with an aortoenteric fistula treated?
A

AAA

  1. Aortoenteric fistula (fistula between aorta and duodenum)
  2. Post-op complications:
    1. Erectile dysfunction (sympathetic plexus injury)
    2. Retrograde ejaculation
    3. Aortovenous fistula (to IVC)
    4. ANTERIOR SPINAL SYNDROME
  3. ​Classically:
    1. ​Paraplegia
    2. Loss of bladder/bowel control
    3. Loss of P/T sensation below level of involvement
    4. Sparing of proprioception
  4. ​Artery of Adamkiewicz–supplies the anterior spinal cord
  5. Staph a. / Staph e. (usually late)
  6. Perform an extra-anatomic bypass with resection of the graft (axillofemoral bypass graft… graft goes from axillary a. to femoral a. and then from one femoral a. to the other (fem-fem bypass)
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13
Q

What is May Thurner Syndrome?

A
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14
Q

AAA

  1. Which vein crosses the neck of the AAA proximally?
  2. What part of the small bowel crosses in front of the AAA?
  3. Which large vein runs to the left of the AAA?
  4. Which artery comes off the middle of the AAA and runs to the left?
  5. Which vein runs behind the R common iliac a.?
  6. Which renal vein is longer?
A

AAA

  1. Which vein crosses the neck of the AAA proximally? Renal vein (left)
  2. What part of the small bowel crosses in front of the AAA? Duodenum
  3. Which large vein runs to the left of the AAA? IMV
  4. Which artery comes off the middle of the AAA and runs to the left? IMA
  5. Which vein runs behind the R common iliac a.? L common iliac vein
  6. Which renal vein is longer? L
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15
Q

Chronic Mesenteric Ischemia

  1. What is it?
  2. What are the sx?
  3. What is “intestinal angina”?
  4. What are the signs?
  5. How is dx made?
  6. What supplies blood to the gut?
  7. What is the classic finding on A-gram?
  8. What are the tx options?
A

Chronic Mesenteric Ischemia

  1. What is it? Chronic intestinal ischemia from long-term occlusion of the intestinal arteries; most commonly results from atherosclerosis; usually in two or more arteries b/c of extensive collaterals
  2. What are the sx? Weight loss, postprandial abdominal pain, anxiety/fear of food b/c of postprandial pain
  3. What is “intestinal angina”? Postprandial pain from gut ischemia
  4. What are the signs? Abdominal bruit
  5. How is dx made? A-gram, duplex, MRA
  6. What supplies blood to the gut?
    1. Celiac axis vessels
    2. SMA
    3. IMA
  7. What is the classic finding on A-gram?
    1. Two of the three mesenteric arteries are occluded, and there is atherosclerotic narrowing of the third patent artery
  8. What are the tx options?
    1. Bypass
    2. Endarterectomy
    3. Angioplasty
    4. Stenting
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16
Q

Acute Mesenteric Ischemia

  1. What is it?
  2. What are the causes?
  3. What are the causes of emboli from the heart?
  4. What drug has been associated with acute intestinal ischemia?
  5. To which intestinal a. do emboli preferentially go?
  6. What are the signs/symptoms of acute mesenteric ischemia?
  7. What is the classic triad of acute mesenteric ischemia?
  8. What is the gold standard diagnostic test?
  9. What is the treatment of mesenteric embolus?
  10. What is the treatment of acute thrombosis?
A

Acute Mesenteric Ischemia

  1. What is it? Acute onset of intestinal ischemia
  2. What are the causes?
    1. Emboli - to mesenteric vessel from heart
    2. Acute thrombosis - of longstanding atherosclerosis of mesenteric artery
  3. What are the causes of emboli from the heart?
    1. AFib**
    2. MI
    3. Cardiomyopathy
    4. Valve disease/endocarditis
    5. Mechanical heart valve
  4. What drug has been associated with acute intestinal ischemia? Digitalis
  5. To which intestinal a. do emboli preferentially go? SMA
  6. What are the signs/symptoms of acute mesenteric ischemia? Severe pain– “pain out of proportion to exam” … vomiting/diarrhea/hyperdefecation
  7. What is the classic triad of acute mesenteric ischemia?
    1. Acute onset of pain
    2. Vomiting, diarrhea, or both
    3. Hx of Afib or heart disease
  8. What is the gold standard diagnostic test? Mesenteric A-gram
  9. What is the treatment of mesenteric embolus? Perform Fogarty catheter embolectomy, resect obviously necrotic intestine, and leave marginal looking bowel until a “second look” laparotomy is performed 24 to 72 hours post-op
  10. What is the treatment of acute thrombosis? Papverin vasodilator via A-gram catheter until patient is in OR; then most surgeons would perform a supraceliac aorta graft to the involved intestinal artery or endarterectomy; intestinal resection/second look as needed
17
Q

Median Arcuate Ligament Syndrome

  1. What is it?
  2. What is the median arcuate ligament comprised of?
  3. What are the symptoms?
  4. What are the signs?
  5. How is the dx made?
  6. What is the tx?
A

Median Arcuate Ligament Syndrome

  1. What is it? Mesenteric ischemia resulting from the narrowing of the cliac axis vessels by extrinsic compression by the median arcuate ligament
  2. What is the median arcuate ligament comprised of? Diaphragm hiatus fibers
  3. What are the symptoms? Postprandial pain, weight loss
  4. What are the signs? Abdominal bruit in almost all pts
  5. How is the dx made? A-gram
  6. What is the tx? Release arcuate ligament surgically
18
Q

Carotid Vascular Disease

  1. What is the anatomy?
  2. 4 signs and symptoms?
  3. What is the risk of CVA in pts with TIA?
  4. What is the noninvasive method of evaluating carotid disease?
  5. What is the gold standard invasive method of evaluating carotid disease?
  6. What is the surgical tx of carotid stenosis?
  7. What are the indications for CEA in asymptomatic pt?
  8. What are the indications for CEA in symptomatic (CVA, TIA, RIND) pt?
  9. In bilateral high-grade carotid stenosis, on which side should the CEA be performed in the asymptomatic, R-handed pt?
  10. What is the most common cause of death during the early post-op period after CEA?
  11. Define “Hollenhorst plaque”
A
  1. ID: ICA, ECA, “Bulb,” Superior thyroid a., common carotid a.
  2. S&S:
    1. Amaurosis fugax: Temporary monocular blindness (“curtain coming down”): seen with microemboli to ophthalmic a. (first branch off the ICA in the brain) –> ipsilateral retinal ischemia lasting a few min; example of TIA
    2. TIA: Focal neurologic deficit with resolution of all sx within 24 hrs
    3. RIND: Reversible Ischemic Neurologic Deficit: transient neurologic impairment (w/o any lasting sequelae) lasting 24 to 72 hrs
    4. CVA: stroke: neurologic deficit with permanent brain damage
  3. ~10% a year
  4. Carotid U/S / Doppler: gives general location and degree of stenosis
  5. A-gram
  6. Carotid Endarterectomy (CEA): removal of diseased intima and media of carotid artery, often performed with a shunt in place
  7. Carotid artery stenosis >60% (greatest benefit in pts with >80% stenosis)
  8. Carotid stenosis >50%
  9. Left CEA first, to protect the dominant hemisphere and speech center
  10. MI
  11. “Hollenhorst plaque”: Typically seen with amaurosis fugax: Cholesterol microemboli to retinal arterioles seen as bright, yellow defects… highly suggestive of embolization from a plaque at the carotid bifurcation
19
Q

Carotid Vascular Disease: classic CEA intra-op questions:

  1. What thin muscle is cut right under the skin in the neck?
  2. What are the extracranial branches of the ICA?
  3. Which vein crosses the carotid bifurcation?
  4. What is the first branch of the external carotid?
  5. Which muscle crosses the common carotid proximally?
  6. Which muscle crosses the carotid artery distally?
  7. Which nerve crosses approximately 1 cm distal to carotid bifurcation?
  8. Which nerve crosses the internal carotid near the ear?
  9. What is in the carotid sheath?
A

Carotid Vascular Disease: classic CEA intra-op questions:

  1. What thin muscle is cut right under the skin in the neck? Plastysma
  2. What are the extracranial branches of the ICA? None
  3. Which vein crosses the carotid bifurcation? Facial vein
  4. What is the first branch of the external carotid? SUperior thyroidal a.
  5. Which muscle crosses the common carotid proximally? Omohyoid m.
  6. Which muscle crosses the carotid artery distally? Digastric m.
  7. Which nerve crosses approximately 1 cm distal to carotid bifurcation? Hypoglossal nerve; cut it and the tongue will deiate toward the side of the injury
  8. Which nerve crosses the internal carotid near the ear? Facial nerve (marginal branch)
  9. What is in the carotid sheath?
    1. Carotid artery
    2. Internal jugular vein
    3. Vagus nerve
    4. Deep cervical lymph nodes
20
Q

Subclavian Steal Syndrome

  1. What is it?
  2. Which artery is most commonly occluded?
  3. What are the symptoms?
  4. What are the signs?
  5. Treatment?
A

Subclavian Steal Syndrome

  1. What is it? Arm fatigue and vertebrobasilar insufficiency from obstruction of the left subclavian a. proximal to vertebral a. branch point; ipsilateral arm mvmt causes increased blood flow demand, which is met by retrograde flow from vertebral a., thereby “stealing” from vertebrobasilar arteries
  2. Which artery is most commonly occluded? L subclavian
  3. What are the symptoms?
    1. UE claudication
    2. Syncopal attacks
    3. Vertigo
    4. Confusion
    5. Dysarthria
    6. Blindness
    7. Ataxia
  4. What are the signs? UE BP discrepancy, bruit (above the clavicle), vertebrobasilar insufficiency
  5. Treatment? Surgical bypass or endovascular stent
21
Q

Renal Artery Stenosis

  1. What is it?
  2. What is the etiology of the stenosis?
  3. Classic profile of a pt with renal artery stenosis from fibromuscular dysplasia?
  4. What antihypertensive medication is CONTRAINDICATED in pats with HTN from renovascular stenosis?
A

Renal Artery Stenosis

  1. What is it? Stenosis of renal artery, resulting in decreased perfusion of the JGA and subsequent activation of the RAAS (i.e., HTN from renal artery stenosis)
  2. What is the etiology of the stenosis? 66% result from atherosclerosis (men > women), 33% result from fibromuscular dysplasia (women > men)
  3. Classic profile of a pt with renal artery stenosis from fibromuscular dysplasia? Young woman w HTN
  4. ACEI (result in renal insufficiency)
22
Q

Splenic Artery Aneurysm

  1. Causes? Women? Men?
  2. How is dx made?
  3. What is the risk factor for rupture?
  4. What is the tx?
A
  1. Women: medial dysplasia / Men: atherosclerosis
  2. Usually by abdominal pain –> U/S or CT scan, in teh OR after rupture, or incidentally by eggshell calcifications as seen on AXR
  3. Pregnancy
  4. Resection or percutaneous catheter embolization in high-risk (e.g., portal HTN) pts
23
Q

Misc.

  1. “Milk leg”
  2. Phlegmasia cerulea dolens
  3. Raynaud’s phenomenon
  4. Takayasu’s arteritis
  5. Buerger’s disease
  6. “Paradoxical embolus”
  7. Behcet’s Disease
A

Misc.

  1. Milk leg: aka phlegmasia alba dolens (alba = white): often seen in pregnant women with occlusion of iliac vein resulting from extrinsic compression by the uterus (thus, the leg is “white” b/c of subcutaneous edema)
  2. Phlegmasia cerulea dolens: 2/2 to severe venous outflow obstruction –> cyanotic leg; extensive venous thrombosis results in arterial inflow impairment
  3. Raynaud’s: Vasospasm of digital arteries: white (spasm), then blue (cyanosis), then red (hyperemia)
  4. Takayasu’s arteritis: Arteritis of the aorta and aortic branches, resulting in stenosis/occlusion/aneurysms - seen mostly in women
  5. Buerger’s disease: aka thromboangiitis obliterans: occlusion of the small vessels of the hands and feet; seen in young men who smoke; often results in digital gangrene –> amputations
    1. ​ONLY TREATMENT = SMOKING CESSATION
  6. Paradoxical embolus: venous embolus gains access to L heart after going through an intracardiac defect, most commonly a PFO, and then lodges in a peripheral artery
  7. Behcet’s disease: Genetic disease with aneurysms from loss of vaso vasorum; seen with oral, oculuar, and genital ulcers/inflammation (inc. incidence in Japan, Mediterranean)

DVS Part XVI Vascular (3 decks)

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