URR Treatment of LE Arterial Disease

Question 1

medical management of extrem arterial disease?

Answer 1

-lifestyle modification: diet, exercise, stop smoking
-medicine: antihypertension meds, aspirin to reduce viscosity of the blood
-surgical: endarterectomy stent, bypass graft

Question 2

surgical and invasive procedures that require an arterial puncture have an increased risk of hemorrhage when the blood is thinned by?

Answer 2

anticoagulants

Question 3

Most common bypass grafts?

Answer 3

-aorto-bifem: used to correct distal aortic stenosis and bilat iliac stenosis
-fem-fem: used to correct unilateral iliac stenosis
-fem-pop: used to correct unilateral femoral stenosis
-fem-tib: used to correct distal fem or pop stenosis
-ax-fem: least common; used to bypass multiple sites of stenosis, diseased aorta, or those who cannot undergo aorto-bifem or fem-fem procedures

Question 4

axillary -fem grafts and fem - fem grafts are used in those patients who are poor candidates for surgery because…

Answer 4

they can be placed more superficially in the body

Question 5

what are the different kinds of synthetic grafts?

Answer 5

-dacron - synthetic polyester; walls of the graft demonstrate a sawtooth pattern (not smooth)
-gore-tex (polytetrafluorethylene, PTFE), also known as teflon; demonstrate a double layer wall
-all synthetic grafts should demonstrate uniform diameter

Question 6

abnormal velocity criteria bypass graft?

Answer 6

-<40 cm/s at any segment in the graft
-2:1 increase in PSV between two segments or at anastomosis indicates 50% diameter reduction
-4:1 increase in PSV between 2 segments or at anastamosis indicates > 75%
-abnormal ABI indicated by a decrease >0.15 from last exam
-change from triphasic flow to biphasic flow (or monophasic)

Question 7

complications of synthetic grafts?

Answer 7

-early graft failure in the first month is usually due to errors in placement/attachement
-reperfusion of the leg via bypass graft can lead to the acute onset of anterior compartment syndrome
-re-stenosis caused by myointimal hyperplasia usually occurs in the first 2 years after placement
-re-stenosis caused by atherosclerosis usually occurs in grafts that area more than 2 years old
-leakage and rupture
-thrombus
-aneurysm (seen in mature grafts)

Question 8

what are vein grafts?

Answer 8

-> 3mm in diameter preferred, but 2mm and up can be used
-extrem, coronary or dialysis graft
-GSV, cephalic vein, basilic vein, and SSV commonly used for graft
-for pre op patient evaled in trendelenburg position, r/o thrombus, measure diameter of vein in multiple locations from upper thigh to lower calf

Question 9

what is a reversed saphenous graft?

Answer 9

-vein removed and placed in new position in the leg
-branches must be ligated
-valves remain and stay open due to gravity
-smaller end located prox, larger diameter end located dist
-flow velocities are elevated in the smaller prox portion and stenosis of the prox anastamosis is the most common complication

Question 10

what is an in-situ vein graft?

Answer 10

-GSV NOT harvested prior to use
-prox GSV connected to the A prox to stenosis and dist to GSV connected to A dist to stenosis
-valves destroyed by valvulatome
-valve remnants can cause stenosis
-branches/perforators must be ligated or AV fistula will form
-AV fistula is the most common complication with this type of graft

Question 11

abnorm vein graft criteria?

Answer 11

-vein grafts demonstrate mild thickening of the intima and a nonuniform diameter
-in-situ grafts should be evaled for valve remnants that can cause stenosis and patent branches that can cause AV fistula formation
-reversed vein grafts should be evaled for patent branches that can cause AV fistula
-reversed vein grafts should be evaled for patent branches that can cause AV fistula
-velocity ratio best indicator for graft stenosis; PSV at stenosis divided by the PSV just prox to stenosis
-norm velocities within graft average 60-70 cm/s
-abnorm = decrease in PSV > 30 cm/s from last exam
-abnorm = decrease in ABI by more than .15 from last exam

Question 12

what is the internal mammary artery?

Answer 12

-AKA internal thoracic artery
-originates from subclav a
-used in TRAM flap breast reconstruction and as coronary graft for left anterior descending (LAD) a

Question 13

what is the epigastric artery

Answer 13

-superior EA originates from the internal mammary artery and shares anastomoses with the inferior EA
-inferior EA originates from the external iliac artery
-both vessels supply the rectus abdominis muscle used in TRAM flap procedure for breast reconstruction
-evaled to locate the section of muscle with the best perfusion for surgery

Question 14

the radial a is used as a coronary a graft instead of sephaneous veins becuase

Answer 14

it has thicker walls and is similar to a coronary a in caliber

Question 15

what is the allen test?

Answer 15

-evals patency of palmar arch so the radial a can be harvested for cardiac bypass
-compress radial a just < 1 min while patient clenches fist to increase distal resistance to inflow
-patient releases fist, continue to compress a
-NL - hand returns to normal
-ABNL - hand remains pain, ulnar artery occluded

Question 16

what is intraoperative duplex monitoring

Answer 16

-used to eval the flow changes during and after graft placement, before wound closure
-surgeon applies higher frequency probe directly to the wound or exposed vessel/graft to assess flow characteristics
-techs control US outside of sterile field
-transducers should be sterilized by soaking them in alcohol for 30 mins prior to procedure
-requires sterile sheath to cover probe
-acoustic gel is used inside the sheath
-ankle/metatarsal/digit PVR, PPG, or CW doppler used to monitor lower extrem flow during recovery
-most distal vessels are preferred for flow eval because it demonstrates the quality of distal perfusion
-PVR amplitude should increase by 50% or more
-ankle pressures may be performed immediately after surgery
-Damped PVR or PPG waveforms and reduced ankle/foot pressures indicate failure of the bypass graft

Question 17

what is post op exam protocol?

Answer 17

-doppler is preffered
-obtain 2D and PW doppler images of inflow native A, prox anastomosis, body of the graft (take multiple samples to obtain mean graft velocity; average velocity from 3-4 sites in norm segment or graft), distal anastomosis, outflow native A
-PV and phasicity of the flow should be reported
-ABI is usually performed bilat (NEVER place cuff over graft)
-monophasic flow w/ increased diastolic flow may still be identified in the first 2 months
-if stenosis identified, the velocity ratio should be reported with the PSV
-PSV ratio = velocity divided by the PSV in the segment that is immediately prox to stenosis

Question 18

what are the causes of graft failure when post op is <30 days

Answer 18

-technical issues cause failure; improper suture placement, stricture or kinking
-thrombosis is the most common cause of acute bypass graft stenosis/occlusion

Question 19

what are causes of graft failure 1-24 months post op

Answer 19

-valve stenosis or partial valve remnant in venous graft
-myointimal hyperplasia; most common cause of chronic bypass graft stenosis/occlusion; anastomosis sites are #1 SITE OF GRAFT STENOSIS related to “over-healing” of the anastamosis

Question 20

what are causes of graft failure >24 months post op

Answer 20

usually caused by progression of atherosclerotic disease; less common cause of failure than myointimal hyperplasia

Question 21

bypass graft velocity ratio?

Answer 21

PSV at stenosis/PSV prox to stenosis

Question 22

what is percutaneous transluminal angioplasty (PTLA)

Answer 22

-aka balloon angioplasty
-balloon tipped catheter inserted into stenosed A
-balloon expanded to compress the atherosclerosis and increase the lumen size
-this catheter based technique can also be used to deploy a stent into the stenosed A
-anticoagulation therapy should be discontinued prior to procedure
-stents are usually made of Nitinol and are very echogenic
-during procedure, doppler should be done on PTA, DPA, or peroneal A
-doppler US used to assess stent patency and stenosis

Question 23

velocity ratio for post PTLA?

Answer 23

PSV at the stenosis in treated segment/ PSV prox to stenosis

Question 24

what is intravascular US (IVUS)

Answer 24

-catheter contains transducer array w/ multiple elements to provide circumferential view; slide onto the guidewire that the physician inserts into the vessel
-average 20-40 MHz
-can be used to guide the procedure or eval stent posiiton after palcement
-allows for constant eval of the lumen characterisitcs as the angioplasty is performed

Question 25

what is thrombin for?

Answer 25

used to treat pseudoaneurysms (cant be used on patients on blood thinners or an associated AVF)

Question 26

what is done during US guided thrombin injection?

Answer 26

-US tech does prelim exam to locate the optimum area for vis and needle puncture of the body of the psuedoaneurysm
-associated AVF must be ruled out to prevent thrombin from entering the venous system
-use sterile field
-use probe cover
-physician inserts 21-22 g needle into pseudoaneurysm and confirms the location with US
-US beam should be perpendicular to the long axis of the needle
-thrombin must be injected at a location far from the neck of the pseudoaneurysm to prevent entrance into the arterial system
-.5-1.0 mL injected in small increments and thrombosis is monitored on real time imaging
-thrombosis should begin immediatly
-re-eval pseudoaneurysm with color and oppler 20-30 mins after procedure
-repeat doppler eval of pedal pulses or ABI
-there should be no change from baseline
-eval native feeding A for patency

Question 27

how to do US guided compression of a pseudoaneurysm?

Answer 27

-compression techniques applied to close the stalk and stop the flow
-compression performed in 10 one minute intervals with a re-eval of flow with color doppler after each compression interval

Question 28

the most common site of plaque formation in the lower extrem is

Answer 28

in the fem A in the adductor canal
-CFA bif is the 2nd most common site

Question 29

what is the most common symptom of peripheral arterial disease

Answer 29

claudication

Question 30

what is the most common cause of arterial occlusive disease?

Answer 30

atherosclerosis obliterans

Question 31

buerger disease is most common in men, age what?

Answer 31

20-30
-always associated with heavy smoking

Question 32

takayasu arteritis is most commonly seen in who?

Answer 32

young females in Asia and india more than the US (20-40years)

Question 33

giant cell arteritis is most commonly found in who?

Answer 33

females

Question 34

in extrems, which artery is most commonly affected by aneurysm?

Answer 34

pop A

Question 35

what is the most common complication of peripheral artery aneurysm?

Answer 35

embolization

Question 36

blue toe syndrome is commonly associated with what?

Answer 36

AAA or after a recent angiography procedure

Question 37

right heart catheterization is the most common procedure associated with what?

Answer 37

a traumatic AV fistula

Question 38

pop entrapment is commonly found in who?

Answer 38

runners and athletes and is the most common cause of unilateral claudication in young athletes

Question 39

compartment syndrome most commonly demonstrates acute onset and is associated with what?

Answer 39

broken leg or arm

Question 40

adventitial cysts most commonly affect the what artery?

Answer 40

pop A in young to middle aged men

Question 41

what cuff method is most commonly used on segmental pressure exams?

Answer 41

4

Question 42

what are the most common limitations of a digital inflow exam?

Answer 42

room temps and improper cuff placement

Question 43

what is the most common med used in a penile eval for erectile dysfunction?

Answer 43

papaverine

Question 44

what is the most common catheter insertion pint in lower extrem angiography?

Answer 44

CFA

Question 45

most common complication of a reversed vein graft?

Answer 45

stenosis of prox anastamosis

Question 46

most common cause of acute arterial bypass graft stenosis/occlusion

Answer 46

thromboiss

Question 47

most common cause of chronic bypass graft stenosis/occlusion

Answer 47

myointimal hyperplasia