Vascular Flashcards
Three most common organisms in Mycotic aortic aneurysms?
1) Salmonella 2) E. coli 3) Enterococcus
Most common location for traumatic aortic injury?
immediately distal to the ligamentum arteriosum
Most common location for syphilitic aneurysm?
ascending aorta
Classification and treatment of thoracic aortic dissection?
Type A: proximal to the ligamentum arteriosus
Type B: distal to the ligamentum
Rx for dissections • Alpha blockade followed by beta blockade
Type A Must treat surgically - Replace with graft or insert stent.
- Type B Surgery only if medical management complicated by failure of BP control, continued pain, size increase, development of CNS problems or visceral or extremity ischemia
What size is aortic root surgery indicated in in Marfans?
6 cm
Most life-threatening/acute complication of aortic dissection?
proximal extension into pericardium causing tamponade
Most common major complication of thoracoabdominal aneurysm repair?
How do you minimize it?
Thoracoabdominal aortic aneurysm repair carries risk of paraplegia.
Short cross-clamp times are helpful, but not 100% preventative.
What is genetic pattern of Marfans?
Autosomal Dominant
What size do you repair a AAA?
5 cm
How do you get initial control in a ruptured AAA?
Control above celiac initially, then infrarenal after better exposure
What is the best test for aortic dissection?
The best test for aortic dissection is the quickest one available once dissection is suspected. It can be a contrast CT, MRI, aortogram, or transesophageal echo.
CXR findings for traumatic aortic transection? (6)
- widening of the mediastinum
- blunting of the aortic knob
- pleural capping of the left apex
- depression of the left bronchus
- esophageal deviation to the right as seen by NGT displacement
- fractures of left 1st and 2nd ribs.
Most common cause of death after AAA surgery?
MI
Most common non-lethal complication of AAA surgery?
Impotence
Best test for AAA active surveillance?
yearly ultrasound for all aneurysms >3.5 cm
Post-op AAA follow-up?
SVS reccomendations
Open: noncontrast CT q 5years
EVAR: contrast imaging at 1 and 12 months
q6 months ultrasound to follow an endoleak
Endoleak classification:
Type Iendoleakoccurswhen there is a gap between thegraftand the vessel wallat “seal zones.” This type ofendoleaktypically requires urgent attention due to high risk of sac enlargement and rupture.
AType IIendoleakresultswhenincreased pressure within the sidebranches oftheaortaforce blood to leakback into the lower-pressure aneurysm sac.Thisis the MOST COMMON type ofendoleak, andis generally considered benign.
AType IIIendoleakresults from a defector misalignment between the components ofendografts. Type IIIendoleakalso requires urgent attention.
AType IVendoleakoccurs soon after some EVAR procedures due to theporosity of certain graft materials.
AType Vendoleak, sometimes calledendotension,is apoorly understood phenomenon.It is thought to occur when increased graft permeabilityallowspressureto betransmittedthroughtheaneurysm sac, affectingthenative aortic wall, butthisis only atheory.
Groin mass after vascular access?
usually hematomas. 2% may be lymphoceles or lymph fistulae. Proximal lymphatic injury is likely
Fistulization is best treated by re-exploration and ligation of the lymph source. 20. Lymphoceles may respond to aspiration and pressure dressings.
define Primary varicosities
disease of superficial veins and their valves
define secondary varicosities
disease of superficial veins and valves secondary to deep venous insufficiency
Treatment of primary varicosities?
Primary lower extremity VVs are best treated by compression stockings for symptomatic relief of aching. • Most symptomatic cases may be treated by superficial saphenous ligation and stripping. Spider varices respond to sclerotherapy.
What is the treatment of superficial phlebitis?
Remove source if a veinous catheter was etiology (catheter removal).
Excise vein if septic phlebitis.
Diagnosis and treatment of DVT?
st diagnosed by Doppler flow studies and B mode sonographic imaging.
Standard treatment is heparinization; clot lysis is reserved for more severe cases, and thrombectomy is rarely indicated.
e. Anticoagulation: raise PTT 2x, and INR should be 2.0 once oral Rx is effective. Heparin therapy should precede Coumadin Rx to prevent worsening
What are hard indications for IVC filter?
- Recurrent PE in adequately anticoagulated patient
- For prophylaxis in patient with DVT and contraindication to anticoagulation
- Post pulmonary artery embolectomy
Where do you position IVC filter?
infrarenal vein position
What is medical support for IVCF related IVC occlusion?
- Anticoagulate if possible
2. give volume, not vasoconstrictors.
What is normal venous pressure of the foot?
100 mm Hg
Describe an emergent open AAA repair
- Midline abdominal incision
- evacuate hematoma and pack all four quadrants
- Obtain supraceliac proximal control by exposing the aorta thru the gastrohepatic ligament and cross clamping.
- Warn anesthesia and heparinize with 5000 U IV just prior to clamping
- obtain distal control at the common iliacs
- open and evacuate the mesenteric hematoma
- obtain infrarenal control of the aorta
- open the sac longitudinally and excise the aneurysm
- Look for back bleeding from the IMA
- Look for back bleeding from lumbar vessels and ligate them
- sew in a PTFE tube graft
- Flash the anastomosis prior to completion to evacuate and potential clot/emboli
- Close the sac over the graft
- evaluate for intact hypogastrics and perfusion of the sigmoid prior to close.
what gauge is a large bore IV
14 or 16 gauge
Preop stuff for an AAA?
Ancef Central line and request Swann or TEE 6u RBC on hold aline, foley, ngt prep from nipples to midthigh
What do you do for an AAA <5cm?
ultrasound surveillance q6 months.
Annual risk of rupture of a 5cm AAA?
5%
Annual risk of rupture of a 7cm AAA?
20%
AAA physical exam?
Do complete pulse exam and consider ABI. Get a stat abdominal ultrasound in ED to check for hemoperitoneum
Should you give heparin with a ruptured AAA?
no! patient likely coagulopathic already
Acute limb ischemia: Last move before closing
Completion angiogram
What do you do for an acute occlusion of a venous bypass?
usually hard to embolize, but can try first.
If this fails then replace with a gortex graft.
Indications for a carotid endartarectomy:
Symptomatic pts with ≥ 70% stenosis Symptomatic pts with < 70% and ulcerated plaque or failure of medical therapy Asymptomatic pts with ≥ 80% stenosis Crescendo TIAs
What are crescendo TIAs?
Crescendo TIAs are defined as two TIAs within 24 hours, three within 3 days, or four within 2 weeks.
How do you do a CEA?
Position pt supine with head elevated and turn to opposite
side
Gentle prepping of neck (don’t want to injury fragile
plaque)
Oblique incision along anterior border of SCM
Dissect common carotid along medial border to avoid
vagus nerve injury
Expose common carotid, internal carotid, and external
carotid with minimal manipulation
Divide facial vein as usually enters IJ at level of
bifurcation
Apply clamps/tourniquets in disease free areas
Anticoagulate pt with Heparin 100U/kg
Select shunt (safest on the oral exam to shunt all pts
and perform surgery under general anesthesia)
Arteriotomy begins on proximal CCA and extends onto
ICA (above and below gross intimal disease)
Make sure to carefully back-bleed shunt free of
air/debris
Dissect plaque free of arterial wall with blunt dissector
Make sure there is no loose flap or tack down shelf
(6-O prolene double arm, vertically placed so as not
to constrict lumen of ICA, knots on outside of
vessel)
Close vessel with vein patch or Hemashield patch
Flush all vessels before closure and releasing ICA
clamp
Open external first again to flush air/debris away from
ICA distribution
Reversal of heparin with protamine and use of drains is
surgeon dependent
What is management of Carotid disease with acute stroke?
Don’t rush to operate→get CT of
head, treat with TPA if in first 3 h, otherwise ASA,
physical therapy, and CEA in 6 weeks)
Preop tests for lower extremity bypass?
CTA with distal runoff
Ultrasound vein mapping to evaluate saphenous for in situ.
How do you expose the peroneal and posterior tib?
Exposure of peroneal and posterior tibial below trifurcation
are best exposed by detaching the soleus muscle
from the tibia
How do you expose the anterior tib?
Anterior tibial exposed by a longitudinal incision two
fingers-breadths lateral to the anterior tibial border
exposing the anterior tibial between the anterior tibialis
and extensor digitorum longus
How do you incise valves for an in-situ bypass?
For in-situ grafts, valves are incised through side
branches using Mills valvulotome
What is 5 year patency of infrainguinal bypass for claudication?
~70% at 5 years
Brodie-trendelenburg test
elevate leg until drained of
venous blood, place tourniquet below knee, have pt
stand, see if more blood flows into varicosities
when tourniquet released after they fill from arterial
pressure (30 seconds
venous stasis ulcer For superficial vein incompetence alone
high ligation
and stripping of greater saphenous vein
surgery
For superficial and perforator incompetence→
subfascial endoscopic perforator veins
Non-operative management of venous stasis ulcers
Conservative treatment with: compression therapy leg elevation/antibiotics weekly application of Unna boots topical agents (PDGF, EGF)
