Vascular

Question 1

Three most common organisms in Mycotic aortic aneurysms?

Answer 1

1) Salmonella 2) E. coli 3) Enterococcus

Question 2

Most common location for traumatic aortic injury?

Answer 2

immediately distal to the ligamentum arteriosum

Question 3

Most common location for syphilitic aneurysm?

Answer 3

ascending aorta

Question 4

Classification and treatment of thoracic aortic dissection?

Answer 4

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.

4. 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

Question 5

What size is aortic root surgery indicated in in Marfans?

Answer 5

6 cm

Question 6

Most life-threatening/acute complication of aortic dissection?

Answer 6

proximal extension into pericardium causing tamponade

Question 7

Most common major complication of thoracoabdominal aneurysm repair?
How do you minimize it?

Answer 7

Thoracoabdominal aortic aneurysm repair carries risk of paraplegia.
Short cross-clamp times are helpful, but not 100% preventative.

Question 8

What is genetic pattern of Marfans?

Answer 8

Autosomal Dominant

Question 9

What size do you repair a AAA?

Answer 9

5 cm

Question 10

How do you get initial control in a ruptured AAA?

Answer 10

Control above celiac initially, then infrarenal after better exposure

Question 11

What is the best test for aortic dissection?

Answer 11

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.

Question 12

CXR findings for traumatic aortic transection? (6)

Answer 12

1. widening of the mediastinum
2. blunting of the aortic knob
3. pleural capping of the left apex
4. depression of the left bronchus
5. esophageal deviation to the right as seen by NGT displacement
6. fractures of left 1st and 2nd ribs.

Question 13

Most common cause of death after AAA surgery?

Answer 13

MI

Question 14

Most common non-lethal complication of AAA surgery?

Answer 14

Impotence

Question 15

Best test for AAA active surveillance?

Answer 15

yearly ultrasound for all aneurysms >3.5 cm

Question 16

Post-op AAA follow-up?

SVS reccomendations

Answer 16

Open: noncontrast CT q 5years
EVAR: contrast imaging at 1 and 12 months
q6 months ultrasound to follow an endoleak

Question 17

Endoleak classification:

Answer 17

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.

Question 18

Groin mass after vascular access?

Answer 18

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.

Question 19

define Primary varicosities

Answer 19

disease of superficial veins and their valves

Question 20

define secondary varicosities

Answer 20

disease of superficial veins and valves secondary to deep venous insufficiency

Question 21

Treatment of primary varicosities?

Answer 21

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.

Question 22

What is the treatment of superficial phlebitis?

Answer 22

Remove source if a veinous catheter was etiology (catheter removal).
Excise vein if septic phlebitis.

Question 23

Diagnosis and treatment of DVT?

Answer 23

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

Question 24

What are hard indications for IVC filter?

Answer 24

1. Recurrent PE in adequately anticoagulated patient
2. For prophylaxis in patient with DVT and contraindication to anticoagulation
3. Post pulmonary artery embolectomy

Question 25

Where do you position IVC filter?

Answer 25

infrarenal vein position

Question 26

What is medical support for IVCF related IVC occlusion?

Answer 26

1. Anticoagulate if possible | 2. give volume, not vasoconstrictors.

Question 27

What is normal venous pressure of the foot?

Answer 27

100 mm Hg

Question 28

Describe an emergent open AAA repair

Answer 28

1. Midline abdominal incision 2. evacuate hematoma and pack all four quadrants 3. Obtain supraceliac proximal control by exposing the aorta thru the gastrohepatic ligament and cross clamping. 4. Warn anesthesia and heparinize with 5000 U IV just prior to clamping 5. obtain distal control at the common iliacs 6. open and evacuate the mesenteric hematoma 7. obtain infrarenal control of the aorta 8. open the sac longitudinally and excise the aneurysm 9. Look for back bleeding from the IMA 10. Look for back bleeding from lumbar vessels and ligate them 11. sew in a PTFE tube graft 12. Flash the anastomosis prior to completion to evacuate and potential clot/emboli 13. Close the sac over the graft 14. evaluate for intact hypogastrics and perfusion of the sigmoid prior to close.

Question 29

what gauge is a large bore IV

Answer 29

14 or 16 gauge

Question 30

Preop stuff for an AAA?

Answer 30

``` Ancef Central line and request Swann or TEE 6u RBC on hold aline, foley, ngt prep from nipples to midthigh ```

Question 31

What do you do for an AAA <5cm?

Answer 31

ultrasound surveillance q6 months.

Question 32

Annual risk of rupture of a 5cm AAA?

Answer 32

5%

Question 33

Annual risk of rupture of a 7cm AAA?

Answer 33

20%

Question 34

AAA physical exam?

Answer 34

Do complete pulse exam and consider ABI. Get a stat abdominal ultrasound in ED to check for hemoperitoneum

Question 35

Should you give heparin with a ruptured AAA?

Answer 35

no! patient likely coagulopathic already

Question 36

Acute limb ischemia: Last move before closing

Answer 36

Completion angiogram

Question 37

What do you do for an acute occlusion of a venous bypass?

Answer 37

usually hard to embolize, but can try first. | If this fails then replace with a gortex graft.

Question 38

Indications for a carotid endartarectomy:

Answer 38

``` Symptomatic pts with ≥ 70% stenosis Symptomatic pts with < 70% and ulcerated plaque or failure of medical therapy Asymptomatic pts with ≥ 80% stenosis Crescendo TIAs ```

Question 39

What are crescendo TIAs?

Answer 39

Crescendo TIAs are defined as two TIAs within 24 hours, three within 3 days, or four within 2 weeks.

Question 40

How do you do a CEA?

Answer 40

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

Question 41

What is management of Carotid disease with acute stroke?

Answer 41

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)

Question 42

Preop tests for lower extremity bypass?

Answer 42

CTA with distal runoff | Ultrasound vein mapping to evaluate saphenous for in situ.

Question 43

How do you expose the peroneal and posterior tib?

Answer 43

Exposure of peroneal and posterior tibial below trifurcation are best exposed by detaching the soleus muscle from the tibia

Question 44

How do you expose the anterior tib?

Answer 44

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

Question 45

How do you incise valves for an in-situ bypass?

Answer 45

For in-situ grafts, valves are incised through side | branches using Mills valvulotome

Question 46

What is 5 year patency of infrainguinal bypass for claudication?

Answer 46

~70% at 5 years

Question 47

Brodie-trendelenburg test

Answer 47

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

Question 48

venous stasis ulcer For superficial vein incompetence alone

Answer 48

high ligation and stripping of greater saphenous vein surgery

Question 49

For superficial and perforator incompetence→

Answer 49

subfascial endoscopic perforator veins

Question 50

Non-operative management of venous stasis ulcers

Answer 50

``` Conservative treatment with: compression therapy leg elevation/antibiotics weekly application of Unna boots topical agents (PDGF, EGF) ```