VASCULAR Flashcards
AAA - OR
A line, foley Midline incision RP exposure Dissect up to renals, clamp infrarenal Get control of iliacs Heparin 100U/kg Open aneurysm, evacuate thrombus, suture ligate lumbars, place graft (size it) Close peritoneum over top of graft PALPATE DISTAL PULSES Return to ICU
Screening and confirmatory for HIT
PF4 antibody
Serotonin Release Assay
Suspicion for acute limb ischemia - first step
Evaluate pt for risk of hemorrhage
If no contraindication, START HEPARIN GTT
Exposure of below knee pop
bump under distal thigh
medial incision about 1 fingerbreadth behind tibia to access popliteal artery by retracting gastroc posteriorly
if no saphenous vein available for conduit
arm vein mapping
if forced to do prosthetic conduit
6 mm ringed PTFE with saphenous vein patch on artery
sew ptfe to patch of vein, hope to prevent intimal hyperplasia distally
once you have your saphenous vein and proximal/distal exposure, next steps for SFA –> below knee bypass
tunnel in anatomic plane and leave tunneler in position
sew vein in reverse orientation and start this by beveling end of it
ensure adequate heparinization
clamp cfa proximally and distally
make arteriotomy and sew anastomosis with 5-0 prolene
pressurize vein and look for any bleeders, ID correct orientation of vein
Bring vein through tunnel and sew to below knee pop using 5-0 prolene
Consider fasciotomy
signal in foot marginally improved since prior to bypass - next steps?
listen to signal in foot with bypass clamped and unclamped
angiogram on table
angiogram shows “string sign” at distal anastomosis with limited flow to foot
re-perform anastomosis
H&P/first steps for carotid stenosis
Review EKG Detailed neuro exam medical and surgical history order echo obtain carotid duplex dual antiplatelet therapy + statin check a1c and ensure DM well controlled
symptomatic carotid stenosis - when to perform cea
at least 2 days after but within 2 weeks
CEA - OR
shoulder roll + extend neck
make incision along anterior border of SCM
take down through platysma, ID facial vein and ligate
retract IJ laterally and ID common carotid prox with care to ID vagus nerve
dissect CCA distally and loop out CCA, ICA, and ECA
heparinize patient with 100U/kg
clamp in ICE order
longitudinal arteriotomy
place argyle shunt using clamps to hold in place
perform endarterectomy and then patch angioplasty with bovine pericardium and sew in place with 5-0 prolene
remove shunt, flush carotid
confirm good repair with intraoperative US and assess for intimal flaps
CVA s/p CEA - US shows patch is patent, carotid a is patent - next steps?
CTA
CVA s/p CEA - US shows patch is thrombosed
Embolectomies
If no technical defect, assume platelet aggregation issue
Use saph vein instead of bovine patch, apixiban gtt following case
Lymphatic leak s/p bypass - OR
Groin exploration
Ligation of lymphatics
Washout
Close skin with wound vac
Saphenous vein ablation
US guidance to access GSV just below knee and use micropuncture needle and wire
Then place 7 fr sheath and place ablation catheter through this and follow it up to saphenofemoral junction
Inject tumescence around GSV throughout course in leg
Pull cath back 2 cm distal to SFJ and begin ablating down extent of vein
Remove catheter + sheath, eval SFJ to ensure no evidence of DVT in common femoral vein
Treatment of post-ablation VTE
2 weeks of anticoagulation and repeat imaging
Saddle embolus + evidence of R heart strain
Consult PE team
IR/vasc for catheter directed thrombolysis
Basilic vein access - important to remember
Need to be brought up more superficially for access
2 stages
1. connect basilic v to brachial a, wait for maturation
2. transposition (free up throughout course and make superficial tunnel in arm to make it more easily accessable)
Brachiocephalic access
Mark a and v with duplex
make oblique incision incorporating both above antecubital crease
Dissect adequate vein proximally and distally
Open brachial sheath and isolate brachial artery for 4 cm segment
Heparinize with 3000U
Clamp proximally, distally, make arteriotomy and sew in vein end to side fashion using 6-0 prolene
Feel for thrill in vein, ensure no kinks or restrictive tissue
Feel pulses in hand
Close after hemostasis
Follow-up after autologous fistula
US at one month
Then qmonth until mature
Rule of 6s
6 mm diameter
6 mm deep to skin
flow velocities 600 mm/sec
Extreme pain in hand immediately in PACU but good pulse
Ischemic monolelic neuropathy
Ligate fistula
Extreme pain in hand immediately in PACU but weak pulse
Steal
Ligate fistula
