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BTK Review 2023 > Vascular > Flashcards

Vascular Flashcards

1
Q

What are the structures within the carotid sheath?

A

carotid artery, internal jugular vein, vagus nerve

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2
Q

What are the segments of the vertebral arteries?

A
  • V1: origin off subclavian to foramina of C6
  • V2: foraminal from C6-C2
  • V3: foramen of C2 to dura
  • V4: intra-cranial
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3
Q

What structure overlies the bifurcation of the carotid?

A

the facial vein off the IJ

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4
Q

What is the first branch of the external carotid?

A

the superior thyroid artery

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5
Q

How does the flow of the internal and external carotids differ?

A
  • internal is low resistance with biphasic, forward flow
  • external is high resistance with triphasic flow and brief flow reversal
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6
Q

Can the external carotid be ligated?

A

yes

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7
Q

What is the first branch of the internal carotid?

A

the ophthalmic artery

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8
Q

What likely happened if a patient is hoarse after carotid endarterectomy?

A

likely clamped the vagus along with the carotid and injured the nerve

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9
Q

What likely happened if a patient has tongue deviation after carotid endarterectomy?

A

ipsilateral deviation is a sign of hypoglossal nerve injury, it lies just cephalic to the carotid bifurcation so can easily be damaged

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10
Q

What likely happened if a patient has mouth droop after carotid endarterectomy?

A

likely caused a marginal mandibular injury from retraction on the mandible while repairing a high lesion

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11
Q

What nerves run near the carotid artery bifurcation?

A

the vagus nerve is within the sheath, the hypoglossal runs just cephalad to the bifurcation and the glossopharyngeal nerve runs cephalad to that

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12
Q

Describe the course of the glossopharyngeal nerve. Damage results in what?

A
  • deep to the posterior belly of the digastric
  • damage can result in disabling dysphagia
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13
Q

What layers are removed during an endarterectomy?

A

the intima and part of the media

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14
Q

Where is the typical location of carotid atherosclerosis?

A

the bifurcation since there is turbulent flow

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15
Q

What are the indications for performing carotid endarterectomy?

A
  • symptomatic with 50-70% stenosis
  • asymptomatic with > 80% stenosis (EDV > 140)
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16
Q

How should you manage a patient with symptoms of carotid stenosis but < 50% stenosis on US?

A

medically with ASA, plavix, statin

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17
Q

How should you manage a patient who suffers a stroke and is found to have complete occlusion of carotid?

A

medically with AC to prevent progression, no benefit to revascularization

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18
Q

What is an indication for emergent carotid endarterectomy?

A

crescendo TIAs

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19
Q

What is the most common non-stroke cause of morbidity and mortality following CEA?

A

MI

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20
Q

When should you operate on a symptomatic carotid?

A
  • within two weeks once symptoms resolved for a small stroke or TIA
  • at 6-8 weeks after a hemorrhagic stroke
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21
Q

What is the best next step if a patient has symptoms of stroke in PACU after CEA?

A

suggestive of intimal flap or thrombus requiring RTOR, start with US

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22
Q

When would you consider carotid stenting rather than endarterectomy?

A
  • those with severe cardiac disease and prohibitive peri-operative risk
  • those with a history of neck dissection or radiation
  • those with recurrent carotid disease
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23
Q

Which carotid revascularization option has the lowest stroke rate?

A

TCAR (transcarotid artery revascularization)

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24
Q

How should an asymptomatic blunt trauma carotid dissection be treated?

A
  • start anticoagulation/anti-platelet with either heparin or plavix
  • repeat imaging prior to d/c
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25
Q

How should a symptomatic blunt trauma carotid dissection be treated?

A

likely needs a covered stent

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26
Q

How are carotid body tumors managed?

A
  • all require resection
  • consider embolization pre-op given risk of bleeding
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27
Q

Name the structures of the thoracic outlet from anterior to posterior.

A
  • subclavian vein
  • phrenic nerve
  • anterior scalene
  • subclavian artery
  • brachial plexus
  • middle scalene
  • first rib
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28
Q

What anatomic anomaly puts patients at risk for thoracic outlet syndrome?

A

a cervical rib

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29
Q

What type of thoracic outlet syndrome is most common and what are the symptoms?

A
  • most commonly neurogenic
  • presents with pain, weakness, numbness, and ulnar deviation of the hand worse with elevation of the arm
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30
Q

How is neurogenic thoracic outlet syndrome treated?

A
  • physical therapy is first line
  • if this fails, get a scalene nerve block or conduction test to confirm the diagnosis
  • then consider first rib resection and scalenectomy with neurolysis
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31
Q

A swimmer presents with a blue swollen arm, what is this and how is it managed?

A
  • subclavian vein thrombosis (aka Paget-Schroetter syndrome)
  • treat with catheter directed thrombolysis followed by first rib resection
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32
Q

How is arterial thoracic outlet syndrome treated?

A
  • usually an anomalous cervical rib leading to aneurysm of subclavian
  • treatment is first rib resection with interposition graft
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33
Q

What is subclavian steal?

A

a proximal subclavian narrowing results in flow reversal in the vertebral artery which can lead to vertebrobasilar symptoms

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34
Q

How is subclavian steal syndrome treated?

A

with endovascular recanalization and stenting or potentially a carotid-subclavian bypass

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35
Q

Why are tunneled HD catheters worse than an AVF/AVG?

A

because they have a higher infection rate and a higher risk of central venous stenosis

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36
Q

How long should a temporary HD catheter be left in?

A

less than 3 weeks

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37
Q

What is the ideal location for an HD catheter?

A

in the R IJ where flow to the right atrium is more direct

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38
Q

Why should an HD catheter be placed on the opposite side as a planned AVF?

A

because it will lead to central venous stenosis and failure of permanent access

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39
Q

What is the most common reason for AVF failure?

A

venous outflow problems

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40
Q

How is AVF venous outflow stenosis treated?

A

with balloon angioplasty

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41
Q

What is the problem if a patient has high venous return pressures and increased bleeding after dialysis?

A

this is venous outflow stenosis

42
Q

What is the rule of 6s for fistulas?

A

ready to use when 6mm in diameter, < 6mm deep, and with > 600mL/min of flow

43
Q

How long should it take for an AVF to mature?

A
  • less than 6 weeks
  • more than this and you should investigate
  • likely an inflow problem with stenosis at anastomosis or competing flow from side branches
44
Q

What is the indication for prophylactic fasciotomies?

A

acute limb ischemia > 4 hours

45
Q

What nerve can be injured when making a lateral fasciotomy incision?

A

the superficial perineal nerve leading to difficulties with foot eversion and numbness over the lateral leg

46
Q

How do you release the deep posterior compartment of the lower extremity during fasciotomies?

A

take the soles off the tibia

47
Q

Where are most thoracic aortic injuries located?

A

just distal to the subclavian artery in the descending artery at the ligament arteriosum

48
Q

What are the size criteria for treating descending thoracic aortic aneurysms?

A
  • greater than 5.5cm if endovascular repair is possible
  • greater than 6.5cm if open
49
Q

What is the risk of paraplegia with thoracic aortic repair?

A
  • 20% for open
  • less than 5% for endovascular
50
Q

What steps are taken to reduce the risk of paraplegia after a thoracic aortic repair?

A
  • endovascular approach
  • lumbar drains (lower the spinal drain to reduce ICP and increase spinal perfusion pressure)
  • maintain normo to hypertension
51
Q

What are the four types of acute mesenteric ischemia?

A
  • embolic
  • thrombotic
  • venous thrombosis
  • non-occlusive
52
Q

What is the best test to diagnose mesenteric ischemia?

A

CT angio

53
Q

How does the distribution of embolic and thrombotic mesenteric ischemia differ?

A

embolic has skip lesions since it affects distal branches whereas thrombotic is more likely to occur at the ostium/takeoff

54
Q

Which is more likely to require bypass, those with embolic or thrombotic acute mesenteric ischemia?

A

those with thrombotic

55
Q

How do you identify the SMA?

A
  • lift the transverse colon cephalad
  • go to the base of the mesocolon
  • the SMA will be just to the right of Treitz
56
Q

What are the features of mesenteric venous thrombosis?

A
  • sub-acute presentation with days of pain and bloody diarrhea
  • usually have a history of hypercoagulability
  • CTA shows wall thickening, mesenteric edema, and venous thrombus
57
Q

How does the treatment of venous thrombus mesenteric ischemia differ from that of inflow problems?

A

venous thrombus rarely requires surgery, just need heparin and operative intervention for dead bowel

58
Q

What are the watershed areas of the bowel that are most threatened by non-obstructive mesenteric ischemia?

A

the splenic flexure and superior rectum

59
Q

Does thrombotic and embolic mesenteric ischemia spare the jejunum?

A

embolic since it usually lodges distal to the first branch of the SMA

60
Q

What is the most common site of upper extremity embolus?

A

brachial artery bifurcation

61
Q

What is the most common site for a lower extremity embolism to lodge?

A

the CFA bifurcation

62
Q

Where should you get proximal control for an emergent AAA rupture repair?

A

the supra celiac aorta

63
Q

What is the BP goal for a ruptured AAA pre-operatively?

A

permissive hypotension with SBP 80-100

64
Q

What is the most common organism for vascular graft infection?

A

Staph epidemidis

65
Q

What is the treatment for popliteal entrapment syndrome?

A

resect the medial head of the gastrocnemius

66
Q

How is fibromusuclar dysplasia treated?

A

usually with balloon angioplasty of the affected vessels

67
Q

What are the indications for hepatic/SMA aneurysm interventions?

A

resect if > 2cm

68
Q

What is the size criteria for treating iliac artery aneurysms?

A

stent if > 3.5 cm

69
Q

What is the size criteria for treating femoral artery aneurysms?

A

resect if > 3.5cm

70
Q

What is the usual complication of a femoral artery aneurysm?

A

embolus or thrombus (unlikely to rupture)

71
Q

What is the size criteria for treating popliteal artery aneurysms?

A

treat if > 2cm or symptomatic

72
Q

If a patient is found to have a popliteal artery aneurysm, what other screening do they need?

A

work up for possible AAA

73
Q

What is the size criteria for treating the following:
- TAA
- AAA
- iliac
- femoral
- popliteal

A
  • TAA: >5.5 cm if endovascular or > 6.5 cm if open
  • AAA: > 5.5 cm in males, > 5.0 cm in females, > 1cm growth/year, symptomatic, infected
  • iliac: > 3.5 cm
  • femoral: > 3.5cm
  • popliteal: > 2cm or symptomatic
74
Q

What is the size criteria for treating AAAs?

A
  • greater than 5.5 cm for males
  • greater than 5.0 cm for females
  • more than 1.0 cm growth/year
  • symptomatic or infected
75
Q

What is the preferred method for treating popliteal artery aneurysms?

A

open repair with venous interposition graft or bypass

76
Q

What vein is at risk for injury in an open AAA repair when getting proximal control?

A

the left renal vein

77
Q

How is chylous ascites treated?

A

a low-fat, high protein diet with medium-chain fatty acid supplementation

78
Q

What is the best next step if a patient develops abdominal pain and bloody diarrhea after a AAA repair? How is this managed?

A
  • sigmoidoscopy to evaluate for colonic ischemia
  • can usually manage non-op with antibiotics, IVF, and serial abdominal exams
79
Q

What is the appropriate interval for surveillance imaging for AAA?

A
  • get an annual US if < 4.0 cm
  • get an US every 6 months if > 4
80
Q

What is the preferred treatment for an infrarenal aortic graft infection?

A

bilateral axillary to femoral bypass with aortic graft excision

81
Q

What are the anatomic criteria for EVAR?

A
  • neck less than 32mm
  • neck angle less than 60 degrees
  • neck length of at least 10mm
  • iliac diameters of at least 7mm
  • lack of thrombus or calcification in infrarenal neck
82
Q

What are the types of endoleaks and their treatments?

A
  • type I: poor seal at either end, requires repair with placement of a cuff
  • type II: back flow into sac, only needs repair if it grows and can do so with coil embolization
  • type III: components of endograft aren’t sealed, requires re-inforcement with bridge across connection
  • type IV: porosity of graft, may need to re-line
83
Q

How is ABI calculated?

A

take the highest pedal pressure (DP/PT) and divide by the highest brachial pressure (L/R)

84
Q

What is a normal ABI?

A

0.9 - 1.4

85
Q

At what ABI will you see claudication, rest pain, and tissue loss?

A
  • claudication: 0.5-0.9
  • rest pain: 0.3-0.5
  • tissue loss: less than 0.3
86
Q

What is the value of a toe-brachial index?

A

these vessels are generally free from calcification and more reliable in patients with non-compressible, calcified vessels

87
Q

What are the mainstays for medical treatment of claudication?

A

smoking cessation, exercise, statin therapy

88
Q

What are the indications for surgical intervention in someone with claudication?

A
  • lifestyle limitation that failed to improve with medical management
  • tissue loss
  • rest pain
89
Q

Why is conventional angiography better in some cases than a CTA?

A
  • angiography allows for visualization of more distal vessels
  • angiography can use less contrast and even CO2 if renal function is very poor
90
Q

Generally, endovascular revascularization is better than open under what circumstances?

A

short lesions that are not heavily calcified

91
Q

Why is the CFA usually treated in an open fashion?

A

because it is in a highly mobile area and endovascular fixes are likely to kink

92
Q

What is Leriche syndrome?

A

a syndrome of buttock claudication, impotence, and absent femoral pulses that arises due to thrombotic disease of the distal aorta

93
Q

How does the treatment differ for a thrombus versus an embolus in the distal aorta?

A
  • embolus: amenable to embolectomy
  • thrombus: usually requires bilateral aorta-femoral bypass
94
Q

Where do the arteries of the lower extremity run?

A
  • the AT is in the anterior compartment
  • the PT and peroneal are in the deep posterior
95
Q

Which renal vein can you ligate?

A

the left if proximal to the the gonadal vein

96
Q

What is the most common location of a DVT?

A
  • iliofemoral DVTs are most common
  • with a preponderance for the left
97
Q

A provoked DVT should be treated with what duration of anti-coagulation?

A

three months

98
Q

How long should a DVT be treated in someone with cancer?

A

until they are cured

99
Q

How is the supra celiac artery exposed in a trauma patient?

A

enter the lesser sac through the gastrohepatic ligament, divide the posterior crus of the diaphgram

100
Q

What is the biggest risk factor for ischemic colitis in a patient with ruptured aneurysm?

A

pre-operative hypotension

101
Q

What is the most common organism found in mycotic aneurysms?

A

Staphylococcus

BTK Review 2023 (18 decks)

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