Vascular

Question 1

Describe AVF placement

Answer 1

Use ultrasound to identify location of vein, dissect and skeletonize artery and vein, heparinize patient, ligate and divide the vein, dilate and spatulate the end and perform end to side anastomosis onto artery in tension free manner using 6-0 prolene, check for palpable thrill and bruit on doppler.

Question 2

Tunneled line placement

Answer 2

Access vein using ultrasound, pass wire, make counter incision on chest and make subQ tunnel, pass in catheter using peelaway sheath, check length with fluoro, make sure cuff is in tunnel.

Question 3

4 conpartment fasciotomy

Answer 3

Lateral incision 2 fingerbreadths anterior to fibula, from 2 fingerbreadths below the knee and 2 fingerbreadths above the ankle.
Make H-shaped incision in the intramuscular septum and open it cephalad and caudad to expose lateral and anterior compartments.
Medial incision 2 FB posterior to the tibia, and 2 fingerbreadths below the knee and 2 fingerbreadths above the ankle. Open the fascia and remove the soleus fibers from the underlying tibia until I identify the neurovascular bundle. allowing access to superficial and deep posterior compartments.

Question 4

EVAR

Answer 4

Access in one of the common femoral arteries. Aortogram. Place a sheath with a wire.
Position stent infrarenal. Cannulate the contralateral sIde and deploy the iliac branch. Completion angiogram. Check for distal pulses and close with a percutaneous device.

Question 5

Supraceliac control

Answer 5

Dissect gastrohepatic ligament making sure not to injure an aberrant or replaced left hepatic artery, dissect off the right crus, find the aorta and put a clamp in the 2-o’clock position.

Question 6

Carotid Endarterectomy

Answer 6

Continuous intraoperative EEG monitoring. Place towel-roll behind shoulders and turn his head away from side of disease.
Incise on anterior border of the sternocleidomastoid muscle. Retract the muscle laterally, find the carotid sheath, open it and ligate the facial vein. Dissect common, internal, and external carotids with no touch technique.
Give systemic heparin, 100 units per kilogram, and then clamp the ICA first, common carotid second, and external carotid third.
Open common carotid at the bifurcation and extend it up to the ICA as far distally as I can to perform the endarterectomy between the intima and media.
Preserve the vagus nerve and hypoglossal nerve
Remove plaque, clean debris, watch for edges/flap. Flush w heparnized saline and reconstruct with a patch angioplasty using bovine pericardium.
Back bleed arteries, finish the repair, and then remove the clamps by taking off the external carotid first, and then common carotid so any debris gets flushed into the face instead of the brain.
close the neck in layers and leave a subplatysmal drain.
Perform neuro exam after waking

Question 7

BKA

Answer 7

Compress leg to remove blood then place sterile tourniquet.
Mark out the borders of the incision with a posterior flap.
Dissect the muscle and soft tissue off the bone using electrocautery and a periosteal elevator
Oscillating saw to transect the tibia
Transect fibula 2 cm proximal to tibia
File edges of bone
Amputation knife to cut the remainder of the muscle and soft tissue off the posterior flap.
Suture ligate greater saphenous vein and nerve, the anterior tibial artery and nerve, the posterior tibial artery and nerve, the peroneal nerve and artery, and the lesser saphenous vein with 2-0 silk ties.
Take down the sterile tourniquet and look for any areas of bleeding.
Irrigate the wound and close the fascia first and then the skin using vertical mattress sutures.