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BTK Review 2024 > Vascular > Flashcards

Vascular Flashcards

1
Q

What are the segments of the vertebral artery?

A

V1: origin off subclavian to foramina of C6
V2: from the foramen of C6-C2
V3: C2 foramen to dura
V4: intracranial

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2
Q

What structure commonly overlies the carotid bifurcation?

A

the facial vein

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3
Q

What is the first branch off the external carotid artery?

A

the superior thyroid artery

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4
Q

True or false, the external carotid can be ligated?

A

true

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5
Q

What is the first branch of the internal carotid?

A

the ophthalmic artery

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6
Q

Is the internal carotid artery flow high or low resistance?

A

low resistance, biphasic, no flow reversal

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7
Q

Are the external and internal carotid arteries triphasic or biphasic?

A
  • external: high resistance so triphasic
  • internal: low resistance so biphasic
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8
Q

If a patient has hoarseness after carotid endarterectomy, what structure was likely injured? How?

A

the vagus was likely caught in the clamp applied to the carotid

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9
Q

If a patient has ipsilateral tongue deviation after carotid endarterectomy, what structure was likely injured?

A

the hypoglossal nerve (XII), which lies just cephalic to the carotid bifurcation

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10
Q

If a patient has ipsilateral mouth droop after a carotid endarterectomy, what structure was likely injured? How?

A

the marginal mandibular branch of the facial nerve due to traction on the mandible when exposing high lesions

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11
Q

Which nerve lies deep to the posterior belly of the digastric? What defect is associated with injury?

A
  • the glossopharyngeal nerve (IX)
  • dysphagia
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12
Q

Which layers are removed during a carotid endarterectomy?

A

the intima and part of the media

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13
Q

What is the typical location of carotid atherosclerosis?

A

the bifurcation

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14
Q

What are the indications for carotid endarterectomy?

A
  • over 50% with symptoms
  • over 70% or with EDV over 100cm/s
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15
Q

How should a patient with symptoms of carotid stenosis < 50% be managed?

A

medically with DAPT, smoking cessation, and a statin

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16
Q

How should a patient with a stroke and 100% occlusion of the carotid be managed?

A
  • medically with DAPT or anti-coagulation
  • there is no role for recanalization and this would increase the risk of hemorrhagic conversion
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17
Q

In what situation would an emergent carotid endarterectomy be indicated?

A

crescendo TIAs

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18
Q

Why is cardiac clearance so important before carotid endarterectomy?

A

MI is the most common non-stroke cause of morbidity and mortality after CEA

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19
Q

When should you operate on a patient who recently had a stroke from carotid stenosis?

A
  • within 2 weeks of symptom resolution for a TIA or small stroke
  • 6-8 after a hemorrhagic stroke
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20
Q

What is the downside of carotid shunt during endarterectomy?

A

it limits visibility of the distal end point

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21
Q

What are four ways to monitor neurologic status and to decide whether to shunt during carotid endarterectomy?

A
  • awake CEA
  • EEG
  • ICA stump pressures (>40, no shunt)
  • cerebral oximetry
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22
Q

How does cerebral hyper perfusion syndrome present?

A

as headaches and hypertension but normal neurological exam following carotid endarterectomy

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23
Q

What is cerebral hyper-perfusion syndrome?

A
  • a rare, potentially deadly complication of carotid endarterectomy
  • usually seen in those with severe, bilateral carotid stenosis
  • caused by dysfunction in cerebral vascular autoregulation
  • presents as hypertension and headache post-op
  • CT is used to rule out acute infarct and is likely to show cerebral edema
  • treat medically with BP control, ICU monitoring, and seizure ppx
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24
Q

What is the best next step in a patient who appears to have stroke symptoms in PACU following carotid endarterectomy?

A
  • duplex US
  • patent ICA: to CT for distal emboli/watershed infarct
  • thromboses ICA: to OR for thromboectomy
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25
Q

What would be reasons to perform carotid stent over CEA?

A
  • history of neck dissection or irradiation
  • recurrent carotid disease
  • severe cardiac disease
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26
Q

Which surgical treatment of carotid stenosis has the lowest stroke rate?

A

TCAR

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27
Q

How should you manage asymptomatic, traumatic carotid dissection?

A
  • plavix or heparin
  • repeat imaging prior to discharge
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28
Q

How should you manage symptomatic traumatic carotid dissection?

A
  • heparin
  • likely to need stent
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29
Q

How should you manage traumatic carotid occlusion?

A
  • heparin
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30
Q

How are carotid body tumors managed?

A
  • all are resected
  • consider embolization of feeding branches off the external carotid prior to resection
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31
Q

What is the diagnosis for a young patient presenting with stroke symptoms and beads on a string appearance of the ICA? How is it treated?

A
  • fibromuscular dysplasia
  • typically managed with anti-platelet agent
  • may require angioplasty if recurrent
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32
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
  • 1st rib
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33
Q

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

A

a cervical rib

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34
Q

Which type of thoracic outlet syndrome is most common?

A

neurogenic (95%)

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35
Q

What are the symptoms of neurogenic thoracic outlet syndrome?

A

pain, weakness, numbness, and numbness (particularly in the ulnar distribution), which worsen with manipulation and elevation of the arm

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36
Q

How is neurogenic thoracic outlet syndrome treated?

A
  • first line is physical therapy
  • if this fails, confirm diagnosis with scalene block
  • then perform first rib resection and scalenectomy with neurolysis
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37
Q

A swimmer presents with a blue, swollen arm, what is the diagnosis and management?

A
  • diagnosis is Paget-Schroetter syndrome (subclavian vein thromobosis)
  • treat with catheter directed thrombolysis followed by first rib resection
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38
Q

A young person with no risk factors presents with ischemia of the hand. What is the diagnosis and management?

A
  • arterial thoracic outlet syndrome
  • perform first rib resection with interposition graft for the thrombosed artery (risk of native artery aneurysm)
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39
Q

Where is the anatomic stenosis that results in subclavian steal?

A

proximal subclavian, results in reversal of blood flow in the vertebral artery

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40
Q

Why are AVF/AVG preferred over tunneled central lines?

A

they have lower infectious risk and lower rates of central venous stenosis

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41
Q

What is the “fistula first” mantra?

A

the idea that reducing catheter days improves live expectancy

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42
Q

How big of an artery and vein are required for AVF formation?

A
  • 3mm vein
  • 2mm artery
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43
Q

What characteristics make a suitable artery for AVF creation?

A

should be at least 2mm and have a triphasic waveform (this reduces the risk of steal syndrome)

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44
Q

What is the most common reason for AVF to malfunction over time?

A

venous outflow problems

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45
Q

High venous return pressures during dialysis with a AVF indicates what? How is this diagnosed and managed?

A
  • indicative of venous outflow stenosis
  • diagnosed with duplex US
  • treated with IR balloon angioplasty
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46
Q

What are the criteria for fistula maturation?

A

should be…
- 6mm in diameter
- less than 6mm deep
- should have more than 600mL/min of flow

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47
Q

What is the best next step for evaluating a fistula that has failed to mature?

A

duplex US

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48
Q

What symptoms of steal syndrome after AVF creation, mandate intervention?

A

tissue loss or constant pain

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49
Q

How is steal syndrome after AVF confirmed?

A
  • waveform analysis of the digits with and without compression of the AVF
  • 50% improvement with compression confirms the diagnosis
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50
Q

What are the surgical options for AVF steal syndrome?

A
  • ligation or banding
  • distal revascularization and interval ligation
  • proximalization of inflow
51
Q

How should a bleeding AVF be managed?

A
  • pinpoint hole bleeding can be managed with a stitch and urgent fistulogram
  • ulceration is a surgical emergency
52
Q

When should you consider fasciotomies in a patient with acute limb ischemia?

A

when the pathology has been present for > 4hrs

53
Q

During a lateral fasciotomy incision, what nerve is most likely to be injured and what would be the resulting deficit?

A

superficial peroneal nerve, leading to difficulties with foot eversion

54
Q

How do you release the deep posterior compartment of the leg?

A

through the medial incision, 2cm posterior to the tibia; then take the soles off the tibia

55
Q

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

A

over 5.5cm if end-vascular repair is possible; otherwise, 6.5cm

56
Q

What is the rate of paraplegia after thoracic aortic aneurysm repair?

A

5% for endovascular and 20% for open

57
Q

Which thoracic aortic aneurysms are surgical emergencies?

A
  • any type A (prior to takeoff of subclavian)
  • type B with rupture or malperfusion
58
Q

What is the most common type of mesenteric ischemia?

A

embolic

59
Q

Which type of mesenteric ischemia will have proximal jejunal sparing?

A

embolic because it lodges just to distal to first branch of SMA

60
Q

How do you identify the SMA to perform embolectomy during laparotomy?

A
  • lift the transverse colon cephalad and follow to the base of the mesocolon
  • just to the right of the ligament of treats will be the SMA
  • mobilize the LOT to access the SMA at it’s origin
61
Q

How is venous thrombosis mesenteric ischemia treated?

A

generally with heparin, rarely need surgical intervention for re-vascularization

62
Q

Where do the gonadal veins drain?

A
  • the right into the IVC
  • the left into the left renal vein
63
Q

Lis the structures of the renal hilum from anterior to posterior.

A
  • vein
  • artery
  • pelvis/ureter
64
Q

What is the most common site for an upper extremity embolus to lodge?

A

the brachial artery at the bifurcation of the radial and ulnar arteries

65
Q

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

A

the CFA at the bifurcation of the profunda and SFA

66
Q

What is the recommended BP goal for a patient with ruptured AAA?

A

SBP 80-100

67
Q

What is the most common organism in vascular graft infections?

A

Staph epidermidis

68
Q

What is the treatment for popliteal entrapment syndrome?

A

resect medial head of gastrocnemius or resect crossing band or popliteus muscle that is compressing the artery

69
Q

What size criteria should prompt hepatic artery aneurysm repair?

A

> 2cm

70
Q

What size criteria should prompt SMA aneurysm repair?

A

should repair all these with resection and reconstruction

71
Q

What size criteria should prompt treatment of an iliac artery aneurysm?

A

> 3.5cm

72
Q

What size criteria should prompt repair of a femoral artery aneurysm?

A

2.5 cm historically but shifting toward 3.5

73
Q

What criteria should prompt treatment of a popliteal artery aneurysm?

A

> 2cm or smaller aneurysms with significant mural thrombus

74
Q

Patients with popliteal artery aneurysms should also be screened for what?

A

AAA (>50% will have)

75
Q

How should popliteal artery aneurysms be repaired?

A
  • gold standard is bypass or interposition with vein
  • can stent if not a good surgical candidate
76
Q

If a patient presents in acute limb ischemia from a thromboses popliteal aneurysm, what should you do?

A
  • start with heparin and angiogram
  • if there is no runoff, place a lysis catheter with tPA
  • if there is a good target, can go straight to bypass
77
Q

Give the size cutoff for treating the following aneurysms:
- TAA
- AAA
- CIA/EIA
- Femoral
- Pop

A
  • TAA: 5.5 if amenable to endovascular repair
  • AAA: 5.5 in males, 5.0 in females, growth > 0.5cm/6mo, growth > 1cm/year
  • CIA/EIA: 3.5
  • Femoral: 2.5
  • Pop: 2.0
78
Q

What are the size criteria for repairing AAA?

A
  • over 5.5cm in men
  • over 5.0cm in females
  • over 0.5cm growth in 6 months
  • over 1cm growth in 1 year
79
Q

Which patients should be considered for open AAA repair?

A
  • young patients with good cardiac and pulmonary function
  • patients with complex aortic anatomy including no normal infrarenal aorta or small iliacs
80
Q

During open AAA repair, when should you re-implant the IMA?

A
  • marginal back bleeding (no flow and pulsatile back bleeding mean colon likely doesn’t rely on IMA flow)
  • if colon is dusky
  • if they’ve had prior colon surgery
81
Q

What vein is at risk during open AAA repair when clamping the proximal aorta?

A

could injure a retro-aortic left renal vein

82
Q

How do you manage chylous ascites?

A

a low fat, high protein diet with MCFA supplementation

83
Q

What is the standard surveillance guidelines for AAA?

A
  • every 6 months if > 5cm
  • yearly if 4-5cm
84
Q

What is the preferred management of an infected infrarenal aortic graft?

A
  • ax to bi-fem bypass with graft excision
  • alternatively, could explant and reconstruct with femoral vein or cryopreserved aorta
85
Q

What is the feared surgical complication after extra-anatomic bypass with aortic ligation? How is this best prevented?

A
  • aortic stump blowout
  • prevent with oversewing the aorta in multiple layers, cover with omentum, and buttress with tensor fascia lata
86
Q

What complication presents in patients years after an aortic operation with hematemesis and hypotension? How is it managed?

A
  • aorta-enteric fistula
  • treat with EVAR to temporize if unstable
  • will ultimately need extra-anatomic bypass with aortic ligation or in-line reconstruction with biologic material
87
Q

When performing an aorto-bifemoral bypass, how do you decide whether to do an end-to-side or end-to-end anastomosis?

A
  • must ensure perfusion to at least one internal iliac
  • if external iliac is patent, can do an end-to-end and rely on retrograde perfusion of internal iliac
88
Q

How do you tunnel an aorto-bifemoral bypass relative to the ureters?

A

tunnel under the ureters to prevent hydronephrosis

89
Q

If a frail patient presents with an occluded aorta, what is your best option for reconstruction?

A
  • too frail to undergo aorto-bifem
  • can perform ax to bifem instead (lower morbidity, lower patency rates)
90
Q

What anatomic criteria are needed to perform an EVAR?

A
  • neck diameter less than 32mm
  • neck angle less than 60 degrees
  • neck length at least 10mm
  • iliac diameters at least 7mm
  • lack of thrombus or calcification in infrarenal neck
91
Q

What are the types of endoleaks?

A
  • Ia: proximal seal breakdown
  • Ib: distal seal breakdown
  • II: retrograde flow from IMA or lumbars
  • III: lack of seal between components
  • IV: leak through graft material (porous or torn)
92
Q

What are the types of endoleaks and their management?

A
  • Ia/b: proximal/distal seal, require a cuff to re-seal
  • II: retrograde filling, only require embolization if sac grows
  • III: between components, require a cuff to re-seal
  • IV: through graft material (tear or porosity), may need to reline
93
Q

How can you confirm MALS?

A

if a celiac plexus block relieves pain

94
Q

How do you calculate an ABI?

A

highest pedal pressure divided by highest brachial pressure

95
Q

How does ABI correlate with symptoms?

A
  • 0.9 to 1.4 is normal
  • 0.5 to 0.9 is likely to have claudication
  • 0.3 to 0.5 is likely to have rest pain
  • 0.3 or less is likely to have tissue loss
96
Q

When are ABIs unreliable? How can you bypass this?

A
  • non-compressible vessels due to calcification
  • overcome by checking toe-brachial index
97
Q

What is the safest and most effective treatment for claudication?

A

structured exercise therapy

98
Q

What does medical therapy involve when treating peripheral arterial disease?

A
  • smoking cessation
  • anti-platelet therapy
  • high intensity statin with goal LDL < 100
99
Q

What are the indications for operative intervention for PAD?

A
  • lifestyle limiting claudication
  • rest pain
  • tissue loss
100
Q

When are endovascular interventions preferred over open repair of peripheral arterial disease?

A

for short-segment lesions without heavy calcification

101
Q

Why isn’t the femoral artery often treated endovascularly?

A

because it is a mobile area that is prone to kinking and because of the relative ease of an open approach

102
Q

What is a contra-indication to atherectomy?

A

this end-vascular “rotor-rooter” carries a high risk of distal embolization and is therefore contra-indicated in patients with limited tibial vessel runoff

103
Q

A lesion in which vessel is likely to result in thigh claudication?

A

iliac

104
Q

What test should you perform for a patient who describes classic claudication but has normal ABIs? What explains this finding?

A
  • perform a walking treadmill test until the onset of significant pain and then recheck ABIs
  • patients with proximal iliac lesions may have normal ABIs because of collateralization that doesn’t become symptomatic until demand increases
105
Q

Describe a normal angiogram below the knee.

A
  • popliteal gives off the AT first
  • the TP trunk then gives off the peroneal and posterior tibial
  • the peroneal runs behind the fibula dn the PT runs behind the tibia
106
Q

Through which lower leg compartments do the following run:
- anterior tibial artery
- posterior tibial artery
- peroneal artery
- superficial peroneal nerve
- tibial nerve

A
  • AT: anterior
  • PT: deep
  • peroneal art: deep
  • superficial peroneal: lateral
  • tibial nerve: deep
107
Q

A patient presents with unilateral leg swelling and deep venous reflux on US, what can you offer?

A
  • compression stockings an elevation
  • cannot ablate these and there is no surgical treatment for deep venous reflux
108
Q

What is the best treatment for GSV reflux from the sapheno-femoral junction to the thigh?

A

chemical or heat ablation

109
Q

What is the best treatment for GSV reflux below the knee?

A

chemical ablation with glue or sclerosant

110
Q

Why is heat ablation reserved for the great saphenous vein above the knee?

A

because below the knee it carries too much risk of saphenous nerve injury

111
Q

How far away should you begin your ablation from the sapheno femoral junction?

A

2-3cm to prevent endothermal heat-induced thrombosis from encroaching on the sapheno-femoral junction

112
Q

How is endothermal heat-induced thrombosis managed?

A
  • invasion into the CFV: anticoagulation x3 months
  • flush with the CFV: short-course AC versus repeat imaging in two weeks
  • within 2cm of the CFV: repeat imaging in 1-2 weeks
113
Q

Who is a candidate for GSV stripping?

A
  • rare now
  • would be indicated for a very large GSV or one that is too superficial for heat ablation
114
Q

What is the most common location for DVTs?

A

iliofemoral

115
Q

Which leg has a higher rate of DVT?

A

the left is 2x more common than the right

116
Q

Where should an IVC filter be placed in relationship to the renal veins?

A

caudal to them

117
Q

How long should patients be treated for a DVT if they have active cancer?

A

until they are cured

118
Q

How should superficial thrombophlebitis of the GSV be treated?

A
  • if < 5cm and not near the saphenofemoral junction, can treat with NSAIDs and warm compresses
  • if longer or near the junction, anticoagulant with fondaparinox for 45 days
119
Q

What presents with a non-healing wound on the medial malleolus of the left ankle? How is it managed?

A
  • this is a classic venous stasis ulcer
  • treat with an unnamed boot
120
Q

How can you differentiate venous insufficiency from lymphedema of the lower extremity?

A

venous insufficiency swelling usually stops at the feet

121
Q

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

A

preoperative hypotension

122
Q

What organism causes most mycotic aneurysms?

A

Staphylococcus

123
Q
A

BTK Review 2024 (19 decks)

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