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vascular Flashcards

1
Q

early defection post op

A

-tachy, hypotension
-IMA!!! (not SMA) loses perfusion -> left colon dies -> ischemia
-not enough colaterization of SMA to IMA via marginal artery
-sloughing off of the bowel- mass contraction
-STAT sigmoid scope to look for how much ischemia
-EMERGENT surgery before colon perforates
-hartmanns or reimplant IMA if you can
-LLQ pain, fever, diarrhea, bloody stool

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2
Q

lower extremity vasculature

A

-at the inguinal ligament the external iliac becomes the common femoral artery
-superior, middle, inferior genicular arteries - collateral circulation
-anterior tibial -> dorsalis pedis

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3
Q

first and last branch off the abdominal aorta

A

-last- median sacral artery
-first branch off is the inferior phrenic

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4
Q

ischemia of lower limb risk factors

A

-Advanced age
-Race (non-Hispanic blacks).
-Male gender.
-Diabetes
-Dyslipidemia.
-Smoking.
-Hypertension.
-Hypercoaguability.
-Chronic kidney disease.

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5
Q

signs of ischemia of the lower limb

A

-Vascular Claudication- distance you can walk is uniform -> rest -> repeat
vs
-Neurogenic Claudication- lumbar nerves -> non-uniform, varies with distance, feet are warm

-Acute signs:
-6 P’s
-Pallor
-Pain
-Paresthesia
-Paralysis
-Pulselessness
-Poikilothermia- cold

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6
Q

history

A

-Hx of vascular disease and their interventions
-Cardiac hx and search for current symptomatology.
-Smoking history.
-Food aversion.
-Visual events.
-H/O diabetes.
-Claudication.
-Rest pain.
-Nonhealing ulcers- medial (venous) vs lateral (arterial)
-THEY ARE VASCULOPATHS!

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7
Q

plaque

A
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8
Q

physical exam

A

-Blood pressure in both upper extremities.
-Peripheral pulse assessment (presence, strength, and character). This is NOT just feeling pulses it is interpreting them.
-Lower extremity motor and sensory examination.
-Muscle wasting, thin and dry skin, or ulceration may be present.
-Hypertrophic nails, hair loss, loss of subcutaneous tissue, cold or cool extremity, arterial ulcers -> mottled

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9
Q

pulses to check

A

-Radial
-Ulnar
-Brachial
-Carotid
-Femoral
-Popliteal
-Dorsalis Pedis
-Posterior Tibialis
-Listen for Bruits as well
-Perform ABI

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10
Q

ankle brachial index (ABI)

A

-ABI of >1.2: Calcification of arteries
-3-4: calcified artery- DM2 -> Mönckeberg’s sclerosis (MS)

-ABI of 0.9 – 1.2: Normal.

-ABI of <0.9: Suggests arterial stenosis

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11
Q

work up

A

arterial dopplers- turbulent flow
-pulse volume recordings
-CTA

-high velocity flow - stenosis
-BART- blue away, red towards

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12
Q

pulse volume recordings

A

-cuff that has lower wave -> disease is proximal
-dimished tracing - disease is proximal
-disease starts in right iliac -> gets worse as you move down

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13
Q
A

-plaques
-poor circulation on the right
-reconstitute-
-claudication- walk through the pain -> anoxia is a stimulate for vascular growth -> collateral circulation
-walking program

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14
Q
A

-left - reconstitution of flow -> flow below the knee
-distal SFA proximal popliteal
-level of the ADDUCTOR CANAL that you find the MC area for occlusion of the superficial femoral artery !!!!!!!!!!!!!!!! bc of intrinsic compression
-reconstitutes distally bc of flow through geniculate arteries -> collateral
-older pts do better - hypertrophic nails, hair loss -> signs that there is collateral circulation
-younger (afib) -> no collaterals -> limb loss

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15
Q

acute limb ischemia: most important preoperative assessment

A

-40 - 50% of pts with PAD have CAD
-GOAL: Improvement of cardiovascular function and stabilization of cardiac issues through optimization is the prime directive.
-Beta-blockers**
-Anti platelet agents- maybe not post op -> bleeding risk
-Statins**
-ACE inhibitors

-BB and statins- continue post op if they were taking it before
-if you stop statins abruptly -> plaque instability -> occlusions

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16
Q

treating vascular pt: conservative approach

A

-Smoking cessation
-Exercise program- claudication -> anoxia -> collaterals
-Statins/diet modification
-Anti-platelet therapy

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17
Q

vascular surgical approach

A

-acute limb ischemia- HEPARIN
-critical ischemia
-heparin
-thrombectomy
-embolectomy
-thrombolysis
-fasciotomy- ischemic -> after 3 hrs -> irreversible muscle damage -> swelling -> cuts off circulation in leg -> limb loss

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18
Q

what is approach to PAD once conservative measures fail

A

-Endovascular interventions:
-Angioplasty (percutaneous)
-Stents

-Bypass- last choice
-balloon- crack the plaque

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19
Q

PAD lesions

A

-femoropopliteal - PTFE (a tube) is okay
-infrapopliteal- vein

-KEY ASPECT- above and below the knee
-once you get bending of the knee polytetrafluoroethylene (PTFE) grafts dont do well -> occlude

-below knee -> use vein (saphenous, umbilical, composit) -> something more sturdy

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20
Q

femoropopliteal lesions (dont need to know)

A

-as letter go up -> worse
-Type A: focal lesion less than 3 cm in length and do not involve the origins of the SFA or the distal popliteal artery.
-Type B: single lesions 3 to 5 cm in length not involving the distal popliteal artery or multiple or heavily calcified lesions less than 3 cm in length.
-Type C: lesions, multiple stenoses or occlusions greater than 15 cm in length or recurrent stenoses or occlusions that need treatment after two endovascular interventions.
-Type D: lesions are those with complete occlusion of CFA, SFA, or popliteal artery

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21
Q

PAD events

A

-acute limb ischemia-anticoagulation- heparin w/o bolus

-embolic event-balloon embolectomy- if embolism -> stick catheter in -> balloon -> pull clot out
-send to pathology after

-arterial thrombosis -catheter -> thrombolytic agents -> IR TPA directly to the area
-stent

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22
Q

complications

A

-Muscle injury
-Compartment Syndrome- fasciotomy -> wound grafts may be needed
-Rhabdomyolysis- IV fluids, check CPK
-Limb Loss

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23
Q

chronic limb ischemia finding

A

->2 weeks duration
-ulcers
-ischemia rest pain
-abnormal ABI

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24
Q

venous vs arterial ulcers

A

VENOUS
-Location:Medial part of lower legs, around medial malleolus.
-Appearance:Shallow, irregular borders, indurated and dark skin around ulcer.
-Discomfort:Low level of discomfort, not painful unless infected.
-Other Symptoms:Leg swelling
-gaiters area- venous disease -> tibial tuberosity and down

ARTERIAL
-Location:Feet, heels, toes of legs (Lateral).
-Presentation:Round shape, regular margins, pale/yellow base, feel stiff with cold skin.
-Pain –Can be painful mostly when walking.
-Other symptoms:Affected leg or foot cool to the touch, shiny skin, loss of hair, muscle atrophy.

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25
fem-pop disease
-non limb threatening -claudication -limb threatening (revascularization): -rest pain -ulcerations -gangrene - dry or wet - IV/local antibx, debridement, wound care -mal perforans- arterial ulcer -hammer toes -DM
26
indications for surgery for chronic disease
-Claudication limiting lifestyle - if you can still walk 3 blocks -> surgery is too risky -Ischemic rest pain. -Tissue loss. -Gangrene wet or dry. -type a- endovascular -B&C- no recommendation -D- open procedural interventions -antegrade -retrograde -scaffolding- antiproliferative compounds- block proliferation of plaques -adventitial- dexamethasone- prevent proliferation of plaque
27
percutaneous graft -PTFE is used bc its above the knee -tube
28
-saphenous or umbilical vein -fem-pop -fem-tibial -profundaplasty -must assess distal vessels -want 2 out of 4 distal vessels patent -you need to ensure inflow and OUTFLOW -without outflow -> it wont work
29
LeRiche syndrome
-buttock claudication -impotency -absent femoral pulses -blockage at the distal aorta
30
aorta occlusion tx
-open aorta for tx? -axillobifemoral bypass -tight clothes, belt, sleeping on it -> issues -tube grafts made of PTFE- pseudointima forms -> transient bacteremia -prophylactic antibiotics -stent
31
AAA tx
-left renal vein - comes off the IVC - just superior to the neck of the aneurysm -most aneurysms are infrarenal -move left renal vein superior -transect and cut left renal if its over the aneurysm -open aorta- understand that there will be plaque and the IMA is already occluded -tube or Y graft- both left and right iliacs
32
AAA risk factors and causes
-Matrix metalloproteinases (MMP). -Atherosclerotic disease. -Age (6th to 7th decade of life). -Male Caucasians. -Smoking. -Familial distribution. -Hypertension. -CAD. -COLD. -Inflammatory etiology. -Infectious -Connective tissue diseases. -Dyslipidemia.
33
AAA history
-Asymptomatic unless ruptured. -Expansion can cause groin pain. -Search for risk factors. -Smoking.**
34
AAA physical exam
-Search for vasculopathy disease: -Carotids -Cardiac -PAD -Pulsatile Expansile Abdominal Mass. -Pulses. -Bruits in the abdomen. -COPD. -Look for hypertension. -Marfan’s Syndrome.
35
-vasa vasorum goes all around the aorta to bring O2 -adventitia and outer part wont get O2 -> cant produce elastic or collagen -weakens -inside filled with plaque -> O2 cant get through -> intima weakens -harden and balloon out -sheer flow -> causes plaques
36
workup prior to AAA repair
-Imaging: -Ultrasound -CT Scan with contrast -Cardiac Assessment- enzymes, EKG, echo -Pulmonary Function- get up and go, mets -Renal Assessment- BUN/Cr -Cognitive Assessment- neuro exam, carotid bruits -> stroke -fix comorbidities before the aneurysm so there are less post op complications
37
-laminated clot- thrombus -measure it -from outer wall to outer wall -medially
38
-lateral view of abdomen -pick up calcifications of aorta -allow you to see -not used anymore
39
-saccular aneurysm -longitudinal view
40
-aneurysm -impended rupture -mass felt
41
-CTA allow you to plan the surgery -look at other vasculature -kidneys- horseshoe kidneys
42
-ruptured but contained aneurysms -blood retroperitoneal -plan surgery -not ideal -tube (2 anastomose) or wire (1 proximal and 2 distal- left and right iliac) graft
43
optimization AAA
-Smoking cessation. -Activity level. -Compliance with cardiac medications. -Glucose control. -Address cholesterol. -Diet and weight management
44
surgical options AAA
-Endovascular Repair (EVAR)- ideal -measurements -find out which graft you need -tube or wire (shown in pic) -stents -aneurysm is still there but you made a new lumen -Open Repair- brutal -cross clamp the aorta to stop bleeding -cross clamp each iliac artery and aorta below the renal arteries -posterior lumbars will still bleed -2-3L of blood is lost usually -autotransfused back to the pt
45
EVAR complications
-endovascular repair -Device: Endoleak, endograft migration or collapse, kinking, stenosis, and infection.  -Cardiovascular: MI, CVA, post-implantation syndrome,  -Renal complications: Contrast induced AKI, renal failure. -Ischemia:: Limb, intestinal, pelvic, and renal.  -Bleeding complications: Bleeding, hematoma, and DVT.  -Pulmonary complications: PNA, resp failure, atelectasis, ARDS, pulmonary edema, pleural effusion, hypoxia.  -Other complications: Spinal cord vascular injury, ureteral injury, and ED. -artery of adamkiewicz occlusion -> anterior spinal cord syndrome
46
-graft in an open repair -aorta closed over the graft -dont want the graft to touch the bowel -> infection -aorta fistulas can form
47
open AAA complications
-Bleeding. -MI - increase after load from clamping -Infection -AKI/Renal Failure. -Incisional hernia- from incision -DVT. -Leg ischemia. -Bowel ischemia. -Ischemic injury to spinal cord. -Pulmonary complications- pain -Wound complications. -Graft infection
48
carotid disease symptoms
-numbness or tingling on the face, arm, leg -confused dizzy -trouble seeing -headaches -difficulty walking/balance -difficulty swallowing -usually one side of body -TIA -subclavian steal- reversal of flow -> prevertebral subclavian artery stenosis
49
indications for carotid artery surgery
-North American Symptomatic Carotid Endarterectomy Trials (NASCET) 1987. -Pts with 50% or more stenosis. -H/O ipsilateral stroke or TIA. -Asymptomatic patients with 70% or more narrowing -Carotid endarterectomy- check backflow from other carotid first -open- take out plaque- stent and shunt first so blood can still flow -stent
50
TIA
-Amaurosis fugax. -Hemiparesis. -Facial weakness. -Speech loss.
51
carotid disease workup
-Cardiac workup. -pulmonary workup- smoker -CV exam -Thorough neuro examination. -Carotid Duplex Ultrasound (CDU) - look for turbulent flow and pitting -CTA. -CE-MRI -Antiplatelet therapy (unless absolute contraindicated) prior to surgery -> CNS surgery
52
-fibromuscular dysplasia- curly findings -normal -MRI
53
-plaque -MRI
54
-carotid siphon -large vessel disease in their brain -may need internal to external carotid bypass -done by neurosurgeon
55
-bruits if enough stenosis -plaque forms at areas of bifurcations bc of turbulent flow -narrows lumen of vessel -pressure gradient
56
TCAR
-allows you to use a system put into a filter and is returned to the pt -negative flow -> reversal flow -any debree cant go to brain -> sucked back and returned to extremity while taking out the plaque -allow you to perform surgery -embolic filter that doesnt get debris back into
57
open carotid endarectomy
-patch angioplasty -remove plaque in its entirety -open procedure -gortex or saphenous vein -necessary so you dont cause a point of stenosis
58
mesenteric ischemia risk factors
-Smoking -Sedentary lifestyle. -HPL/Dyslipidemia. -Diabetes. -HTN. -NOMI (non-occlusive)- hypotension, watershed infarcts -CAD. -Aortic dissection. -Drug use: -Cocaine -Methamphetamine 
59
acute vs chronic mesenteric ischemia
ACUTE -Sudden onset. -Bloating, diarrhea, vomiting, fever, and nausea. -Acute occlusion emboli/thrombus. -Treat with surgery -TRAID- abdominal pain out of proportion to findings (doughy abdomen), fever, heme positive stool -CHRONIC -Associated with food intake. -Vague abdominal discomfort/pain. -Plaque development. -Treat with angioplasty or surgery -TRIAD- colicky abdominal pain approx 30 min after ingestion of food, inadvertent wt loss, auscultation of bruit (SMA)
60
hypercoagulable states
61
common findings in mesenteric ischemia
-THUMBPRINTING
62
helpful laboratory tests: mesenteric ischemia
-CBC. -BMP with anion gap. -ABG with lactic acid. -D-Dimer. -Hypercoagulation panel
63
imaging: mesenteric ischemia
-plain radiograph -mesenteric US -CTA abdomen
64
-Left is normal -right is occluded at the SMA -US
65
-picture on the right is ischemia for the entire bowel -> bad -CTA
66
-pneumatosis intestinalis -surgery -lactic acidosis - ischemia -put pt on heparin if there is suspicious areas of ischemia -> look again -> try to salvage what you can -short gut syndrome- total parental nutrition for life

Surgery (26 decks)

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