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Vascular Flashcards

1
Q

Smooth muscle proliferation

A

Smooth muscle proliferation occurs in media with artery disease.

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2
Q

1 RF for atherosclerotic disease

#1 RF for cerebrovascular disease

A

Smoking is #1 RF for atherosclerotic disease
HTN#1 RF for cerebrovascular disease

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3
Q

Conduits for bypass

A

Conduits for bypass - internal mammary, radial, internal iliac in children. GSV, lesser saphenous, cephalic

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4
Q

MCC of hemorrhagic stroke

MCC of stroke is from emboli from CCA bifurcation

A

MCC of hemorrhagic stroke: HTN

MCC of stroke is from emboli from CCA bifurcation

Heart is 2nd MC cause of emboli

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5
Q

Homocysteinemia

A

increases atherosclerosis
Tx: Folate, B12, and B6

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6
Q

ICA & ECA normal flow

A

ICA has normal continuous flow

ECA has triphasic flow: antegrade in systolic, retrograde in early diastolic, then anterograde in late diastolic

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7
Q

Carotid endarterectomy indications

A

Get Peak systolic velocity for ICA = Best indicator of stenosis
Indications for CEA: asymptomatic >70% stenosis and symptomatic >50%
CEA removes intima and part of media
Men gain the most benefit from CEA

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8
Q

How to expose more carotid

A

Can divide posterior belly of digastric mm and omohyoid mm to expose carotid
- Superiorly: posterior belly of digastric
- Inferiorly: omohyoid

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9
Q

Criteria for shunting during CEA

A

Criteria for shunting during CEA: stump pressure (back pressure on distal ICA) < 50 mmHg, EEG changes, contralateral stenosis or occlusion, operating on awake patient and they have neuro changes

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10
Q

Nerve injury during CEA

A

-Hypoglossal – superior to CCA bifurcation, near ICA: injury causes dysphagia and tongue deviation on ipsilateral side

-Glossopharyngeal – near mastoid process: injury causes dysphagia only

-Excessive retraction at angle of mandible can cause marginal mandibular nerve injury (branch of facial nerve): droop at corner of mouth

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11
Q

Medical therapy after CEA

A

All patient’s s/p CEA need life long aspirin and 3 months of plavix

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12
Q

MCC of mortality after CEA

A

MI

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13
Q

Neuro deficit after CEA

A

Neuro deficit less than 12 hours after CEA: back to OR, open wound. If loss of flow in ECA or ICA, open the anastomosis. If no loss of flow to these: do on table arteriography

Neuro deficits 12-24 hours after CEA: Could be cerebral hyperperfusion syndrome or other causes: CTA 1st not OR

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14
Q

Best timing of CEA after stroke:

A

-if non-disabling stroke, perform CEA 2 weeks after stroke. Earlier has risk of reperfusion injury.
-If has large stroke, depressed level of consciousness or midline shift, wait 4-6 weeks.
-Hemorrhagic stroke: 6-8 weeks

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15
Q

Carotid stenting indicated for:

A

Previous CEA, can’t tolerate anesthesia, hx of neck XRT, damage to contralateral vocal cord, previous neck surgery (MRND)

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16
Q

Re-stenosis after CEA

A

<4 weeks = technical
< 2 years = intimal hyperplasia
> 2 years = atherosclerosis

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17
Q

CABG or CEA first

A

If patient needs a CABG and CEA. Usually always perform CABG 1st. The exceptions are below. Perform CEA first in these patients:
-A recently symptomatic carotid stenosis 50-99% stenosis in men and 70-99% stenosis in woman.

-Bilateral asymptomatic 80 to 99% carotid stenoses

-A unilateral asymptomatic stenosis of 70 to 99 percent combined with a contralateral total (100 percent) carotid occlusion

If asymptomatic with 50-99% carotid stenosis: Do not perform CEA first

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18
Q

Vertebrobasilar artery disease

A

diplopia, vertigo, tinnitus, incoordination

Tx: Aspirin unless both vertebral arteries have >60% stenosis with symptoms then: percutaneous transluminal angioplasty with stent

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19
Q

CEA Steps

A

Supine, extend neck, turn head away
Incision anterior to SCM
Through platysma, avoid greater auricular nerve
Ligate facial vein – vein is over the CCA bifurcation
Find carotid sheathe – Medial is artery, posterior is vagus, lateral is vein
Dissect circumferentially around CCA and encircled with #2 silk,
Dissect superiorly on CCA to bifurcation: #2 silk on ECA, clip on superior thyroid, Preserve the hypoglossal, ICA place elastic potts loop above the plaque
Positioned Rummel Tourniquets
80 units/kg heparin, wait 3 minutes
Arteries clamped
Profunda clamp: ICA 1st!! 2nd ECA, 3rd CCA
11 blade on CCA then pots scissors to extend onto ICA
10F shunt inserted
Performed endarterectomy using freer, good distal end point
Close with 5-0 prolene
flush 1st into ECA , then into ICA, a few beats before full closure

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20
Q

AAA

A

MCC of AAA – atherosclerosis
Top 3 risk factors for AAA – Age, male, smoking
Screening: US for 65-75 for males who have ever smoked
Male:female is 6:1

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21
Q

Pros/cons of EVAR for AAA

A

EVAR has less peri-op morbidity and mortality but equalizes 2 years post op, but has significantly higher rates of re-intervention

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22
Q

RF for AAA rupture

A

COPD, smoking, HTN, females, larger size, family history, eccentric shape

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23
Q

Hemodynamically unstable patients with a known history of AAA

A

proceed directly to the operating room without additional imaging: perform endovascular AAA repair, preferred over open.

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24
Q

AAA indications for repair

A

ANY symptoms are present (acute dissection, thromboemboli, claudication, rest pain, compression)

> 5.5 cm or 5.0 cm for women or high risk (COPD, uncontrolled HTN, eccentric).

Growth > 1 cm/year

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25
Q

Re-implant IMA/ hypogastric artery

A

Re-implant IMA if: IMA back pressure < 40, SMA stenosis, previous colon surgery, or if flow seems inadequate

Re-implant one hypogastric artery into the Internal iliac) if:
-Performing aortobifemoral repair and there is poor back bleeding from bilateral internal iliac arteries (hypogastric arteries)
-Prevents pelvic ischemia (buttock claudication MC sx, impotence, bladder issues)

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26
Q

MCC of death after AAA and risk factors for mortality

A

MCC of death overall after AAA and MCC early: Myocardial infarction

MC late: Renal failure

RF for AAA repair mortality: Renal failure Cr >1.8 is #1, Previous MI (Q waves on EKG) CHF, EKG ischemia, pulmonary dysfunction, older age, females

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27
Q

Complications of AAA repair

A

-Pelvic ischemia (internal iliac artery) – buttock Claudication, sexual dysfunction
-Spinal cord ischemia
-Colonic ischemia: sigmoidoscopy to dx: If necrosis: ex lap
-AKI 2/2 to renal occlusion

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28
Q

Right and left renal artery position

A

Right renal artery – crosses posterior to IVC

Left renal vein – Crosses anterior to aorta, tucked under SMA

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29
Q

Major vein injury during AAA

A

Common during proximal cross clamp, when you have retro-aortic left renal vein, usually left renal is anterior

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30
Q

Cold foot after aorto-bifemoral repair

A

Cold foot after aorto-bifemoral repair (and has no femoral pulse): return to OR for a groin exploration (patient has a thrombosed graft branch): balloon thrombectomy and intra-op angiography

If cold foot and normal proximal pulses: atherosclerotic debris from aneurysm, observe

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31
Q

If patient has AAA which needs repair and also has colon CA

A

-Treat the symptomatic one first
-If elective, do colon first (get dirty case out of the way)

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32
Q

Endoleak types

A

Type I - proximal or distal graft attachment site has inadequate seal. Tx: All need repair (found intra-op generally). Balloon expandable stent, balloon angioplasty or place overlapping stent cuff
*Ia- proximal aortic – use extension cuffs here
*Ib- distal iliac – use iliac extension limb here

Type II is most common 80%. Collaterals (IMA, lumbar, intercostals) fill aneurysm sac. Tx: Observe unless persisting > 6 months, expanding, or symptoms: Tx: Embolize

Type III – Mechanical failure of graft. Graft tear or separation. Tx: Placement another graft stent on graft failure site

Type IV - Graft wall porosity or suture holes. Tx: Usually just Observe. Can place non-porous stent if fails

Type V – (endotension) Expansion of aneurysm without leak Tx: Predisposes to rupture. No intervention. Needs close follow up

Type I and III are associated with increased risk of rupture and need urgent repair

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33
Q

Ideal criteria for AAA endovascular repair

A

Common femoral aa diameter needs to be > 8 mm

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34
Q

Suprarenal vs pararenal vs juxtarenal vs infrarenal aneurysm

A

Suprarenal aneurysm – The aneurysm involves the origins of one or more visceral arteries (SMA) but does not extend into the chest - requires separate renal artery reconstruction

Pararenal – The renal arteries arise from the aneurysmal aorta but doesn’t extend above it, and does not include SMA

Juxtarenal – aneurysm just below renal arteries. 0-1 cm distal to renal artery

Infrarenal – aneurysm > 1 cm below renal artery

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35
Q

Ascending/descending aortic aneurysms

A

-Descending thoracic aortic aneurysm = distal to left subclavian artery to diaphragm
-Associated with connective tissues disorders (marfans and Ehlers Danlos)
-Can get compression of vertebra (back pain), RLN (voice changes), bronchi (dyspnea PNA), or esophagus (Dysphagia)

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36
Q

Indications for repair for ascending and descending aortic aneurysms:

A
  • Any size with symptoms (rupture, dissection, dysphagia, PAIN!!)
  • ≥ 5.5 cm
  • > 5 cm with Marfan’s, Ehlers Danlos, Turners
  • increase in size > 1 cm/yea
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37
Q

Treatment for ascending/descending aortic aneurysms

A
  • Ascending aortic aneurysm: median sternotomy, with cardiopulmonary bypass, and composite graft
  • Descending aortic aneurysm: TVAR is best. If open need left sided thoracotomy
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38
Q

Complications after ascending/descending aortic aneurysms repair

A

ischemic spinal cord injury: CAUSES PARAPLEGIA= injury to artery of Adamkiewicz T8-L1)
Place CSF drains prevent this

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39
Q

Ehlers-Danlos Syndrome

A

Ehlers-Danlos Syndrome – Many subtypes

Hypermobile joints

Associated with Osgood-Schlatter (pain at tibial tubercle): lump at knee
Associated with aortic root aneurysm and aortic dissection 2/2 to cystic medial necrosis: lose collagen and elastic fibers
-Marfans has this too

Defect in collagen type III

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40
Q

Aortic dissection

A

Aortic dissection
- All ascending need open repair regardless of symptoms
- Descending is medically managed, unless has any sign of mal-perfusion, peritonitis, LE ischemia, persistent HTN or chest pain, expanding hematoma: TVAR (thoracic)
- Medical management: B blocker (esmolol) HR60-70, BP systolic 100-110

Stanford classification for aortic dissection:
- Class A: Any dissection that involves the ascending aorta. Can be ascending + descending. Aorta.
- Class B: Does not involve the ascending aorta. Distal to left subclavian.

DeBakey classification for aortic dissection – based on site of tear and extent of dissection
- Type I – ascending, arch and descending aorta
- Type II - ascending only
- Type III – Dissections that originate distal to left subclavian. descending only

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41
Q

Inflammatory aneurysms

A

Inflammatory aneurysms (No infection here)

CT shows thickened aneurysmal wall above calcification on CT scan. Often get adhesions to 3rd and 4th portion of duodenum, ureters (hydro), IVC, left renal vein. Has elevated ESR.

Tx: resect aneurysm and place graft vs EVAR. Avoid trying to free up involved structures, (inflammatory process resolves after resection and graft placement)

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42
Q

Mycotic AAA

A

Mycotic AAA – MCC staph aureus. Bacteria infects plaque and causes aneurysm. Periaortic fluid/gas on CT = key to make diagnosis

-Tx: Extra-anatomic bypass. Axillary to fem with fem-fem crossover and resection of infected aorta.

-Can also place autogenous vein instead of bypass.

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43
Q

Aortic graft infection

A

Aortic graft infection - MCC overall and early staph aureus (1st 2 weeks). MCC late staph epidermidis. Tx: Axillary to fem with fem-fem crossover, resect entire graft.
-Can also do in situ reconstruction using LE deep veins, cadaveric arterial allografts, or abx impregnated graft. Wrap omentum around them

Best way to diagnose infected aneurysm: CT and positive blood culture. WBC is scan outdated

Staph epi infections
-Much less virulent, do not present with systemic signs of infection. That’s why it is found later
-Blood cultures generally negative

Rest of organisms will present early and with sepsis

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44
Q

Aortoenteric fistula

A

1 first step CTA will show fluid/inflammation/air around perigraft (likely won’t show extravasation)

MC occurs 1-5 years post op

MCC is infection with an anastomotic pseudoaneurysm that erodes into bowel

MC 3rd or 4th portion of duo.

MC presentation is GI bleeding. Usually, these patients get a EGD for GIB work up.

If CTA negative: EGD to look at duodenum.

Treatment: Only close hole in duodenum,, Fistula takedown and resect the ENTIRE graft and extra-anatomic bypass, Axillary to fem with fem-fem crossover. Wrap graft in omentum.
- Can also do in situ reconstruction using LE deep veins, cadaveric arterial allografts, or abx impregnated graft. Wrap omentum around them

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45
Q

Collateral circulation in PAD

A

Forms from abnormal pressure gradients

Circumflex iliac to subcostal arteries. Circumflex femoral to gluteal.
Geniculate around knee.

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46
Q

Leriche syndrome

A

Claudication, absent femoral pulses, erectile dysfunction

Tx: aortobifemoral bypass

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47
Q

Exam finding of PAD

A

hair loss, pallor, Rubor – sign of more severe disease. Redness goes away with elevation

ABI < 0.9 is abnormal = reduced perfusion

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48
Q

Intermittent claudication

A

Cramping or burning sensation while walking but resolves with rest.

-ABI 0.5-0.9 = claudication
-Typically occurs in calves, thighs, buttocks
-Treatment is medical: Statin, aspirin, exercise
-Cilastazol phosphodiesterase inhibitor – decreases plt aggregation
-Surgery/endovascular intervention if above fails

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49
Q

Critical limb ischemia

A

Needs work up and intervention
- ABI < 0.4 = rest pain
- ABI < 0.4 is associated with tissue loss (ulcers and wounds)
- Typically manifests as SEVERE FOOT pain at rest
- REST PAIN OR ULCERS/WOUNDS

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50
Q

Claudication

A

pain is located below the level of stenosis
- Aortoiliac – buttock and thigh pain
- Common femoral – thigh pain
- SFA – calf
- Tibial/peroneal - foot

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51
Q

Claudication workup

A
  • Start with ABI and US to check presence of PAD, Pulse volume (waveform) recording (doppler US) – Gives you level of stenosis
  • ABI artificially elevated with DM and ESRD 2/2 to medial calcinosis in artery of tibial vessels: Instead you should use doppler wave forms, pulse volume recordings or check toe pressures in these patients.
  • Diabetics MC have tibial artery disease
  • Imaging workup US/CTA/MRA or straight to angiography
  • If you suspect aortoiliac disease due to loss of femoral pulse need CTA of abdomen with run off
  • Intervention is warranted for failure of medical management of Intermittent claudication or presence of critical limb ischemia
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52
Q

Endovascular and surgical therapy for PAD in LE

A

Indications to revascularize – life style limitation despite medical tx, rest pain, threatened limb, ABI <0.5, ulcers

Fix the most proximal problem 1st

  • ALL patients need cardiac workup prior. Patients with PAD have a 25% 5-year mortality from CVA and cardiac related issues
  • Endovascular treatment is usually the preferred treatment in intermittent claudication
  • Performed through retrograde femoral access of the contralateral extremity
  • Endovascular used for FOCAL lesions (generally < 10-15 cm), surgery reserved for multifocal and advanced disease
  • If performing open surgery: Need vein mapping first. Need 3 mm veins
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53
Q

Claudication without risk PAD risk factors

A

Popliteal artery entrapment syndrome, adventitial cystic disease presents with claudication relieved with rest. But these patients are young, don’t smoke, no HLD, HTN

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54
Q

Venous Insufficiency

A

Presents with aching of the LE with pain and edema relieved with elevation. Will see varicosities with lipodermatosclerosis (brawny skin discoloration). Can have history of DVT

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55
Q

Diabetic peripheral neuropathy

A

Burning sensation or paresthesia in forefoot. Key here is the pain is constant NOT relieved by rest or position

56
Q

Neurogenic claudication

A

Compression from spinal stenosis. Presents with burning and cramping with walking. Key is that it extends from buttock to foot. Relieved by sitting and bending forward.

57
Q

MC location for atherosclerotic occlusion in LE

A

SFA at hunter’s canal. Sartorius lies over this

58
Q

Diabetic foot ulcers

A

Usually at charcot’s joint (head of 2nd MTP) and HEEL 2/2 to neuropathy

Diabetic foot osteomyelitis dx:
- Start with X-ray
- MRI is best if concerned for osteomyelitis
- Don’t do bone biopsy for diabetic osteomyelitis of foot work up. For all other cases bone biopsy is best for dx.

Treatment: Abx with local wound care: sharp debridement

59
Q

Arterial ulcer (tissue loss)

A

Usually occurs at distal aspect of the extremity (toes)

If patient presents with an arterial ulcer that is INFECTED and septic, hold off on surgical revascularizing of PAD (as long as not threatened). Treat the infected ulcer first. Then work up and treat PAD

Work-up – start with ABI. <.4 = tissue loss

Treatment
*Endovascular intervention is best for iliac
*Long segment stenosis: bypass
-Patients with tissue loss have multilevel dz and thus bypass is the best option in this case (usually)

60
Q

Medical therapy after bypass

A

All patients after bypass need to be on DAPT (Plavix and aspirin) for 1-6 months after the procedure.

After that lifelong single antiplatelet therapy (aspirin or clopidogrel)

61
Q

Aortoiliac disease

A

Usually, occlusive disease is not amenable to stenting and must do open repair. Stenting used for stenotic lesions.
Aortoiliac disease is the exception

TASC A and B lesions: angioplasty and stent
- < 10 cm CIA and EIA stenosis
- Unilateral occlusion of CIA and EIA

TASC C and D lesions: Aortobifemoral bypass. If high risk surgical patient: Axillofemoral bypass

Isolated iliac stent/occlusion: PTA with stent, if that fails fem-fem crossover graft
- If chronic iliac occlusion in patient with severe co-morbid conditions (COPD): fem-fem bypass

62
Q

MCC of swelling after LE bypass

A
  • Early (<48 hours) – reperfusion injury
  • Intermediate (3-7 days) – DVT
  • MC! Late (>7 days) – lymphedema: compression stockings
63
Q

MCC of failure of reversed saphenous vein graft:

A
  • Early < 30 days: technical
  • Intermediate 30 days – 2 years: intimal hyperplasia
  • Late > 2 years: vein atherosclerosis
64
Q

Risk factors for graft occlusion on surveillance US (indicating need for intervention) after LE bypass graft:

A
  • PSV >300
  • PSV ratio >3.5
  • End diastolic velocity >20
  • > 70% diameter reduction on angio
65
Q

Gangrene

A

Dry gangrene (no infection) – Tx: NWB

Wet gangrene (infection) – early debridement. Surgical emergency if pus coming out of toes with red streaks: Ray amputation. Or if septic shock: amputation

66
Q

Predictors of healing post LE amputation

A

1. Transcutaneous O2 >40

Predictors of healing post LE amputation:

#2 presence of proximal pulses
- TCOM < 20 = poor healing

67
Q

Acute limb ischemia

A

LOSS of pulse

-1st start with giving aspirin and heparin bolus 80 units/kg then drip 18 units/kg/hr

-MC site of emboli from heart: common femoral
-MC UE site emboli from heart: Brachial

  • For Acute arterial emboli: usual treatment is open embolectomy, can consider thrombolytics if non-threatened
  • For Acute arterial thrombosis and threatened: heparin, open embolectomy
  • For Acute arterial thrombosis and non-threatened: thrombolytics, heparin.
  • Emboli to aortoiliac bifurcation (loss of both femoral pulses): BL femoral artery cut downs and transfemoral retrograde embolectomy
  • Femoral pulse must be present for thrombolytics. Otherwise these would need open embolectomy. So, any loss of femoral pulse= open embolectomy
  • If infant has loss of femoral pulse (from a line) and cold foot: too hard to operate= Tx: heparin
  • Thrombosis of LE graft (PTFE or vein)  if non-threatened: thrombolytics. Threatened: OR for thrombectomy
68
Q

Lytic therapy vs open embolectomy/thrombectomy

A
  • If motor and sensation intact: clot likely distal (usually at trifurcation): tPA and run for 24-48 hours
  • Thrombolytics are better at trifurcation, too difficult to perform embolectomy here.
  • If any loss of motor or sensation: need cut down and open balloon catheter embolectomy
  • Never do tPA (thrombolytics) for common femoral (loss of femoral pulse) or more proximal clot: open embolectomy
69
Q

Thrombolytics (tPA)

A
  • Need to follow fibrinogen levels because using fibrinolytics causes hypofibrinogenemia
  • Fibrinogen 150 or less increases risk of bleeding. (normal 200-400)
  • Absolute contraindications: Recent stroke/TIA (3 months) , active bleeding, recent head bleed, intracranial mass
  • Most effective in patients with ischemia < 2 weeks
  • Can use for up to 48 hours
  • Bleeding risk increases with low fibrinogen and longer time
  • The reversal for tPA is cryoprecipitate, if this is not available, then you can use aminocaproic acid vs TXA
70
Q

Rutherford classification

A

Threatened = Class IIb
Class I – heparin, can do thrombolytics or OR as well
Class IIa: MINIMAL Sensory loss, ONLY TOES HERE. heparin + thrombolytics
Class IIb: Sensory or motor loss: OR
Class III: amputation

71
Q

Amputation

A

50% mortality within 3 years for leg amputation

BKA: 80% heal, 70% walk again, 5% mortality
AKA: 90% heal, 30% walk again, 10% mortality

72
Q

Renal artery stenosis

A

MCC of renal artery stenosis: atherosclerosis

Atherosclerotic renal artery stenosis: DO NOT STENT. Medical treatment is best

Renal artery stenosis caused by atherosclerosis usually older male. MORE proximal on renal artery close to aorta= spillover from aorta

73
Q

Upper extremity occlusive disease

A

MC site of upper extremity stenosis: subclavian artery

Upper extremity occlusive disease: proximal lesions usually asymptomatic due to collaterals (subclavian)

74
Q

Subclavian steal syndrome

A

Tight proximal subclavian stenosis, causes reversal of flow in ipsilateral vertebral artery into distal subclavian artery.

Tx: PTA and stent. Common carotid to subclavian bypass if that fails

-Subclavian steal can also occur in patients with previous CABG and left internal mammary (comes off of subclavian) artery to left anterior descending= blood taken away from heart = ANGINA
Tx: subclavian stent

Vascular steal can also occur in femoral-to-femoral cross-over grafts who have proximal stenosis in the DONOR artery (proximal iliac stenosis in the donor leg). Tx: PTA with stent

75
Q

Acute mesenteric ischemia

A

MCC of mesenteric ischemia – embolic

Never do percutaneous endovascular treatment (thrombolytics) of mesenteric ischemia if the patient is unstable or has peritonitis

76
Q

SMA embolism

A

Hx of atrial fibrillation, endocarditis, recent MI, recent angiography

Pain out of proportion to exam; pain usually sudden onset. Hematochezia and peritoneal signs are late findings.

See meniscus sign 3-10 cm distal to origin of SMA

MC the proximal jejunum and transverse colon is spared – lands distal to middle colic, just after jejunal artery branches

Treatment;
Heparin given initially to prevent clot propagation

*MC do this for embolism!!! Especially if peritonitic/septic/sick/ischemic bowel: ex lap and open embolectomy with Fogarty catheter
*Transverse arteriotomy using embolectomy balloon catheter – Will need bypass if embolectomy does not produce blood flow

SMA exposure: divide ligament of Treitz; SMA to the right near base of transverse colon mesentery

Planned 2nd look laparotomy: best to not resect questionable/ marginally perfused bowel; leave abdomen open and re-explore in 24 hours

77
Q

SMA thrombosis

A

Occlusion right at ORIGIN of SMA or 1-2 cm from it

Typically, these patients have previous chronic abdominal angina (food fear, weight loss over months to years)
Sx similar to embolism; may have developed collaterals

MC jejunum and transverse colon is involved (entire midgut)

Tx:
*Longitudinal arteriotomy: needed for bypass
*Typically requires bypass – Use #1 suprarenal aorta, infrarenal aorta, right iliac artery
-Bypass with Greater Saphenous vein graft
*Simple thrombectomy rarely useful because of extensive disease
*Intraoperative retrograde superior mesenteric artery angioplasty and stenting is another option

78
Q

Finding SMA

A
  • Method 1 Lateral: reflect TV colon superiorly and small bowel to the right. Take down ligament of treitz. SMA is palpated to the right of ligament of Treitz over 3-4 portion of duo
  • Method 2 Anterior: TV up, SB to right, trace middle colic, horizontal incision at root of mesentery is made. SMA is found medial to SMV
79
Q

Non-occlusive mesenteric ischaemia (NOMI)

A

Critically ill state; low cardiac output
Watershed areas most vulnerable

Tx: give volume and abx; can give intra-arterial papaverine; give dobutamine if 2/2 to CHF volume resuscitation and improve cardiac output

80
Q

Mesenteric vein thrombosis

A

Short segments of intestine involved

Subacute: multiple days of bloody diarrhea and crampy abdominal pain

Heparin only!!!

Only operation to do is bowel resection if needed.

Patient should be screened for hypercoagulable state/Cancer

If continued abd pain without peritonitis: thrombolytics can be used in the ARTERIAL system!!= catheters in SMA and splenic artery

81
Q

Chronic mesenteric ischemia/ angina

A

-Fear of eating, weight loss
-Disease is usually at origin of artery. Celiac or SMA
-Dx: Duplex US is used for screening, confirmed with CTA
-Tx: Indications for treatment: weight loss, food fear, chronic symptoms
*Best treatment is endovascular angioplasty with stent. Only treat if > 70% stenosis. Only need to treat one artery
*If long segment or fibromuscular dysplasia: bypass

82
Q

Watershed areas

A

Griffith’s point – splenic flexure – middle colic to left colic

Sudak’s point – upper rectum – superior rectal, middle rectal

83
Q

Arc of Riolan

A

Collateral between the SMA and IMA

84
Q

Superior mesenteric artery syndrome, SMA syndrome

A

-Compression of 3rd portion of duodenum between SMA and vertebral column.

-Postprandial epigastric pain and vomiting. Fear of eating= weight loss.

-Lying prone or right lateral decubitus improves symptoms

-RF: MCC weight loss and surgery for scoliosis, supine immobilization, body cast, eating disorders

-Aortomesenteric angle < 25 = SMA syndrome. Normal 35-65

-Tx: For ALL refeeding 1st, NJ tube etc. Try to increase fat pat. Usually can avoid surgery and this refeeding alone suffices
Once nutritional status restored and still symptomatic= duodenojejunostomy
Usually, acute cases resolve with medical management
Chronic cases more likely to need surgery

85
Q

Median arcuate ligament syndrome

A

-Causes celiac artery compression.
-Hear bruit at epigastrium
-Weight loss, chronic pain, and diarrhea.
-Tx: transect median arcuate ligament

86
Q

Visceral and peripheral aneurysms

A

Rupture – MC complication of aneurysm above inguinal ligament.

Emboli – MC complication for below inguinal ligament

87
Q

Visceral artery aneurysm (splanchnic)

A

Two types:
- Visceral arterial aneurysm  true aneurysm. Lower risk of rupture
- Visceral arterial pseudoaneurysm  high risk of rupture

Risk factors: medial fibrodysplasia, portal HTN, pregnancy

Repair all splanchnic visceral aneurysm > 2 cm (hepatic, left gastric, SMA)  Covered stent or coil embolization (preferred) if that fails  ligation of aneurysm with bypass, or just ligation, if it has lots of collaterals like gastric arteries
If patient has a ruptured aneurysm  need open surgery with ligation, proximal and distal +/- bypass

Hepatic artery: embolization

88
Q

Size to repair renal, illiac, femoral aneurysm:

A

Common iliac > 3.0 cm= covered stent
Renal artery > 2 cm= covered stent
common femoral > 3.0 cm= resection with interposition bypass graft, avoid stents across joint lines

89
Q

Splenic aneurysm

A

MC visceral artery aneurysm
MC in women
Overall rupture risk is much lower than other visceral aneurysms.

Patients present with “double rupture – initially ruptured splenic artery is contained in the lessar sac. Patients are non-distended, normotensive.
Then lessar sac ruptures through foramen of Winslow, and patient becomes hypotensive.

Repair if:
- Symptomatic, pregnant, women of child bearing age, >2 cm

Treatment options (endovascular is preferred):
- Endovascular embolization (preferred): if in distal 1/3 of artery and hilum.
- Endovascular stent placement if in proximal or middle 1/3 of artery (preserves spleen)
- Open repair, resection with end-to-end repair: if in proximal and middle 1/3.
- If ruptured aneurysm or pregnant (radiation): open with ligation
- Can also do laparoscopic ligation of (proximal and distal)
- DON’T need splenectomy with above

90
Q

Popliteal aneurysm

A

*Popliteal aneurysm – MC peripheral aneurysm
*MCC atherosclerosis
*MC male in 50-60s, smoker
*Prominent popliteal pulses
*50% are BL
*30% have a AAA= need to be screened for AAA if you find this
*MC get #1 thrombosis and limb ischemia or #2 emboli
*Rarely rupture

*Dx: duplex

*Indications for surgery: > 2 cm, symptomatic, mycotic, distal embolization, intramural thrombus inside artery (regardless of size)

Tx:
* LIGATE and bypass: Use saphenous, ligate proximally and distally (medial approach)
* If patient presents with compressive symptoms, venous congestion, paresthesia: aneurysmorrhaphy with interposition graft (posterior approach): Open aneurysm, place bypass graft in aneurysm sac and close it.
* Acute thrombosis of popliteal aneurysm: Usually involves trifurcation vessels so open embolectomy difficult: treatment is tPA acutely with definitive repair (bypass) as above during that admission

91
Q

Popliteal entrapment syndrome

A

*Often BL
*Presents as intermittent Claudication in a YOUNG patient, men 20s and 30s WHO DO NOT SMOKE
*Loss of pulses with plantarflexion
*MCC is medial deviation of popliteal artery around the medial head of gastrocnemius muscle
*Dx: CT angio
*Tx: Resect medial head of gastrocnemius. May need reconstruction of popliteal artery with saphenous graft

Symptoms may progress to parasthesias as they develop fibrosis of the popliteal artery, which occurs from arterial compression; fribrosis can lead to complete occlusion or thrombis

92
Q

Cystic adventitial disease

A

*Claudication, Men in 30’s – 50’s
*These patients get claudication
*Change in symptoms with knee flexion/extension.
*MC area is popliteal fossa. Occurs in peripheral vessels close to a joint
*Dx: CT angio will see scimitar sign = compression of artery from a cyst!!.
*Tx: resection of cyst. May need graft

93
Q

Pseudoaneurysm

A

*MC location is femoral artery
*Dx: Duplex: Will show a “to and fro” pattern
*If 2/2 to percutaneous intervention= US guided thrombin. Need urgent OPEN repair if expanding, nerve compression or compromised skin
*If 2/2 to disrupted suture line (Between graft and artery) with recent bypass = technical error= open repair
*If late after bypass (months-years)= infection= resect entire graft and bypass through non-contaminated field
*If femoral artery and IV drug user= ligation without reconstruction (yes ligate the femoral artery). Has collaterals.

94
Q

Buerger’s disease

A

Key is digital necrosis with long history of smoking

Criteria (need all 5):
1. Age < 45
2. Smoker
3. Distal extremity ischemia (ulcer, gangrene, rest pain)
4. Angiogram with corkscrew collaterals
5. Need to exclude autoimmune, hypercoagulable, DM, emboli

Dx: angiogram:
-Need to see corkscrew collaterals with severe distal disease (digits)
-NORMAL arterial tree proximal to popliteal/brachial. This is a small vessel disease

Tx: Stop smoking

95
Q

Fibromuscular dysplasia

A

*Young women, 50% have bilateral lesions, have risk of cerebral aneurysms
*Presentations: #1 HTN (RAS), #2 headaches/stroke (carotid), claudication (iliac),
*MC variant is medial type fibrodysplasia
*MC vessel involved: #1 Renal artery, most commonly on the right, then #2 is carotid, #3 is SMA
*Causes stenosis that is usually MORE DISTAL than atherosclerosis
*Dx: Angiogram= string of beads
*Treatment: PTA WITHOUT stent, open bypass if it fails. No endarterectomy, no stent

96
Q

Temporal arteritis

A

medium-large vessels (aortic arch + branches including carotids)

Older white women 70s.

RF: Polymyalgia rheumatica

Tx: steroids

97
Q

Takayasu’s arteritis

A

*Granulomatous vasculitis with MASSIVE intimal fibrosis and vascular narrowing
*MC aortic arch and branches (subclavian, carotid). Can involve pulm and coronary arteries
*MC Asian women in 20s-30s
*Symptoms: Has antecedent inflammatory phase (fever, malaise, elevated ESR) followed by pulselessness phase. Pulseless UE, neuro symptoms, headaches, seizure, claudication, angina, abdominal pain.
*Dx: CTA and High ESR.
*Tx: Steroids. If that fails, do bypass ONLY when inflammation subsides

98
Q

Raynaud’s

A

*Pulses are NORMAL
*Small vessel disease
*Treatment of raynaud’s  Avoidance of cool temp, diltiazem

99
Q

Acquired AV fistula

A

MCC is trauma (GSW).

Tachycardia is improved with shunt compression

Sx: arterial insufficiency, MC claudication
* CHF (pulm edema, tachy,
* Aneurysm
* Limb length discrepancy
* Low diastolic pressure and venous HTN

Dx: Duplex – will feel a thrill or bruit

Treatment is open repair with lateral venous suture; patch arterial side. Interpose muscle between artery and vein to avoid recurrence

100
Q

Guidelines to placing HD access

A

For short term dialysis access: right internal jugular temporary non-tunneled catheter = BEST (shortest route). 2nd line is left IJ 3rd option is femoral
- Avoid subclavian, can cause stenosis, especially if they may need lifelong dialysis (issues with AV fistula)

Tunneled catheters are usually not placed in the acute, intensive care unit setting but are reserved for the subacute phase when a patient needs long-term access (>3 weeks)

101
Q

Dialysis access graft and fistula

A

Once a patient reaches Stage 4 CKD (GFR<30): they should be referred to a surgeon for AVF creation

In a CKD patient avoid ALL PICC lines and subclavian lines

All patients must have duplex for venous mapping prior to fistula formation

Obtain venography to rule out central stenosis in patients with hand swelling or previous central/PICC lines

102
Q

Selecting site

A

Radiocephalic fistula (cimino) is the first choice for AV access procedures. #2 is brachiocephalic, #3 brachio-basilic #4 synthetic graft

For grafts: #1 radial artery to brachial vein, #2 distal brachial artery to proximal brachial vein, #3 distal brachial artery to distal axillary vein

Prefer non-dominant arm, Requires at least >3 mm size vein, Need a diameter of 2 mm for artery

Cimino – radial artery to cephalic vein – wait 6 weeks to allow vein to mature  MC nerve injured is superficial radial

103
Q

Time to mature

A

AV graft – takes 2 weeks to mature
AV fistula – takes at least 4-6 weeks to mature

Rule of 6’s: at 6 weeks need fistula of 6 mm diameter, 6 cm length (to allow 2 needle access), depth < 6 mm, flow rate > 600 cc/min

104
Q

How to check for central stenosis

A

Venogram – used only to check for central stenosis: if you did AVF/graft then arms swelling: need to rule out central stenosis

105
Q

HeRO PTFe graft

A

Hemodialysis Reliable outflow graft – Used when there is central vein stenosis. Uses right atrium as venous outflow connected to brachial artery

106
Q

Failure of A-V graft

A

MC failure of A-V graft = venous obstruction 2/2 to intimal hyperplasia at the graft-venous anastomosis

MCC of early failure – technical.

Late = intima hyperplasia

107
Q

AVF complications

A

Most are detected during dialysis

High venous pressure, poor arterial inflow indicates access problems

Diagnostic test of choice is a fistulogram

108
Q

Hand swelling after AV graft or AVF

A

Hand swelling after AV graft or AVF: venous obstruction

Elevation generally improves symptoms = 1st treatment. Should resolve in a few weeks.

If persistent or SEVERE: suggests major venous outflow obstruction: MC this is at the venous anastomosis. Can also be central stenosis

Dx: Fistulogram: Tx: PTA without a stent

109
Q

Dialysis access steal syndrome

A
  • Will see hand pain with dialysis
  • AVF grafts much more at risk than fistula
  • Severe ischemia
  • Mild symptoms: Pain with use or dialysis, cold hand, paresthesia: No treatment
  • Severe symptoms: Rest pain, motor dysfunction, tissue loss/ulcers
110
Q

Acute dialysis access steal syndrome

A

-usually upper arm grafts
-Symptoms: loss of pulse, motor weakness, intolerable pain, rest pain = all need intervention

Diagnosis:
-Compressing the fistula improves symptoms = confirms the diagnosis
-Start with Duplex, However US will not find proximal stenosis if there is one,
-So, if duplex is normal you need an angiogram (not fistulogram) to rule out out-flow problems

111
Q

Acute dialysis access steal syndrome Treatment options:

A
  • If there is a proximal inflow stenosis): percutaneous angioplasty
  • If you don’t find the above then do below
  • Distal Revascularization-Interval Ligation (DRIL) (ligate artery distal to anastomosis, place another bypass graft)
  • Leaves the fistula undisturbed
  • Revision Using Distal Inflow (RUDI): The fistula is ligated on the venous side followed by a revision from a more distal arterial source to the venous limb. In contrast to the DRIL procedure, the RUDI procedure maintains the native arterial circulation.
  • Ligation of fistula: avoid this… can’t use graft after
112
Q

Chronic venous insufficiency

A

Caused by incompetent valves, inadequate muscle pump function, DVT

Sx: leg pain, fatigue, heaviness, edema, brawny skin, ulceration, talengectasias

RF: obesity, smoking, low activity or long standing

Venous ulcer= medial malleolus – treated medically first

113
Q

Chronic venous insufficiency Dx

A

Duplex: You are looking for:
1. Incompetent sapheno-femoral valve - dx made if relief of muscle pressure proximally (thigh) causes retrograde flow in the vein

  1. Incompetent perforator veins
  2. DVT – need to make sure patient does not have a DVT
  3. Incompetent deep system (femoral, popliteal, trifurcation)

Normal venous duplex = augmentation of antegrade flow with distal compression OR release of proximal compression

Perforator veins direct blood from superficial system to the deep system

Duplex US tells you if there is reflux in the superficial (saphenous), perforators or deep veins

114
Q

Chronic venous insufficiency Tx

A

-Medical 1st with leg elevation, compression, avoid standing, weight loss, stop smoking.
-Ulcers < 3 cm usually heal with medical tx  compressive stockings

If that fails: surgery= Fundamentals of surgery = ablation of reflux source (escape point)

CI to surgery: DVT, venous outflow obstruction, pregnant

Need post op US to make sure there is not DVT at the saphenofemoral junction.

115
Q

Chronic venous insufficiency indications for intervention:

A
  • Venous insufficiency, venous ulcers, varicosities: if their US reveals reflux in perforators or superficial veins they are candidates for intervention
  • There are no techniques to address deep vein issues
  • Telangiectasias and small varicosities without reflux: sclerotherapy
  • Superficial venous system (saphenous): # 1 MC radiofrequency ablation (best, least invasive)
  • Perforator reflux: Endoscopic perforator ablation or US guided sclerotherapy
  • If you see reflux in both perforator and superficial system:
  • Treat incompetent superficial valves 1st (saphenous), usually resolves the perforator issue
  • If still having issues: treat perforators incompetence= US guided sclerotherapy
116
Q

Suppurative thrombophlebitis

A

Will see pus with fluctuation, fever, high WBC, red streaking: remove IV and start abx. If there is pus: I&D

Superficial thrombophlebitis – will see erythema: warm compress, remove iv

Staph aureus is MC for both

117
Q

Lymphedema

A

Woody edema

MCC of cellulitis here is streptococcus

Dx: Rule out other causes of edema 1st. Lymphoscintigraphy and indocyanine green map lymphatics

Tx: Compression, PT (manual lymphatic massage)

118
Q

Lymphocele after GROIN surgery

A

1st PC drainage. Lymphocele resection if that fails. Can give isosulfan blue dye into foot to find lymphocele

119
Q

Carotid anatomy

A

-Structures of carotid sheath: Carotid artery, internal jugular vein, vagus nerve

-Segments of vertebral artery:
-V1: origin off subclavian to foramina of C6
-V2 (Foraminal): From the transverse foramen of C2-C6
-V3: From C2 to Dura
-V4: intracranial

-Structure commonly overlies carotid artery bifurcation: facial vein off of IJ generally overlies bifurcation

-First branch of external carotid artery: superior thyroid artery

-External carotid artery flow high or low resistance: high resistance (flows to muscular facial muscles), triphasic flow on doppler, brief reversal of flow

-External carotid can be tied off to help control excessive facial bleeding in trauma

-Internal carotid artery main blood supply to brain, first branch is the ophthalmic
-Low resistance as it is supplying brain tissue -> continuous forward flow= biphasic doppler signal; long diastolic phase

120
Q

Segments of vertebral artery:

A

-V1: origin off subclavian to foramina of C6
-V2 (Foraminal): From the transverse foramen of C2-C6
-V3: From C2 to Dura
-V4: intracranial

121
Q

-Hoarseness after carotid endarterectomy?

A

-Likely injury to Vagus nerve

-From clamping the carotid the vagus nerve was also clamped

122
Q

-Tongue deviation to side of injury?

A

-Likely hypoglossal nerve injury

-Nerve lies just cephalad to carotid bifurcation so can easily be damaged

123
Q

-Ipsilateral mouth droop after a carotid?

A

-Marginal mandibular injury

-From retraction on mandible, generally when trying to expose high lesions

124
Q

-This nerve lies deep to posterior belly of digastric and if divided can cause disabling dysphagia.

A

-Glossopharyngeal

125
Q

-What layers of carotid are removed during an endarterectomy?

A

-Intima and part of the media

126
Q

-What is the typical location of carotid atherosclerosis?

A

-Carotid bifurcation due to turbulence

127
Q

-Indications for performing carotid endarterectomy

A

-Symptomatic (stroke or TIA), 50-70% warrants surgery

-Asymptomatic – controversial if over 80% or EDV (end diastolic velocity) > 140 cm/s (which correlates with 80% stenosis)
-Should start with medical management aspirin and a statin

What if patient is symptomatic but duplex shows <50% stenosis?
-No surgery indicated
-Optimize medical management – aspirin, Plavix and a statin

What if patient has a stroke and imaging shows a completely occluded carotid artery?
-Anticoagulation to prevent progression, no benefit to recanalizing

128
Q

-What situations would an emergent carotid endarterectomy be indicated

A

-Crescendo TIAs: TIA symptoms are recurring and becoming more severe or lasting longer in duration

129
Q

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

A

-Myocardial infarction

130
Q

-When should you operate on a symptomatic carotid

A

-Small stroke or TIA – within two weeks once symptoms resolve

-Hemorrhagic stroke – 6-8 weeks

131
Q

-What if patient demonstrates symptoms of stroke in PACU after carotid endarterectomy

A

-Return to OR to evaluate for intimal flaps or thrombus

-In OR start with US

132
Q

-Which clinical scenarios would you consider carotid stenting over carotid endarterectomy

A

-Hx of neck dissection, neck irradiation, recurrent carotid disease
-Severe cardiac disease

-TCAR (Transcarotid Artery Revascularization) or transfemoral stenting should be considered in patients with previous neck surgery or radiation. TCAR has lowest stroke rate.

133
Q

Anastomotic pseudoaneurysm after femoral aneurysm repair

A

-Although most due to progressive degeneration, must culture excised graft to rule out coagulase-negative Staphylococcus infection

134
Q

No blood return during subclavian central venous catheter placement with infraclavicular approach

A

Aiming the needle more cephalad facilitates penetration of the vessel at the broader confluence of the great veins

135
Q

Acute vs chronic DVT

A
136
Q

Abdomen Vascular Zones

A

Zone 1: aorta, IVC, SMA, renal arteries
Zone 2: renal veins, renal arteries
Zone 3: pelvic area= iliac arteries, iliac veins
Zone 4: liver= hepatic veins, portal vein, hepatic artery

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