Vascular 2 Flashcards
What should be done for a patient s/p blunt trauma with asymptomatic carotid dissection?
Should be anticoagulated (either heparin or Plavix, not standardized)
Repeat imaging before leaving hospital.
What is the likely treatment for a patient s/p blunt trauma with symptomatic carotid dissection?
Will likely require a covered stent.
What is the prognosis for a patient s/p blunt trauma with traumatic occlusion of the carotid artery?
If already have neurologic injury/completed stroke unlikely to get better with intervention.
Antithrombotic therapy.
What is the required treatment for carotid body tumors?
All require resection.
Consider embolization prior to surgery due to risk of bleeding.
What are the structures of the thoracic outlet in order from anterior to posterior?
Subclavian vein, Phrenic nerve, Anterior scalene, Subclavian artery, Middle scalene, First Rib.
What anatomic anomaly puts patients at risk for thoracic outlet syndrome?
Cervical rib.
Where is the brachial plexus located in relation to the thoracic outlet?
Brachial plexus is along the middle scalene, posterior to the subclavian artery.
Which type of thoracic outlet syndrome (TOS) is most common and what are its classic symptoms?
Neurogenic (95%); pain, weakness, numbness, tingling in the hand, particularly in ulnar distribution; symptoms worse with manipulation/elevation of arm.
What is the treatment for neurogenic TOS?
Physical therapy; confirm with scalene block or nerve conduction test.
1st rib resection + scalenectomy with neurolysis = operation of choice for refractory neurogenic TOS.
What condition does a swimmer with a blue swollen arm likely have and how is it treated?
Subclavian Vein Thrombosis (Paget-Schroetter), compression at costoclavicular junction.
Treatment: catheter directed thrombolysis -> 1st rib resection within the same hospital stay or shortly after.
What is the likely diagnosis for a young person with ischemia of the hand and no atherosclerotic risk factors?
Arterial TOS, though arterial TOS is very rare.
Likely an anomalous cervical rib is compressing the subclavian artery & will lead to an aneurysm, which is an embolic risk.
Tx= 1st rib resection with interposition graft for the artery
Where is the anatomic stenosis that results in subclavian steal?
-Proximal subclavian narrowing
-Reversal of blood flow in vertebral= vertebrobasilar sx
-Sx occur when extremity is exerted= steals blood from cerebral circulation
-Tx= recanalization + stenting or potentially carotid subclavian bypass are subclavian transposition
Reversal of blood flow in vertebral = vertebrobasilar symptoms; symptoms occur when extremity is exerted = steals blood from cerebral circulation.
What is the recommended duration for leaving a temporary catheter in place and why?
3 weeks; infection risk.
How do long-term tunneled catheters differ from temporary catheters?
-Permacath
-They are cuffed & tunneled; lower risk of central infection
-Still higher infection rate & high risk of central venous stenosis compared with fistula or graft
Still higher infection rate & high risk of central venous stenosis compared with fistula or graft.
What is the preferred location for temporary dialysis access?
-Right IJ direct to right atrium
-Avoid side where you plan to place permanent AV Fistula
-Will cause central venous stenosis, will lead to failure of permanent access
Avoid side where you plan to place permanent AV Fistula to prevent central venous stenosis, which will lead to failure of permanent access.
What is the preferred location for AV fistula creation for dialysis access?
-“Fistula First” Always start distal on non-dominant arm, and upper extremities before lower extremities, Start distal to not burn bridges.
-Reducing catheter days, improves life expectancy
-Focus is now moving to choosing the right access for the right person, a person with a short life expectancy, a fistula may not be the best access
Start distal to not burn bridges; reducing catheter days improves life expectancy.
What is the most common reason for AV fistulas to malfunction over time?
Venous outflow problems.
What is the likely problem if a patient reports high venous return pressures and increased bleeding after dialysis?
-Likely has venous outflow stenosis
-Dx: duplex US
-Tx: Fistulogram with balloon angioplasty
Diagnosis: duplex US; Treatment: Fistulogram with balloon angioplasty.
What are the criteria for fistula maturation, known as the ‘Rule of 6s’?
Needs to be 6 mm in diameter, less than 6 mm deep, greater than 600 mL/min in flow.
What are some likely causes of failure to mature in a brachio-cephalic fistula 6 weeks after creation?
-Possible inadequate inflow, r/o stricture at anastomosis, potential balloon angioplasty vs revision of anastomosis
-Competing flow from side branches, branches need to be ligated or coiled
Competing flow from side branches may require ligation or coiling.
How can a bleeding fistula with pinpoint hole bleeding be treated?
Can be treated with a stitch and urgent fistulogram.
Bleeding from an ulcer on a fistula is a surgical emergency.
Bleeding from an ulcer on a fistula is a surgical emergency.
When are fasciotomies indicated and what are the symptoms?
-In a patient with documented lower extremity compartment syndrome
-A patient that had acute limb ischemia for > 4 hours, should be considered for prophylactic fasciotomy
-Patients will have tight compartments, pain with passive motion of foot
A patient that had acute limb ischemia for > 4 hours should be considered for prophylactic fasciotomy; symptoms include tight compartments and pain with passive motion of foot.
Where should the incision be made to access anterior and lateral compartments?
-Make incision lateral to tibia in between the tibia and
fibula (H type incision to pen both anterior and lateral compartments, incisions should be anterior and posterior to intermuscular septum.
What nerve can be injured with the lateral incision and what deficit would you see?
Superficial peroneal nerve which can lead to difficulties with foot eversion.