VASCULAR

Question 1

Aneurysm of the superior mesenteric artery

Answer 1

caused most commonly by infectious endocarditis,

occlusive nature of these dissections often leads to chronic intestinal ischemia.

Rupture is uncommon, but when it occurs the mortality rate is 50%.

The most often reported surgical procedures used to manage superior mesenteric artery aneurysm have been ligation and aneurysmorrhaphy, although direct revascularization with venous grafts when possible is favored.

Question 2

predictive of healing of a below-knee amputation pressures at the knee and thigh

Answer 2

A blood pressure of 55 mm Hg at the knee
or
60 to 75 mm Hg in the low thigh

usually is predictive of healing of a below-knee amputation.

Question 3

tests that are accepted to determine level of amputation

Answer 3

Both transcutaneous oxygen determination

and

measurement of skin blood flow with a laser Doppler device have gained increased acceptance.

have not yet received widespread acceptance:
Other techniques, such as isotope clearance, fluorescein injection, and photoplethysmography or thermography,

Question 4

Five years after aortobifemoral bypass graft, a patient develops an asymptomatic right femoral pseudoaneurysm. Blood cultures grow no organisms. Gram’s stain of perigraft fluid discovered at exploration demonstrates white blood cells with no organisms. The graft appears well-incorporated above the inguinal ligament. Which of the following is the most appropriate management option?

Answer 4

LOW grade coagulase-negative staphylococci in 60% of prosthetic graft infections.

SOMETIMES managed by graft preservation or by in situ prosthetic replacement in selected patients.

The less virulent coagulase-negative staphylococci (eg, Staphylococcus epidermidis) can only survive in the mucin biofilm located directly on the graft and relatively protected from antibiotic penetration and leukocyte destruction.

Removal of the local graft infection may allow the remaining graft to be preserved because the remaining graft and perigraft tissues are not involved in the infectious process.

Clinical criteria of a graft biofilm infection include presentation of a pseudoaneurysm or graft-cutaneous sinus months to years after implantation, a lack of systemic signs of infection, and NO GROWTH on blood cultures.

The perigraft tissue and fluid may demonstrate inflammatory cells but no bacteria on Gram stain.

The offending bacteria can sometimes only be cultured after ultrasonic oscillation of the removed graft itself.

The treatment in such cases involves adequate proximal control of well-incorporated graft with removal of all unincorporated graft material and debridement of the native artery to normal-appearing wall.

Perigraft tissue is debrided with pulse-irrigation.

PTFE is the replacement graft of choice, based on animal studies demonstrating a reduced bacterial adherence when compared with other synthetic grafts.

The new graft is covered with viable muscle and antibiotics are given for at least six weeks.

At five years, no graft-related mortality was noted, but 20% of patients required excision of retained graft segments due to progressive biofilm infection, again presenting without systemic signs.

Question 5

Indications for upper and lower extremity sympathectomy

Answer 5

Sympathectomy is most effective for management of hyperhidrosis.

Successful and durable results were consistently reported in over 90% of patients.

Question 6

Predictors of improved outcome with reflex sympathetic dystrophy (RSD) respond to sympathectomy

Answer 6

treated early in its evolution

temporary transcutaneous sympathetic blockade with local anesthetic agents improved symptoms

variable results.

Question 7

Developmental ostial stenosis among children is caused by what

Answer 7

HYPOplastic

hourglass-shaped hypoplastic renal arteries at their aortic origins

(CAREFUL - this is NOT hyperplastic or hyperplasia)

Question 8

Developmental ostial stenosis among children is treated with

Answer 8

aortic reimplantation of the transected and spatulated normal renal artery BEYOND the stenosis.

Aortoplasty or thoracoabdominal bypass may be necessary for simultaneous management of coexistent coarctation of the abdominal aorta.

(When stenosis occurs with coarctation of the abdominal aorta, several renal arteries to each kidney usually are affected.)

NOT Venous graft - because of late aneurysmal changes.

NOT percutaneous transluminal angioplasty - you will rupture a true HYPOplastic vessel

Question 9

outcome for Developmental ostial stenosis among children surgery

Answer 9

The cure rate after surgical intervention for renovascular hypertension among children is better than for all other age groups with this disease.

Question 10

risk factors for the development of abdominal aortic aneurysm - and what are NOT risk factors

Answer 10

Male sex,
hypertension,
smoking

spinal cord injury twofold greater risk of AAA t- Autonomic nervous system dysfunction and the associated decreased vascular resistance and increased flow velocity may result in compensatory aortic dilation in response to increased shear exerted on the intima. Decreased intra-abdominal pressure would increase transmural pressure gradients, potentially leading to enlargement of the vessel.

NOT risk factors
DM!
black population - less than or equal to that in whites.

Question 11

NASCET study

Answer 11

(North American Symptomatic Carotid Endarterectomy Trial [NASCET])

symptomatic stenosis, benefit was gained among patients with moderate and severe stenoses,

more than 70% of luminal diameter [50% to 69%]

Question 12

ACAS trial

Answer 12

and without symptoms (Asymptomatic Carotid Atherosclerosis Study [ACAS]). In the

benefit with stenosis greater than 60% of luminal diameter.

Question 13

mortality and morbidity after carotid endarterectomy

Answer 13

representative of the collected experience, in which morbidity and mortality routinely average 3% to 5%. In some series, mortality and morbidity rates as high as 7% to 10% have been cited. The “acceptable” mortality and morbidity in contemporary series is approximately 3% to 5%.

Some select series have had mortality and morbidity after carotid endarterectomy as low as 1%, but such reports are not

Question 14

regarding aortic anatomy abdominal aorta begins

Answer 14

The abdominal aorta begins at the aortic hiatus (T12)

Question 15

regarding aortic anatomy abdominal aorta ends bony and external landmarks

Answer 15

approximately L4, where it bifurcates into the common iliac arteries.

approximate level of the umbilicus.

Question 16

renal vein landmark in aortic surgery.

Answer 16

retroaortic in 5% of cases.

Question 17

Multiple renal arteries are encountered in what percent

Answer 17

5% to 7% of cases,

renal vein, the aorta approximates the vena cava.

Question 18

anterior to posterior relationship of renal vasculature and ureter / pelvis

Answer 18

V
A
U

Question 19

Common misconceptions are that superficial venous insufficiency

Answer 19

Common misconceptions are that superficial venous insufficiency will never cause venous ulcers and that obstruction in the deep system precludes superficial stripping or ablation since the obstruction will be worse afterward. Superficial venous disease has been shown to commonly be the cause of a venous ulcer, and with mild to moderate deep disease as described in this case, ablation will aid in preventing recurrent ulceration. Compression is critical to control edema and aid in healing but does not correct the underlying hemodynamic abnormality so is not the only appropriate therapy. Ascending venography is not required to determine the extent of deep disease since duplex imaging is the more standard diagnostic study in current practice and was used in this case. Obstruction is not the major pathology in this case and a saphenopopliteal bypass is not indicated.

Question 20

method of choice for treatment of May-Thurner syndrome

Answer 20

Percutaneous endovascular stent placement has emerged as treatment of choice! Cameron

Open venous reconstruction is usually performed only in selected cases of failed stent procedures or occlusion of the stent.

Question 21

Mortality rates for patients undergoing thoracoabdominal and descending thoracic aortic aneurysm repair

Answer 21

range between 4% and 21%. The variable success rates are partly related to the heterogeneity of the patient population and to the expertise of the treating team and operator experience. Using multivariable analysis, advanced age, renal failure, and paraplegia have been identified as important risk factors for mortality. One of the strongest predictors for mortality is preoperative calculated glomerular filtration rate. This becomes more sensitive than serum creatinine alone. Patients age 79 years or older with at least one of three factors (emergency presentation, a history of diabetes, or congestive heart failure) have been identified as a particularly high-risk group with 30-day mortality as high as 50%. The 5-year survival for patients after thoracoabdominal aortic aneurysms is between 60% and 70%. Recently, negative predictors for long-term survival were found to include advanced age, extent II thoracoabdominal aortic aneurysms, renal failure, emergency surgery, cerebrovascular disease, and active tobacco smoking.

Question 22

In patients with minor or major strokes and evidence of occlusion of an intracranial vessel what is treamtment

Answer 22

catheter-directed thrombolysis

and

glycoprotein platelet receptor antagonists administered.

Question 23

splenic artery aneurysm

risk factors

Answer 23

multiperous

10% portal hypertension

-common presence of splenic artery aneurysm among recipients of orthotopic liver transplants.

4% renal arterial fibrodysplasia
patients.

Question 24

where along the splenic artery is the aneurysm most likely to be

Answer 24

These aneurysms usually occur at branchings beyond the main splenic artery

and

multiple in 20%

Question 25

Arterial fibrodysplasia is categorized by

Answer 25

the primary vessel wall layer involved—

the intima, media, or perimedial-adventitial region.

Dissections and aneurysms are considered secondary complications of the former lesions.

Intimal disease usually manifests as focal narrowing in young patients.

Medial fibroplasia occurs as a string-of-beads lesion among 35- to 45-year-old women and is bilateral in 60% of cases.

Perimedial dysplasia occurs in which accumulation of elastic tissue causes serial stenosis without aneurysmal dilatation.