VASCULAR

Question 1

The upper epiglottis nerve supply is via the

Answer 1

glossopharyngeal nerve,

the sensory pathway of the gag reflex

Question 2

the sensory pathway of the gag reflex

Answer 2

glossopharyngeal nerve,

Question 3

The lower epiglottis is supplied by the

Answer 3

recurrent laryngeal nerve,

which also innervates all the muscles of the larynx except the cricothyroid.

Injury to an unilateral recurrent laryngeal nerve can lead to hoarseness
The recurrent laryngeal nerve is primarily a motor nerve, whereas the superior laryngeal nerve is sensory (choice D).

Question 4

management of patient having creciendo TIA with 42% stenosis

Answer 4

medical managment!!

There is no benefit to stroke prevention when operating on patients with <50% stenosis whether or not they have symptoms as medical management has the same outcome!!

Question 5

acute limb ischemia The majority are from emboli from a cardiac source if the cardiac workup is negative, the next most common etiology is from

Answer 5

a proximal atherosclerotic lesion that ruptured and sent off emboli downstream.

The best test to evaluate for proximal atherosclerosis of the major vessels is with a CT angiogram with contrast.

Question 6

High output heart failure secondary to AV fistulae

Answer 6

proportional to the size and proximity of the involved vessels.

iliacs have the largest diameter under the highest pressure.

they have the most impact on the patients hemodynamics.

with increase CI
increase LVEDP
Decr peripheral vascular resistance

When a large proportion of arterial blood is shunted from the left-sided circulation to the right- sided circulation via the fistula, the increase in preload can lead to increased cardiac output.

Over time, the demands of an increased workload may lead to cardiac hypertrophy and eventual heart failure.

Patients may present with the usual signs of high-output heart failure including tachycardia, elevated pulse pressure, hyperkinetic precordium, and jugular venous distension.

Bottom Line: Hemodynamic changes related to AV fistulae are proportional to the size of the vessels and its proximity to the heart.

Question 7

Non-aneurysmal aortic infection

Answer 7

suprarenal aortic area.

Salmonella now the most prevalent infection in non-aneurysmal aortic infections.

CAREFUL! Although staphylococcal infections are the most prevalent aortic infections over all but the are associated with aneurysmal degeneration.

Streptococcal
USED to BE the most prevalent aortic infection due to bacterial endocarditis, but these are now less common with the use of antibiotics.

Question 8

Post-thrombotic syndrome

Answer 8

caused by valvular incompetence secondary to a deep venous thrombosis (DVT).

Question 9

Absolute contraindications to thrombolytic treatment:

Answer 9

-active internal bleeding

 -recent (within 2 months):
cerebrovascular accident, 
trauma
intracranial surgery
spine surgery 

• known intracranial neoplasm
• severe uncontrollable hypertension
• uncontrollable clotting disorders
• previous severe allergic reactions to the thrombolytic agent

Question 10

Relative contraindications to thrombolytic treatment:

Answer 10

RELATIVE!

• recent (within 10 days) operative or obstetric procedures, biopsy or procedure in a location that is not compressible, gastrointestinal bleeding, or trauma, including cardiopulmonary resuscitation
• left heart thrombus
• subacute bacterial endocarditis
• severe liver or kidney disease
• diabetic hemorrhagic retinopathy
• acute pancreatitis
• pregnancy
• any other condition in which bleeding constitutes a significant hazard or would be particularly difficult to manage because of its location.

Question 11

Symptoms of posterior circulation ischemia include

Answer 11

eg, vertebral artery stenosis

 dizziness, 
vertigo,
tinnitus, 
dysphagia, 
dysarthria, 
 ataxia.

Question 12

management of stenotic vertebral artery

Answer 12

if asx non-operative management

Surgical intervention is considered only when there are symptoms of posterior circulation ischemia.

Question 13

symptomatic right internal carotid stenosis of 50 percent with an ulcerated plaque.

Answer 13

requires surgical intervention for the decrease risk of stroke in the future

Bottom Line: Rarely is vertebral artery stenosis intervened upon.

Question 14

The phrenic nerve, scalene, subclavian, brachial plexus anatomy

Answer 14

arises from C3, C4, and C5 (choice A) and is encountered in the base of the neck where it courses between the anterior scalene muscle and its overlying fascia (choice B). The nerve then passes from the neck posterior to the subclavian vein to enter the thorax (choice C), innervate the ipsilateral diaphragm (choice E), and supply portions of the pericardium, mediastinum, pleura, and peritoneum (choice D).
Bottom Line: The phrenic nerve arrises from C3-5, travels anterior to the anterior scalene muscle, posterior to the subclavian vein, supplies portions of the pericardium, mediastinum, pleura and peritoneum, and provides motor innervation of the ipsilateral diaphragm.
Surgery Board Insight: You should know the relationship of the vessels and nerves to the anterior scalene muscle. The subclavian vein and phrenic nerve lie anterior to the anterior scalene muscle and the subclavian artery and brachial plexus are located posterior to the anterior scalene muscle. These structures all lie within the posterior neck triangle.

Question 15

Intimal hyperplasia is due to

Answer 15

spindle cells that cause further ingrowth and luminal compromise.

Question 16

The treatment for intimal hyperplasia after bypass graft

Answer 16

balloon angioplasty utilizing a cutting balloon.

Balloon angioplasty is particuarly effective after six months.

If intimal hyperplasia occurs with the first three months after surgery, revision with vein patch or vein graft should be performed.

Question 17

The anterior compartment of the lower leg consists of:

Answer 17

extensor hallucis longus, 
extensor digitorum longus, 
tibialis anterior, 
and 
peroneus tertius. 

deep peroneal nerve

and

anterior tibial artery a

Question 18

CABG revasc vessle choices comparisions and patentcy rates

Answer 18

The internal thoracic arteries (ITAs, left and right)

preferred conduits because their patency rates exceed 90% at 10 years.

The left ITA is generally used to graft the left anterior descending (LAD) artery, and reversed saphenous vein segments are used to graft the remaining vessels.

The right ITA pedicle can be used to graft the right coronary artery (RCA); if it is of sufficient length, it can be used to graft the posterior descending artery (PDA) or branches of the left coronary artery (LCA).
Because there is some evidence that there may be a survival benefit associated with using only arterial grafts, the radial artery (choice A) is often used in conjunction with ITA grafts to revascularize the heart. Another pedicled arterial conduit that can be used is the gastroepiploic artery (GEA) (choice C). This conduit is more appropriate for vessels in the inferior and lateral portions of the left ventricle.
The most commonly used conduit is the greater saphenous vein (choice B). Whether the right or left leg is chosen depends on a variety of factors, such as
evidence of previous saphenous vein stripping, venous stasis disease, arterial vascular insufficiency, presence of nonhealing wounds, varicose veins, or history of superficial thrombophlebitis.
If the saphenous vein is inadequate or unavailable, the lesser saphenous vein (choice D) can be used.
Bottom Line: The ideal conduit is the internal mammary artery with patency rates of 90% at 10 years. Other conduits that can be used are radial artery, gastroepiploic artery, greater saphenous vein, and lesser saphenous vein.

Question 19

duplex ultrasound

diagnostic criteria to determine severity of stenosis. velocities

Answer 19

< 50% stenosis velocities less than 125 cm/s

50-69% stenosis - 125 cm/s to 230 cm/s are within the moderate range of

> 70% stenosis velocities higher than 230 cm/s

Question 20

Failure of vascular access is mainly due to

Answer 20

outflow stenosis

VEIN - This typically occurs anywhere in the vein of an AV fistula or at the anastomosis of an AV graft which leads to limited clearance.

The cause for outflow stenosis is typically intimal hyperplasia.

Question 21

Fibromuscular Dysplasia presentaiton

Answer 21

(FMD)

female and present in the fourth or fifth decades of life.

found incidentally.

TIA, stroke, and disability.

Evaluation includes duplex ultrasound and CT-A or angiogram which typically show a “string of beads” finding.

Question 22

Fibromuscular Dysplasia treatment

Answer 22

If asymptomatic, patients should be treated medically with antiplatelet therapy

Open arteriotomy and serial dilation have good results with perioperative stroke rate of 1.4-2.6%.

Angioplasty is another method that is gaining wide acceptance.

NOT Carotid stenting as the artery may have redundancy, kinks, and coils of the cervical internal carotid artery. Also, these lesions are much longer than normal atherosclerotic lesions.

Question 23

Popliteal entrapment caused by

Answer 23

male

develops in utero during the migration and development of either the

popliteal artery

or

MEDIAL HEAD gastrocnemius muscle.

Question 24

The development of atherosclerosis and peripheral vascular disease has many factors. Conventional factors that increase this risk include:

Answer 24

smoking

diabetes

hyperlipidemia

Hypertension

Predisposing risk factors are

age, 
obesity, 
insulin resistance, 
family history, 
 race.

Question 25

Factors that decrease the risk of PVD and the level of formation of atherosclerosis include:

Answer 25

HDL, nitrous oxide

and prostacyclins.

Question 26

modifiable risk factors that lead to atherosclerosis formation.

Answer 26

Smoking, diabetes, hyperlipidemia, and hypertension

Question 27

answers increase the risk of abdominal aortic aneurysm - what is the biggest risk factor and what is pathophys

Answer 27

SMOKING

Bottom Line: Smoking has the greatest impact on the development of an abdominal aortic aneurysm (AAA). Degeneration of the walls of a AAA are from increases in matrix metalloproteinases and decreases in elastic and smooth muscle fibers.

The most changes in tunica media and intima.

include accumulation of lipids in foam cells, extracellular free cholesterol crystals, calcifications, thrombosis, and ulcerations and ruptures of the layers

COMMON path tunica media by means of proteolytic process seems to be the basic pathophysiologic mechanism of the AAA development.

increased expression and activity of matrix metalloproteinases (MMP) in individuals with AAA. This leads to elimination of elastin from the media, rendering the aortic wall more susceptible to the influence of the blood pressure

Hemodynamics affect the development of AAA. It has a predilection for the infrarenal aorta. The histological structure and mechanical characteristics of infrarenal aorta differ from those of the thoracic aorta.

The diameter decreases from the root to the bifurcation, and the wall of the abdominal aorta also contains a lesser proportion of elastin. The mechanical tension in abdominal aortic wall is therefore higher than in the thoracic aortic wall.

The elasticity and distensibility also decline with age, which can result in gradual dilatation of the segment

Question 28

Patients with 60& renal artery stenosis with adequately controlled htn undergoing EVAR should be treated how

Answer 28

Medical management!

treated as if the renal artery is a separate entity!

Bottom Line: Patients with renal stenosis and coinciding abdominal aortic aneurysm (AAA) should only be treated with AAA repair and medical management of the renovascular hypertension.

Revascularization of stenotic renal arteries is no different from medical management in patients with renovascular hypertension.

Revascularization may be needed in the setting of uncontrolled hypertension despite multiple medical treatments.

Question 29

The indications for surgical treatment of aortoiliac occlusive disease include

Answer 29

unrelenting claudication,
rest pain,
or
non-healing wounds.

Question 30

treatments aortoiliac occlusive disease

Answer 30

Endovascular for short segment aortoiliac disease and even longer segmental disease in patients who are poor surgical candidates.

Question 31

aortoiliac occlusive disease long term patency rates based on treatment

Answer 31

long term patency rates for long segment disease:
bypass BETTER

RARE to try a full segment endarterectomy but is still indicated in patients with smaller vessels or with symptoms of impotence, where an endarterectomy can restore blood through a diseased internal iliac artery.

Question 32

acute mesenteric ischemia Embolic events will usually lodge

Answer 32

in the SMA past the takeoff of the middle colic artery.

Question 33

acute ebolic mesenteric ischemia tx

Answer 33

surgical emergency

embolectomy.

A longitudinal arteriotomy is preferred to facilitate the placement of a bypass graft in case the embolectomy procedure is not successful.

Question 34

The arc of Riolan

Answer 34

is a collateral between the SMA and IMA and would be dilated in patients with chronic mesenteric ischemia.

Question 35

Carotid body tumors are located

Answer 35

bifurcation of the common carotid artery in the posterior medial adventitia.

Question 36

Carotid body tumors cell origin

Answer 36

extra-adrenal paraganglia system derived from

neural crest cells.

Question 37

Carotid body tumors diagnoses presentation and imaging

Answer 37

Typically, this tumor is diagnosed incidentally with US, CT, or MRI

They typically are asymptomatic!!

When symptomatic present with neck pain, dysphonia, hoarseness, stridor, dysphagia, or sore throat.

RARE to have the extraadrenal like symptoms such as palpitations, tachycardia, and hypertension.

Question 38

Carotid body tumors tx

Answer 38

Treatment for carotid body tumors is surgical excision

Some surgeons preoperatively embolize this tumor as it is very hypervascular.

Question 39

The best procedure to treat aortoiliac disease

Answer 39

direct reconstruction with an aortofemoral bypass.

if hostile abdomen:
extra-anatomic bypass is indicated

Femorofemoral bypasses are performed in cases of unilateral iliac occlusion or stenosis, where essentially a single iliac artery is providing the blood supply to both lower extremities.

For optimal results, the donor artery must be assessed for adequate inflow to ensure that it can meet the demand of the increased perfusion requirements.

Lesions that are small and isolated can be treated first with angioplasty to improve the inflow and optimize the overall patency of the bypass graft.

Question 40

arterial emboli secondary to atrial fibrillation most commonly lodge where

Answer 40

COMMON femoral artery.

Question 41

Emboli from atrial fibrillation form where

Answer 41

in the left atrial appendage

and move into the ventricle and into the circulation.

Question 42

what are the first cliical signs of acute limb ischemia

Answer 42

SENSORY (pain) nerves are the first clinical sign of acute limb ischemia (careful, alternate source said palor - but claudication does come before white leg by history)

followed by motor deficits

finally skin changes.

Question 43

what type of doppler signal rules out acute limb ischemia

Answer 43

Biphasic signals rule out acute limb ischemia,

monophasic signal suggests a proximal occlusion with patent distal vessels.

Absent signals may be a sign of more advanced limb ischemia.

Question 44

what do Monophasic pedal signals suggest about level of occlusion

Answer 44

a proximal occlusion with reconstitution.

Question 45

Aortobifemoral bypass unilateral limb presentation that occurs years after the initial surgery must raise concern for an

Answer 45

occlusion at the distal anastomosis on the ipsilateral side which is most commonly due to intimal hyperplasia.

even if at 2 years

Technical error will usually manifest within the first 30 days.

Pseudoaneurysms can be palpated and will have a pulsatile mass at the target location.

Restenosis of the aortic anastomosis would manifest with bilateral lower extremity symptoms.

Question 46

effort induced thrombosis diagnostic study of choice

Answer 46

Duplex ultrasound can confirm the diangosis.

Question 47

treatment of effort induced thrombosis

Answer 47

Anticoagulation prevents pulmonary embolism (PE) and decrease symptoms.

Patients presenting with acute symptomatic primary ASVT:

may be candidates for thrombolytic therapy

A venogram is performed through a catheter placed in the basilic vein to document the extent of thrombus.

A catheter is placed within the thrombus and a lytic agent infused.

Heparin is also administered..

After completion of thrombolytic therapy, a follow-up venogram is performed to identify any correctable anatomic abnormalities.

Following thrombolytic therapy, balloon angioplasty for residual venous narrowing

and

first rib resection or decompression of the thoracic outlet may be performed.

Question 48

preferred site of cutdown with Acute arterial emboli with cold leg

Answer 48

The common femoral artery - this is the most common site of emboli

ease of exposing the anatomy.

Once the vessel is exposed, vessel loops should be applied to gain control of the artery.

A transverse arteriotomy is preferred in an otherwise healthy artery to avoid narrowing of the vessel upon closure.

Embolectomy catheters are then passed both proximally and distally until good back bleeding from both ends are achieved.

A completion angiogram is recommended at the end of the case to ensure there are no underling lesions that may need addressed.

Anticoagulation is required prior to vessel occlusion and passing of the embolectomy catheters.

Question 49

The Adson test

Answer 49

(scalene test)
maximally extend their neck
turn their head toward the effected extremity.

The ipsilateral radial pulse is palpated, and the test is considered positive if the pulse decreases or disappears.

Question 50

The treatment for embolic mesenteric ischemia is

Answer 50

Emergent SURGICAL embolectomy.

Question 51

Embolic mesenteric ischemia should be suspected in patients with

Answer 51

atrial fibrillation
or
previous MI

ischemic distribution that spares the proximal jejunum and transverse colon (because lodges past the ileocolic after take off or right colic)

Question 52

The treatment for thrombotic mesenteric ischemia may include

Answer 52

mesenteric bypass.

The segment of occlusion is usually the proximal SMA leaving a sizable enough vessel distal to the occlusion for anastomosis.

Question 53

Paget–von Schroetter syndrome The venous pathology is a direct result of

Answer 53

repetitive injury to the subclavian vein

at the level of the costoclavicular space,

the most medial aspect of the thoracic outlet.

The main structures causing compression of the vein are:
the first rib,
the clavicle with its associated subclavius muscle
fibrous costocoracoid ligament,
the anterior scalene muscle and tubercle.

Question 54

The most common splanchnic aneurysm in descending order of incidence:

Answer 54

Splenic (60%),
Hepatic (20%),

SMA (5.5%),
Celiac (4%).

Question 55

arteriovenous (AV) fistula. Steal syndrome what is presentation

Answer 55

The radial pulse is USUALLY absent!

Compression of the access may result in relief of symptoms and return of a radial pulse, which is diagnostic of access-induced steal syndrome.

Patients with steal syndrome may present with various symptoms, ranging:

from hand coolness
or
paresthesias
pain, stiffness, or swelling of the fingers.
delayed capillary refill and decreased sensation.

Question 56

severe symptomatic DVT in the ileofemoral treatment

Answer 56

catheter directed thrombolysis to restore venous patency, reduce the pain and edema of the extremity, preserve venous valve function, and reduce the incidence of post thrombotic syndrome

Question 57

phlegmasia alba dolens

Answer 57

“alba” = albino - white = still blanches (better than cold and blue)

thrombosis involves ONLY major deep venous channels of the extremity, therefore sparing collateral veins.

The venous drainage is decreased but still present; the lack of venous congestion differentiates it

Question 58

phlegmasia cerulea dolens

Answer 58

cerulea = azule = blue cold dead leg = lost arterial inflow

PCD, the thrombosis extends to collateral veins, resulting in venous congestions with massive fluid sequestration and more significant edema. Without established gangrene, these phases are reversible if proper measures are taken.

Of PCD cases, 40-60% also have capillary involvement, which results in irreversible venous gangrene that involves the skin, subcutaneous tissue, or muscle. Under these conditions, the hydrostatic pressure in arterial and venous capillaries exceeds the oncotic pressure, causing fluid sequestration in the interstitium.

Question 59

Acute limb ischemia secondary embolic event most common and second most common sources

Answer 59

MOST are CARDIAC
and #1 cardiac is atrial fibrillation,

but other cardiac causes include:
left ventricular aneurysm, 
dislodged vegetation, 
atrial myxoma, 
or 
after an acute myocardial infarction.

Second most common cause after cardiac:
a proximal atherosclerotic lesion that ruptured and sent off emboli downstream.

Question 60

Emboli most commonly lodge where

Answer 60

most frequently cause an occlusion at

femoropopliteal level.

Question 61

presenting with non-occlusive acute mesenteric ischemia

Answer 61

profound hypotension and on vasopressors,

Angiography will show patency of the mesenteric vessels, with evidence of vasospasm more distally (eg, SMA is OPEN)

Question 62

tx with non-occlusive acute mesenteric ischemia

Answer 62

maximize resuscitation

discontinue any vasopressors if possible.

INTRA-artial (NOT systemic )
papaverine has also been used to treat the vasospasm which can be performed with a percutaneous, catheter directed delivery.

Any patients with signs of peritonitis need to be taken immediately to the OR to rule out bowel infarction.