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A ORAL BOARDS 2016 > VASCULAR > Flashcards

VASCULAR Flashcards

1
Q

Normal toe pressure

A

110

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2
Q

First step in bypassing for vascular occlusion

A

Find distal target first!

If there is no target then you are done with the case.

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3
Q

Steps of bypass for vascular occlusion

A

Find distal target first!

Then evaluate proximal inflow (may have todo endarterectomy)

if SFA is too calcified - need to go to profunda patch

Harvest Vein 20-30 % more than you need.
Reverse the vein.

Tunnel

Heparinize

prox anast

mark for orientation

Distal anast.

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4
Q

Medications for vascular path

A

Beta blocker
Statin
Lipitor

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5
Q

Contraindications for cilostazol

A

this is pletal

no if in cardiac failure

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6
Q

Treatment for lesion just proximal to aortic bifurcation

A

Angioplasty

not enough room for stance- they would set timer for 30 minutes just running to each other

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7
Q

Trial of asymptomatic carotid disease

A

ACS

60 % angio (80% by duplex) occlusion

11% risk of CEA on meds

5% risk of stroke with CEA

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8
Q

Trial of symptomatic carotid disease

A

Symptomatic

70% stenosis of angio or duplex

26% stroke risk meds

9% stroke risk with CEA

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9
Q

CEA

A 
vericle incision along SCM
retract lateral
enter carotid sheath 
find IJ
facial vein ligate and divide
btw IJ and common carotid is vagus nerve - this is protected

encircle with vessel loops
common
Internal
external

watch hypoglossal

Heparnize
Verify with ACT

Order of clamping:

ICE
is
NICE

Inertnal
Common
External

If no change on neuromonitor EEG or awake and fine- then no need to shunt

Ateriotmy
endarterectomy : feather, tack as needed
patch

Release clamps:

Temp open each clamp

External - fills with blood
Common carotid
Internal

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10
Q

What is white clot

A

probably HIT

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11
Q

Super celiac aortic control

A

Vertical Midline incision

Opened gastrohepatic ligament (pars facida)

(watch replaced left heptic)

Take down triangular ligament - retract left lateral lobe of liver) to the right

Grab the OG and move esophagus to patient’s LEFT

compress aorta against spine (wait for anesthesia to catch up - then can place clamp)

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12
Q

What is a argyle shot made out of

A

vinyl

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13
Q

What is alternative to argyle shunt

A

foley

chest tube

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14
Q

Alternative proximal just to control technique

A

Balloon occlusion

Pruitt balloon

(you can also inject heparin through this baloon)

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15
Q

Imaging for a ruptured AAA

A

Noncontrast CT scan

Permissive hypotension systolic in the 90s

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16
Q

Initial step in managing acute mesenteric ischemia

A

Heparin

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17
Q

Where it is in black usually lodge in the SMA

A

Distal to the middle colic take off

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18
Q

Management of chronic mesenteric ischemia

A

Usually open operation(because stenting is associated with higher the operation rate)

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19
Q

Bypass option for chronic mesenteric ischemia SMA

A

common illiac

external illiac

infrarenal illiac

supra celiac aorta

from the chest

stent via open approach retrograde

(can just bypass one artery)

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20
Q

when to reimplant IMA

A

NO flow

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21
Q

Aortoenteric fistula stable patient

A

Stable post herold bleed

Ax bifem

Super celiac
Aortic proximal control

Iliac distal control

Take out the graft

Repair the duodenum

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22
Q

Aortoenteric fistula unstable patient

A

Endograft seals whole

then ax bifem

take out graft and stent

Super celiac control
Iliac control

Resect repair duodenum

If doing well then do
ax bifem

if not doing well:
oversew stump of aorta and

If not doing well

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23
Q

types of vascular shunts

A

Argyle - vinyl conduit
Pruitt–Inahara shunt - double balloon
Pruite
Bard Javid Carotid Bypas Shunt - T - SHUNT WITH

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24
Q

treatment of SMV thrombosus

A

Hep!

lysis is not standard of care - but people do it and this can be mentioned

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25
Q

Claudication numbers and presentation

A

ABI above .5

no ulcers

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26
Q

Medical managemnt of claudicant

A

1 ASA

2 Statin LDL goal

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27
Q

Occlution at bifurcation of Aorta

A

Bypass
Aorto bi illiac - graft open

or

Ax bifem

or

stent one side then do fem-fem

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28
Q

Steps of thrombectomy and possible bypass for Acute limb ischemia - oclusion of below knee pop

A 
Prep - groin to toes
Heparin
ABx
Angio
Duples saphenous in lower calf

Medial incision to finger bredth posterior to proximal tibia

expose posterior compartment

Retract gastroc muscle down

this exposes bundle of nerve artery and vien

mobalize vein - to expose below knee popliteal artery

then inferiroly reflect the soleus from periostium - this exposes the trifurcation

This exposes anterior tibial vein - mobilize to expose the anterior tibial artery

encircle anterior tibial trunk

transverse arteriotomy for emolectomy just proximal to trifurcation - this allows cannulation of AT, PT, and peroneal with fogarty

run retrograde

check for signals at the foot

POSSIBLE fasciotomy:

the superficail posterior compartment is already done having exposed the trifurcation

to release the complete DEEP posterior compartment release - you must release the entire solus off of the tibia (this is done if true compartment syndrome

Lateral incision just anterior to fibula
transferse superfical entrance of facia
release mets pointed away from septurm fascia anterior to intermuscular septum knee to ankle (careful of superficial peroneal n can have variable course not in its normal position posterior to septum)

Then release posterior to intermuscular septum sissors pointed away from septum.

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29
Q

Reperfusion syndrom

A

massive hyper K
acidotic
hypo vol

(may need to reocclude)

(may have to pull off first liter of blood)

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30
Q

lysis therapy

A

first choice thrombectomy

if too sick:
lysis takes time and may get neuro - motor def

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31
Q

Trauma steps pop a GSW

A

Prep BOTH legs

proximal control of above knee pop
distal control

Is patient going to live

vein from other leg

fasciotomy
watch for reperfussion syndrome

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32
Q

Exposure of ABOVE knee pop

A

Incision interval btw vastus and adductor hiatus

Mobalize greater saphanous

Sartorius mobalized and retracted posterior

This gives access to above knee popliteal artery

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33
Q

Basic indications for IVC filter

A

contraindication of anti coag

expansion of clot while anticoag (theraputic)

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34
Q

dialysis access

A

non dominate

w/n 6 mo - need

Compare PB in booth arms to make sure no subclavian disease

do they have pain when they have that hand - does it hurt or do they get dizzy - assess for arterial sufficiancy

Hx of vein problems: PICC line, central line probs, ssx venous congestion

min vein diameter: 3 mm or greater

Radial cephalic
brachial cephalic
brachial basilic

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35
Q

management of pain in hand post brachial cephalic fistula

A

dose pain resolve with occlusion of the fistula?

if yes:
DRIL
distal revasc interval ligation

This is simply bypass with vein proximal to fistula to distal to fistula so blood with go into that connection first and what is left over will go to fistula

Then can ligate the segment of artery distal to fistula (so it does not continue to draw blood and you do not need this flow anymore because bypass)

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36
Q

Management of patient in recovery who has pain that persists even after compressing the fistula

A

Ischemic Monomelic Neuropathy

May need to ligate the fistula - osler vascular answer

Surgery has little to offer in established IMN - emedicine answer

OT

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37
Q

Management of hand swelling post AV fistula

A

elevate hand normal

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38
Q

Management of severe UE swelling post AV fistula

A

Look for central venous thromb

MRV

venogram

balloon and fix

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39
Q

How fast can you use AV fistula

A

6 mo

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40
Q

How fast can you use graft

A

6 wks

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41
Q

What may be happening and what is management of if you stick the graft for dialysis run and you get a lot of blood coming back

A

MOST common is neointermal hyperplasia of of DISTAL anstimosis

(may be central venous occlusion / thromb)

balloon / cutting balloon

(very rarely patch distal anastimosis)

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42
Q

pseuodaneurysm at lower extremity bypass

A

eval for infection

if bypass was for claudication - can just remove the graft - because will just get claudication again - no big deal (they lived with occluded vessel prior to surgery)

if bypass was done for rest pain or limb ischemia:
remove graft and tunnel in unaffected tissue

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43
Q

Clinical scenarios cards

A

from text

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44
Q

What imaging should be done for AAA besides CT scan

A

Duplex of:
Popliteal
Femoral

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45
Q

requirements for EVAR

A

60 (min tortuosity)
25
15 mm infra renal neck
greater than 5 mm illiac (6-8 mm)

graft oversized by 20-30 % of proximal landing zone

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46
Q

Management if AAA is associated with a concomitant iliac aneurysm

A

May include one of the INTERNAL iliac arteries with coil and Cover with graft

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47
Q

Management of iliac if bilateral concomitant iliac aneurysms with AAA

A

Bypass internal to external iliac

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48
Q

Basic steps of EVAR

A 
A line
Nipples to toes
Bilateral femoral cutdown's
Heparinized
Bilateral ilial femoral sheets placed
Captures place in the aorta and renal arteries marked
Aortogram performed
Verify Lanks internal iliac arteries
Body of the Integraph inserted over stiff wire and deployed just below the renal arteries

Contralateral Gate is opened and cannulated - stiff wires introduced

Contralateral lamb is introduced over the wire and docked into the main body and deployed

Balloon angioplasty performed the Upper and lower fixation sites as well as graft junctions

Smooth out any wrinkles in the graft

Completion angiography
Confirm exclusion of AAA and evaluate for endoleak

Wires and sheets are removed

arteriotomiesclosed

flow confirmed to distal arteries

Protamine administered

groin wounds closed

Distal extremity pulses are checked

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49
Q

Postoperative management after EVAR

A

Diet is immediately advanced

Home on postoperative day one or two

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50
Q

Types of Endo leak

A

Type I -failed to seal

Type II - feeding branch

Type III - leak between junctions of the graft - if expanding aneurysm then meet need to be addressed endovascular – Coil

Type IV - leak through the pores of graft

Type V - seroma

Type I and type III in the leaks are repaired immediately

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51
Q

Suvellance EVAR

A

Abdominal and pelvic CT scan:

One, six, 12 months
Then annually if no leak

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52
Q

open AAA repair steps of the operation

A

Prep Nipples to toes

Midline laparotomy

Transverse bowel retracted cephalad

Small bowel retracted to the patient’s right

Reset the duodenum off of the aorta

Expose the aorta blow the renal arteries

Expose bilateral common iliac arteries

Left renal vein maybe divided if needed for exposure to the aorta

Diuresis if the patient can tolerate

Administer heparin for activated clotting time of 250

Clamp lax then aorta– Alert anesthesia

Enter aneurysm ( at the level of the IMA)
evacuate clot
ligate lumbars

So the proximal graft in place

ligate lumbar if there is could back bleeding from it

Re-implant IMA if there is port back bleeding

(careful, may just ligate if completely included – already dependent on collateral)

So in proximal graft then distal graft

Back bleed clot and debris

Stage reperfusion of legs

Reverse heparin

Close the aneurysm sac over the graft

Check distal extremity pulses

Close the abdomen

53
Q

Which is fixed first aortic aneurysm or colon cancer

A

Aorta aneurysm (this is considered most immediately life threatening problem)

Wait six weeks then : cancer

If near obstruction colon cancer EVAR would be best

54
Q

Findings and tx with acute reperfusion

A

hypotension,
acute renal failure,
incr K
increasing serum creatinine phosphokinase

Supportive management fluid resuscitation

Renal replacement therapy if needed

55
Q

un explained incr WBC post AAA

A

watch colonic ischemia

56
Q

Tricky presentation of ruptured aorta aneurysm

A

varicocele - ruptured into IVC with subsequent IVC fistula

femoral nerve compression

hematuria

57
Q

Survival of patient with ruptured aortic aneurysm

A

1/3 to 1/2 of patients will die before arriving to the hospital

In the hospital, mortality can reach 40%

58
Q

Graft choices for a endovascular approach with ruptured aortic aneurysm

A

aortouni-iliac (tube)

-0r-

Bifurcated end of graft
(the contralateral gate is open cannulated cannulated in the contralateral lamb is docked into the in the graft and deployed)

CO2 angiography may be used

59
Q

Options for rapid proximal control of ruptured aortic aneurysm

A

Aortic occlusion balloon inserted transfemoral or trans brachial

This can minimize drop in blood pressure with general anesthesia

Be careful to limit kidney and mesenteric and spinal ischemia time

watch for abdominal compartment sydndrome

smoking cessation

60
Q

What are the defined numbers for abdominal compartment syndrome

A

Abdominal compartment pressure greater than 25 mm per mercury with 50-100 mL of fluid instilled

61
Q

ACT goal

A

250

62
Q

increase rupture risk

A 
female
age
diameter
smoking
copd
63
Q

DX of HIT

A

heparin
antibody assays

or

platelet agglutination tests,

however treatment should not
be delayed awaiting the test results

64
Q

Anticipate reperfusion syndrome of acute mesenteric ischemia with findings of

A

respiratory failure

elevated liver enzymes.

The patient may require prolonged respiratory support

65
Q

One week after surgery the patient returns to the emergency department with
a severe headache and hypertension (200/100 mmHg). management of treatment

A

She is suffering from
hyperperfusion and requires prompt treatment (of blood pressure).

CT scan of the
head to evaluate for cerebral hemorrhage or edema.

hospitalized for blood pressure control.

Failure to control her blood pressure
could result in seizures, cerebral edema, and cerebral hemorrhage.

66
Q

The patient returns one week after surgery with the complaint of drooling. management and treatment

Her
left lower lip appears to droop and she has a small amount of drooling.

A

This
most likely represents an injury to the marginal mandibular nerve due to
retraction.

The nerve injury is usually transient and the patient can expect a
full recovery.

67
Q

2 months after surgery the patient returns for a follow-up carotid duplex
which shows slightly elevated peak systolic and end diastolic velocities in the
left internal carotid artery consistent with a 50%-69% stenosis.

She remains
asymptomatic.

A

This most likely represents neointimal hyperplasia.

n the
absence of symptoms:

moderate stenosis can be treated with continued
duplex ultrasound surveillance and anti-platelet therapy.

The indications for
intervention are:

neurologic symptoms,
progression of disease to severe
stenosis.

Often, these patients can be treated with balloon angioplasty and
stenting.

68
Q

The anterior compartment of the lower leg consists of:

A

deep peroneal nerve

and

anterior tibial artery a

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

69
Q

duplex ultrasound
diagnostic criteria to determine severity of stenosis.

VELOSITIES

A

70% stenosis velocities
higher than 230 cm/s

remember this like systolic bp:
up to 125 is treated as normal

125 - 230 dangerous

greater than 230 severe danger

70
Q

hyper coag work up

A

factor V Leiden,

prothrombin 20210 A,

protein C or S deficiency,

antithrombin
deficiency,

hyperhomocysteinemia,

antiphospholipid antibody);

may
need lifelong anti-coagulation
G20210A

71
Q

Consideration of intervention with DVT

A

Consideration for surgical

in patients with extensive ileofemoral DVT and signs of phlegmasia cerulea
dolens or venous gangrene:

thrombectomy
or
thrombolysis

72
Q

DVT in pregnant patient:

A

treat with low molecular weight heparin
because Warfarin is contraindicated during pregnancy due to
teratogenic effects

73
Q

6 weeks after AV fistula and is about to start dialysis.

His left
arm brachiocephalic arteriovenous fistula is pulsatile and the vein is not well
defined.

A

This most likely represents a stenosis of the cephalic vein.

evaluated with a duplex ultrasound or a fistulogram.

Treatment options
include balloon angioplasty

or

surgical revision

74
Q

A 55 year old man has had a left forearm loop AV graft with PTFE for 1 year.
He was admitted to the emergency department with bleeding from the AV
graft that has been controlled with prolonged direct pressure. Physical exam
of the bleeding area reveals a localized outpouching of the AV graft with skin
breakdown.

A

This represents a pseudoaneurysm of the AV graft. It poses a
hemorrhagic risk because of the overlying skin breakdown and should be
repaired surgically with an interposition graft that is routed around the area of
compromised skin.

75
Q

A 62-year-old man returns to the office 2 weeks after a left forearm
arteriovenous graft was place using PTFE. Physical exam reveals erythema,
induration, and expressible purulence from his left antecubital incision.

A

This
represents a graft infection and requires prompt surgery for removal of the
entire graft. Partial graft salvage or preservation is not possible in a newly
placed graft because it is not incorporated and therefore the infection involves
the entire graft. The outflow vein can be oversewn while the arterial defect left
when the graft is removed should be patched with autogenous tissue if
possible.

76
Q

The most convenient muscle flap for groin

A

sartorius muscle rotation

77
Q

infected pseudoaneurysm of the proximal fem-pop anastomosis

A

and
constitutes a surgical emergency. The patient should be taken to the
operating room for hemostatic control and removal of the infected graft.
Imaging needs and revascularization options will have to be determined intraoperatively

78
Q

Pre-operative imaging studies demonstrate that the patient’s infected bypass
graft is occluded.

A

As long as the patient’s foot is viable and not ischemic, the
entire bypass graft can be removed and no revascularization procedure is
necessary

79
Q

The patient’s gunshot wound to the thigh does not demonstrate any hard
signs of arterial injury and his ABI is in the injured leg is 1.0.

A

This patient does
not require operative intervention or further diagnostic imaging. His normal
ABI indicates an extremely low probability of a missed vascular injury.
Arteriography for a proximity injury in the absence of hard signs and a normal
ABI is not warranted

80
Q

Absence of femoral pulses after tube graft repair: most likely represents

A

a
technical error of distal anastomosis; treat with conversion to aorto-iliac or
aorto-femoral bypass

81
Q

The patient’s pre-operative evaluation revealed severe coronary artery
disease with an ejection fraction of 20%.

with symptomatic greater than 70% carotid

A

This patient represents a high
surgical risk. According to FDA guidelines, patients with symptomatic, severe
carotid stenosis who present a high risk for surgery because of medical or
anatomic conditions are appropriate candidates for carotid angioplasty and
stent placement.

82
Q

antihypertensives to use for bp of 240/ 120 po CEA

A

BB
CA block
nipride

look these up

83
Q

wedge goal for ressus

A

low teens

84
Q

indications for HD

A

hyperka-

lemia, acidosis, or fluid overload/pulm edema.

85
Q

thrombolisis for PE post AAA

A

Well, I will proceed with direct thrombolisis, only if patient is very symptomatic because the care is difficult,

monitoring TPA with fibrinogen levels will increase the risk of bleeding ( I gave her other details ).

Can you give thrombolisis any other way ?

Me: yes, you can give systemic, but with a fresh aortic repair, he will bleed!!!

86
Q

asystole during AAA

A

ABCs are important here, and I state that I ask if the ETT is correctly positioned, not clogged, and that the A-line is functioning properly. When told that these are fine, I state that I examine the pericardium to ensure that it is not bulging that might indicate a tamponade injury from placing the central line (I read of this complication on an old exam).
• Through the pericardium I see the heart quivering, so I open it from the abdomen and use paddles to cardiovert.
• What settings? Start at 10 J and go up to 20 J.

Further I administer Ca (for cardiac stabilization), Mg, lidocaine and start a Nitroglycerin drip. I also ask the anesthesiologist to check all of his lines and the ETT

87
Q

I finish my repair and open the clamp, at which point the patient arrests again. So, I re-clamp the aorta, then re-shock the patient. He recovers.

What probably caused the second arrest

A

Acute hypovolemia (I could have averted this if I mentioned that I would open the aortic clamp one click at a time, thought of that while having beers later on), and a reperfusion process whereby lactic acid and K+ are washed out. These would be treated by IVF, administering bicarb, possibly giving Mannitol (free radical scavenger) and treating hyperkalemia aggressively (described the usual shift/protection protocols).

88
Q

K+ of 6.8 with peaked Ts

A 
calcium, 
insulin/glucose, 
lasix, 
bicarb, 
kayexylate…
89
Q

What were my criteria for dialysis

A

Acidosis,
inability to control electrolytes or fluid status,

uremia

(AEIOUs)

A – Acidosis – metabolic acidosis with a pH 6.5 mEq/L or rapidly rising potassium levels; see previous postfor a review of the causes and management of hyperkalemia

I – Intoxications – use the mnemonic SLIME to remember the drugs and toxins that can be removed with dialysis: salicylates, lithium, isopropanol, methanol, ethylene glycol

O – Overload – volume overload refractory to diuresis

U – Uremia – elevated BUN with signs or symptoms of uremia, including pericarditis, neuropathy, uremic bleeding, or an otherwise unexplained decline in mental status (uremic encephalopathy)

90
Q

ARF causes from AAA repair

A

(ischemia, hypotension, supraaortic X-clamp, cholesterol plaque emboli, nephrotoxicity from CT…)

91
Q

Describe a retroperitoneal approach.

  • What do you do if the neck of the aneurysm is right at the renal arteries?
  • Would you repair it with a tube graft or a Y graft?
A

look these up

92
Q

subclavian steal
where is it
what is tx

A
  • stenosis just prox to vert

- tx: carotid subclavian bypass

93
Q

Endovascular anatomy requirements

A

o Infrarenal neck: 10mm length
o Non-aneurysmal common iliac arteries for distal landing zone
o 7mm in diameter

94
Q

exposures for chest trauma by injured structure

A

o Descending thoracic aorta: posterolateral left thoracotomy
o Right subclavian artery: median sternotomy
o Proximal left subclavian artery: anterolateral left thoracotomy
o Distal left subclavian artery: supraclavicular incision
o Thoracic duct: right thoracotomy
o Left main stem bronchus: left posterolateral thoracotomy

95
Q

Headache symptoms not due to technical error after CEA

A

Get a CT scan

This may be reperfusion

96
Q

12 months after surgery the patient returns for a follow-up carotid duplex
which shows slightly elevated peak systolic and end diastolic velocities in the
left internal carotid artery consistent with a 50%-69% stenosis. She remains
asymptomatic.

what is dx and what tx

A

This most likely represents neointimal hyperplasia. In the
absence of symptoms, moderate stenosis can be treated with continued
duplex ultrasound surveillance and anti-platelet therapy. The indications for
intervention are neurologic symptoms, progression of disease to severe
stenosis. Often, these patients can be treated with balloon angioplasty and
stenting.

97
Q

Chronic mesenteric ischemia and bypass options

A

Common iliac
External iliac
Infrarenal aorta

98
Q

When do you fix a abdominal aneurysm in female versus male

A

Female 5.0 cm

male 5.5 cm

99
Q

Where is also ration scene in varicose vein disease

A

MEDIA malleolus

100
Q

Test varicose veins clinically

A

Trendelenburg test
Elevate legs
Stand for 30 seconds with below the knee tourniquet

If when the trinket is released, there is more blood that goes to the varicosities then Val is incompetent

101
Q

Hypercoagulable workout

A

Protein C
Protein S

Prothrombin
Anti-thrombin III

Anti-cardiolipin
Lupus antibody

Factor five lighting

102
Q

Study work up for varicose vein disease

A

Duplex:
Eval valve competence
Obstruction
Deep or superficial perforators

? Ascending venography locate the level

103
Q

Russia advocate for compression stockings

A

30 – 40 millimeters of mercury

104
Q

Treatment for varicosities without venous insufficiency

A

Stockings
Stab phlebectomy
Endovenous ablation (Radio frequency)

Sclerotherapy

105
Q

Contraindication to performing venous oblation

A

Deep system Venus obstruction

106
Q

Patients with a reversible cause of DVT may be then treated how long and what are exceptions

A

3 months
coumadin

exception active diagnosis of cancer:
3 months of LMWH.

107
Q

Newer treatment modalities for DVT

A

thrombolysis

108
Q

goal of thrombolysis for DVT

A

decrease the chance long-term sequelae of DVT, chronic venous insufficiency.

109
Q

Chronic venous insufficiency

A

due to longstanding venous hypertension,

 due to 
valvular incompetence, 
obstruction 
or 
both.

It occurs in up to 30% to 40% of patients 5 years after developing a DVT, with an even higher incidence in those with iliofemoral DVT and those with ipsilateral recurrent DVT.

110
Q

Risk factors for chronic venous insufficiency

A 
multiple DVTs, 
advanced age, 
cancer, 
recent surgery, 
immobilization 
or
 trauma, 
pregnancy, 
hormone replacement therapy, 
obesity, 
gender.
111
Q

In younger patients without a clear etiology what should you look for as cause of unprovoked DVT

A

May-Thurner syndrome,

compression of the left iliac vein by the overlying right iliac artery,

112
Q

Treatment of the May-Thurner syndrome

A

venoplasty and stenting

if thrombosis:
thrombolysis,
venoplasty, and stenting

113
Q

with severe symptoms of leg swelling and extensive DVT, more aggressive intervention is indicated.

A

In the most severe form,

phlegmesia cerulea dolens

require venous decompression in order to decrease the chance of venous gangrene and the associated 20% to 50% amputation rate.

catheter-directed catheter-directed thrombolysis,

fail to respond to thombolysis:
open venous thrombectomy

In severe cases with limb threat:
fasciotomy after or simultaneous with thrombolysis or thrombectomy may be required to avoid amputation.

114
Q

Thrombolysis for DVT

A

prepping the bilateral lower extremities circumferentially.

accessed in the groin
or
peripherally at the popliteal area.

guidewire is passed across the lesion and position confirmed within the distal vein,

an infusion catheter may be placed with an infusion run overnight.

mechanical catheters are also used.

may decrease both the amount of thrombolysis needed and also the time thrombolysis is required

115
Q

open thrombectomy for DVT

A

femoral vein is exposed through a groin incision.

Cephalad and caudad control is obtained with vessel loops and

a venotomy is made through the vein itself or a sidebranch.

Five or six French venous thrombectomy catheters may be carefully passed in order to remove thrombus and reestablish venous flow.

In patients with a chronic DVT, the femoral vein often contains webs (scar tissue) that requires removal.

Once adequate flow is established,

venotomy may be closed with a polypropylene suture or with a patch of vein or polyester.

A completion duplex is

In some patients, an additional venogram may be needed in order to confirm adequate clearance of clot.

a low-flow state. This requires the use of intraoperative duplex in order to evaluate for technical errors that may be easily remedied at the time of the initial procedure but may be catastrophic at a later point

116
Q

(HIT)

A

disseminated intravascular coagulation

usually manifests 3 to 10 days after administration of heparin,

time can be reduced with prior exposure.

117
Q

DIC

A

can complicate thrombolysis and requires the serial measurement of fibrinogen levels.

118
Q

Outflow into pelvic veins thrombus treatment

A

can usually be treated using combination

stenting and venoplasty.

119
Q

lack of inflow into pelvic veins treatment

A

additional stent placement across the inguinal ligament

or

creation of an arteriovenous fistula in order to augment inflow

120
Q

Postoperative Management after thrombectomy for DVT

A

elevation,
compression,
ambulation

can reduce the incidence of chronic venous insufficiency (postthrombotic syndrome) by 50% and should be recommended to all patients with DVT along with adequate anticoagulation.

121
Q

Contraindications to thromboembolism prophylaxis

A

Absolute
Active hemorrhage

Severe trauma to head
or
spinal cord
with hemorrhage in the last 4 wk

Relative:
Intracranial hemorrhage within last year!

Craniotomy within 2 wk

Intraocular surgery within 2 wk

Gastrointestinal, genitourinary hemorrhage within last month

Thrombocytopenia (18 s)

End-stage liver disease

Active intracranial
lesions/neoplasms

Hypertensive
urgency/emergency

Postoperative bleeding concerns

“Other Conditions”

Immune-mediated heparin-induced thrombocytopenia

Epidural analgesia with spinal catheter (current or planned)

122
Q

Surgery for Axial Venous Incompetence

A

conventional stab phlebectomy
and
powered phlebectomy (TRIVEX, Inavein, Lexington, MA).

The patient’s varicosities are marked after standing to allow for optimal dilation and visualization of affected veins.

local anesthesia with tumescence and IV sedation.

First, 1-mm incisions are made along Langer skin lines and the vein is retrieved with a hook.

Continuous retraction of the vein segment affords maximal removal of the vein and direct pressure is applied over the site.

Incisions are made at approximately 2-cm intervals.

The extremity is wrapped with a layered compression dressing, and patients are instructed to ambulate on the day of surgery.

Compression stockings are worn for 2 weeks following the procedure.

123
Q

duplex-guided percutaneous

A

access to the great or small saphenous vein. Tumescent anesthesia is administered along the course of the vein to be treated, which is then examined for complete administration with the duplex. Closure of the vein is accomplished with radiofrequency heat or laser.

124
Q

Deep leg veins

A

iliac,
femoral,
popliteal,
tibial veins.

125
Q

Where do you make your anastomosis if you’re going to make a arterial venous fistula for low venous flow problem

A

At the ankle on the OPPOSITE side:

Posterior tibial artery

to

Saphenous vein

126
Q

What does heparin and inhibit

A

Anti-thrombin III

127
Q

What where does Lovenox work

A

Factor tenet

128
Q

What is the name of aortic occlusion balloon

A

Pruitt

129
Q

What are the names of some common shunts

A

Argyle shunt

Javid Shand

A ORAL BOARDS 2016 (30 decks)

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