VASCULAR

Question 1

List hypercoagulability work up

Answer 1

Antithrombin (deficiency)
Prothrombin gene mutation

Protein C (deficiency) 	
Protein S (deficiency) 	

Antiphospholipid antibodies
Lupus anticoagulant
Factor V Leiden

Question 2

contents of the anterior leg compartment

Answer 2

First web space numb - most commonly injured from compartemtn syndrome

(this compartment is lateral to the tibia)

DEEP peroneal nerve

ANTERIOR tibial artery
(between the tibailis anterior and flexor hallucis longus)

    muscular
        tibialis anterior 
        extensor hallucis longus 
        extensor digitorum longus 
        peroneus tertius 
    neurovascular

Question 3

all compartment s

Answer 3

muscular
        tibialis anterior 
        extensor hallucis longus 
        extensor digitorum longus 
        peroneus tertius 
    neurovascular
        deep peroneal nerve
        anterior tibial vessels

Lateral compartment

    muscular
        peroneus longus 
        peroneus brevis 
    neurovascular
        superficial peroneal nerve

Superficial posterior compartment

    muscular
        gastrocnemius 
        plantaris 
        soleus 
    neurovascular
        sural nerve

Deep posterior compartment

    muscular
        tibialis posterior 
        flexor hallucis longus 
        flexor digitorum longus 
        popliteus 
    neurovascular
        tibial nerve
        posterior tibial vessels

Question 4

EVAR criteria

Answer 4

60 32 15 7 hike (about 1/2 every time)

60 dgr angulation
32 mm diameter
15 mm neck
7 (6-8) mm iliac for sheath

non-friable iliac

Question 5

aortic occlusion balloon

Answer 5

“Coda” balloon 32-40 mm - 14 fr sheeth

“Reliant” balloon 10 - 46 mm 12 fr sheath

Berenstein balloon (boston sc) 11.5 mm 6.f

50% / 50% iodinated contrast -

In inflate until outer edges of the balloon change from convex to parallel as the balloon takes on the contour of the aortic wall

secure with sutures - an assistant

remove sheaths with open exposure of the vessel! (because the are big)

Question 6

Endo leak

Answer 6

I - btw aorta and graft - fix
II - branch to aneurysm sac - Watch
III - between graft components - fix
IV - porosity of graft - Watch
V - lymph seroma - watch

Question 7

assess IMA reimplant

Answer 7

No backflow do not need to re-implant

Brisk backflow do not need to re-implant

Modest backflow less than 40 mmHg - need to re-implant

Back flush graft

Question 8

sudden hypertension during CEA

Answer 8

Lidocaine at the carotid body

2-mL injection of 1% lignocaine into adventitial tissue

Question 9

Treatment of a free-floating clot in the iliac vein

Answer 9

IVC filter

Question 10

Treatment of DVT inferior/Below the inguinal ligament

Answer 10

Anti coagulation

Question 11

Duration of anticoagulation after PE

Answer 11

Six months if provoked

Lifetime if unprovoked

Question 12

After IBC filter placed do you need anticoagulation

Answer 12

Yes because filter itself is thrombogenic

Question 13

inflammatory aneurysm

Answer 13

fibrotic reaction involving the aortic wall and retroperitoneum is encountered. The inflammatory reaction may involve the duodenum, inferior vena cava, left renal vein, and ureters and is manifested as a thick white plaque overlying the aorta. Inflammatory aneurysm is an important cause of abdominal pain in patients with abdominal aortic aneurysms that must be distinguished from ruptured aneurysms on CT scans or MRI. These aneurysms are best repaired via the retroperitoneal approach mobilizing the aorta above the renal vein, taking care not to dissect the duodenum off the aneurysm wall. Venous anomalies such as left-sided or double inferior vena cava should be identified and preserved. ♦ No attempt should be made to dissect the aorta or iliac arteries circumferentially to minimize the risk of venous bleeding. ♦ Elective ligation and division of the left lumbar vein allows cephalad retraction of the renal vein, reduces the risk of bleeding, and improves exposure. ♦ Large lymphatic vessels and the cisterna chyli are often present at the level of the renal vein and should be suture ligated to prevent the rare occurrence of chylous ascites. ♦ Dissection of the left common iliac artery bifurcation should be undertaken by dividing the lateral peritoneal attachments of the descending colon, thus avoiding injury to the hypogastric nerves bilaterally. Routing the left limb of the graft through the lumen of the common iliac artery also minimizes the risk of this complication. ♦ If the renal vein is not present in its usual anterior location, a retroaortic

renal vein should be suspected and care taken in placing the proximal clamp. ♦ Rectal bleeding in the early postoperative period should prompt careful sigmoidoscopy and prompt return to the operating room if significant ischemia is present or acidosis persists.

Townsend Jr., Courtney M.; B. Mark Evers (2010-04-16). Atlas of General Surgical Techniques (Kindle Locations 12469-12471). Elsevier Health Sciences. Kindle Edition.

Question 14

DRIL

Answer 14

distal revasc interval ligation

Bypass anastomoses are proximal and distal to fistula so the blood sees proximal bypass first the remaining blood goes to the fistula

The brachial artery and proximal to the distal bypass can be ligated

Question 15

What are guidelines for graft flow and depth below skin

Answer 15

6 mm below skin
600 mL per minute flow equals mature

No more than 15 mmHg difference info

Question 16

Back bleeding pressure in the I am a that would require reimplantation

Answer 16

Less than 30 – 40

Unless included then you do not need to re-implant

Question 17

Order of clamp release in carotid end are directing me

Answer 17

ICE is NICE

Internal carotid on
Common carotid on
External carotid on

back flush

External carotid off
Common carotid off
Internal carotid off

Question 18

Just prior to completion of the arterial closure, the carotid clamps are sequentially briefly released and re-clamped in what order

Answer 18

to back bleed
ECA
ICA

and

forward flush
CCA

then irrigated with heparinized saline and suctioned of any residual debris.

After the suture line is completed, flow is restored first to:
ECA
ICA

(Uptodate)

Question 19

Endograft requirements for AAA

Answer 19

60°
32 mm
15 mm
6 – 8 mm

Question 20

Anterior spinal cord syndrome

Answer 20

Anterior = Anterior Lateral System
- spinothalamic tract

Lose pain and temperature

lose motor

(preserved light touch and proprioception)

Lumbar drain upper limits of blood pressure)

Question 21

max diameter of IVC for IVC filter

Answer 21

28 mm

Question 22

Diameters for EVAR

Answer 22

60 dgr
32 mm
25 mm (iliac)
15 mm neck infra renal
6 mm femoral sheath required

Question 23

Hypercoag work kup

Answer 23

C deficiency
S deficiency
Antithrombin III def

Lupis anticoag
Anticardiolipin
Antiphospholipid

factor V leidin

Prothrombin

Question 24

What needs to happen before you showed anyone for peripheral vascular trauma

Answer 24

Give heparin!