Vascular Flashcards
What is the most common site of stenosis in the carotids?
At the bifurcation
What is the flow pattern in the external vs internal carotid?
Internal -> continuous flow
External -> triphasic flow
What two arteries allow for communication of the ECA and ICA?
Ophthalmic and internal maxillary artery
What is the tx for a carotid traumatic injury with fixed deficit?
Occluded -> do not repair due to bleeding risk
Not Occluded -> Repair
What are indications for CEA?
Symptomatic > 70%, asymptomatic > 80% stenosis
If recent stroke wait 4-6 weeks
What side should be repaired first in bilateral carotid disease?
Tightest side first, if equal then repair dominant side first
What is the most common complications from CEA?
Vagus injury > hypoglossal > glossopharyngeal
What is the treatment for pseudoaneurysm after CEA?
Drape and prep prior to intubation, then intubate and repair
What causes hypertension post-CEA?
Damage to carotid body
What are indications for repair of ascending aortic aneurysms?
Acutely symptomatic
> 5.5 cm (5.0 with Marfan’s)
>0.5 cm/yr size increase
What are indications for repair of thoracic descending aortic aneurysms?
> 5.5 cm for endovascular
>6.5 cm for open repair
What are indications for operative management of thoracic descending dissections?
Ischemia or contained rupture
What is the most likely site of rupture for a AAA?
Left posterolateral wall, 2-4 cm below renal arteries
What are significant risk factors for rupture?
Diastolic HTN
COPD
What are indications for AAA repair?
Symptomatic
> 5.5 cm
Growth > 0.5 cm/yr
What are indications for IMA re-implantation?
Backpressure < 40 mmHg (poor back-bleeding)
Previous colonic surgery
Stenosis at SMA
Inadequate flow to left colon
Why should you ensure flow to at least one internal iliac when performing aorto-bifemoral repair?
To avoid vasculogenic impotence
What is the most common vein injury with aortic crossclamp in AAA repair?
Retro-aortic left renal vein
What are causes of death after AAA repair?
Acute -> MI
Late -> Renal Failure
What are risk factors for mortality in AAA repair?
Cr > 1.8, CHF, ischemia on EKG, COPD, increased age, female sex
What are the types of endoleaks?
I: Graft attachment sites (Tx extension cuffs)
II: Collaterals (Observe or embolize)
III: Overlap sites (secondary endograft)
IV: Wall porosity or suture holes (observe)
V: Expansion of aneurysm without evidence of leak (re-do EVAR or open repair)
Where are adhesions found in inflammatory aneurysms?
3rd/4th portions of duodenum Ureteral entrapment (25%)
What is the most common causes of mycotic aneurysms?
Salmonella > Staphylococcus
What are sx/signs of mycotic aneurysm?
Pain, fevers
Periaortic fluid, gas, RP soft tissue edema, LAD
What is the tx for mycotic aneurysm?
Extra-anatomic bypass and resection of aorta to clear infection
What is the most common cause of aortic graft infection?
Staph > E. Coli
Blood cultures often negative
What is the treatment of infected aortic graft?
Bypass through non-contaminated field and resection of graft
What are the signs of an aortoenteric fistula?
Herald bleed with hematemesis
Then blood per rectum
Usually erode into the duodenum
Where do claudication symptoms occur relative to the lesion?
Symptoms occur one level below lesion
What is Leriche syndrome?
Occlusion at the aortic bifurcation:
- No femoral pulses
- Buttock or thigh claudication
- Impotence
What is the most common location for lower extremity PAD?
Hunter’s Canal (distal SFA exit)
What are the ABIs for symptoms?
< 0.9 - Claudication
< 0.5 - Rest Pain
< 0.4 - Ulcers
< 0.3 - Gangrene
Where should synthetic grafts not be used?
Below the knee
What must you check for when doing an aorto-bifemoral repair?
Flow to at least 1 internal iliac artery (want good back bleeding from at least one artery, or else need to bypass to internal iliac as well)
Why are distal lesions more limb threatening?
Lack of collaterals
What is the 5-year patency for LE bypasses?
Fem-pop: 75%
Femoral-Distal: 50%
What is a complication of femoral-femoral crossover graft?
Vascular steal in the donor leg
What are the #1 causes of saphenous vein graft failures?
Early - Technical problem
Late - Atherosclerosis
What is a Mal Perforans ulcer?
Ulcer at metatarsal heads (2nd MTP most common)
When is re-perfusion/compratment syndrome more likely to occur?
With ischemia times > 4-6 hours
What is the most common site in the leg for compartment syndrome?
Anterior compartment (results in foot drop)
What are the symptoms of popliteal entrapment syndrome?
Loss of pulses with plantar flexion.
Cause is medial aviation of artery around medial head of gastroc
What is adventitial cystic disease?
Men in 40s. Bilateral ganglia originate from joint capsule causing compression in popliteal fossa (most common). Symptoms change with knee flexion/extension
What is the most common site of peripheral obstruction from emboli?
Common femoral artery
What is atheroma embolism?
Cholesterol clefts that lodge in small arteries. Renals most common site
What is the most common source of Blue Toe Syndrome?
Aortoiliac disease that keeps embolizing
What is the treatment of acute arterial thrombosis?
Threatened limb -> heparin and OR
Non-threatened -> angiography and thrombolytics
What is the most common site of renal atherosclerosis?
Proximal left artery
What are indications for nephrectomy with renal HTN?
Atrophic kidney < 6 cm with persistently elevated renin levels
What is the most common site of upper extremity occlusive disease?
Subclavian artery
What is the most common symptom of TOS?
Neurologic involvement with ulnar nerve involvement (triceps weakness and intrinsic hand muscles)
What is the common cause of subclavian artery TOS?
Anterior scalene hypertrophy (weight lifters) causing hand pain from ischemia
What is Adson’s test?
Absent radial pulse with head turn to ipsilateral side
Why can you have motor function in digits after prolonged hand ischemia?
Motor groups for digits are in proximal forearm
What history elements might distinguish SMA embolism from thrombosis?
Thrombosis has more chronic history of food fear, weight loss
What are the symptoms of mesenteric venous thrombosis?
Bloody diarrhea, cramps pain
Hx of: vasculitis, hyper coagulable, portal HTN
What are Griffith’s and Sudan’s areas?
Watershed areas in colon, splenic flexure and upper rectum respectively
What is median arcuate ligament syndrome?
Celiac artery compression causing bruit near epigastrum
What is the arc of Riolan?
important collateral between SMA and IMA
What are the common complications of aneurysms above and below the inguinal ligament?
Above -> Rupture
Below -> Thrombosis
When should splanchnic artery aneurysms be repaired?
> 2 cm EXCEPT splenic
When should splenic artery aneurysms be repaired?
Symptomatic
Pregnant
Childbearing Age
>3-4 cm
What is the treatment for splanchnic artery aneurysms?
Covered Stent (bypass if fails) Splenic -> Ligate aneurysm
When should renal artery aneurysms be treated?
> 1.5 cm -> covered stent
When should iliac and femoral artery aneurysms be treated?
Iliac > 3 cm
Femoral > 2.5 cm
What are surgical indications for a popliteal aneurysm?
> 2 cm
Mycotic
Symptomatic
What is the treatment of choice for popliteal aneurysms?
Exclusion and bypass NOT covered stent
What is implied by a pseudyaneurysm at a suture line months to years after surgery?
Graft infection
What is the classic imaging finding of Breuger’s disease?
Corkscrew collaterals
What are the timelines of radiation arteritis?
Early -> Sloughing/thrombosis
Late (1-10 years) -> scar, fibrosis, stenosis
Very late (3-30 years) -> atherosclerosis
What is the most common cause of dialysis graft failure?
Venous obstruction due to intimal hyperplasia
What is Phlegmasia Alba Dolens?
Tenderness + Pallor + edema
Tx: Heparin
What is Phlegmasia Cerulia Dolens?
Tenderness + cyanosis + massive edema
Tx: Heparin (rarely surgery)
What is the source of a PE with an IVC filter in place?
Ovarian veins, IVC superior to filter, SVC/upper extremities
What is the most common organism causing cellulitis and lymphangitis?
Strep
What is Stewart-Treves syndrome?
Lymphangiosarcoma from chronic lymphedema 2/2 breast axillary dissection
