Vascular Flashcards
Carotid Screening?
Age > 70 w/ atherosclerotic RF: Cardiac disease Smoker PVD TIA/Stroke - only 20% of all strokes Bruit on exam - get duplex US
How to screen
Duplex US
Duplex US criteria
> 50-60% symptomatic dz
80% asymptomatic dz
PSV in ICA > 230
Medical mgmt for carotid dz
ASA + Statin + stop smoking
Beta blocker
Control DM
Transient monocular visual loss
Amaurosis Fugax
Tx for Carotid Stenosis
CEA
Structures worried about injuring
Vagus - Carotid sheath (btw IJ and Carotid) - hoarseness
Hypoglossal - just sup to carotid bifurcation, ipsilateral tongue deviation
Glossopharyngeal - oropharygeal dysfunction
Marginal mandibular branch of facial - mouth drooping, traction stunning - usually see in higher dz around angle of manible (retract on digastric muscle instead)
BP dropping during CEA
Hitting carotid body - Parasympathetic fibers ->
inject 1% lidocaine to fix
Clamping, non shunting
Stump pressures > 40
EEG - selective shunting
Keep awake - most sensitive indicator of cerebral perfusion
External carotid flows
Similar to peripheral artery - Triphasic flow
Internal carotid flows
Uninteruppted, continual flow - biphasic flow (diastolic)
Aortic Dissection
Class A - Ascending Aorta
Class B - Descending Aorta (post L subclavian)
Marfan’s
Dissections in medial layer
Type A dissection
CT surgery reconstruction of aortic arch
Type B dissection
Medical if no end organ problems
Meds:
BP - esmolol drip, nipride (reduce afterload)
Complications of TEVAR
Paraplegia
MI
Renal failure
Minimize risk of paraplegia
Permissive HTN
Lumbar drain
Most dangerous area to overlay (what artery)
Artery of adamkiewicz aroudn T8 - L1
Supplies blood from aorta to spine
RF for AAA formation
HLD, HTN, Smoking, Age
FmHx is the most potent risk factor
Repair of AAA?
Asymptomatic > 5.5 cm for M, > 5 F
Growth > 1 cm / year
AAA is a disease of what part of the artery
Media
AAA Tx
EVAR Must have adequate neck length (15 mm landing zone) - Below renals and before hypogastrics Neck diameter infrarenal must be < 30 mm Not too much angulation < 60 Deg Iliacs > 8 mm but < 18 mm
Types of endoleak
Type 1a: Leak at proximal
Type 1b: Leak at distal
Type 2: Retrograde flow from lumbar or intercostals
Type 3: Structural failure of graft, leakage btw components of graft
Type 4: Leakage through graft due to porosity
Type 5: Endotension
Must Fix 1/3 prior to leaving OR
Small type 2 endoleaks can be observed
1 reason AAA and CEA patients die in hospital?
MI
Pass blood per rectum on POD 1 after AAA repair
Colonic ischemia
Sigmoidoscopy, fluid resuscitation, abx if not crashing
Colectomy if crashing
If has AAA, must look at…
Popliteal
Popliteal aneurysms complications
Thromboembolic
When to treat pop aneurysms
> 2 cm
With thrombus inside
Iliac aneurysm
3.5 cm to 4 cm
Tx for popliteal aneurysm
Medial approach with exlusion and bypass (saphenous vein) for small
Posterior approach for large (stent graft gore viabond), complication is acute thrombosis
Open AAA w/ hematemesis 6 months post repair
Herald bleed of aortoenteric fistula
Duodenum lies of incision line
Tx of aortoenteric fistula
AxFem bypass - same that you do for any infected graft
Debride aorta, remove graft, omentum into dead space
Mycotic aneurysm bugs
Stapholococcus
Salmonella
Infected aortic graft
Staph epi
E. Coli
Intermittent claudication med tx
Statin, ASA, stop smoking, exercise program, cilostazol
What % of patients with claudication need amputation
5% in 5 years
ABIs
Not reliable in DM, CKD (calcification of arteries), Obese people
Get Toe pressures on them (<30 is critical limb ischemia)
< 0.4 for critical limb ischemia
< 0.9 for intermittent claudication
Smoker distribution
Proximal disease
Ileofemoral
Diabetes distribution
Distal
Below the knee
Determine level of disease
1 level above pain
Lariche syndrome
Buttock claudication No femoral pulses Impotence Lesions at aortic bifurcation or above Tx: Aortobifem graft
Where to sew in aortobifem graft
Where SFA and profunda take off - distal CFA
Finished fem-tib bypass and goes down < 30 days
Technical error
1-2 yrs intermediate failure
intimal hyperplasia
MC occurs @ graft venous anastamosis
> 2 yrs late bypass graft failure
Progression of atherosclerotic dz Inflow or outflow vessels
Fistula access
Vein mapping 3 mm vein for autologous graft Start distal (radiocephalic, then brachiocephalic)
Ensure not at risk for steal pre op
Allen test
Ulnar aa is dominant in 80% of people
Immediate post op terrible pain after fistula
IMN - steal syndrome to nerves
Can develop Volkmann’s contracture
Need to go back to OR
Tingling out of OR -> cramping in hand when doing dialysis 6 weeks later
Steal syndrome
1st improve arterial inflow with endovascular ballooning etc
DRIL
Too little blood going to hand
Rule of 6s
6 mm of skin
600 cm/sec
Dilate up to 6 cm
6 weeks post op for maturation
Venous insufficiency
Medial malleolus ulcer
Edema
Small veins in foot
Tx: Compression therapy, evaluate with duplex us, if reflux in saphenous
Buerger Disease
Young M smoker with necrosis of fingers
Angiogram -> corkscrew collaterals
Tx: stop smoking
Fibromuscular dysplasia
Female renal a HTN, beaded vessels
Tx: Angioplasty
Marfan’s
Defect in fibrillin gene, dissections and aneurysms
Ehler’s Danlos
Defect in collagen, dissections and aneurysms
Kawasaki’s disease
Febrile kid, aneurysm in coronary aa.
Giant cell arteritis
HA, blurred vision
Tx: Steorids
Tx for catheter related venous thrombosis
Remove catheter and start anticoagulation
