Vascular Flashcards
What are the common sites for plaque formation in arteries
Branch points (carotid bifurcation) Tethered sites (SFA)
What are the three layers of artery?
- Intima 2. Media 3. Adventitia
What is a true aneurysm?
Dilation (>2xnL diam) of all three layers of vessel
1 Aorta
2 Internal iliac (hypogastric)
- External iliac
- common femoral
- Profundi femoral artery
- Superficial femoral artery (SFA)
- Popliteal
- Trifurcation
9 Anterior tibial artery
10 Peroneal artery
- Posterior tibial artery
- Dorsalis pedis artery
How can you remember the orientation of the lower exterior arteries below the knee on A-gram?
LAMP
Lateral Anterior tibial
Medial Posterior tibial
What is the most common site of arterial atherosclerotic occlusion in the lower extremities?
SFA in hunters canal
What are the sx of PVD?
Intermittent claudication, rest pain, erectile dysfunction, sensorimotor impairment, tissue loss
What is Intermittent claudication
Pain and cramping (usually in calf) after walking a specific distance, resolves when stop walking for a certain amount of time.
What is rest pain
pain in LE (usually top of foot) arising at rest, usually when sleeping
SIGNS of PVD
absent pulses, bruit, muscular atrophy, decreased ahair growth, thick toenails tissue necrosis/ulcers/infusions
ABI’s associated with normals, claudicators and rest pain
Normal ABI->/= 1.0
Claudicator-<0.6
Rest pain - <0.4
Why would a pt get a false ABI reading
Completely calcified arteries (esp. pt’s with DM)
Indications for surgical tx of PVD
STIR
Severed claudication refractory to tx
Tissue necrosis
Infection
Rest pain
What is risk of limb loss w/ claudication
5% in 5 years
What is the risk of limb loss w/ rest pain
>50% of these pts will lose a limb at some point
in pt with PVD what is the main post op concern?
CARDIAC!!! - Most pt’s with PVD have coronary artery dz as well.
MI is most common cause of post op death after a PVD operation
What are the classic signs/symptoms of acute arterial occlusion?
the 6 p’s
Pain
paresthesias
paralysis
pallor
Poikilothermia
Pulselessness
What is the immediate preoperative management of acute arterial occlusion
- Anticoagulate wit hIV heparin (bolus w/ cont infusion)
- A-gram
What is the most common cause of embolus from the heart?
afib
What is the most common site of arterial occlusion by an embolus
carotid artery
(SFA mc site of arterial occlusion from atherosclerosis)
What is the tx for acute arterial occlusion?
surgical embolectomy with cutdown
fogarty balloon
What is the most common site for AAA
Infrarenal
What are sx of AAA?
Most commonly asymptomatic
Signs of ruptured AAA?
1 abd pain
- pulsatile mass
3 hypotension
Laplace’s Law
Wall tension = pressure x diameter
What are indications for AAA surgery?
AAA >5.5cm diameter
rupture of AAA
Any size AAA with rapid growth
symptoms/embolization of plaque
What is the mortality rate for elective rx of AAA
4%
What is the mortality rate for AAA that is ruptured?
~50% operative mortality
What is the leadign cause of post op death in pt undergoing elective AAA tx
MI
What is mean normal aortic diameter
2cm
Why is colonic ischemia a concern with AAA rx?
often the IMA is sacrificed during surgery. if collaterals are not adequate pt will have colonic ischemia
Operative complications of AAA rx?
MI
Atheroembolism
declamping hypotension
acute renal failure
uretal injury
hemorrhage
sx of colonic ischemia
Heme positive stool
Bright red blood per rectum
diarrhea
abdominal pain
What is the possible long term complication that oftn presents with both upper and lower GI bleeding?
Aortoenteric fistula
What are sx of anterior cord syndrome (complication of AAA repair)
- Paraplegia
- Loss of bladder/bowel control
- Loss of pain/temp sensation below level of involvement
- SPARING OF PROPRIOCEPTION
How is a graft infection with an aortoenteric fistula tx?
xtra-anatomic bypass (ax-bifem)
Which vein crosses the neck of athe AAA proximally?
L renal vein
What part of the small bowel crosses in front of the AAA
Duodenum
Which artery comes off the middle of the AAA and runs to the left?
Inferior mescenteric artery
Which vein runs behind the R common iliac artery?
L common iliac vein
which renal vein is longer?
L
sx and sg of carotid vascular dz
Amaurosis fugax
TIA
Reversible ischemic neurologic deficit
CVA
Indications for CEA in Asymptomatic patient?
Carotid Stenosis >60% (greates tbenefit is probably in pt’s with >80%)
Indications for CEA in SYMPTOMATIC patient
Carotid stenosis >50%
Post operative complications for CEA
CVA
MI
hematoma
wound infection
hemorrhage
hypiotension/hypertension thrombosis
vagus nerve injury (change in voice)
Hypoglossal injury (ipselateral tongue deviation)
Mortality rate of CEA
~1%
Most common cause of death during early postop period for vascular surgery
MI
What thin muscle is cutright under the skin in the neck?
Platysma
What are the branches of the ICA?
NONE
Which vein crosses the carotid bifurcation?
facial vein
What is the first branch of the external carotid
Superior thyroid
What muscle crosses the common carotid proximally
Omohyoid
Which muscle crosses the carotid artery distally?
Posterior belly of the digastric (D=Distal, D=digastric)
Which nerve crosses approximately 1cm distal to the carotid bifurcation
Hypoglossal
Which nerve crosses the interal carotid near the ear
facial nerve
What is in the carotid sheath
- Carotid artery
- internal Jugular vein
- vagus nerve
- Deep cervical lymph nodes
what should be examined in a pt with politeal artery aneurysm
contralateral side - 50% of pt’s with pop artery aneurysm have one on contralateral side
rest of arterial tree (especially aorta) - 75% of all patients with popliteal aneurysm have additional aneurysms elsewhere (50% are located in aorta/iliac)
What are indications for elective surgical rx of a pop aneurysm?
- >/= 2cm in diameter
- Intraluminal thrombus
- artery deformation
Indications for surgical rx of following aneurysm?
Thoracic aorta
>6.5%
Indications for surgical rx of following aneurysm?
Abdominal aorta
>5.5cm
Indications for surgical rx of following aneurysm?
Iliac artery?
>4cm
Indications for surgical rx of following aneurysm?
Femoral artery
>2.5cm
Indications for surgical rx of following aneurysm?
Popliteal artery
>2cm
what are the branches of the ECA
Superior thyroid
Ascending pharyngeal
Lingual
Facial
occipital
posterior auricular
maxillary
superficial temporal
What order are the clamps put on in CEA
I C E
Internal
Common
External
What order are the vessels unclamped in CEA?
E C I
External
Common
Internal
What is median arcuate ligament syndrome
mesenteric ischemia from narrowing of the celiac axis vessels by extrinsic compression by the median arcuate ligament
What is the median arcuate ligament comprised of?
Diaphragm hiatus fibers
What are symptoms of median arcuate ligament syndrome?
Postprandial pain, weight loss
What are SIGNS of median arcuate ligament syndrome?
Abd bruit in almost all pateints
Tx: of median arcuate ligament syndrome?
Release arcuate ligament surgically
What are associated risks/clues of renal artery stenosis
Fam hx
early onset HTN
HTN refractory to medical tx.
sx/sg of renal artery stenosis
Most are asx but may have HA
DIASTOLIC HTN
Flank bruit
Dec renal fxn
What are dx tests of renal artery stenosis
Agram (GOLD STANDARD)
IVP
Renal vein renin ratio
What is surgical tx for renal artery stenosis?
Invasive but non-surgical tx for renal artery stenosis?
Surgical - Resection, bypass, vein/graft interposition, or endarterectomy
Non-surgical - PRTA/stenting
What anti-hypertensive med is CONTRAINDICATED in pt w/ hypertension from renovascular stenosis
ACE - I
Define “Milk leg”
AKA plegmasia alba dolens;
Often seen in pregnant women w/ occlusion of iliac vein resulting from xt. compression by uterus
Phlegmasia cerulea dolens
2nd to severe venous outflow obstruction and results in cyanotic leg: extensive venous thrombosis results in arterial inflow impairment
Takayasu’s arteritis
arteritis of the aorta and aortic branches, resulting in stenosis/occlusion/aneurysms
Buerger’s disease
thromboangitis obliterans; seen in young men who smoke
Digital gangrene –> amputations
Tx for beurger’s disease
smoking cessation
+/- sympathectomy
