VASCULAR Flashcards
Best options for SMA bypass for chronic mesenteric ischemia
- suprarenal aorta (infrarenal typically has high degree atherosclerotic burden)
- right iliac artery
Sxs of chronic mesenteric ischemia
postprandial abdominal pain, fear of food, unintentional weight loss (not typically N/V)
To remember for traumatic isolated LE vascular injuries…
- death MC injuries to CFA/SFA than to pop/tib arteries
- death MC penetrating injuries than blunt
- amputation MC injuries to pop/tib than CFA/SFA
- amputation MC blunt injuries than penetrating
Mgmt for penetrating wound close to major vascular structure, but wo hard signs of vascular injury…?
arterial pressure index (API) - doppler arterial pressure distal to site of injury/doppler pressure in uninvolved contralateral extremity
- if <0.9 -> need angiography
- if >0.9 -> unlikely to have vascular injury
Surgical approach for repair of popliteal artery? Exposure gives view of what structures?
medial incision of popliteal space w/ division of medial head gastrocnemius and semimembranosus and semitendinosus muscles - exposure gives complete view of poplliteal artery/vein and tibial nerve
Mgmt ileofemoral DVT
cath-directed pharmacologic thrombolysis or pharmacomechanical thrombectomy
Criteria for early thrombus removal of first episode acute iliofemoral DVT
- symptom duration <14d
- low risk bleeding
- ambulatory
- good functional capacity
Why iliofemoral DVT worse prognosis than femoropopliteal DVT?
- associated with long-term postthrombotic syndrome, which is related to residual venous obstruction and valvular reflux
- associated with higher risk recurrent VTE
What is “nonocclusive” mesenteric ischemia due to?
typically low-flow states - dehydration, sepsis, cardiac failure, vasopressor use
Presentation of nonocclusive ischemic colitis
acute onset abdominal pain, cramping, bloody diarrhea (2/2 mucosal injury)
Mgmt ischemic colitis
bowel rest + IV fluids
Tx DVT (including iliofemoral, unless life-threatening) during pregnancy
SQH for duration of pregnancy + 6-wk post-partum
Can repair of thoracic aorta be done endovascularly in pediatrics?
NO - bc growing.
Blockage of left subclavian artery during TEVAR may result in…
- paraplegia: blood supply to upper spinal cord through vertebral artery connection to anterior spinal artery
- left arm ischemia
- vertebrobasilar ischemia: covering flow to left vertebral artery results in reversal of blood flow in left vertebral, stealing flow from posterior circulation
Sxs of vertebrobasiliar ischemia
syncope, diplopia, vertigo
Is angiography good way to dx colonic ischemia?
NO - bc colonic ischemia (unlike midgut mesenteric ischemia) is usually associated with small vessels
Mesenteric venous thrombosis typically associated with…?
hypercoagulable state
Presentation of mesenteric venous thrombosis
slow onset abdominal pain, made worse by meals, +/- abdominal distention - hx hypercoag state
Postthrombotic syndrome (PTS)
occurs after DVT destroys compentency of deep venous valvular system -> reflux and HTN of venous system -> swollen, heavy, and painful leg that is worse with standing/walking
Mgmt postthrombotic syndrome
anticoag 6-mo + compression stockings for at least 24-mo
Surgical approach to access origin/proximal/distal subclavian artery
@origin - partial or complete sternotomy
@prox left - anterolateral
@distal or right side - supraclavicular
Can pts receiving thrombolytic therapy also receive heparin?
YES.
Association of thrombolytic therapy and stroke?
Thrombolytic therapy associated with 3x increase risk of periprocedural stroke
Anatomical relationship between right vs. left external iliac vein and artery
Right: vein posterior and lateral to artery
Left: vein posterior and medial to artery
MC acute thoracic aortic pathology
aortic dissection
If have flank/abdominal pain with known aortic dissection, think…?
progression of intimal tear -> occlusion renal or mesenteric vessels -> ischemia
MC occurring visceral aneurysm (#1, #2)
splenic (#1), hepatic artery (#2)
MC location of aneurysm along splenic artery
75% occur in distal third
“Saturday night palsy”
compressive brachial plexopathy and ischemia of UE -> may need compartment release
Pts with popliteal artery entrapment syndrome will usually c/o…?
calf pain with walking
Dx imaging for popliteal artery entrapment syndrome
angiography or MRI w/ pt’s feet in both dorsiflexion and plantar flexion (provocative studies)
Sxs chronic exertional compartment syndrome
pain or tightness, cramping, burning, or aching over affected compartment with exercise; may also have weakness
Dx chronic exertional compartment syndrome
measuring pre- and post-exercise compartment syndrome
Risk factors with immediate score of 5 on Caprini model = highest risk
- stroke within past month
- elective major LE arthroplasty
- hip, pelvis or leg fx within past month
- acute spinal cord injury (paralysis) within past month
- multiple trauma within past month
Effected bowel in acute embolic vs. thrombotic mesenteric ischemia
Embolic (occludes SMA distal to middle colic): sparing of proximal jejunum + transverse colon
Thrombotic (occludes at proximal SMA): all SMA effected
Prevention of post-thrombotic syndrome after acute DVT involves…?
wearing 30-40mmHg compression stockings from time of dx for up to 2 years
What is post-thrombotic syndrome?
development of chronic pain, swelling, ulceration, and discoloration after DVT - may develop ulceration 2/2 venous stasis
RF post-thrombotic syndrome
- older age
- proximal DVT
- recurrent DVT in same limb
- morbid obesity
- persistent sxs despite AC
Mgmt: penetrating injury w/o hard signs vascular injury
ABI - if <0.9, need to further evaluate with CT angio
Fistula stenosis physical exam finding (what type of flow?)
pulsatile flow compared to palpable thrill
May-Thurner syndrome
(Iliac vein compression syndrome)
2/2 compression of common venous outflow tract of LLE that may cause swelling and DVT in iliofemoral veins
MC nerve damaged during LE fasciotomy
Superficial peroneal nerve
Location of artery of Adamkiewics
Between T7 and L1
MC location which cardiac emboli lodge in LE
Common femoral artery
What does monophonic signal suggest about flow?
Proximal occlusion with patent distal vessels
Most significant RF for stroke
HTN
MCC ischemic stroke
Cardioembolic disease
Which PSA not likely to spontaneously thrombose (aka. Need intervention) after angio puncture?
- > 3cm size
- presence of anticoagulation
Steps of thrombin injection for Tx of PSA
- Duplex US: characteristic “swirling” flow within cavity
- US-guided needle injection of thrombin
- 1000U/cc thrombin injected SLOWLY over 15s - once thrombosis achieved, must stop injection to avoid thrombin reaching circulation
- bed rest for 1hr
- repeat duplex US in 24hrs to confirm thrombosis
Patho of arterial wall thickening (HTN) 2/2 atherosclerosis
Artery wall thickens due to invasion and accumulation of WBC and proliferation of intimacy smooth muscle cells
Patho fibromuscular dysplasia (on micro vasculature level)
Multi-focal fibroplasia -> thickening of media and collagen formation
Visceral aneurysms listed from descending order of incidence
spleen > hepatic
Pt w/ recent exposure to heparin, who presents with acute thrombosis… suspect?
HIT
Approach for LE open embolectomy
- CFA preferred site of cutdown
- once exposed, vessel loops to gain control of artery
- transverse arteriotomy preferred incision to avoid narrowing of vessel upon closure
- embolectomy cath passed both prox and distal until back bleeding achieved
- completion angiogram
Appropriate diameter of vein and artery for HD access
Vein >3mm without evidence signif stenosis
Artery >2mm
MCC (#1 and #2) of peripheral arterial embolic occlusion
#1 = atrial fibrillation #2 = proximal atherosclerosis
Which mesenteric artery cannot be ligated even in trauma? (Bc incompatible with life if ligated)
SMA
Renal artery stenosis causing HTN in young females typically caused by…?
fibromuscular dysplasia
Pathophys: fibromuscular dysplasia
thickening of media and collagen formation
s/p TEVAR, with bloody diarrhea that improves with fluids and IV Abx… next step to evaluate?
sigmoidoscopy - black mucosa signifies transmural necrosis and needs OR
(NOT CT angio A/P bc cannot evaluate severity)
MC organism non-aneurysmal aortic infection
salmonella
MC organism aortic infections (both aneurysmal and non)
S.aureus - associated with aneurysmal degeneration
on US, acute DVT vs. chronic DVT appears how?
acute = echolucent (black) chronic = echogenic (white)
Tx septic thrombophlebitis superficial vs. deep veins?
Abx and excision of superficial vein (entire lenght) - if deep/central veins, then only IV Abx + hep gtt for 2-3wk (cannot excise)
Paget-Schroetter syndrome
venous thoracic outlet syndrome; exercise-induced thrombosis of subclavian and axillary veins
Sxs and Tx Paget-Schroetter syndrome
Sxs: short hx pain/swelling arm
Tx: cath-directed thrombolysis
Vessel lumen is not compromised until >?% stenosis occurs
> 40%
Nerves that may be damaged during CEA and their deficits
- vagus nerve (long recurrent laryngeal): hoarseness
- superior laryngeal (br off vagus): loss high-pitches
- marginal mandibular: drooping of ipsilateral lip
- hypoglossal: ipsilateral deviation of tongue
Which LE artery has longest patency after angioplasty?
iliac arteries - proximal has better patency
Dx compartment syndrome via pressure transducer
pt’s compartment pressure - pt’s DBP <30mmHg, then Dx supported
Presentation of porto-mesenteric vein thrombosis (PMVT)
abrupt onset abdominal pain >10d after discharge (s/p bypass)
Thickness of vein wall for acute vs. chronic DVT
Acute = thin, smooth Chronic = thick, contracted (2/2 inflammation)
Rule of 6s criteria for cannulation of dialysis access
- vein diameter 6mm
- access depth of 6mm
- access flow of 600 cc/min
30d mortality for endovascular vs. open repair of infrarenal AAA
endo: 1.6%
open: 4.8%
* no long-term benefit shown with EVAR vs. open
90d mortality for open thoracoabdominal aneurysm repair
8-10%
% mortality endo vs. open repair of ruptured AAA
endo: 25%
open: 50%
