Vascular

Question 1

what is hyperperfusion syndrome after a CEA? pathophysiology? treatment?

Answer 1

impaired autoregulation of cerebral blood flow – typically occurs POD#5, management = control BP (beta blocker), avoid vasodilators, and anti-seizure meds

Question 2

young female with dizziness, syncope, upper extremity claudication, elevated ESR, absent radial and carotid pulses. dx / tx?

Answer 2

Takayasu arteritis - inflammatory disease, involves branches of aorta and coronary/pulmonary arteries, tx w/ steroids and cytotoxic agents – carotidynia (pain along the inflamed arteries) pathognomonic for Takayasu arteritis

Question 3

features and management of blunt carotid injury

Answer 3

Horner syndrome is common with this injury - anticoagulation (heparin) or antiplatelet is the treatment of choice for small dissection

Question 4

indication for screening for blunt carotid injury

Answer 4

severe cervical hyperextension/hyperflexion, closed head injury w/ DAI, near hanging and resulting anoxic brain injury, seat belt abrasion to anterior neck, basilar skull fracture involving carotid canal, cervical vertebral body fx

Question 5

causes of re-stenosis – within 1 month? 1 month to 2 years? greater htan 2 years?

Answer 5

within 1 month = technical, within 1 month - 2 years myointimal hyperplasia, greater than 2 years usually due to atherosclerosis

Question 6

sudden ICA occlusion in a young patient - dx, tx?

Answer 6

spontaneous dissection. tx w/ anticoagulation

Question 7

characteristics of thromboangiitis obliterans?

Answer 7

non-atherosclerotic inflammation of small-medium sized arteries, veins, nerves of upper and lower extremities, 20-50 yrs old, men who smoke, extensive collateralization / corkscrew collaterals – spares aortoiliac segments / coronary arteries

Question 8

conditions that falsely elevate ABIs?

Answer 8

ESRD and diabetes

Question 9

categories of acute limb ischemia

Answer 9

class 1 (non-threatened) normal motor and sensory function, class 2 (threatened) - 2a sensory deficit only, 2b (immediately threatened) both motor and sensory deficit, class 3 irreversible complete motor and sensory loss

Question 10

management of class 2b ischemia

Answer 10

2b threat of limb loss more immediate, thrombolytics often take more than 24-48 hrs to restore flow, thrombolysis contraindicated, shoudl be taken to OR

Question 11

management of class 3 ischemia

Answer 11

class 3 ischemia w/ irreversible complete motor/sensory loss, proceed w/ amputation

Question 12

causes of acute mesenteric ischemia

Answer 12

embolization (30-50%), arterial thrombosis (mesenteric atherosclerosis), venous thrombosis (hypercoag state), non-occlusive mesenteric ischemia

Question 13

most common area of mesenteric embolization

Answer 13

SMA just distal to the middle colic artery – ischemia spares proximal jejunum and transverse colon

Question 14

management of acute mesenteric ischemia without evidence of peritonitis

Answer 14

heparin drip – if embolic -> open SMA embolectomy, if thrombotic / mesenteric atherosclerosis -> arteriography and possible arterial bypass or stent, if mesenteric vein thrombus -> heparin alone; if NOMI -> correct underlying shock, consider catheter directed papaverine

Question 15

medication for claudication? mechanism?

Answer 15

cilostazol (pletal) – causes inhibition fo platelet aggregation, increases vasodilation more effective than pentoxifylline

Question 16

most common cause of leg edema after fem-pop bypass?

Answer 16

dysruption of lymphatics

Question 17

pt who had CABG who presents with recurrent chest pain / angina – BP R arm > L arm: dx, pathophys, tx?

Answer 17

after cabg w/ LIMA to LAD graft – in setting of subclavian stenosis or occlusion proximal to takeoff of IMA, arm exercise leads to vasodilation of arm vessels and lower resistance (giving flow pref to arm instead of heart -> angina) – either stent subclavian artery or carotid to subclavian bypass

Question 18

how do you obtain operative exposure of the SMA for embolectomy?

Answer 18

1) rotating small bowel to the right, sharply dissecting the ligament of Treitz, 2) SMA will be found at the root of the mesentery 3) transverse arteriotomy (longitudinal will cause stenosis upon closure) and embolectomy w/ Fogarty 4) non-viable bowel resected, borderline viable bowel left in place for second look

Question 19

5 year risk of major amputation in a pt w/ claudication? 5 year survival rate? MCC of death?

Answer 19

1-3.3% risk of major amputation; 70% survival rate (40-60% of deaths caused by coronary artery disease)

Question 20

mesenteric ischemia that spares the proximal jejunum is most likely due to….

Answer 20

embolus – usually lodges just past the SMA origin beyond 1st jejunal branch, often have sparing of proximal jejunum and transverse colon because middle colic artery patent – if thrombosis, usually involves SMA origin and would not spare proximal jejunum

Question 21

most common visceral artery aneurysms? #1, #2

Answer 21

splenic (60%), hepatic (20%)

Question 22

mortality rates of AAA open vs endo? ruptured? elective?

Answer 22

ruptured similar mortality rates, in elective setting endo w/ lower mortality rates

Question 23

popliteal aneurysms and AAA relationship? most common symptom of popliteal aneurysm?

Answer 23

30% of pt w/ pop aneurysm also have AAA – 50% w/ thrombosis causing acute/chronic ischemia, 2nd most common is distal embolization, rupture is rare

Question 24

indications for repair of popliteal aneurysm, surgical approach

Answer 24

large aneurysm (>2 cm), presence of intraluminal thrombus (regardless of size), or symptomatic – can eigher do a medial or posterior approach, typically proceed w/ bypass w/ saphenous vein and ligation of pop artery; also endoaneurysmorraphy – in acute thrombosis, lytics are treatment of choice

Question 25

diagnosis of aortoenteric fistula s/p AAA repair in the hemodynamically stable pt

Answer 25

1) upper endoscopy, 2) CT angio 3) tagged WBC scan (can demonstrate graft infection)

Question 26

surgical treatment of aortoenteric fistula s/p AAA repair

Answer 26

extra-anatomic bypass (ax bi-fem), or excision of graft and insitu placement of human aortic homograft

Question 27

threshold for treating asymptomatic common iliac aneurysjm?

Answer 27

> 3.5 cm

Question 28

what are the endoleak types

Answer 28

type 1 (leak from poor proximal 1a or distal 1b seal), type 2 (leak from collaterals e.g. lumbars), type 3 modular diassociations (from overlapping segments i.e. iliac limb), type 4 (from ‘graft porosity’), and type 5 endotension (who knows)

Question 29

What does a white clot mean?

Answer 29

suggests thrombus from HIIT – prothrombotic state, antibodies to platelet factor 4 and heparin

Question 30

most common congenital hypercoagulable disorder?

Answer 30

factor V leiden - resistance to activated protein C

Question 31

most common acquired hypercoagulable disorder? #1/#2

Answer 31

1 = smoking, #2 = HITT

Question 32

1st branch of internal carotid artery

Answer 32

opthalmic artery

Question 33

1st branch of external carotid artery

Answer 33

superior thyroid artery

Question 34

most common cranial nerve injury with CEA

Answer 34

vagus nerve injury - hoarseness due to RLN

Question 35

symptom of hypoglossal nerve injury?

Answer 35

tongue deviates TOWARDS side of injury - speech/mastication difficulty

Question 36

symptom of glossopharyngeal nerve injury?

Answer 36

difficulty swallowing

Question 37

weird smile after CEA

Answer 37

injury to mandibular branch of facial nerve

Question 38

major vein injury with proximal cross clamp of aorta

Answer 38

left renal vein

Question 39

1 cause of acute death after AAA repair? late death?

Answer 39

MI; renal failure

Question 40

ideal criteria for AAA endovascular repair

Answer 40

neck: length > 1.5 cm, diameter <3 cm, <60 degree angulation; distal (common iliac) length > 1 cm, diameter <1.8 cm – non-torturous, noncalcified iliac arteries

Question 41

most common organisms in mycotic aneurysms

Answer 41

1 salmonella, #2 staphylococcus

Question 42

most common organism in aortic graft infections

Answer 42

1 staphylococcus, #2 e. coli

Question 43

important structures within the lower leg anterior compartment? lateral compartment?

Answer 43

anterior - deep peroneal nerve (dorsiflexion, sensation between 1st and 2nd toes), and anterior tibial artery; lateral - superficial peroneal nerve (eversion, lateral foot sensation)

Question 44

important structures within the lower leg superficial and deep posterior compartments?

Answer 44

superficial - sural nerve (sensory, lateral foot); deep - tibial nerve (plantarflexion, posterior tibial artery, peroneal artery)

Question 45

treatment of homocystinuria

Answer 45

increases risk of atherosclerosis – tx w/ folate and B12

Question 46

pt w/ no femoral pulse, buttock claudication, impotence

Answer 46

lesion at aortic bifurcation or above, tx w/ aortobifemoral bypass

Question 47

mild intermittent claudication, loss of pulse w/ plantar flexion; dx/ tx

Answer 47

popliteal entrapment syndrome == treat w/ resection of medial head of gastrocnemius muscle (w/ or w/o arterial recon)

Question 48

intermittent claudication, worsening syptoms with knee flexion: dx / tx

Answer 48

adventitial cystic disease - often in popliteal fossa, often bilateral, dx is angiogram and resect cyst, vein graft if the vessel is occluded

Question 49

course of the R renal artery?

Answer 49

posterior to the IVC

Question 50

relationship of muscle/vein/artery/nerves between 1st rib and clavicle?

Answer 50

ANTERIOR -> POSTERIOR – subclavian vein, anterior scalene, subclavian artery, brachial plexus, middle scalene / posterior scalene

Question 51

subclavian vein vs subclavian artery compression/thrombus – characteristics, tx

Answer 51

vein thrombus -> Paget-von Schrotter disease; baseball pitchers – venography gold standard, duplex US, tx w/ thrombolytics followed by cervical rib / 1st rib resection, divide anterior scalene; subclavian artery vcompression secondary to anterior scalene hypertrophy (less common), absent radial pulse with head turned to ipsilateral side (Adson’s test), duplex US or angiogram, tx w/ cervical rib and 1stg rib resection, divide anterior scalene

Question 52

bruit near epigastrium, chronic pain, weight loss, diarrhea – dx, tx?

Answer 52

median arcuate ligament syndrome – causes celiac artery compression; tx w/ transection of median arcuate ligament +/- arterial recon

Question 53

treatment of proximal DVT (iliofemoral)

Answer 53

if unprovoked, recommendation is long-term anticoagulation (>12 months) w/ ~2 years of compression; direct Xa inhibitors (dabigatran, rivaroxaban, apixaban, edoxaban) are preferred over warfarin in pt without cancer hx; however pt w/ cancer hx would recommend LMWH over warfarin and Xa inhibitors

Question 54

massive iliofemoral DVT w/ swelling, pain, ischemic foot

Answer 54

phlegmasia alba dolens -> phlegmasia cerulea dolens; treat with thrombolytics

Question 55

heparin drip: what do you bolus with? rate? goal labs?

Answer 55

bolus with 80u / kg, initial rate of 18u/kg/hr, for DVT goal aPTT of 60-90

Question 56

recurrent unprovoked superficial venous thrombus

Answer 56

superficial migratory thrombophlebitis – c/f hypercoagulability and malignancy, associated with pancreatic cancer (Trousseau’s sign), and also stomach/lung Ca

Question 57

most effective treatment that maintains fistula function for steal syndrome

Answer 57

distal revascularization and interval ligation (ligate native flow distal to arterial anastamosis, revascularize proximally to distal native flow) – banding / plication can increase resistance in the graft to reduce steal but can cause graft thrombosis or persistent steal if inadequate