Vascular Flashcards
what is hyperperfusion syndrome after a CEA? pathophysiology? treatment?
impaired autoregulation of cerebral blood flow – typically occurs POD#5, management = control BP (beta blocker), avoid vasodilators, and anti-seizure meds
young female with dizziness, syncope, upper extremity claudication, elevated ESR, absent radial and carotid pulses. dx / tx?
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
features and management of blunt carotid injury
Horner syndrome is common with this injury - anticoagulation (heparin) or antiplatelet is the treatment of choice for small dissection
indication for screening for blunt carotid injury
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
causes of re-stenosis – within 1 month? 1 month to 2 years? greater htan 2 years?
within 1 month = technical, within 1 month - 2 years myointimal hyperplasia, greater than 2 years usually due to atherosclerosis
sudden ICA occlusion in a young patient - dx, tx?
spontaneous dissection. tx w/ anticoagulation
characteristics of thromboangiitis obliterans?
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
conditions that falsely elevate ABIs?
ESRD and diabetes
categories of acute limb ischemia
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
management of class 2b ischemia
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
management of class 3 ischemia
class 3 ischemia w/ irreversible complete motor/sensory loss, proceed w/ amputation
causes of acute mesenteric ischemia
embolization (30-50%), arterial thrombosis (mesenteric atherosclerosis), venous thrombosis (hypercoag state), non-occlusive mesenteric ischemia
most common area of mesenteric embolization
SMA just distal to the middle colic artery – ischemia spares proximal jejunum and transverse colon
management of acute mesenteric ischemia without evidence of peritonitis
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
medication for claudication? mechanism?
cilostazol (pletal) – causes inhibition fo platelet aggregation, increases vasodilation more effective than pentoxifylline
most common cause of leg edema after fem-pop bypass?
dysruption of lymphatics
pt who had CABG who presents with recurrent chest pain / angina – BP R arm > L arm: dx, pathophys, tx?
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
how do you obtain operative exposure of the SMA for embolectomy?
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
5 year risk of major amputation in a pt w/ claudication? 5 year survival rate? MCC of death?
1-3.3% risk of major amputation; 70% survival rate (40-60% of deaths caused by coronary artery disease)
mesenteric ischemia that spares the proximal jejunum is most likely due to….
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
most common visceral artery aneurysms? #1, #2
splenic (60%), hepatic (20%)
mortality rates of AAA open vs endo? ruptured? elective?
ruptured similar mortality rates, in elective setting endo w/ lower mortality rates
popliteal aneurysms and AAA relationship? most common symptom of popliteal aneurysm?
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
indications for repair of popliteal aneurysm, surgical approach
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
diagnosis of aortoenteric fistula s/p AAA repair in the hemodynamically stable pt
1) upper endoscopy, 2) CT angio 3) tagged WBC scan (can demonstrate graft infection)
surgical treatment of aortoenteric fistula s/p AAA repair
extra-anatomic bypass (ax bi-fem), or excision of graft and insitu placement of human aortic homograft
threshold for treating asymptomatic common iliac aneurysjm?
> 3.5 cm
what are the endoleak types
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)
What does a white clot mean?
suggests thrombus from HIIT – prothrombotic state, antibodies to platelet factor 4 and heparin
most common congenital hypercoagulable disorder?
factor V leiden - resistance to activated protein C
most common acquired hypercoagulable disorder? #1/#2
1 = smoking, #2 = HITT
1st branch of internal carotid artery
opthalmic artery
1st branch of external carotid artery
superior thyroid artery
most common cranial nerve injury with CEA
vagus nerve injury - hoarseness due to RLN
symptom of hypoglossal nerve injury?
tongue deviates TOWARDS side of injury - speech/mastication difficulty
symptom of glossopharyngeal nerve injury?
difficulty swallowing
weird smile after CEA
injury to mandibular branch of facial nerve
major vein injury with proximal cross clamp of aorta
left renal vein
1 cause of acute death after AAA repair? late death?
MI; renal failure
ideal criteria for AAA endovascular repair
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
most common organisms in mycotic aneurysms
1 salmonella, #2 staphylococcus
most common organism in aortic graft infections
1 staphylococcus, #2 e. coli
important structures within the lower leg anterior compartment? lateral compartment?
anterior - deep peroneal nerve (dorsiflexion, sensation between 1st and 2nd toes), and anterior tibial artery; lateral - superficial peroneal nerve (eversion, lateral foot sensation)
important structures within the lower leg superficial and deep posterior compartments?
superficial - sural nerve (sensory, lateral foot); deep - tibial nerve (plantarflexion, posterior tibial artery, peroneal artery)
treatment of homocystinuria
increases risk of atherosclerosis – tx w/ folate and B12
pt w/ no femoral pulse, buttock claudication, impotence
lesion at aortic bifurcation or above, tx w/ aortobifemoral bypass
mild intermittent claudication, loss of pulse w/ plantar flexion; dx/ tx
popliteal entrapment syndrome == treat w/ resection of medial head of gastrocnemius muscle (w/ or w/o arterial recon)
intermittent claudication, worsening syptoms with knee flexion: dx / tx
adventitial cystic disease - often in popliteal fossa, often bilateral, dx is angiogram and resect cyst, vein graft if the vessel is occluded
course of the R renal artery?
posterior to the IVC
relationship of muscle/vein/artery/nerves between 1st rib and clavicle?
ANTERIOR -> POSTERIOR – subclavian vein, anterior scalene, subclavian artery, brachial plexus, middle scalene / posterior scalene
subclavian vein vs subclavian artery compression/thrombus – characteristics, tx
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
bruit near epigastrium, chronic pain, weight loss, diarrhea – dx, tx?
median arcuate ligament syndrome – causes celiac artery compression; tx w/ transection of median arcuate ligament +/- arterial recon
treatment of proximal DVT (iliofemoral)
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
massive iliofemoral DVT w/ swelling, pain, ischemic foot
phlegmasia alba dolens -> phlegmasia cerulea dolens; treat with thrombolytics
heparin drip: what do you bolus with? rate? goal labs?
bolus with 80u / kg, initial rate of 18u/kg/hr, for DVT goal aPTT of 60-90
recurrent unprovoked superficial venous thrombus
superficial migratory thrombophlebitis – c/f hypercoagulability and malignancy, associated with pancreatic cancer (Trousseau’s sign), and also stomach/lung Ca
most effective treatment that maintains fistula function for steal syndrome
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
