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Surgery > Vascular > Flashcards

Vascular Flashcards

1
Q

2 types of aneurysms

A

Saccular (outpouching, mushroom)

Fusiform (entire diameter grows)

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2
Q

Difference bt aneurysm and dissection

A 
aneurysm = all layers of arterial wall (intima, media, adventitia)
dissection = defect in intima, allows blood to go bt layers
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3
Q

Branches of abd aorta

A 
celiac trunk
SMA
IMA
renal arteries
gonadal arteries
95% of abd aneurysms are distal to the takeoff of the renal arteries.
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4
Q

PhysEx for abd ao aneurysm

A

pulsatile abd mass

lower extremity pallor, cool temp, unequal/diminished pulses

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5
Q

Diagnostic eval for abd aneurysms

A

US- size and if there’s a clot in the arterial lumen
CT or MRI- anatomic detail and localization
Aortogram- can check for involvement of other vessels, help plan surgery

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6
Q

Rx for abd ao aneurysm

A

If asx: depends on size-
<4cm medical- beta blockers
4-5cm- can do early op or can do close followup.
5+cm surgical repair.
surgery- new use of stent grafts via femoral

If ruptured/leaking- fluids and immed op

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7
Q

Surgical repair of AAA

A

midline incision or oblique over 11th IC space.
Midline: push bowel to right, incision of posterior peritoneum to the L of the Ao exposes entire Ao.
Oblique- only for retroperitoneal approach. Entire peritoneal contents pushed to right, exposing Ao.

Get prox and distal control, give heparin before clamping, place graft w permanent sutures.
If transabd approach, close peritoneum over graft.

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8
Q

branches off of thoracic aorta

A

brachiocephalic, L common carotid, L subclavian, bronchial arteries, esophageal, intercostal arteries

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9
Q

Cause of thoracic Ao aneurysms

A

Cystic medial necrosis or atherosclerosis

less common- trauma, dissection, infection

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10
Q

HPE for thoracic Ao aneurysm

A

Most are asx
if ruptured- chest pain/prs
if expanded- can compress tracha –> cough, if erodes into trachea –> hemoptysis
if close to Ao valve, can cause dilation of the annulus–> Ao insuff and chest pain, dyspnea, syncope
on physEx- hypotension, tachycard
if involves annulus, ao regurg and CHF

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11
Q

Dx Eval for thoracic Ao aneurysm

A

CXR- wide mediastinum
EKG- myocardial ischemia
If asx- do CT or echo
Aortography for planning op

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12
Q

Rx for thoracic Ao aneurysm

A

If asx, operate if 5+cm

Sxtic- immed op

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13
Q

Why do Ao dissections occur (path)?

A

HTN, trauma, Marfan syndrome, Ao coarctation

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14
Q

HPE Ao dissection

A

Immediate onset severe pain, tearing, in chest, back, abd.
Also nausea, lightheadedness
May be hypotensive, may have diminished periph pulses

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15
Q

Dx Eval of Ao dissection

A

CXR- wide mediastinum
CT- may show dissection or clot in arterial lumen
Dx via TEE, MRI, or aortogram

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16
Q

Classifications of Ao dissection

A

DeBakey Type I: both ascending and descending Ao
Type II: just ascending
Type III: just descending

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17
Q

Rx for Ao dissection

A

Depends on type. DeBakey Type II (ascending)- surgery! bc can go retrograde to Ao root. Give anti-HTN before surgery to halt progression
DeBakey Type III (descending)- medical only. give anti-HTN: Na+Nitroprusside and B Block.

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18
Q

From where does the common carotid arise?

A

On right side: from brachiocephalic (which comes off of Ao)

On left: directly from Ao.

19
Q

What arteries does the common carotid branch into?

A

Bifurcates into Internal and External branches.

Internal carotid gives of opthalmic artery, then continues to circle of willis in brain.

20
Q

Why does carotid artery disease occur (pathogenesis)?

A

Atherosclerosis.

But you get the stroke bc of plaque rupture, ulceration, hemorrhage, thrombosis, low flow states.

21
Q

Pt Hx in carotid artery dz

A

Prev neurologic events:
TIA (24 hr resolution); fixed neuro deficit
Amarosis fugax

22
Q

What is amarosis fugax

A

transient mono-ocular blindness
shade being pulled down.
d/t occlusion of a branch of the opthalmic artery (which is a branch of the internal carotid

23
Q

PhysEx in carotid artery dz

A

May have fixed neuro deficit
Hollenhorst plaques on retinal exam = evidence of previous emboli
Carotid bruit - evidence of turbulent carotid flow

24
Q

Dx Eval of carotid artery dz

A

Carotid duplex scanning

Angiography more accurate for assessing degree of stenosis

25
Q

Rx for carotid artery dz

A

Depends on Hx, degree of stenosis, and plaque characteristics.
Anti-plt therapy w aspirin prevents neurologic events
If acute event and CT confirms it’s non-hemorrhagic: give heparin
Carotid endarterectomy only in serious pts.
Stenting being researched.

26
Q

What patients should get a carotid endarterctomy?

A 
Pts w:
>75% stenosis
>70% stenosis + sx
bilateral dz + sx
>50% stenosis and recurring TIA despite aspirin
27
Q

Carotid endarterectomy procedure

A

IV abx (1st gen ceph) before incision
Incision over anterior border of SCM
ligate facial vein –> expose carotid
carotid is just medial to JV
don’t injure hypoglossal nerve or spinal accessory nerve.
give heparin, open artery, dissect out plaque.
close with patch.

28
Q

What is the celiac axis?

A

arterial supply to liver, spleen, pancreas, stomach

29
Q

thrombosis of which vein can cause visceral ischemia?

A

Superior mesenteric vein

30
Q

Acute ischemia of mesentery occurs how? (path)

A

acute embolization
acute thrombosis
non-occlusive ischemia
mesenteric vein thrombosis

31
Q

Acute mesenteric ischemia- HPE

A

May have hx of prev embolic events, Afib, CHF.
Abd pain is sudden and severe, w diarrh/vom
Pain out of proportion to exam
Abd may be distended
Rectal exam - guaiac+ stool

32
Q

Chronic mesenteric ischemia- HPE

A

Hx of crampy abd pain after eating–> decrsd oral intake and weight loss.
can have naus/vom/diarrh/constipation
Can be mistaken for malignancy d/t weight loss
May have abd bruits, guaiac+ stool, PVD or CAD

33
Q

Dx Eval of acute mesenteric ischemia

A

elevated WBC, metabolic acidosis, elevated hematocrit (d/t fluid sequestering in infarcted bowel)
Abd XR normal early on, but later shows thumbprinting of bowel wall.

34
Q

Rx of acute mesenteric ischemia

A

Laparotomy, exam and resect any infarcted bowel.
Sometimes angiography can be dxtic/therapeutic.
Mortality extremely high even with intervention.

35
Q

Rx for acute mesenteric vein thrombosis

A

Anticoagulate

Laparotomy if there is susp of necrotic bowel

36
Q

Peripheral vascular dz occurs in what arteries?

A 
Iliac
Common and superficial femoral
Popliteal
Peroneal
Anterior tibial
Posterior tibial

Even tho there are 3 vessels that supply the ankle/foot, you only need 1 to be adequate for life.

37
Q

Pathogenesis of acute vs chronic PVD

A

acute- caused by embolus, usu from Ao or heart (Afib)

chronic- from progressive atherosclerotic dz–> narrowing of lumen and decreased blood flow

38
Q

HPE of acute PVD

A

sudden/severe lower extremity pain and paresthesias.
5 P’s:
pain, parasthesia, pulselessness, pallor, poikilothermia (coolness)

39
Q

HPE of chronic PVD

A

claudication- pain on activity, relieved on rest.
butt claudication = aortoilliac dz; calf claudication = femoral atherosclerosis.
may have ulcers too.
can have loss of hair, pallor on elevation, rubor on dependent positioning, wasting, thick nails, thin skin

40
Q

Dx Eval of PVD

A

Angiography for acute PVD
doppler for chronic (normal = triphasic. as progresses, becomes bi, mono, then absent.
Arteriography is gold standard for defining level/extent of dz and surgery planning

41
Q

Ankle brachial index in PVD

A

Claudication ABI = 0.5
Rest pain ABI = 0.3-0.5
Gangrene ABI = <0.3

42
Q

Rx for acute ischemic embolus in PVD

A

heparin, thrombolysis, embolectomy

43
Q

Rx for chronic ischemia in PVD

A

smoking cessation and graded exercise

44
Q

Peripheral bypass operation for PVD

A

Usu have CAD too, so give Bblocker intraoperatively. Plus IV 1st gen ceph. artery is dissected, use either synthetic grafts or, if infra-popliteal, use in situ or reversed saphenous vein.

Surgery (20 decks)

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