Vascular Flashcards
What are the indications to operate on AAA for men? For women?
Why was this size chosen?
Men > 5.5cm
Women > 5cm because women have higher risk for rupture (x4.5 times higher)
Size chosen because the risk of rupture at 5.5cm (~5%/yr) was about the same as the mortality risk from operating.
What is the most common perioperative complication after AAA repair?
What is the incidence of this complication?
Cardiac event. (~15%)
Cardiac stents and AAA
How long do you wait after bare metal stent?
Drug eluting stent?
Plavix- stop or continue for open AAA vs EVAR?
Bare metal: 4-6 weeks
Drug eluting: 1 yr
Plavix- stop 10 (or 5) days pre-op for open. Continue through surgery for EVAR
A pt in the ED complains of back pain. BP 85/50. pulsatilr abdominal mass. You suspect a ruptured AAA but the patient is awake and talking to you. Next best step?
A) give blood and resuscitate B) beside ultrasound C) CTAP D) emergent transfer to OR E) diagnostic angio
Answer is C. CT scan.
Giving blood and resuscitating can increase bleeding
Ultrasound may not be able to see the rupture
only 15% of pts with rAAA die within 2hrs of presentation
CT scan provide better information for endovascular repair planning
EVAR requirements
Proximal aortic neck length
Proximal aortic neck diameter
Proximal aortic neck angulation
External iliac artery diameter
Proximal aortic neck length >10 mm
Proximal aortic neck diameter <32 mm
Proximal aortic neck angulation <60 degrees
External iliac artery diameter >7 mm
Is diabetes a risk factor for AAA?
Actually if you have diabetes you have lesser odds of having an aneurysm
What is an average growth rate for aneurysm
~10% a year
AAA pre-op Eval
- when do you do EKG
- when do you do echo
- when do you do stress test?
- EKG on EVERYONE
- echo for (+) dyspnea or heart failure
- stress test: pts with unknown fx status or if they have 3 or more CV risk: CAD, CHF, stroke, diabetes, renal
Pre-op placed bare metal stent. What to do?
Drug eluting stent?
What to do with plavix for open AAA vs. EVAR?
Bare metal: delay surgery 1 month
Drug eluting: delay 1 year
angioplasty: 2 weeks
Open: stop plavix 10 days prior
EVAR: continue plavix through surgery
Problem with US for evaluating for AAA rupture?
May not be able to tell there’s a rupture or not
Mortality for patients who presented to the ED with ruptured AAA within 2 hrs?
15%
For AAA repair mortality for suprarenal clamp vs infrarenal?
Mortality is the same
When you’re doing AAA, is it okay to divide the left renal vein?
Yes it it. Divide it as close to the IVC as possible. That way it will preserve the collaterals (gonadal, adrenal, lumbar veins)
Who needs IMA reimplantation?
T/F: if a pt has a large meandering IMA, that means the collaterals are sufficient and there is no need to reimplant the IMA
- celiac/SMA occlusive disease
- prior colon resection
- poor IMA backbleeding (means the collaterals are not strong)
False. enlarged meandering IMA shows that the pt is living off of this IMA and collateral is not great. Better reimplant this
For AAA repair, why prep and drape before induction?
When theyre awake, they’re muscles may be tamponading the bleed. When they go to sleep, all those muscles go out the window and the pt may start crashing
Describe gaining proximal control for AAA repair
1) take down left lobe of the liver
2) make sure they have an OG. Move the esophagus out of the way
3) find and divide the crus of the diaphragm
4) with the clamp, get all the way down to the spine and clamp
Describe the different types of endoleak
I: proximal or distal seal zone leaks II: backflow from aortic branches III: graft separation IV: pores in the graft V: sac enlargement in the ABSENCE of a detectable leak
EVAR requirements (4)
1) proximal aortic neck length >10mm
2) proximal aortic neck diameter <32mm
3) proximal aortic neck angulation <60 degrees
4) external iliac artery diameter >7mm
Minimal aortic neck thrombus
What is the risk of endoleak over 10 years after EVAR?
25%
Rate of intestinal ischemia after elective AAA repair?
Rate after ruptured AAA open vs EVAR?
Elective: 2%
Ruptured: 40% open, 20% EVAR
Aortoenteric fistula
CTA vs. endoscopy which one is better?
Treatment?
CTA (almost 94% sensitivity). look for air around the graft.
old Treatment
Vasc: do ax bifem. Next day, aortic explant
GI: separate the aorta and the bowel and close the visceral tear
new Treatment:
endovascular stent first + open repair
EVAR complications
- Hypotension after withdrawal of delivery sheath
- severe leg claudication 6 months after endograft
- Hypotension after withdrawal of delivery sheath: iliac artery injury. Balloon tamponaded then stent graft
- severe leg claudication 6 months after endograft: endograft thrombosis. Thrombectomy or fem-fem bypass
Non-obstrucing colon cancer and operative AAA. What do you do?
Repair AAA first
Resect colon in 4-6 weeks
AAA + obstructive, perforated, or bleeding colon cancer. what do you do?
Colon resection/diversion followed by AAA repair
Renal/ovarian malignancy + AAA?
Can do at the same time
Gallstones during open repair
Avoid concomitant cholecystectomy
Indication for thoracic aortic aneurysm repair?
Higher or lower risk of repair compared to AAA?
Repair when > 6cm
Higher risk of repair compared to AAA (Spinal cord ischemia, renal failure, visceral ischemia, resp failure)
Median size of thoracoabdominal aneurysm rupture?
Risk of paralysis after repair?
Mortality rate?
7cm
7-15% paralysis
5-10% mortality
Femoral/popliteal artery aneurysm.
What is the risk?
What % is associated with AAA?
Treatment elective vs emergent?
Risk of thrombosis or embolism
40-60% have AAA
Elective: autogenous vein bypass, aneurysm exclusion
Emergent: thrombolysis (to improve outflow) followed by bypass
When do you do surgery for splenic artery in pregnant women?
What operation?
Always. Because there is near 100% fetal loss with rupture
Ligate, splenectomy
angioembolization can be definitive
Treatment for infected pseudoaneurysm?
Ligation and muscle flap coverage
Person with DVT now has acute arterial emboli. What test to confirm etiology?
TEE to look for PFO
Most common site of arterial emboli?
Common femoral
Most commonly missed compartment during fasciotomy?
Anterior. Often the incisions are made too posteriorly
How do you calculate the ABI?
Cuff around ankle
Systolic pressure of ankle at which Doppler signal appears
Over
Higher of the 2 brachial bp
What to do for
- complete aortic occlusion now has claudication
- complete aortic occlusion with threatened limb, high surgical risk
- common femoral stenosis/occlusion
- aorto bifem
- ax bifem (can be done under local)
- femoral endarterectomy. Do not stent
No stent zones:
Common femoral
Profunda
Popliteal
What is the May-Thurner syndrome?
Compression of the left common iliac vein by the right commom iliac artery
Pradaxa, eliquis, Xarelto.
Other names and their mechanism?
Pra(DA)xa: (DA)bigatran. (D)irect thrombin inhibitor
idarucimab (praxbind) or dialysis
Eliquis: apixaban. Xa inhibitor
PCC
least renal clearance (use in renal pts)
Xarelto: rivaroxiban. Xa inhibitor
PCC
How long to anticoagulate for
DVT due to reversible cause? (Line)
3-6 months
How long to anticoagulate for
Unprovoked proximal DVT vs. distal DVT?
proximal unprovoked: extended therapy
distal unprovoked: 3 mo.
How long to anticoagulate for
DVT and cancer?
Lovenox 3-6 months then Coumadin indefinitely
What is the treatment for phlegmasia cerulean dolens?
When do you do surgery?
Start hep gtt
Fluid resuscitation
Elevate limb
Prepare for lysis
Surgical intervention: failure of initial management or compartment syndrome
What is the most common complication after surgery or endovenous procedure for varicose veins?
Recurrent varicose veins (15-30%)
What should you do if a pt gets a PICC line thrombus and the PICC still works?
Leave it in if the pt needs it still. If you take it out then the other PICC will most certainly clot again.
What is PSV and EDV in carotid duplex?
What velocities indicate 50-70% stenosis? >70? 80-99%?
Peak systolic velocity
End diastolic velocity
Any PSV > 125 means stenosis > 50%
Any EDV > 110 means stenosis 80-99%
> 70% stenosis is PSV > 230 or EDV 90-110
What’s a NASCET trial
For symptomatic.
Measured stroke rate in Best medical therapy (26%) vs CEA (9%)
What’s the ACAS trial?
For asymptomatic carotids.
Stroke rate in best medical therapy (12%) vs CEA (5%)
Indications for CEA for asymptomatic vs symptomatic
Asymptomatic >70%
Symptomatic > 50%
You do a CEA. IN PACU pt has Neuro deficits after waking up. What is the cause and what do you do?
Thrombosis due to technical error. Re-explore, do thrombectomy or angio
You do a CEA. In PACU pt has neck fullness and respiratory difficulty. What do you do?
Cervical hematoma. Take back to OR. intubate and evacuate. No reason to do it in PACU
You do a CEA. Pt has tongue deviation. Reason? What do you do?
Hypoglossal nerve injury. Deviates to the side of the injury. Swallow eval, observe