Vascular Surgery Flashcards
Indications for endovascular repair thoracic aortic aneurysm?
Endovascular:
1. Degenerative or traumatic > 5.5 cm
2. Saccular
3. Postop pseudoaneurysms
Indication for open thoracic aortic aneurysm repair?
Chronic and > 6.5cmm if comorbidities favorable.
Or >5mm growth in 6 mos
Connective tissue disorders.
Open exposure of the thoracic aorta for aneurysm repair?
Left posterolateral thoracotomy.
Proximal descending - 4th interspace
Distal descending - 6th interspace
Control of the thoracic aorta?
Proximal - clamp between the left common carotid and left subclavian
*avoid vagus, recurrent laryngeal, phrenic nerve as they cross arch here
Control of the abdominal aorta supraceliac access
Through gastrohepatic ligament, right under crus, press AORTA AGAINST SPINE
Indications for left subclavian artery revascularization during TEVAR?
- dominant L vertebral artery
- patent LIMA to coronary
- LUE AV fistula
- Hypoplastic/absent R vertebral artery
- Termination of L vert onto PICA
- Anomalous origin of L vertebral from aortic arch
- High risk SCI with high coverage
When to give heparin?
If single cross clamp, 5000U at time of clamp.
If assisted circulation/bypass, 400 U/kg.
Management of postoperative spinal cord ischemia?
MAP > 90.
Most important sign of new onset SCI?
Inability to flex at the hips.
Indication to operate on a pseudoaneuryms?
> 2 cm, any that have failed ultrasound guided compression q10 min holds, or thrombin failure, AC therapy, rapidly expanding.
fem PSA < 2-3cm tx
just observe and repeat imaging
Consideration of pseudoaneurysm neck size?
Shorter fatter necks have higher rate of thromboembolism during injection.
How to do US guided thrombin injection?
22G needle, confirm placement by injecting saline (see swirl on doppler), 3cc syringe injects 1000 IU/mL of topical thrombin (probably only need 1 cc), bed rest 6 hours, repeat duplex now and in 24 hours.
How to do open PSA repair?
obtain proximal/distal control, fully dissect artery and find injury/defect, administer systemic heparin, repair with full thickness prolene interrupted or horizontal mattress; give protamine, reapproximate sheath, leave a drain, close all defects.
How to perform open thrombectomy (I.e. after thromboembolic event after thrombin injection?)
control femoral artery, systemic heparin, Fogarty via transverse arteriotomy, close transversely,
steal syndrome AVF
hand ischemia
dx: compress fistula and >50% improvement in waveform of digits
mgmt: DRIL distal revasc with interval ligation
saphenous vein on US
“saphenous eye” between fascia (both great and lesser)
ischemic monomelic neuropathy
distal nerve fibers wipes after fistula formation
severe numb/pain, weakness with palpable pulses/warm hand
(usually with brachial arterial fistula)
mgmt: immediate ligation of fistula
landmarks for port and cannulation of subclavian vein
port is inferio to clavicle in deltopectoral groove
vein accessed at midclavicular line directed at sternal notch (prevent PTX)
medial ulcer valve incompetence?
GSV or medially located perforators
lateral ulcer valve incompetence?
small saph vein or lateral perforators
diagnosis varicosities
> 0.5 seconds rflux on duplex
varicose vein tx
sclerotherapy stop smoking, lose weight
brawny edema in venous ulcers
hemosiderin deposits
what size can you medically manage venous ulcers
<3 cm just Unna boot (otherwise need to ligate perforators or vein strip)
MC reason for long term failure of prosthetic AV access
intimal hyperplasia at distal anastomosis (graft to vein)
phlegmasia cerulean dolens
extension of DVT
blue leg causing gangrene/amputation
requires AC and thrombectomy
50% have concurrent cancer- work up required
GSV SVT?
fondaprinux (I don’t think you treat other SVT)
sclerosants
sotradecol (sodium tetradecyl sulfate) and polidocnol (asclera)
AV graft requirement measurements for absite
2mm artery, 2.5mm veind
difference arterial/neuro vs venous TOS
compression in venous is at intersection of 1st rib and clavicle (resect it either way
instead of in TOS
advanced removal of IVC filter indicated after how much time
7 mos
first branch of ICA vs ECA
ICA: opthalmic
ECA: superior thyroid aa
main collateral between ICA and ECA
opthalmic (ICA) and internal maxillary (ECA)
MC cause of ischemic event
ARTERIAL embolization from ICA
hollenhorst plaques on fundoscopy
little bright filling defects after AMAUROSIS FUGAX (occlusion to opthalmic)
if carotid injured with big defecit and it’s OCCLUDED vs NOT OCCLUDED
OCCLUDED: don’t touch it (rebleed)
NOT OCCLUDED: stent or open fix
CEA indications
sx >50%
or asx > 70% or EDV > 100
order of CEA
repair tighter side first (if b/l)
or dominant side if equally tight
clamp ICA then CCA then ECA
release flush ICA to back bleed; replace clamp
release ECA and CCA
then ICA
CEA what is removed
intima and part of media
indication to shunt in CEA
back pressure < 50 mm Hg (butterfly stump pressure) or diseased contralateral side
can also do awake CEA
EEG monitoring
brain ox
nerve injury CEA
vagus (from clamping)»_space;> hypoglossal > glossopharyngeal (if high repair, under digastric)
carotid sheath components
- carotid aa
- internal jugular vein
- CN X
- sympathetic plexus with ansa cervicalis (innervate straps), C1-C3 loopca
carotid body tumor
painless
near bifurcation
neural crest, VERY VASCULARIZED, can secrete catecholamines
mgmt: resect
indication to repair a thoracic ASCENDING aortic aneurysm
acutely sx
5.5+ cm
(Marfan 5+ cm)
>0.5 cm / year
indication to repair an thoracic DESCENDING aortic aneurysm
endovascular is 5.5+ cm M
open is 6.5+ cm
stanford calssification
A vs. B yeah ok
debakey classification
I: ascending and descending
II; ascening only
III: descending only
spinal cord ischemia after aortic graft placed? what artery is occluded
intercostals and artery of Adamkiewicz (perfuses the anterior spinal artery)
spinal cord ischemia rate
endovascular <5%
open 20%
MC site of AAA rupture
left posterolateral wall 2-4cm below the RENALS
indication for AAA (non thoracic) repair
5.5+ cm for male
5+ cm for female or with high rupture risk (severe COPD, bad HTN, eccentric)
> 1+ cm / yr
or if: infected, symptomatic
anti impulse control for ruptured AAA or dissection aorta?
SBP 80-100 (permissive hypotension)
indication to reimplant IMA
if backpressure < 40 mm Hg / bad
previous colonic surgery
stenosis at SMA
flow to L colon is bad
impotence after endovascular repari
hypogastric aa covered - vasculogenic impotence
AAA morphology that is repairable
neck length > 1.5 cm
neck diameter > 3 cm
neck angulation < 60 degrees
common iliac aa length > 1 cm
common iliac artery diameter .8-1.8cm
endoleak four types
I: ATTACHMENT SITES (treat now)
II: COLLATERALS (observe mostly or coil if growing - lumbars, IMA, intercostals, accessory renals ie) *** MOST COMMON
III: OVERLAPS of grafts (treat now - overlap the overlaps)
IV: POROSITY or small suture holes (observe)
V: ENDOTENSION?? (repeat EVAR or open repair
inflammatory aneurysms causing adhesive disease - to what organs
D3 and D4
ureteral entrapment
mgmt: fix the aneurysm
MC bug in mycotic aneurysm
S. aureus > Salmonella
MC bug in aortic graft infection
S.epi
leriche syndrome
ATHEROSCLEROTIC (not embolic) at aortic bifurcation or above; lose fem pulses too
sx: impotence
, buttock/thigh claudication
mgmt: aortobifem or endo reconstruction
MC atherosclerotic occlusion in legs to cause claudication
Hunters canal - distal SFA (sartorius mm covers this)
hunters canal contents and borders
borders: vastus medialis, adductor magnus and longus, sartorius
content: SFA and SFV, saph NERVE
MC atherosclerotic lesion in thigh claudication
iliac
ABIs 0.9, 0.5, 0.4, 0.3
<0.9 claudication
<0.5 reset pain
<0.4 ulcers
<0.3 gangrene
PTFE use in PAD bypass
only ABOVE knee (saphenous below)
dacron
for aorta and large vessels only
what med decreases CV events after bypass
ASA
what muscles border the popliteal artery
posterior: gastrocnemius
anterior: popliteus
popliteal entrpment syndrome sx
loss of pulses with PLANTARflexioon
cause of popliteal entrapment syndrome
medial deviation of pop artery around medial head of the gastrocnemius muscle
because can lead to popliteal aa fibrosis
mgmt popliteal entrapment syndrome
resection of medial gastrocnemius head
adventital cystic disease
popliteal fossa»_space;»
sx: intermittent claudication but change in s with KNEE FLEXION?EXTENSION (not plantar flexion)
mgmt of adventitial cystic disease
resect cyst; use vein graft if vessel is occluded
MC site of peripheral embolization
CFA
indication OR for thrombectomy vs angiography for thrombolytics in arterial THROMBOSIS
threatened limb = sensory/motor loss needs OR.
treatment of renal artery stenosis vs fibromuscular dysplasia
stent the stenosis
percutaneous transluminal angioplasty for dysplasia
indication for npehrectomy with renal HTN
if atrophic kidney < 6 cm with persistently high renin levels
fibromuscular dysplasia dx, path, tx
dx: CTA beads on a string
MC variant of path: medial layer fibroplasia
tx: anti plt then balloon angioplasty (no stent); bypass if fails
subclavian steal
proximal SCA stenosis causes ipsilateral vertebral flow into subvlavian instead
mgmt: stent and angioplasty if fails
MC TOS
neurogenic
MC abnormality in TOS
cervical rib
dx of neurogenic (brachial plexus compression) in TOS
EMG
see Tinsel test: tapping reproduces sx
ulnar nerve distribution mostly
mgmt neurogenic TOS
1, PT (first line)
fails?…
2. confirm dx with scalene block
- cervical and 1st rib resection
divide anterior scalene mm
Paget von Schrotter disease in pitchers/swimmers
effort induced thrombosis of subclavian VEIN (venous TOS) at costoclavicular junction
tx of Paget Schroetter syndrome
catheter directed thrombolysis followed by 1st resection & ant scalene division during same admission
compression of subclavian artery
mostly 2/2 anterior scalene hypertrophy (arterial TOS) weight lifters
arterial TOS mgmt
first rib resection and interposition graft for artery if needed
Adsons test arterial TOS
turn head towards side and hold breath, causes absent RADIAL pulse
MC cause of mesenteric ischemia
embolic 50% (MC From heart) > thrombotic 25% > nonocclusive > venous thrombosis
median arcuate ligament syndrome
celiac aa compression (bruit at epigastric region, chronic pain, diarrhea) by crura of diaphragm
mgmt median arcuate ligament syndrome
confirm with celiac plexus block (if that relieves the pain)
transect median arcuate ligament; likely wont need arterial recon
chronic mesenteric angina dx
lateral visceral vessel aortographym; 30 min after meal pain
mgmt chronic mesenteric angina
stent, bypass if fails
MC visceral aneurysm
splenic aa aneurysm
stenting of splanchnic artery aneurysm
> 2cm - REPAIR! except splenic
only operate if splenic is symptomatic, if pregnant, or if >3-4 cm (3rd tri rupture)
** REPAIR ALL SMA ANEURYSMS
when to stent renal aa aneurysm
> 1.5 cm
when to stent iliac aa aneurysm
3.5+cm, commonly seen with aortic aneurysm
when to treat femoral aa aneurysm
> 2.5cm
may be able toobserve
high risk clot… so resect with interposition
MC peripheral aneurysm
POPLITEAL
MC complication of popliteal artery aneurysm
THROMBOSIS
rate of AAA with popliteal aneurysm
50% have aortic disease too
mgmt of popliteal aneurysm
> 2cm + mycotic/symptomatic/sig thrombus needs EXCLUSION AND BYPASS OR VEIN INTERPOSITION (NOT STENT, unless cannot tolerate IR)
if lots thrombus and smaller, tx.
Buergers disease
young M, smokers
rest pain with b/l ulceration, gangrene fingers
dx Buergers disease
Angiogram: corkscrew collaterals and distal disease bad (SMALL VESSEL DISEASE)
Marfans disease defect
fibrilllin defect (connective tissue elastic fibers) causing medial cystic necrosis
temporal arteritis dx
biopsy: giant cell arteritis; granulomas
mgmt temporal arteritis
steroids, bypass if needed ( NO ENDARTERECTOMY)
mgmt Raynaud’s
CCBs and warm
traumatic AV fistula mgmt
lateral venous suture & arterial patch vs bypass graft
interpose tissue between to avoid recurrence
unna boot
has zinc oxide and calamine - compression wrwap for venous ulcers
what is associated with migrating thrombophlebitis
pancreatic ca
lymphatics are not in what areas
bone, muscle, tendon, cartilage, brain corner
NO BASEMENT MEMBRANE
papverine
intestinal vasodilation without increasing O2 consumption in intestine
infected aortobifem graft tx
explant and RIGHT axillobifem
or remove graft and reconsruct with femoral vein or crypreserved aorta
walk at what speed to improve claudication
when claudication can onset 3-5 min
fenestrated graft must get thru what size of iliacs
at least 7.5 mm
carotid sstent vs CEA
stent has more stroke
least compartment syndrome in thigh
medial comartment
sma acute lodges into what artery
ileocolic (jej to transverse dusky)
chronic SMA fails stent/plasty
C loop iliac to sma bypass
indications for CEA
50% + asx
7-% asx or >100 cm/s EDV
(start with medical therapy)
PAD medical therapy?
smoking cessation
ASA
high intensity statin (LDL < 100)
nascet stroke risk carotid stenosis
70% to 99%: 2-year risk of ipsilateral stroke of 26% if treated with medical therapy alone
9% if treated with carotid endarterectomy
50%-69%) had a 2-year risk of ipsilateral stroke of 22.2% if treated with best medical therapy. T
15.7% with carotid endarterectomy
plavix indication
if no surgery indicated or <50% symptomatic carotid stenosis….
plavis + Statin + ASA + meds
LDL goal
<70-100
tx for 100% occlusive sx carotid artery disease?
AC or DAPT to prevent progression of clot; otherwise no recanalization due to risk of hemorrhagic conversion
dacron pseudoaneurysm
weakening of the material; painelss bulge (not rly seen with PTFE)
emergent CEA
crescendo TIAs… inevitable big stroke
rutherfords
class I indicates a viable limb
class II indicates a threatened limb
class III indicates a nonviable limb
class I ischemia (viable tissue with intact sensory and motor function) can be managed on an elective basis.
class IIa (issue viability is threatened but has not yet been completely lost) endovascular thrombolysis catheter x 48 hours +/- embolectomy/thrombectomy if can’t tpa. start AC
class IIb (sensory and motor dysfunction), embolectomy/thrombectomy in OR
class III ishcemia (tissue loss with profound anesthesia and paralysis)
debride/amputate.
popliteal entrapment syndrome
gastrocnemius compressing in the deep compartment
incisions for LATERAL/ANTERIOR leg compartment fasciotomy
between tibia and fibular cheat towards tibia… watch out for SUPERFICIAL PERONEAL NERVE injury (foot eversion)
what incision SUPERFICIAL AND DEEP posterior compartment fasciotomy?
2 cm posterior/medial to tibia
take soleus off tibia in order to get the deep compartment
increased energy use after BKA
10-40% more
screening for aortic aneurysm?
1 time 65 to 75 years of age with a history of tobacco use
65 to 75 years of age with a history of a first-degree relative with abdominal aortic aneurysm or for those older than 75 years of age and in good health.
size cut offs for EVAR
external iliac arteries must range in diameter from 7 to 16 mm. The length of the neck of the proximal aorta can be as short as 15 mm. The diameter of the aneurysm can be up to 26 mm and still be repaired endovascularly
how to expose the peroneal artery?
laterally: need to do a partial fibulectomy
MC bugs for mycotic aneurysm?
S. aureus > Salmonella
vertebral aa segments
V1: SCA to C6 foramina
V2: foraminal C2-C6
V3: C2 to dura
V4: intracranial
what overlies the carotid aa bifurcation?
facial V
high vs low resistance artery: ICA vs ECA
ICA is low resistance to brain (biphasic)
ECA is high resistance to facial arteries (triphasic)
ipsilateral mouth droop after CEA?
marginal mandibular nerve injury from retraction on MANDIBLE
IX, X, and XII relative to digastric mm?
IX: deep to posterior belly
X: under and extends inferiorly
XII: inferior to the digastric (and parallel); is cephalad to carotid bifurc
MC morbidity and mortality NON-STROKE after CEA?
MI
timing of CEA
2 wks after TIA/CVA
6-8 wks after hemorrhagic stroke
immediate thrombus in PACU after CEA?
return to OR for saphenous vein
(diagnosed with EMERGENT DUPLEX)
indication for TCAR/stenting instead of CEA
previous neck surgery/irradiation, recurrent disease, severe cardiac disease
asx BCVI carotid dissection tx
AC (heparin or plavix) with repeat imaging
sx BCVI caroti dissection tx
AC then stent
total occlusion traumatic carotid artery
neuro work up… AC or antiplt to worsen extension
subclavian steal syndrome
proximal subclavia stenosis/occlusion..
exertion of arm steals from cerebral through vert (vertebrobasilar symptom)t
subclavian steal mgmt
endovascular recanalization/stent or
open carotid SCV bypass or SCV transposition
how long can you keep a vascath in before infection risk?
3 wks (femoral is only 5 days)
permacath line duration
1 year
size cut offs for A and V for fistula creation
3mm vein
2mm artery with triphasic flow
MC complication of AVF?
venous outflow problems (scar down with high pressure)
venous outflow for AVF presentation
BLEEDING fistula
mgmt of venous outflow stenosis
fistulogram with angioplasty
rule of 6s fistula access
6mm in diameter
6cm long
<6mm to skin
600+cc/min of flow
6 wks typically to mature
landmark Type A vs B dissection
L SCA
MC malperfusion in TBAD
mesenteric > renal, limb
mgmt of acute SMA
revascularization, heparin, and ex lap (don’t resect marginal bowel at index… give it 12-24 hours and takeback)
** embolic: SMA embolectomy open (via cephalad Tcolon)
** thrombotic: SMA bypass vs ostial stenting rather than removal
** venous thrombotic: SMV… heparinize and OR for dead bowel vs TPA lysis catheter
embolic and thrombotic mesenteric ischemia locations
embolic: mostly 1st branch SMA (jejunals)
thromotic (MC cause in severe atherosclerosis): at ostium/takeoff of SMA
jejunal sparing SMA syndrome
points more to embolic cause because it lodges distal to the ostium of the first jejunal branch
MC emboli locations for UE and LE?
UE: brachial @ bifurc radial/ulnar
LE: CFA @ bifurc profunda/SFA
big bleeding after clamping aorta proximally from what anomalous anatomy?
retro-aortic L renal vein (should be normally in front of aorta)
chyle leak after open AAA
low fat
high protein
MCFA supplementation
AAA surveillance
yearly duplex 4-4.9cm
q6mo duplex 5+cm
extra anatomic bypass with aortic graft excision complication and how to prevent
stump blow out
interrupted mattress and continuous sutures to stump closure
omentum over stump
tensor fascia lata buttress
mgmt aortoenteric fistula
stent if dying
eventual: resection and ligation aorta + extra-anatomic bypass or in line reconstruction/repair duodenum
end to side vs end to end in aorto-bifem bypass?
if external iliac PATENT, end to end
if external iliac OCCLUDED, end to side
how to tunnel aorto bifem bypass relative to ureters
tunner under ureter to prevent hydro
PAD lesion tx ways
ENDO: if short, not too calcified (have to be able to hold stent/get pushed with balloon)
OPEN: if long, calcified with good inflow/outflow/conduit (bypass vs endarterectomy)
also if FEMORAL OR POPLITEAL… highly kinkable and easily accessed open
when to avoid roto rooter PAD (atherectomy)
when bulky disease or limited tibial vessel runoff (cuz you can embolize and then they lose foot perfusion without collaterals)
thrombosed bypass graft etiology based on timing
<1 mo: technical
2mo-2yr: neointimal hyperplasia
>2 yr: atherosclerosis
claudication with normal ABIs
do walking treadmill test and then recheck
how to access L COMMON ILIAC VEIN
divide overlying RIGHT ILIAC artery
deep venous reflux dx
seen on duplex after presenting with duplexde
deep venous reflex mgmt
compression stocking
can’t ablate deep veins
saph vein reflux
if above the knee: heat ablation (RF or laser)
if below the knee: chemical ablation with glue (venaseal) or scerlosant (varithena)
saph vein reflux close to SFJ
close to saphenofemoral junction… need to stay 2-3 cm away to prevent:
endotheraml heat-induced thormbosis EHIT
EHIT tx
protrude into CFV: AC x 3 mos
flush with CFV: repeat imaging 2 weeks vs short course AC
within 2cm of CFV: repeat imaging 1-2 weeks if not touching CFV
spider vein/ reticular vein tx
sclerosant CHEMICAL : polidocanol or sotradecol
MC DVT
iliofemoral/Fiser: Calf DVT on the LEFT (2x more than right due to compressing Right iliac artery on Left iliac vein)
where to place IVC
above (“distal”) to renals
DVT AC duration
3 mos if provoked
active ca: LVX until cancer cured
hypercoagulable disorder: for life
GSV superficial thrombophlebitis PALP CORD
focal < 5 cm away from SFJ: NSAID and warm compress
longer thrombus or near SFJ: fondaparinux 2.5mg for 45 days
chronic venous insufficiency treatment
Unna boot (5-7 day soft boot)
subclavian line landmarks
just more than 50% length of clavicle; aim at sternoclavicular junction and flattenunder the bone; aim cephalad if don’t get blood
ESRD anemia morphology
normocystic normochromic hypoproliferative
acute limb revascularization heparin dosing
80 U/kg followed by 1000 U/hr
access to innominate
median sternotomy
access to distal LSCA and descending aorta
L thoracotomy
access to distal R SCA
midclavicular with resection of middle third clavicle
calf claudication lesion
SFA
foot claudication lesion
popliteal
thigh claudication lesion
external iliac artery
collaterals in legs
circumflex iliacs to subcostals
femoral to gluteal
geniculate around knee
DFI most common place
2nd MTP > heel
atheroma MC location and cause
renals (think bigger than just a blood clot)
and atherosclerotic emboli (cholesterol clefts)
MC site UE embolic disease
bifurc brachial to ulnar/radial
MC site UE stenosis
SCA
tx SCA stenosis
stent > bypass (Carotid-sCA) just like in subclavian steal
radiation arteritis pathogenesis early/late
early: sloughing/thrombosis (obliterative endarteritis)
late 10 years: fibrosis/scar/stenosis
late 30 years: advanced atherosclerosis
central line thrombosis
pull if line not needed
treat with heparin gtt or TPA if access required
MC bug in infected lymphangitis
STREP (NOT STAPH!!!!)
