Vascular Surgery

Question 0

Abdominal aortic aneurysm – typical symptoms? Typical physical exam findings? Typical location? Diagnostic test? Management?

Answer 0

Asymptomatic; pulsatile abdominal mass; between xiphoid and umbilicus

X-rays, ultrasound, CT scan

1. If 4 cm or smaller, observe
2. If over 5 cm, repair
3. If growing at 1 cm per year or faster, repair

Question 1

Subclavian steal syndrome – Mechanism? Signs and symptoms?
Diagnosed by? Treatment?

If only vascular symptoms (without neurologic symptoms) suspect?

Answer 1

Arteriosclerotic plaque at subclavian artery (before takeoff of the vertebral artery), allows enough blood supply to reach arm for normal activity but does not meet demand when exercised. Exercising arm causes blood to be sucked into the arm from the vertebral artery, hypoperfusion the brain

Claudication of the arm (Coldness, tingling, muscle pain) and posterior neurologic signs (visual and equilibrium problems)

Duplex scanning is diagnostic when it shows reversal of flow

Bypass surgery for cure

Thoracic outlet syndrome

Question 2

Patient with abdominal aortic aneurysm complains that aneurysm has become tender – signifies?

Answer 2

Will rupture in a day or two, needs immediate repair

Question 3

Patient with abdominal aortic aneurysm complains of excruciating back pain – signifies? Management?

Answer 3

Aneurysm is leaking and retroperitoneal hematoma is forming. Blowout into peritoneal cavity is minutes away. Emergency surgery

Question 4

Role of surgery in arteriosclerotic occlusive disease in the lower extremities? Medical management?

Answer 4

1. Unpredictable natural history, so no prophylactic surgery
2. Surgery only to relieve disabling symptoms or save extremity from impending necrosis

Stop smoking, exercise, cilostazol (Inhibits platelet aggregation)

Question 5

Work up of disabling intermittent claudication?

Answer 5

1. Doppler to look for pressure gradient
2. If no pressure gradient, disease small vessels and surgery not possible
3. If pressure gradient, CT/MRI angio to identify areas of stenosis/obstruction and to look for veins to make a graph
4. Treat shorts tonight segments with angioplasty and stenting
5. More extensive disease may require bypass grafts, sequential stents
6. If multiple lesions, treat proximal first

Question 6

Aortobifemoral (originating at aorta) grafts versus femoropopliteal (Originating more distal been aorta) grafts are derived from?

Answer 6

Prosthetic material versus saphenous vein graft

Question 7

Signs and symptoms of penultimate and ultimate stage of vascular disease?

Answer 7

Rest pain, shiny atrophic skin without hair, no peripheral pulses

versus

ulceration and gangrene

Question 8

Signs of arterial embolization from a distant source? Management?

Answer 8

6 P's
Pain
Pulseless
Paralysis
Pallor
Paresthesias
Poikilothermic (cold)

Question 9

arterial embolization from a distant source - Management?

Answer 9

Treatment must be completed within six hours

1. Doppler to locate obstruction
2. If incomplete obstruction, Clot busters
3. If complete obstruction embolectomy with Fogarty catheter
4. If several hours before revascularization, must do fasciotomy

Question 10

Poorly controlled hypertension patient – worst-case emergency? Physical exam signs? Diagnosis? Treatment?

Answer 10

Dissecting aneurysm of thoracic aorta parentheses aortic dissection)

Unequal pulses, wide mediastinum on CXR

Spiral CT scan preferred. Otherwise MRI angiogram and TEE

Surgery if ascending aorta affected; medically if descending aorta affected