Vascular Surgery Flashcards
Subclavian steal syndrome
Rare but fascinating. Arteriosclerotic stenotic plaque @ subclavian origin allows enough blood to reach arm for normal activity, but not higher demands. If too much arm activity, arm sucks blood from brain by reversing vertebral artery flow
Pt has claudication of arm (cold, tingle, pain) and posterior neuro sings (visual sx, equilibrium problems) w/ arm exercise
Just vasc sx = thoracic outlet syndrome, but w/ neuro sx = subclav steal.
Dx = arteriogram showing flow reversal
Tx = bypass
Abdominal aortic aneurysm
Typicall asx, pulsatile ab mass on exam (between xiphoid and belly button), or on XR, Sonogram, CT, in older man. Size is key- , elective repair
AAA rupture repair
Very high morbid/mortality, so avoid it and operate earlier
Tender AAA
Gonna rupture soon! repair immediately!
Excruciating back pain in pt w/ large AAA
It’s already leaking, retroperiotenal hematoma forming, blowout into peritoneal cavity coming real soon. SURGERY!
Arteriosclerotic occlusive disease of lower extremity
Unpredictable natural hx (except smoking related), no prophylactic surgery possible. Surgery to relieve disabling sx or save extremity from death.
Sx- pain from walking, relieved by rest (intermittent claudication). w/u if messing up pts life
Tx- smoking cessation, exercise, use cilostazo (PDE inhibitor, up CAMP, vasodil + platelet blocker)
W/u for claudication
Doppler looking for pressure gradient. If not, it’s small vessel disease
If gradient- arterogram to find stenosis/obstruction, look for vessels to hook graft
Short stenotic segs? tx = angioplasty and stenting
extensive disease? bypass grafts/sequential stents
Multiple lesions? Repair prox before distal
Grafts from aorta (aortobifemoral) done w/ prosthetic material
Bypass between distal vessels (femoralpopliteal, etc) w/ reversed saphenous vein grafts
Rest pain
Penultimate stage of disease (before ulceration and gangrene)
Pt cannot sleep, b/c of calf pain
Sitting up and dangling leg helps pain, but turns leg from pale to deep purple
P/e shows shiny atrophic skin w/out hair, no peripheral pulses.
Ateriol embolization from distant source
Pt-s w/ a-fib or recent MI (embolus from mural thrombus)
Pt gets sudden painful pale cold pulseless paresthetic paralytic lower extremity
Urgent eval and tx in 6 hrs
Doppler to find obstruction, if early/incomplete occlusion, tx w/ cloth busters
Embolectomy w/ fogarty catheter for complete obstructions
Fasciotomy if several hours have passed
Dissecting aneurysm of thoracic aorta
Pt w/ poorly controlled HTN. Looks like an MI, but sudden severe, tearing chest pain to back and migrates down. Unequal pulses in upper extrememties, CXR w/ widened mediastinum. EKG/enzymes rule out MI. Dx noninvasively (no high pressure aortogram)
MRI angio and transesoph echo work, but sprial CT is best
Dissections of ascending aorta = surgery, descending aorta = medical management w/ hyprtension control in ICU? WHY?
