Vascular Surgery 2 Flashcards
Patient with vascular disease. Arteriogram shows high grade stenosis of the iliac artery but patency of the lower extremity. Surgical options?
- Surgical revascularization using large diameter graft from the aorta to the femoral artery
- Balloon dilation and/or arterial stent placement
Patient with vascular disease. Arteriogram shows occlusion of the superficial femoral artery with distal reconstitution. Surgical plan?
Reversed or in situ saphenous vein graft from common femoral artery to the popliteal artery to bypass obstructions
Patient with vascular disease. Arteriogram shows high-grade stenosis of the iliac artery and occlusion of the superficial femoral artery. Surgical plan?
Lower extremity revascularization in addition to aortoiliac reconstruction
May be performed together or aortoiliac occlusions can be treated first to see if that alone fixes problem
Patient with vascular disease. Arteriogram shows occlusion of the superficial femoral and popliteal arteries with distal reconstitution. Surgical plan?
Femoropopliteal bypass. (Graft Preference given to popliteal or tibial arteries >peroneal artery)
Diabetic with vascular disease. Arteriogram will show disease of what vessel typically? Concern for patients with distant diseased vessels?
Tibial; graft is more likely to fail patients more likely to require amputation
Patient with vascular disease. Arteriogram shows multiple obstructions in upper and distal leg with only small runoff vessels below ankle. Surgical plan?
No reconstruction may be possible – primary amputation may be most appropriate
Patient with peripheral vascular disease – most likely to die from?
CAD
Pt with suspected Leriche syndrome(?) presents with what hallmark sign? Work up?
Aortoiliac occlusive disease secondary to atherosclerosis
Impotence
- ABI measurement with H&P
- Only do arteriogram if decision is made to undergo surgeryr
Post vascular bypass surgery – medications to put patient on?
Aspirin, lipid lowering agents
Pt with suspected Leriche syndrome presents with impotence. Decision is made to intervene. Arteriogram shows occlusion of the common and external iliac arteries with patent aorta. Management option?
If Femoral pulses missing?
Percutaneous transluminal angioplasty (PTA) if patient has single, short segment iliac stenosis
1 . Aortobifemoral bypass if bilateral loss of femoral pulses and occlusion of the entire Iliac system
- Axillofemoral bypass graft if patient is too high risk for aortobifemoral bypass
- If one femoral artery is patent, feromofemoral bypass
Patient undergoes Aortobifemoral bypass graft – during the surgery, when are the cardiovascular risks the highest?
- During Anastasia induction
- Any hemorrhage
- Aortic clamping (markedly increased afterload)
- Unclamping
Patient undergoes a bypass graft surgery– Dangers when unclamping aorta?
- Decrease in afterload leading to increased cardiac output
- Risk of bleeding from graft
- Unclamping flushes static blood from lower extremities. Blood is acidotic and hyperkalemic – may adversely affect cardiac function
Post revascularization surgery, note a painful, cyanotic big toe. Condition? Cause? Treatment?
Trash foot – atheroembolization that has blocked digital arteries or microvesicles during unclamping
Heparinization and long-term antiplatelet therapy. If tibial vessels are patent, will heal
Patient need vascular surgery – when can a patient go straight for surgery? When to perform a coronary angiography? When to do DTS?
- Asymptomatic with active lifestyle
- Stable angina with vigorous lifestyle
- Age over 80
- Moderate to severe angina
- CHF with exertion
- LVEF under 20
- History of MI
- Moderate angina
- Mild angina but sedentary lifestyle
DTS?
Dipyridamole-Thallium scintigraphy
Used to rule out cardiac ischemia (good negative predictive value)
Eagle’s criteria?
Prediction of perioperative cardiac morbidity
- Age over 70
- Q waves
- Angina
- Ventricular arrhythmia
- Diabetes
- DTS redistribution
Number of risk factors:
0 – surgery without preoperative testing
1-2 – DTS testing
3+ – coronary angiography
59-year-old man complains of prominent bulge in upper abdomen. Physical exam shows nontender, pulsatile epigastric mass. Suspected diagnosis? Diagnostic test? Needs surgery if?
Abdominal aortic aneurysm; CT or US
Surgery if larger than 5 cm
Common postoperative problems following AAA repair?
Major Fluid shifts
- 1-2 days after surgery – large third space losses acquiring extra fluid
- By third Day – will mobilize fluid requiring diuresis/IV restriction
68 year old, obese patient brought to ED with low BP and tachycardia. This morning passed out in bathroom. Physical exam suggest pulsatile mass. Suspected Diagnosis? Management?
Ruptured abdominal aortic aneurysm
- Send blood for type & cross and get ECG
- Send to OR
68 year old, obese patient brought to ED with tachycardia. This morning passed out in bathroom. Physical exam reveals questionable pulsatile mass. Management? Perioperative risks?
- Ultrasound or CT scan to visualize AAA and look for nearby hematoma
- If hematoma present (ruptured AAA), surgery
Exsanguination (high as 80%)
72 year old man undergoes repair of ruptured AAA. On third postoperative day develops bloody diarrhea – suspected diagnosis? Specific area most likely affected? Management?
Ischemic colitis
Rectosigmoid segment
- Sigmoidoscopy (diagnosis confirmed with wdema, hemorrhage, necrosis)
- If confirmed, bowel rest, G.I. tract decompression, antibiotics,
- If full thickness involvement, resection of nonviable bowel and colostomy
72 year old man undergoes repair of ruptured AAA. Two months later, patient returns with fever and inflamed femoral incision – suspected diagnosis? Usual cause? Other signs/symptoms? Management?
Vascular graft infection – most serious complication of aortic surgery (usually from contamination by skin flora)
Sepsis, wound abscess, pseudoaneurysm, G.I. hemorrhage, back pain
- CT to confirm diagnosis
- Complete removal of graft and debridement of infected tissues
- Revascularization by extra anatomic bypass
- long-term antibiotics
72 year old man undergoes repair of ruptured AAA. One year later returns with upper G.I. bleed – likely diagnosis? Mechanism? Management?
Aorto enteric fistula (erosion of the graft into the third/fourth part of the duodenum)
- Confirm diagnosis with endoscopy, CT, angiography
- Removal of graft, repair of G.I. tract, extra anatomic bypass
