Vascular Surgery Flashcards
1
Q
What is atherosclerosis?
A
Diffuse disease process in arteries.
Atheromas containing cholesterol and lipid form within the intima and inner media, often accompanied by ulcerations and smooth muscle hypertrophy.
2
Q
What is the common theory of how atherosclerosis is initiated?
A
- Endothelial injury
- Platelets adhere
- Growth factors released
- Smooth muscle hyperplasia and plaque deposition
3
Q
What are the risk factors for atherosclerosis?
A
HTN, smoking, diabetes, family history, hypercholesterolemia, high LDL, obesity, sedentary lifestyle
4
Q
What are the common sites of plaque formation in arteries?
A
Branch points (e.g. carotid bifurcation), tethered sites (e.g. superficial femoral artery in Hunter’s canal in the leg)
5
Q
What must be present for a successful arterial bypass operation?
A
- Inflow (e.g. patent aorta)
- Outflow (e.g. open distal popliteal artery)
- Run off (e.g. patent trifurcation vessels down to the foot)
6
Q
What is the major principle of safe vascular surgery?
A
Get proximal and distal control of the vessel to be worked on
7
Q
What does it mean to Potts a vessel?
A
Place a vessel loop twice around a vessel so that if you put tension on the vessel loop it will occlude the vessel
8
Q
What is the suture needle orientation through graft vs. diseased artery in a graft to artery anastomosis?
A
Needle “in-to-out” of the lumen in diseased artery to help tack down the plaque and the needle “out-to-in” on the graft
9
Q
What are the 3 layers of an artery?
A
- Intima
- Media
- Adventitia
10
Q
Which arteries supply the blood vessel itself?
A
Vaso vasorum
11
Q
What is a true aneurysm?
A
Dilation (> 2 nL diameter) of all 3 layers of a vessel
12
Q
What is a false aneurysm?
A
Dilation of artery not involving all 3 layers (e.g. hematoma with fibrous covering).
Often connects with vessel lumen and blood swirls inside the false aneurysm.
13
Q
What is endovascular repair?
A
Placement of a catheter in artery and then deployment of a graft intraluminally
14
Q
How can you remember the orientation of the lower exterior arteries below the knee on A-gram?
A
LAMP:
Lateral Anterior tibial
Medial Posterior tibial
15
Q
What is PVD?
A
Peripheral Vascular Disease
Occlusive atherosclerotic disease in the lower extremities.
16
Q
What is the most common site of arterial atherosclerotic occlusion in the lower extremities?
A
Occlusion of SFA in Hunter’s canal
17
Q
What are the symptoms of PVD?
A
Intermittant claudications, rest pain, erectile dysfunction, sensorimotor impairment, tissue loss
18
Q
What is intermittent claudication?
A
Pain, cramping, or both of the lower extremity, usually the calf muscle, after walking a specific distance.
Then the pain/cramping resolves after stopping for a specific amount of time while standing.
Pattern is reproducible.
19
Q
What is rest pain?
A
Pain in the foot, usually over the distal metatarsals.
This pain arises at rest (classically at night, awakening the patient)
20
Q
How can vascular causes of claudication be differentiated from nonvascular causes (such as neurogenic claudication or arthritis)?
A
History (in the vast majority of patients); noninvasive tests
21
Q
What is the differential diagnosis of lower extremity claudication?
A
Neurogenic (e.g. nerve entrapment, discs), arthritis, coarctation of aorta, popliteal artery syndrome, chronic compartment syndrome, neuromas, anemia, diabetic neuropathy pain
22
Q
What are the signs of PVD?
A
Absent pulses, bruits, muscular atrophy, decreased hair growth, thick toenails, tissue necrosis/ulcers/infection
23
Q
What is the site of a PVD ulcer vs. a venous stasis ulcer?
A
PVD arterial insufficiency ulcer: usually on the toes/feet
Venous stasis ulcer: medial malleolus
24
Q
What is the ABI?
A
Ankle to Brachial Index:
Ratio of the systolic blood pressure at the ankle to the systolic blood pressure at the arm.
Pressure taken with Doppler.
25
What ABIs are associated with normals, claudicators, and rest pain?
Normal ABI: > 1.0
Claudicators ABI: < 0.6
Rest pain ABI: < 0.4
26
Who gets false ABI readings?
Patients with calcified arteries, especially those with diabetes
27
What are PVRs?
Pulse Volume Recordings:
Pulse wave forms are recorded from lower extremities representing volume of blood per heart beat at sequential sites down leg.
Large wave form means good collateral blood flow.
28
Prior to surgery for chronic PVD, what diagnostic test will every patient receive?
A-gram maps disease and allows for best treatment option (i.e. angioplasty vs. surgical bypass vs. endarterectomy)
29
What is the bedside management of a patient with PVD?
1. Sheep skin (easy on the heels)
2. Foot cradle (keeps sheets/blankets off the feet)
3. Skin lotion to avoid further cracks in the skin that can go on to form a fissure and then an ulcer
30
What are the indications for surgical treatment of PVD?
```
STIR:
Severe claudication refractory to conservative treatment that affects quality of life
Tissue necrosis
Infection
Rest pain
```
31
What is the treatment of claudication?
Conservative treatment (e.g. exercise, smoking cessation, treatment of HTN, diet, aspirin +/- pentoxifylline (Trental)
32
How can the medical conservative treatment for claudication be remembered?
```
PACE:
Pentoxifylline
Aspirin
Cessation of smoking
Exercise
```
33
How does aspirin work?
Inhibits platelets (inhibits cyclooxygenase and platelet aggregation)
34
How does pentoxifylline (Trental) work?
Results in increased RBC deformity and flexibility
35
What is the risk of limb loss with claudication?
5% at 5 years
| 10% at 10 years
36
What is the risk of limb loss with rest pain?
> 50% of patients will have amputation at some point
37
In the patient with PVD, what is the main postoperative concern?
Cardiac status, because most patients with PVD have CAD (20% have an AAA).
MI is the most common cause of postoperative death after a PVD operation.
38
What is Leriche's syndrome?
Buttock claudication, impotence, and leg muscle atrophy from occlusive disease of the iliac arteries and distal aorta
39
What are the treatment options for severe PVD?
1. Surgical graft bypass
2. Angioplasty (balloon dilation)
3. Endarterectomy (remove disease intima and media)
4. Surgical patch angioplasty (place patch over stenosis)
40
What is a FEM-POP bypass?
Bypass SFA occlusion with a graft from the FEMoral artery to POPliteal artery
41
What is a FEM-DISTAL bypass?
Bypass from the FEMoral artery to a DISTAL artery (e.g. peroneal, anterior tibial, or posterior tibial artery)
42
What graft material has the longest latency rate?
Autologous vein graft
43
What is an in situ vein graft?
Saphenous vein is more or less left in place, all branches are ligated, and the vein valves are broken with a small hook or cut out.
A vein can also be used if reversed so that the valves do not cause a problem.
44
What type of graft is used for above-the-knee FEM-POP bypass?
Either vein or Gortex graft.
| Vein still has better patency.
45
What type of graft is used for below-the-knee FEM-POP or FEM-DISTAL bypass?
Must use vein graft.
| Prosthetic grafts have a prohibitive thrombosis rate.
46
What is dry gangrene?
Dry necrosis of tissue without signs of infection
47
What is wet gangrene?
Moist necrotic tissue with signs of infection
48
What is blue toe syndrome?
Intermittent painful blue toes (or fingers) due to microemboli from a proximal arterial plaque
49
What are the indications for lower extremity amputation?
Irreversible tissue ischemia and necrotic tissue; severe infection; severe pain with no bypassable vessels; patient not interested in bypass procedure
50
What are 6 types of lower extremity amputations?
1. AKA (above-the-knee)
2. BKA (below-the-knee)
3. Symes
4. Transmetatarsal
5. Toe
6. Ray (removal of toe and head of metatarsal)
51
What is acute arterial occlusion?
Acute occlusion of an artery, usually by embolization (also, acute thrombosis of atheromatous lesion, vascular trauma)
52
What are the classic signs and symptoms of acute arterial occlusion?
Six P's:
| Pain, Paralysis, Pallor, Paresthesia, Polar, Pulselessness
53
What is the classic timing of pain with acute arterial occlusion from an embolus?
Acute onset; patient can classically tell you exactly when and where it happened
54
What is the immediate preoperative management of acute arterial occlusion?
1. Anticoagulate with IV heparin (bolus followed by constant infusion)
2. A-gram
55
What are the sources of emboli with acute arterial occlusion?
1. Heart (85%: clot from AFib, clot forming on dead muscle after MI, endocarditis, myxoma)
2. Aneurysms
3. Atheromatous plaque
56
What is the most common cause of embolus from the heart?
AFib
57
What is the most common site of arterial occlusion by an embolus?
Common femoral artery (SFA is the most common site of arterial occlusion from atherosclerosis)
58
What diagnostic studies are in order for acute arterial occlusion?
1. A-gram
2. ECG (looking for MI, AFib)
3. Echocardiogram (looking for clot, MI, valve vegetation)
59
What is the treatment for acute arterial occlusion?
Surgical embolectomy via cutdown and Fogarty balloon (bypass is reserved for embolectomy failure)
60
What is a Fogarty?
Fogarty balloon catheter: catheter with a balloon tip that can be inflated with saline, used for embolectomy
61
How is a Fogarty catheter used?
Insinuate the catheter with the balloon deflated past the embolus and then inflate the balloon and pull the catheter out.
62
How many mm in diameter is a 12 French Fogarty catheter?
Divide French number by pi.
| So 12 French is about 4 mm in diameter.
63
What must be looked for postoperatively after repercussion of a limb?
Compartment syndrome, hyperkalemia, renal failure from myoglobinuria, MI
64
What is compartment syndrome?
Leg (calf) is separated into compartments by very unyielding fascia.
Tissue swelling from reperfusion can increase the intracompartmental pressure, resulting in decreased capillary flow, ischemia, and myonecrosis.
Myonecrosis may occur after the intracompartmental pressure reaches only 30 mmHg.
65
What are the signs and symptoms of compartment syndrome?
Pain (especially after passive flexion/extension of the foot), paralysis, paresthesias, pallor.
Pulses are present in most cases because systolic pressure is much higher than the minimal 30 mmHg needed for the syndrome.
66
Can a patient have a pulse and compartment syndrome?
Yes
67
How is the diagnosis of compartment syndrome made?
History, compartment pressure measurement
68
What is the treatment of compartment syndrome?
Treatment includes opening compartments via bilateral calf-incision fasciotomies of all 4 compartments in the calf
69
What is a AAA?
Abdominal aortic aneurysm
| Abnormal dilation of the abdominal aorta (> 1.5-2 times normal), forming a true aneurysm
70
What is the M:F ratio for AAA?
6:1
71
By far, which group is at highest risk for AAA?
White males
72
What is the common etiology for AAA?
Believed to be atherosclerotic in 95% of cases (inflammatory otherwise)
73
What is the most common site of AAA?
Infrarenal (95%)
74
What is the incidence of AAA?
5% of all adults older than 60 years
75
What percentage of patients with AAA have a peripheral arterial aneurysm?
20%
76
What are the risk factors for AAA?
Atherosclerosis, HTN, smoking, male, advanced age, connective-tissue disease
77
What are the symptoms of AAA?
Most AAAs are asymptomatic and discovered during routine abdominal exam by PCPs.
Vague epigastric discomfort to back and abdominal pain.
78
What do testicular pain and AAA signify?
Retroperitoneal rupture with ureteral stretch and referred pain to the testicle
79
What are the risk factors for AAA rupture?
Increasing aneurysm diameter, COPD, HTN, recent rapid expansion, large diameter, symptomatic
80
What are the signs of AAA rupture?
1. Abdominal pain
2. Pulsatile abdominal mass
3. Hypotension
81
By how much each year do AAAs grow?
3 mm/year on average
82
Why do larger AAAs rupture more often and grow faster than small AAAs?
Laplace's Law (wall tension = pressure X diameter)
83
What is the risk of rupture per year based on AAA diameter size?
< 5 cm: 4%
5-7 cm: 7%
> 7 cm: 20%
84
Where does the aorta bifurcate?
At the level of the umbilicus (thus when palpating for an AAA, palpate above the umbilicus and below the xiphoid process)
85
What is the differential diagnosis for AAA?
Acute pancreatitis, aortic dissection, mesenteric ischemia, MI, perforated ulcer, diverticulosis, renal colic
86
What are the diagnostic tests for AAA?
U/S (follow AAA clinically); CT or A-gram (assess lumen patency and iliac/renal involvement)
87
What is the limitation of A-gram with AAA?
AAAs often have large mural thrombi, which result in a falsely reduced diameter because only the patent lumen is visualized
88
What are the signs of AAA on AXR?
Calcifications in the aneurysm wall, best seen on lateral projection
89
What are the indications for surgical repair of AAA?
AAA > 5.5 cm in diameter, if the patient does is not a terrible surgical candidate; AAA rupture; rapid growth; symptoms; embolization of plaque
90
What is the treatment for AAA?
1. Prosthetic graft placement with rewrapping of the native aneurysm adventitia around the prosthetic graft after the thrombus is removed (when rupture is strongly suspected, proceed to immediate laparotomy)
2. Endovascular repair
91
What is endovascular repair of a AAA?
Placement of a stent proximal and distal to a AAA through a distant percutaneous access (usually groin).
92
Why wrap the AAA graft in the native aorta?
To reduce the incidence of enterograft fistula formation
93
What type of repair should be performed with AAA and iliac arteries severely occluded or iliac aneurysm(s)?
Aortobi-iliac or aortobifemoral graft replacement (bifurcated graft)
94
What is the treatment for AAA if the patient has abdominal pain, pulsatile abdominal mass, and hypotension?
Take the patient to the OR for emergent AAA repair
95
What is the treatment if the patient has known AAA and new onset of abdominal pain or back pain?
CT scan:
1. Leak: go to OR
2. No leak: repair during next elective slot
96
What is the mortality rate for elective AAA treatment?
< 4%
97
What is the mortality rate for treatment of ruptured AAA?
50%
98
What is the leading cause of postoperative death in a patient undergoing elective AAA treatment?
MI
99
What are non-atherosclerotic etiologies of AAA?
Inflammatory (connective tissue diseases), mycotic (usually bacteria, not fungi)
100
What is the mean normal abdominal aorta diameter?
2 cm
101
What are the possible operative complications of AAA repair?
MI, atheroembolism, declamping hypotension, ARF, ureteral injury, hemorrhage
102
Why is colonic ischemia a concern in the repair of AAA?
Often the IMA is sacrificed during the surgery.
| If the collaterals are not adequate, the patient will have colonic ischemia
103
What are the signs of colonic ischemia?
Heme-positive stool; BRBPR; diarrhea; abdominal pain
104
What is the study of choice to diagnose colonic ischemia?
Colonoscopy
105
When is colonic ischemia seen postoperatively?
Usually in the first week
106
What is the treatment of necrotic sigmoid colon from colonic ischemia?
1. Resection of necrotic colon
2. Hartmann's pouch or mucous fistula
3. End colostomy
107
What is the possible long-term complication that often presents with both upper and lower GI bleeding?
Aortoenteric fistula
108
What are possible postoperative complications of AAA repair?
Colonic ischemia, aortoenteric fistula, erectile dysfunction, retrograde ejaculation, aortovenous fistula (to IVC), graft infection, anterior spinal syndrome
109
What is anterior spinal syndrome?
1. Paraplegia
2. Loss of bladder/bowel control
3. Loss of pain/temperature sensation below level of involvement
4. Sparing of proprioception
110
Which artery is involved in anterior spinal syndrome?
Antery of Adamkiewicz (supplies anterior spinal cord)
111
What are the most common bacteria involved in aortic graft infections?
1. Staph aureus
| 2. Staph epidermidis (late)
112
How is an aortic graft infection with an aortoenteric fistula treated?
Perform an extra-anatomic bypass with resection of graft
113
What is an extra-anatomic bypass graft?
Axillofemoral bypass graft (not in normal vascular path, usually goes from axillary artery to the femoral artery and then from one femoral artery to the other)
114
Which vein crosses the neck of the AAA proximally?
Left renal vein
115
What part of the small bowel crosses in front of the AAA?
Duodenum
116
Which large vein runs to the left of the AAA?
IMV
117
Which artery comes off the middle of the AAA and runs to the left?
IMA
118
Which vein runs behind the right common iliac artery?
Left common iliac vein
119
Which renal vein is longer?
Left
120
What is chronic mesenteric ischemia?
Chronic intestinal ischemia from long-term occlusion of the intestinal arteries.
Most commonly results from atherosclerosis.
Usually in 2 or more arteries because of the extensive collaterals.
121
What are the symptoms of chronic mesenteric ischemia?
Weight loss, postprandial abdominal pain, anxiety or fear of food, +/- heme occult, +/- diarrhea/vomiting
122
What is intestinal angina?
Postprandial pain from gut ischemia
123
What are the signs of chronic mesenteric ischemia?
Abdominal bruit is common
124
How is the diagnosis of chronic mesenteric ischemia made?
A-gram, duplex, MRA
125
What supplies blood to the gut?
1. Celiac axis vessels
2. SMA
3. IMA
126
What is the classic finding on A-gram with chronic mesenteric ischemia?
2 of the 3 mesenteric arteries are occluded, and there is atherosclerotic narrowing of the third patent artery
127
What are the treatment options for chronic mesenteric ischemia?
Bypass, endarterectomy, angioplasty, stenting
128
What is acute mesenteric ischemia?
Acute onset of intestinal ischemia
129
What are the causes of acute mesenteric ischemia?
1. Emboli to a mesenteric vessel from the heart
| 2. Acute thrombosis of long-standing atherosclerosis of mesenteric artery
130
What are the causes of emboli from the heart?
AFib, MI, cardiomyopathy, valve disease, endocarditis, mechanical heart valve
131
What drug has been associated with acute mesenteric ischemia?
Digitalis
132
To which intestinal artery do emboli preferentially go?
SMA
133
What are the signs and symptoms of acute mesenteric ischemia?
Severe pain (out of proportion to physical exam), no peritoneal signs until necrosis, vomiting, diarrhea, hyperdefecation, +/- heme stools
134
What is the classic triad of acute mesenteric ischemia?
1. Acute onset of pain
2. Vomiting, diarrhea, or both
3. History of AFib or heart disease
135
What is the gold standard diagnostic test for acute mesenteric ischemia?
Mesenteric A-gram
136
What is the treatment of a mesenteric embolus?
Perform Fogarty catheter embolectomy, resect obviously necrotic intestine, and leave marginal looking bowel until a second-look laparotomy is performed in 24-72 hours
137
What is the treatment of acute thrombosis in acute mesenteric ischemia?
Papaverine vasodilator via A-gram catheter until patient is in the OR.
Most surgeons will perform a supraceliac aorta graft to the involved intestinal artery or endarterectomy.
Intestinal resection and second-look as needed.
138
What is median arcuate ligament syndrome?
Mesenteric ischemia resulting from narrowing of the celiac axis vessels by extrinsic compression by the median arcuate ligament
139
What is the median arcuate ligament comprised of?
Diaphragm hiatus fibers
140
What are the symptoms of median arcuate ligament syndrome?
Postprandial pain, weight loss
141
What are the signs of median arcuate ligament syndrome?
Abdominal bruit in almost all patients
142
How is the diagnosis of median arcuate ligament syndrome made?
A-gram
143
What is the treatment for median arcuate ligament syndrome?
Release arcuate ligament surgically
144
What are the signs and symptoms of carotid vascular disease?
Amaurosis fugax, TIA, RIND, CVA
145
What is amaurosis fugax?
Temporary monocular blindness ("curtain coming down").
| Seen with microemboli to retina.
146
What is TIA?
Transient Ischemic Attack:
| Focal neurologic deficit with resolution of all symptoms within 24 hours
147
What is RIND?
Reversible Ischemic Neurologic Deficit:
| Transient neurologic impairment (without any lasting sequelae) lasting 24-72 hours
148
What is CVA?
```
CerebroVascular Accident (stroke):
Neurologic deficit with permanent brain damage
```
149
What is the risk of a CVA in patients with TIA?
10% a year
150
What is the noninvasive method of evaluating carotid disease?
Carotid U/S or Doppler (gives general location and degree of stenosis)
151
What is the gold standard invasive method of evaluating carotid disease?
A-gram
152
What is the surgical treatment of carotid stenosis?
CEA: Carotid EndArterectomy:
| Removal of the diseased intima and media of the carotid artery, often performed with a shunt in place
153
What are the indications for CEA in the asymptomatic patient with carotid disease?
Carotid stenosis > 60%
154
What are the indications for CEA in the symptomatic patient with carotid disease?
Carotid stenosis > 50%
155
Before performing a CEA in the symptomatic patient, what study other than the A-gram should be performed?
Head CT
156
In bilateral high-grade carotid stenosis, on which side should the CEA be performed in the asymptomatic, right-handed patient?
Left CEA first, to protect the dominant hemisphere and speech center
157
What is the dreaded complication after CEA?
Stroke (CVA)
158
What are the possible postoperative complications after a CEA?
CVA, MI, hematoma, wound infection, hemorrhage, hypotension/hypertension, thrombosis, vagus nerve injury (change in voice), hypoglossal nerve injury (tongue deviation toward side of injury), intracranial hemorrhage
159
What is the mortality rate after CEA?
1%
160
What is the perioperative stroke rate after CEA?
Asymptomatic: 1%
Symptomatic: 5%
161
What is the postoperative medication after a CEA?
Aspirin (inhibits platelets by inhibiting cyclooxygenase)
162
What is the most common cause of death during the early postoperative period after a CEA?
MI
163
What is a Hollenhorst plaque?
Microemboli to retinal arteriole seen as bright defects
164
What thin muscle is cut right under the skin in the neck?
Platysma muscle
165
What are the extracranial branches of the internal carotid artery?
None
166
Which vein crosses the carotid bifurcation?
Facial vein
167
What is the first branch of the external carotid artery?
Superior thyroid artery
168
Which muscle crosses the common carotid proximally?
Omohyoid muscle
169
Which muscle crosses the carotid artery distally?
Digastric muscle
170
Which nerve crosses approximately 1 cm distal to the carotid bifurcation?
Hypoglossal nerve (cut it and the tongue will deviate toward the side of the injury)
171
Which nerve crosses the internal carotid near the ear?
Facial nerve (marginal branch)
172
What is in the carotid sheath?
1. Carotid artery
2. Internal jugular vein
3. Vagus nerve (lies posteriorly in 98%)
4. Deep cervical lymph nodes
173
What is subclavian steal syndrome?
Arm fatigue and vertebrobasilar insufficiency from obstruction of the left subclavian artery or innominate proximal to the vertebral artery branch point.
Ipsilateral arm movement causes increased blood flow demand, which is met by retrograde flow from the vertebral artery, thereby stealing from the vertebrobasilar arteries.
174
Which artery is most commonly occluded in subclavian steal syndrome?
Left subclavian
175
What are the symptoms of subclavian steal syndrome?
Upper extremity claudication, syncopal attacks, vertigo, confusion, dysarthria, blindness, ataxia
176
What are the signs of subclavian steal syndrome?
Upper extremity blood pressure discrepancy, bruit (above the clavicle), vertebrobasilar insufficiency
177
What is the treatment for subclavian steal syndrome?
Surgical bypass or endovascular stent
178
What is renal artery stenosis?
Stenosis of renal artery, resulting in decreased perfusion of the juxtaglomerular apparatus and subsequent activation of the renin-angiotensin-aldosterone system
179
What is the incidence of renal artery stenosis?
4% of patients with HTN
180
What is the etiology of renal artery stenosis?
Atherosclerosis (66%) or fibromuscular dysplasia
181
What is the classic profile of a patient with renal artery stenosis from fibromuscular dysplasia?
Young woman with HTN
182
What are the associated risks/clues for renal artery stenosis?
Family history, early onset of HTN, HTN refractory to medical treatment
183
What are the signs and symptoms of renal artery stenosis?
Most patients are asymptomatic.
| HA, diastolic HTN, flank bruits, decreased renal function
184
What is the role of an A-gram in renal artery stenosis?
Maps artery and extent of stenosis
185
What is the role of IVP in renal artery stenosis?
80% of patients have delayed nephrogram phase
186
What is the role of renal vein renin ratio (RVRR) in renal artery stenosis?
If sampling of renal vein renin levels shows ratio between the two kidneys > 1.5, then diagnostic for a unilateral stenosis
187
What is the role of the captopril provocation test in renal artery stenosis?
Will show a drop in BP
188
Are renin levels in serum always elevated in renal artery stenosis?
No: systemic renin levels may also be measured but are only increased in malignant HTN, as the increased intravascular volume dilutes the elevated renin level in most patients
189
What is the invasive non-surgical treatment for renal artery stenosis?
Percutaneous Renal Transluminal Angioplasty (PRTA) +/- stenting
190
What is the surgical treatment for renal artery stenosis?
Resection, bypass, vein/graft interposition, or endarterectomy
191
What antihypertensive medication is contraindicated in patients with HTN from renal artery stenosis?
ACE inhibitors (results in renal insufficiency)
192
What are the causes of splenic artery aneurysm?
In women, medial dysplasia
| In men, atherosclerosis
193
How is the diagnosis of splenic artery aneurysm made?
Usually by abdominal pain, leading to U/S or CT; in the OR after rupture; incidentally by eggshell calcifications seen on AXR
194
What is the risk factor for splenic artery aneurysm rupture?
Pregnancy
195
What are the indications for splenic artery aneurysm removal?
Pregnancy, > 2 cm in diameter, symptoms, woman of child-bearing age
196
What is the treatment for splenic artery aneurysm?
Resection or percutaneous catheter embolization in high-risk patients
197
What is a popliteal artery aneurysm?
Aneurysm of the popliteal artery caused by atherosclerosis and rarely bacterial infection
198
How is the diagnosis of popliteal artery aneurysm made?
PE, A-gram, U/S
199
Why examine the contralateral popliteal artery?
50% of patients have bilateral popliteal artery aneurysm
200
What are the indications for elective surgical repair of a popliteal artery aneurysm?
1. > 2 cm
2. Intraluminal thrombus
3. Artery deformation
201
Why examine the rest of the arterial tree (especially the abdominal aorta) in popliteal artery aneurysm?
75% of patients have additional aneurysms elsewhere
202
What size thoracic aortic aneurysm is considered an indication for surgical repair?
> 6.5 cm
203
What size abdominal aortic aneurysm is considered an indication for surgical repair?
> 5.5 cm
204
What size iliac artery aneurysm is considered an indication for surgical repair?
> 4 cm
205
What size femoral artery aneurysm is considered an indication for surgical repair?
> 2.5 cm
206
What size popliteal artery aneurysm is considered an indication for surgical repair?
> 2 cm
207
What is milk leg?
AKA Phlegmasia alba dolens:
| Seen in pregnant women with occlusion of the iliac vein resulting from extrinsic compression by the uterus
208
What is phlegmasia cerulean dolens?
Cyanotic leg resulting from severe venous outflow obstruction.
The extensive venous thrombosis results in arterial inflow impairment.
209
What is Reynaud's phenomenon?
Vasospasm of digital arteries with color changes of the digits, usually initiated by cold or emotions.
White (spasm), then blue (cyanosis), then red (hyperemia)
210
What is Takayasu's arteritis?
Arteritis of the aorta and aortic branches, resulting in stenosis/occlusions/aneurysms
211
What is Buerger's disease?
AKA Thromboangiitis obliterans:
Occlusion of the small vessels of the hands and feet, often results in digital gangrene.
See in young men who smoke.
212
What is the treatment for Buerger's disease?
Smoking cessation, +/- sympathectomy
213
What is blue toe syndrome?
Microembolization from proximal atherosclerotic disease of the aorta resulting in blue, painful, ischemic toes
214
What is a paradoxical embolus?
Venous embolus gains access to the left heart after going through an intracardiac defect, most commonly a PFO, and then lodges in a peripheral artery
215
What is Behcet's disease?
Genetic disease with aneurysms from loss of vaso vasorum.
| Seen with oral, ocular, and genital ulcers and inflammation.
