Vascular Surgery

Question 1

What does a patient with subclavian steal syndrome experience when the arm is exercised (or put above the heads)?

Answer 1

1) claudication of arm – tingling, coldness, muscle pain

2) posterior neurologic signs (visual symptoms, equilibrium problems)

Question 2

How can you distinguish between thoracic outlet syndrome and subclavian steal syndrome symptomatically?

Answer 2

While both have similar vascular symptoms, subclavian steal features the neurologic symptoms (visual symptoms, dizziness)

Question 3

How do you diagnose subclavian steal? Treat it?

Answer 3

A Duplex scan showing reversal of flow.

Treatment is bypass surgery

Question 4

An abdominal aortic aneurysm can be safely observed if it is __cm or smaller.

Answer 4

4

Question 5

Abdominal aortic aneurysms that grow __ cm/year or faster need elective repair.

Answer 5

1 cm/year

Question 6

WHat is the treatment of a tender AAA?

Answer 6

Immediate repair! Rupture within a day or 2 is likely

Question 7

Excruciating back pain in a patient with a large AAA?

Answer 7

Retroperitoneal hematoma! Blowout is minutes or hours away, and immediate repair is indicated

Question 8

What is the first clinical manifestation of arteriosclerotic occlusive disease of the lower extremities?

Answer 8

Intermittent claudication: pain brought about by walking and relieved by rest

Question 9

When is prophylactic surgery for arteriosclerotic occlusive disease of the lower extremiteis performed?

Answer 9

Never! No role for it because unpredictable natural history. Surgery only if there are disabling symptoms or to save the extremity from impending necrosis

Question 10

What is the treatment of arteriosclerotic occlusive disease of the lower extremity?

Answer 10

Exercise, weight loss, cessation of smoking, cilostazol (PDE inhibitor that causes vasodilation of arteries and decrease of platelet clotting)

Question 11

The workup of disabling intermittent claudication starts with
If positive, what next?

Answer 11

Doppler studies looking for a pressure gradient, If one is found, CT angio or MRI angio

Question 12

If Doppler studies reveal no pressure gradient in the workup of disabling intermittent claudication, what does that mean?

Answer 12

Disease is in the small vessels and is not amenable to surgery

Question 13

In arteriosclerotic occlusive disease, short stenotic segments can be treated with ____________, while more extensive disease requires bypass grafts, sequential stents, or longer stents.

Answer 13

angioplasty and stents

Question 14

When multiple sclerotic lesions are present in a lower extremity, (proximal/distal) lesions are repaired first.

Answer 14

Proximal

Question 15

Which type of vascular grafts are repaired with prosthetic material? Which with reversed saphenous vein grafts?

Answer 15

Prosthetic: aortobifemoral (grafts originating at aorta)

Reversed saphenous vein grafts: between more distal vessels, like femoropopliteal or beyond

Question 16

What are the penultimate and ultimate stages of arteriosclerotic occlusive disease?

Answer 16

penultimate: rest pain (patient cannot sleep because of calf pain)
ultimate: ulceration and gangrene

Question 17

What helps relieve rest pain?

Answer 17

Sitting up and dangling legs

Question 18

What does physical exam reveal in patients with rest pain of the leg?

Answer 18

Shiny atrophic skin without hair and no peripheral pulses

Question 19

In cases of arterial embolization from a distant source occluding vessels in the extremity, what do you see?

Answer 19

painful, pale, poikilothermic, pulseless, paresthetic and paralytic extremity

Question 20

Early incomplete occlusion from arterial embolization can be treated with ________, while complete obstructions are treated with ___________. If several hours have passed, what should be added before revascularization?

Answer 20

incomplete, early: clot buster

complete: embolectomy with Fogarty catheter
late: fasciotomy should be performed prior to revascularization

Question 21

What imaging can diagnose an aortic dissection?

Answer 21

best option: spiral CT
can also use MR angiogram or TEE.
Noninvasive is preferred

Question 22

As a rule (riddled with exceptions), which dissections are treated surgically and which medically with control of the hypertension?

Answer 22

surgically: ascending dissections

medically (control of HTN): descending dissections