Vascular Surgery 3

Question 0

49-year-old woman presents with six-month history of postprandial abdominal pain, 20 pound weight loss, and intermittent diarrhea. Multiple abdominal bruits on exam. Guaiac negative. Suspected diagnosis? Management?

Answer 0

Chronic mesenteric ischemia secondary to atherosclerotic occlusion of celiac and SMA

1. Mesenteric arteriogram to confirm diagnosis
2. Revascularization using bypass from aorta using saphenous vein graft and prosthetics graft

Question 1

58-year-old man with diaphoresis, severe tearing chest pain. Hypertensive and tachycardic – suspected diagnosis? Confirm diagnosis with? Different types?

Answer 1

Aortic dissection

TEE, MRI, spiral CT, or arteriography to confirm diagnosis

Type 1 – ascending and descending dissection
Type 2 – descending dissection
Type 3 – partial descending dissection

Question 2

67-year-old woman undergoes a colectomy for a colon polyp. Postoperatively has suspected DVT – most reliable clinical sign of DVT? Test to confirm DVT (Gold standard versus actually used)? Treatment (and level)?

Answer 2

Unilateral leg swelling

Contrast venography versus duplex ultrasound

1. Heparin or LMWH until PTT reaches 1.5-2 times normal value for 5-7 days
2. Warfarin with INR of 2.0-3.0 for 3-6 months

Question 3

Possible Adverse effect of heparin?

Answer 3

Thrombocytopenia – follow patient’s platelet counts

Question 4

Postthrombotic syndrome caused by? Signs and symptoms? Management?

Answer 4

caused by chronic venous hypertension in lower leg after DVT

1. Chronic, marked edema
2. Skin ulceration around ankle
3. Sometimes Venous claudication

Support hose

Question 5

DVT prophylaxis?

Answer 5

Venodynes and low-dose prophylactic heparin

Question 6

50-year-old male undergoes laparotomy. POD 4 has episode of shortness of breath. No new or concerning physical exam findings – suspected diagnosis? Work up?

Answer 6

PE

1. ECG for MI
2. ABG – decreased PCO2 if PE
3. CXR for pneumonia, atelectasis, pneumothorax
4. If all else fails, V/Q scan for PE

Question 7

Most accurate test to detect PE? Why not used?

Answer 7

Pulmonary angiogram; higher morbidity and mortality than duplex study or VQ scan

(For instance in a patient with atelectasis, VQ scan not helpful to rule out PE)

Question 8

Patient under anticoagulation for PE presents with hematemesis. Management?

Answer 8

1. Discontinue systemic anticoagulants
2. IVC filter for PE protection
3. Antiulcer therapy and further evaluation for bleeding

Question 9

60 a woman with advanced cervical carcinoma with extension to the pelvic wall presents with an acute episode of leg edema, with cyanosis and pain – suspected diagnosis? Mechanism? Management?

Answer 9

Phlegmasia cerulean dolens (Inflammation cyanotic painful)

Acute interruption of the venous outflow from obstruction secondary to pelvic malignancy

If not treated immediately, may lead to sensory loss, motor loss, and gangrene