Vascular surgery

Question 1

Signs of vascular insufficiency on exam

Answer 1

Hairless shiny skin, change in skin color (mottled, blanching, reddened), nail changes, ulcers or gangrene (particularly on malleoli and toes). Reproducible claudication pain (typically of calf muscles). If rest pain (burning, constant, often of forefoot), means severe ischemia.

Question 2

Posterior tibial pulse

Answer 2

Medial malleolus

Question 3

Scoring of pulses

Answer 3

0 = none, 1 = trace, 2 = normal, 3 = normal and strong, 4 = hyperdynamic

Question 4

In what cases might your ankle-brachial index reading be misleading?

Answer 4

Diabetic patients (calcification of vessels makes them less compressible, falsely elevating reading), collateral flow can mask as well

Question 5

Earliest sign of acute arterial insufficiency in LE

Answer 5

Peroneal nerve: hypesthesia along distribution, foot drop, inability to dorsiflex great toe. NB: nerves are most sensitive to ischemia, before muscles.

Question 6

Causes of acute arterial occlusion

Answer 6

Embolism most common (A fib, s/p MI, DVT+PFO), trauma, iatrogenic (e.g. catheter related), thombosis

Question 7

Treatment of acute arterial occlusion

Answer 7

Thrombectomy or grafting. Thrombolytic therapy (via catheter) only if ischemia not severe, as this takes time to dissolve.

Question 8

Chronic ischemia involving aortoiliac vessels can present how?

Answer 8

Claudication, impotence, decreased or absent femoral pulses

Question 9

Subclavian steal disease

Answer 9

Nonhemispheric cerebrovascular sx with mild arm claudication due to decreased flow to posterior cerebral artery when blood flows retrograde through vertebral artery to subclavian artery. Caused by subclavian artery stenosis.

Question 10

Cut off for below the knee amputation (BKA)

Answer 10

Up to the malleolus. If above that need to do above the knee amputation at the least

Question 11

What is the most common type of aneurysm?

Answer 11

Degenerative, caused by atherosclerosis- intima is replaced by fibrin.

Question 12

Other types of aneurysms

Answer 12

Traumatic, post-stenotic (e.g. distal to aortic coarctation), dissecting, mycotic (infected), s/p anastomotic

Question 13

Risk factors for dissecting aneurysm

Answer 13

HTN, Marfan, Ehlers-Danlos, blunt trauma, cystic medial necrosis

Question 14

Complications of AAA repair

Answer 14

Renal failure (ATN or atheroemboli), ischemic colitis (must do immediate sigmoidoscopy to eval if resection is needed), spinal cord ichemia (artery of Adamkiewicz disrupted)

Question 15

AAA rupture

Answer 15

Abdominal pain, syncope, hypotension in pt with hx of AAA. 90% mortality!

Question 16

For fun, what does TED stand for?

Answer 16

thromboembolism deterrant

Question 17

Most common presentation of DVT?

Answer 17

Asx! 2/3 are asx

Question 18

Papaverine

Answer 18

A vasodilator that can be used to dilate the mesenteric vascular bed in a case of low-flow (non-occlusive) mesenteric ischemia

Question 19

When is AAA elective repair indicated?

Answer 19

Greater than or equal to 5.5 cm (male) or 5 cm (female) if patient can tolerate procedure

Question 20

Screening for AAA

Answer 20

All male smokers, once by U/S, age 65-75

Question 21

TIA involving aphasia most likely stems from what?

Answer 21

LEFT carotid atherosclerosis

(in majority of right handed people, language is left brain)

Question 22

How can you have intact pulses during compartment syndrome?

Answer 22

Tissue ischemia is a result of obstruction of capillary blood flow from increased tissue pressure 2/2 edema. Tissue pressure > capillary pressure but not > arterial pressure so pulses intact.

Question 23

What is the most common location for occlusive disease of the LE?

Answer 23

Superficial femoral artery –> will affect the popliteal and pedal pulses.

If femoral pulse is affected, significant aortoiliac disease may also be present.

Question 24

What is the most likely cause of death in a patient with PVD?

Answer 24

PVD usually means diffuse atherosclerotic disease, so most likely cause of death is coronary artery disease

Question 25

How does distal claudication management differ from management of aortoiliac disease?

Answer 25

Distal claudication alone is usually managed well with lifestyle changes, and only intervene if really severe (rest pain, ulcers) or keeping patient from exercising (and patient can tolerate intervention). Aortoiliac disease is more likely to progress and is treated more aggressively- don’t wait for rest pain/ulceration to develop.

Question 26

AAA graft infection

Answer 26

Most commonly from contamination from skin flora (Staph epi or Staph aureus, incl MRSA). May not present for months to years. Tx: remove graft, debride, revascularize with extra-anatomic bypass, long term abx.

Question 27

Upper GI bleed following AAA repair?

Answer 27

Could be due to aortoenteric fistula develping over time between graft and distal duodenum. Can be difficult to see on endoscopy. Tx: removal of graft, extra-anatomic bypass, repair of GI tract

Question 28

What is phlegmasia cerulea dolens?

Answer 28

A uncommon severe form of DVT which results from extensive thrombotic occlusion of the major and collateral veins of an extremity. It is characterized by sudden severe pain, swelling, cyanosis and edema of the affected limb. There is a high risk of massive PE, even under anticoagulation. Foot gangrene may also occur. An underlying malignancy is found in 50% of cases.