Vascular Surgery Flashcards
What are the 3 types of lower extremity occlusive peripheral vascular disease?
- asymptomatic occlusive disease
- intermittent claudication
- critical limb ischemia (must intervene with revascularization or amputation)
What are the important points about lower extremity asymptomatic occlusive disease?
- men more than women
- ankle brachial index (ABI) less than 0.9
- strong marker for atherosclerotic disease
What is the most common presentation of lower extremity occlusive disease?
intermittent claudication
Do most patients with intermittent claudication require surgical intervention?
- NO! 70% will never progress, so we will try medications first.
What are some differential diagnoses for intermittent claudication?
- compartment syndrome
- nerve root compression
- spinal stenosis
- bakers cyst
- arthritis
At what Fontaine grade of claudication do we intervene?
grade III
How will a foot look with severe claudication when standing vs when it is elevated?
- standing= bright red due to capillary dilation
- elevated= white
Are foot ulcers common in pts with peripheral vascular disease?
YES because the lack of blood flow prevents proper healing.
*usually associated with DM
How do you diagnose?
- peripheral vascular physical exam! grade pulses from 1-4.
How do you determine your ABI (ankle brachial index)?
highest ANKLE systolic pressure/ highest BRACHIAL systolic pressure
*normal should be greater than 0.9 bc pressure should be lower due to gravity in the ankle.
If an ABI level is greater than 1.25 what should you think?
falsely elevated due to diabetes
What are some other vascular lab tests?
- exercise testing
- toe systolic pressure
- US duplex scan
- angiography
- CTA
- MRA
- contrast arteriogrpahy
What is the medical management for a pt with PVD?
- anti-platelet therapy
- smoking cessation
- treatment of hyperlipidemia (LDL less than 100 in all pts and less than 80 if we are going to intervene).
- treatment of HTN
- treatment of DM
Where will you feel pain with aortoiliac disease?
butt and thighs
*these are usually younger pts with multiple peripheral vascular levels affected.
What is Leriche syndrome?
buttock claudication, impotence, and absent femoral pulses
How do we quantify PVD?
TASC II classification system= ranks aortoiliac and femoral popliteal disease to determine severity (A-D).
- A= treat endovascularly (easier pts)
- D= open surgery (harder pts)
What is a common open surgical procedure for aortoileal disease?
- aortobifem (aorto to bifemoral bypass).
Will you ever do an endovascular procedure on a pt with juxtarenal occlusion (occluded all the way to the renal arteries)?
NO because you can easily break off a clot.
Why should you always check the BP in both brachial arteries?
- if there is a difference of 15 mmHg in one arm, it’s likely that the pt has osteal disease of the left subclavian.
Does an aorotobifemoral procedure have a high 5 year patency (unobstructed)?
YES 90% :)
*normally the bigger the surgery, the higher the patency.
Is a vein or prosthetic graft always better?
VEIN ALWAYS :)
What are some endovascular procedures?
- drug eluding balloons or stents
- atherectomy
- balloon angioplasty
What did the BASIL trial show?
surgery first has higher mortality, BUT if they survive the first 2 years, they do VERY WELL.
What is the only drug that has ever been proven to increase claudication pts distance of walking without claudication?
Cilostazol (Pletal)= phosphodiesterase inhibitor, but can’t give this to pts with CHF bc it vasodilates everything and puts pt at risk for heart failure.
