Vascular Surgery

Question 1

What are the 3 types of lower extremity occlusive peripheral vascular disease?

Answer 1

1. asymptomatic occlusive disease
2. intermittent claudication
3. critical limb ischemia (must intervene with revascularization or amputation)

Question 2

What are the important points about lower extremity asymptomatic occlusive disease?

Answer 2

• men more than women
• ankle brachial index (ABI) less than 0.9
• strong marker for atherosclerotic disease

Question 3

What is the most common presentation of lower extremity occlusive disease?

Answer 3

intermittent claudication

Question 4

Do most patients with intermittent claudication require surgical intervention?

Answer 4

• NO! 70% will never progress, so we will try medications first.

Question 5

What are some differential diagnoses for intermittent claudication?

Answer 5

• compartment syndrome
• nerve root compression
• spinal stenosis
• bakers cyst
• arthritis

Question 6

At what Fontaine grade of claudication do we intervene?

Answer 6

grade III

Question 7

How will a foot look with severe claudication when standing vs when it is elevated?

Answer 7

• standing= bright red due to capillary dilation

- elevated= white

Question 8

Are foot ulcers common in pts with peripheral vascular disease?

Answer 8

YES because the lack of blood flow prevents proper healing.

*usually associated with DM

Question 9

How do you diagnose?

Answer 9

• peripheral vascular physical exam! grade pulses from 1-4.

Question 10

How do you determine your ABI (ankle brachial index)?

Answer 10

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.

Question 11

If an ABI level is greater than 1.25 what should you think?

Answer 11

falsely elevated due to diabetes

Question 12

What are some other vascular lab tests?

Answer 12

• exercise testing
• toe systolic pressure
• US duplex scan
• angiography
• CTA
• MRA
• contrast arteriogrpahy

Question 13

What is the medical management for a pt with PVD?

Answer 13

• 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

Question 14

Where will you feel pain with aortoiliac disease?

Answer 14

butt and thighs

*these are usually younger pts with multiple peripheral vascular levels affected.

Question 15

What is Leriche syndrome?

Answer 15

buttock claudication, impotence, and absent femoral pulses

Question 16

How do we quantify PVD?

Answer 16

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)

Question 17

What is a common open surgical procedure for aortoileal disease?

Answer 17

• aortobifem (aorto to bifemoral bypass).

Question 18

Will you ever do an endovascular procedure on a pt with juxtarenal occlusion (occluded all the way to the renal arteries)?

Answer 18

NO because you can easily break off a clot.

Question 19

Why should you always check the BP in both brachial arteries?

Answer 19

• if there is a difference of 15 mmHg in one arm, it’s likely that the pt has osteal disease of the left subclavian.

Question 20

Does an aorotobifemoral procedure have a high 5 year patency (unobstructed)?

Answer 20

YES 90% :)

*normally the bigger the surgery, the higher the patency.

Question 21

Is a vein or prosthetic graft always better?

Answer 21

VEIN ALWAYS :)

Question 22

What are some endovascular procedures?

Answer 22

• drug eluding balloons or stents
• atherectomy
• balloon angioplasty

Question 23

What did the BASIL trial show?

Answer 23

surgery first has higher mortality, BUT if they survive the first 2 years, they do VERY WELL.

Question 24

What is the only drug that has ever been proven to increase claudication pts distance of walking without claudication?

Answer 24

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.