Vascular Surgery

Question 1

54 yo old laborer notices coldness and tingling in his left hand and pain in forearm when he does strenuous work; during last few episodes he also experienced transient vertigo, blurred vision and difficulty articulating his speech - dx? Test ?

Answer 1

Subclavian steal syndrome - combination of claudication of arm with posterior cerebral symptoms
- order duplex scan

Question 2

Subclavian steal syndrome

Answer 2

Atherosclerotic stenotic plaque at origin of subclavian allows enough blood supply to reach arm during normal activity but not during exercise; arm sucks blood away from brain by reversing flow in the vertebral AA

Question 3

Tx of subclavian steal syndrome

Answer 3

Surgical bypass

Question 4

A patient notices pain in neck and shoulder, numbness and tingling in fingers and a weak grip - dx.?

Answer 4

Thoracic outlet syndrome

- similar to subclavian steal but only vascular symptoms (no neuro)

Question 5

62 yo man is found on physical exam to have a 6 cm pulsatile mass deep in the abdomen, between xiphoid and umbilicus - dx? Test?

Answer 5

Abdominal aortic aneurysm

- order USG to measure size

Question 6

What are the size indications for surgical repair of AAA?

Answer 6

< 4 cm can be safely observed

> 5-6 cm or if it grows > 1 cm/year requires surgery

Question 7

62 yo man has vague, poorly described epigastric and upper back discomfort, he has a 6 cm pulsatile mass deep in abdomen; the mass is tender to palpation

Answer 7

Abdominal aortic aneurysm that is beginning to leak - will rupture in a day or two; get consultation with vascular surgeons today!

Question 8

68 yo man brought to ER with excruciating back pain that began suddenly; he is diaphoretic, with BP of 90. There is an 8 cm palpable mass deep in the abdomen

Answer 8

Ruptured aortic aneurysm- immediate surgical repair

Question 9

A wealthy retired man has claudication when walking more than 15 blocks. What should you do?

Answer 9

Work up and diagnosis of claudication is only needed if the symptoms are interfering with the patients lifestyle.

Question 10

What are some things that can help improve symptoms of claudication?

Answer 10

Quitting smoking
Exercise program
Cilostazol- anti platelet, pde5 inhibitor

Question 11

What is the normal work up scheme in someone who has symptomatic claudication?

Answer 11

1. Doppler studies - ankle brachial index
2. If severe gradient, do CT angio or MRI angio
3. Bypass surgery or angioplastic stent

Question 12

When is claudication not amenable to surgical treatment?

Answer 12

Not interfering with life

If no pressure gradient found on Doppler studies - implies microvascular problem

Question 13

What are some symptoms/signs of severe arterial insufficiency/ claudication?

Answer 13

Rest pain, ESP at night - pain goes away if leg dangles by side of bed (turns deep purple from pale)
Skin is shiny with no hair
No palpable peripheral pulses

Question 14

45 yo man comes in with a pale, cold, pulseless, paresthetic, painful and paralytic lower extremity that began 2 hours ago

Answer 14

Embolization - need urgent evaluation and tx. Within 6 hours

Question 15

Pt presents with embolization of an artery to an extremity; what is the diagnostic test you do and tx. Options?

Answer 15

Doppler studies

• if complete occlusion, do embolectomy with fogarty catheter
• if incomplete occlusion, clot busters
• if longstanding, add fasciotomy to prevent compartment syndrome

Question 16

An old man presents with sudden tearing chest pain to his back; he has high BP that is unequal across both upper extremities and a widened mediastinum on CXR; ECG and cardiac enzymes are negative for MI - dx? Test?

Answer 16

Dx. Aortic aneurysm dissection

Test - spiral CT

Question 17

Tx of aortic dissection

Answer 17

If in ascending aorta - emergency surgery

If in descending aorta- intensive therapy in ICU for HTN