Vascular Surgery Flashcards
What clues suggest carotid stenosis? How is it diagnosed?
Classic is TIA - esp. amaurosis fugax (sudden onset transient, unilateral blindness, “shade pulled over one eye”). Physical exam may reveal carotid bruit. Diagnosed with ultrasound of carotid arteries (duplex scan).
How is 70-99% carotid stenosis managed?
Usually advised to undergo carotid endarterectomy. Should not undergo this after a stroke that leaves them severely disabled, but small strokes are no contraindications to surgery. Should not be performed during a TIA or stroke in evolution. Surgery is always done electively, not on an emergent basis.
How is less than 50% carotid stenosis managed?
Whether symptomatic or not, do not advise carotid endarterectomy. Treat with daily aspirin and/or clopidrogrel.
What is the most common cause of death during vascular surgery?
Myocardial infarction, regardless of procedure performed. Peripheral vascular and aortic disease are generalized markers for atherosclerosis, and almost all patients have significant CAD. Always evaluate for modifiable and treatable risk factors (e.g. cholesterol, HTN, smoking, DM).
What are the classic findings in a patient with an abdominal aortic aneurysm? How is it evaluated?
Pulsatile abdominal mass that may cause abdominal pain. If pain is present, rupture/leak should be suspected. Ultrasound or CT for initial evaluation and diagnostic confirmation, as well as for serial monitoring.
How is an abdominal aortic aneurysm managed?
< 5 cm - follow with serial U/S to ensure that it is not enlarging; manage with risk factor reduction (smoking cessation, tx of HTN and dyslipidemia)
> 5 cm (or enlarging rapidly) - surgical correction
What clues indicate that an abdominal aortic aneurysm has ruptured?
Pulsatile abdominal mass + hypotension! Do emergent laparotomy because mortality rate is ~90%.
What is the management of an abdominal aortic aneurysm dissection?
Depends on location of dissection. Pts who survive initial tear present with severe sharp or tearing sensation in back or chest. Acute dissections involving ascending aorta are considered surgical emergencies. Dissections confined to descending aorta are treated medically unless dissection progresses or continues to bleed.
Define Leriche syndrome. For what is it a marker?
Combination of claudication in buttocks, buttock atrophy, and impotence in men due to aortoiliac occlusive disease. Most pts need an aortoiliac bypass graft.
Define claudication. What are the associated physical findings?
Pain, usually in the lower extremity, brought on by exercise and relieved by rest. Occurs with severe atherosclerotic disease (equivalent of angina for the extremities). Associated physical findings include cyanosis (with dependent rubor), atrophic changes (thickened nails, loss of hair, shiny skin), decreased temperature, and decreased (or absent) distal pulses.
How are patients with claudication managed?
Best tx is conservative: smoking cessation, exercise, good control of cholesterol, DM, and HTN. Antiplatelet agents are warranted (aspirin preferred, though clopidogrel is acceptable). Cilostazol may be used for intermittent claudication. Beta blockers may worsen claudication (due to beta2 receptor blockade). If it progresses to rest pain (forefoot pain, generally at night, relieved by hanging foot over edge of bed) or interferes with lifestyle or work obligations, perform diagnostic angiography and angioplasty or surgical revascularizaiton.
What is the probable cause of severe, sudden onset foot pain in patients with no previous history of foot pain, trauma, or associated chronic physical findings?
Embolus (look for atrial fibrillation; pulse may be absent in affected area) or compartment syndrome (common after revascularization procedures).
Describe the classic presentation of chronic mesenteric ischemia.
Long history of postprandial abdominal pain (intestinal angina) which causes “fear” of food and extensive weight loss. Look for history of extensive atherosclerosis (MI, stroke, known CAD or PVD), abdominal bruit, hemoccult-positive stool, and lack of jaundice (would suggest pancreatic CA). Negative CT scan raises suspicion of ischemia. Diagnosis can be made with angiogram of mesenteric vessels. Treated with surgical revascularization because of risks of bowel infarction and malnutrition.
How does an acute bowel infarction present?
Patient with history of extensive atherosclerosis or multiple risk factors presents with abdominal pain or tenderness, bloody diarrhea, and possibly peritoneal signs (e.g. rebound tenderness, guarding). Watch for “thumbprinting” (thickened bowel walls) on abd xray. May also have tachycardia, hypotension, and/or shock.
What causes arteriovenous fistulas and pseudoaneurysms in the extremities? How do you recognize them?
Penetrating trauma in an extremity or iatrogenic catheter damage may be followed by the development of AV fistula or pseudoaneurysm. Watch for bruits over the are or a palpable pulsatile mass. Small fistulas can be left alone, but some require surgical or angiographic intervention.
