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ENTREGA > Vascular Surgery > Flashcards

Vascular Surgery Flashcards

1
Q

What is atherosclerosis?

A

Diffuse disease process in arteries.
Atheromas containing cholesterol and lipid form within the intima and inner media, often accompanied by ulcerations and smooth muscle hypertrophy.

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2
Q

What is the common theory of how atherosclerosis is initiated?

A
  1. Endothelial injury
  2. Platelets adhere
  3. Growth factors released
  4. Smooth muscle hyperplasia and plaque deposition
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3
Q

What are the risk factors for atherosclerosis?

A

HTN, smoking, diabetes, family history, hypercholesterolemia, high LDL, obesity, sedentary lifestyle

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4
Q

What are the common sites of plaque formation in arteries?

A

Branch points (e.g. carotid bifurcation), tethered sites (e.g. superficial femoral artery in Hunter’s canal in the leg)

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5
Q

What must be present for a successful arterial bypass operation?

A
  1. Inflow (e.g. patent aorta)
  2. Outflow (e.g. open distal popliteal artery)
  3. Run off (e.g. patent trifurcation vessels down to the foot)
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6
Q

What is the major principle of safe vascular surgery?

A

Get proximal and distal control of the vessel to be worked on

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7
Q

What does it mean to Potts a vessel?

A

Place a vessel loop twice around a vessel so that if you put tension on the vessel loop it will occlude the vessel

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8
Q

What is the suture needle orientation through graft vs. diseased artery in a graft to artery anastomosis?

A

Needle “in-to-out” of the lumen in diseased artery to help tack down the plaque and the needle “out-to-in” on the graft

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9
Q

What are the 3 layers of an artery?

A
  1. Intima
  2. Media
  3. Adventitia
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10
Q

Which arteries supply the blood vessel itself?

A

Vaso vasorum

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11
Q

What is a true aneurysm?

A

Dilation (> 2 nL diameter) of all 3 layers of a vessel

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12
Q

What is a false aneurysm?

A

Dilation of artery not involving all 3 layers (e.g. hematoma with fibrous covering).
Often connects with vessel lumen and blood swirls inside the false aneurysm.

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13
Q

What is endovascular repair?

A

Placement of a catheter in artery and then deployment of a graft intraluminally

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14
Q

How can you remember the orientation of the lower exterior arteries below the knee on A-gram?

A

LAMP:
Lateral Anterior tibial
Medial Posterior tibial

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15
Q

What is PVD?

A

Peripheral Vascular Disease

Occlusive atherosclerotic disease in the lower extremities.

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16
Q

What is the most common site of arterial atherosclerotic occlusion in the lower extremities?

A

Occlusion of SFA in Hunter’s canal

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17
Q

What are the symptoms of PVD?

A

Intermittant claudications, rest pain, erectile dysfunction, sensorimotor impairment, tissue loss

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18
Q

What is intermittent claudication?

A

Pain, cramping, or both of the lower extremity, usually the calf muscle, after walking a specific distance.
Then the pain/cramping resolves after stopping for a specific amount of time while standing.
Pattern is reproducible.

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19
Q

What is rest pain?

A

Pain in the foot, usually over the distal metatarsals.

This pain arises at rest (classically at night, awakening the patient)

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20
Q

How can vascular causes of claudication be differentiated from nonvascular causes (such as neurogenic claudication or arthritis)?

A

History (in the vast majority of patients); noninvasive tests

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21
Q

What is the differential diagnosis of lower extremity claudication?

A

Neurogenic (e.g. nerve entrapment, discs), arthritis, coarctation of aorta, popliteal artery syndrome, chronic compartment syndrome, neuromas, anemia, diabetic neuropathy pain

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22
Q

What are the signs of PVD?

A

Absent pulses, bruits, muscular atrophy, decreased hair growth, thick toenails, tissue necrosis/ulcers/infection

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23
Q

What is the site of a PVD ulcer vs. a venous stasis ulcer?

A

PVD arterial insufficiency ulcer: usually on the toes/feet

Venous stasis ulcer: medial malleolus

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24
Q

What is the ABI?

A

Ankle to Brachial Index:
Ratio of the systolic blood pressure at the ankle to the systolic blood pressure at the arm.
Pressure taken with Doppler.

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25
Q

What ABIs are associated with normals, claudicators, and rest pain?

A

Normal ABI: > 1.0
Claudicators ABI: < 0.6
Rest pain ABI: < 0.4

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26
Q

Who gets false ABI readings?

A

Patients with calcified arteries, especially those with diabetes

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27
Q

What are PVRs?

A

Pulse Volume Recordings:
Pulse wave forms are recorded from lower extremities representing volume of blood per heart beat at sequential sites down leg.
Large wave form means good collateral blood flow.

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28
Q

Prior to surgery for chronic PVD, what diagnostic test will every patient receive?

A

A-gram maps disease and allows for best treatment option (i.e. angioplasty vs. surgical bypass vs. endarterectomy)

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29
Q

What is the bedside management of a patient with PVD?

A
  1. Sheep skin (easy on the heels)
  2. Foot cradle (keeps sheets/blankets off the feet)
  3. Skin lotion to avoid further cracks in the skin that can go on to form a fissure and then an ulcer
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30
Q

What are the indications for surgical treatment of PVD?

A 
STIR:
Severe claudication refractory to conservative treatment that affects quality of life
Tissue necrosis
Infection
Rest pain
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31
Q

What is the treatment of claudication?

A

Conservative treatment (e.g. exercise, smoking cessation, treatment of HTN, diet, aspirin +/- pentoxifylline (Trental)

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32
Q

How can the medical conservative treatment for claudication be remembered?

A 
PACE:
Pentoxifylline
Aspirin
Cessation of smoking
Exercise
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33
Q

How does aspirin work?

A

Inhibits platelets (inhibits cyclooxygenase and platelet aggregation)

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34
Q

How does pentoxifylline (Trental) work?

A

Results in increased RBC deformity and flexibility

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35
Q

What is the risk of limb loss with claudication?

A

5% at 5 years

10% at 10 years

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36
Q

What is the risk of limb loss with rest pain?

A

> 50% of patients will have amputation at some point

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37
Q

In the patient with PVD, what is the main postoperative concern?

A

Cardiac status, because most patients with PVD have CAD (20% have an AAA).
MI is the most common cause of postoperative death after a PVD operation.

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38
Q

What is Leriche’s syndrome?

A

Buttock claudication, impotence, and leg muscle atrophy from occlusive disease of the iliac arteries and distal aorta

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39
Q

What are the treatment options for severe PVD?

A
  1. Surgical graft bypass
  2. Angioplasty (balloon dilation)
  3. Endarterectomy (remove disease intima and media)
  4. Surgical patch angioplasty (place patch over stenosis)
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40
Q

What is a FEM-POP bypass?

A

Bypass SFA occlusion with a graft from the FEMoral artery to POPliteal artery

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41
Q

What is a FEM-DISTAL bypass?

A

Bypass from the FEMoral artery to a DISTAL artery (e.g. peroneal, anterior tibial, or posterior tibial artery)

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42
Q

What graft material has the longest latency rate?

A

Autologous vein graft

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43
Q

What is an in situ vein graft?

A

Saphenous vein is more or less left in place, all branches are ligated, and the vein valves are broken with a small hook or cut out.
A vein can also be used if reversed so that the valves do not cause a problem.

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44
Q

What type of graft is used for above-the-knee FEM-POP bypass?

A

Either vein or Gortex graft.

Vein still has better patency.

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45
Q

What type of graft is used for below-the-knee FEM-POP or FEM-DISTAL bypass?

A

Must use vein graft.

Prosthetic grafts have a prohibitive thrombosis rate.

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46
Q

What is dry gangrene?

A

Dry necrosis of tissue without signs of infection

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47
Q

What is wet gangrene?

A

Moist necrotic tissue with signs of infection

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48
Q

What is blue toe syndrome?

A

Intermittent painful blue toes (or fingers) due to microemboli from a proximal arterial plaque

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49
Q

What are the indications for lower extremity amputation?

A

Irreversible tissue ischemia and necrotic tissue; severe infection; severe pain with no bypassable vessels; patient not interested in bypass procedure

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50
Q

What are 6 types of lower extremity amputations?

A
  1. AKA (above-the-knee)
  2. BKA (below-the-knee)
  3. Symes
  4. Transmetatarsal
  5. Toe
  6. Ray (removal of toe and head of metatarsal)
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51
Q

What is acute arterial occlusion?

A

Acute occlusion of an artery, usually by embolization (also, acute thrombosis of atheromatous lesion, vascular trauma)

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52
Q

What are the classic signs and symptoms of acute arterial occlusion?

A

Six P’s:

Pain, Paralysis, Pallor, Paresthesia, Polar, Pulselessness

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53
Q

What is the classic timing of pain with acute arterial occlusion from an embolus?

A

Acute onset; patient can classically tell you exactly when and where it happened

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54
Q

What is the immediate preoperative management of acute arterial occlusion?

A
  1. Anticoagulate with IV heparin (bolus followed by constant infusion)
  2. A-gram
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55
Q

What are the sources of emboli with acute arterial occlusion?

A
  1. Heart (85%: clot from AFib, clot forming on dead muscle after MI, endocarditis, myxoma)
  2. Aneurysms
  3. Atheromatous plaque
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56
Q

What is the most common cause of embolus from the heart?

A

AFib

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57
Q

What is the most common site of arterial occlusion by an embolus?

A

Common femoral artery (SFA is the most common site of arterial occlusion from atherosclerosis)

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58
Q

What diagnostic studies are in order for acute arterial occlusion?

A
  1. A-gram
  2. ECG (looking for MI, AFib)
  3. Echocardiogram (looking for clot, MI, valve vegetation)
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59
Q

What is the treatment for acute arterial occlusion?

A

Surgical embolectomy via cutdown and Fogarty balloon (bypass is reserved for embolectomy failure)

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60
Q

What is a Fogarty?

A

Fogarty balloon catheter: catheter with a balloon tip that can be inflated with saline, used for embolectomy

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61
Q

How is a Fogarty catheter used?

A

Insinuate the catheter with the balloon deflated past the embolus and then inflate the balloon and pull the catheter out.

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62
Q

How many mm in diameter is a 12 French Fogarty catheter?

A

Divide French number by pi.

So 12 French is about 4 mm in diameter.

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63
Q

What must be looked for postoperatively after repercussion of a limb?

A

Compartment syndrome, hyperkalemia, renal failure from myoglobinuria, MI

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64
Q

What is compartment syndrome?

A

Leg (calf) is separated into compartments by very unyielding fascia.
Tissue swelling from reperfusion can increase the intracompartmental pressure, resulting in decreased capillary flow, ischemia, and myonecrosis.
Myonecrosis may occur after the intracompartmental pressure reaches only 30 mmHg.

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65
Q

What are the signs and symptoms of compartment syndrome?

A

Pain (especially after passive flexion/extension of the foot), paralysis, paresthesias, pallor.
Pulses are present in most cases because systolic pressure is much higher than the minimal 30 mmHg needed for the syndrome.

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66
Q

Can a patient have a pulse and compartment syndrome?

A

Yes

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67
Q

How is the diagnosis of compartment syndrome made?

A

History, compartment pressure measurement

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68
Q

What is the treatment of compartment syndrome?

A

Treatment includes opening compartments via bilateral calf-incision fasciotomies of all 4 compartments in the calf

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69
Q

What is a AAA?

A

Abdominal aortic aneurysm

Abnormal dilation of the abdominal aorta (> 1.5-2 times normal), forming a true aneurysm

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70
Q

What is the M:F ratio for AAA?

A

6:1

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71
Q

By far, which group is at highest risk for AAA?

A

White males

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72
Q

What is the common etiology for AAA?

A

Believed to be atherosclerotic in 95% of cases (inflammatory otherwise)

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73
Q

What is the most common site of AAA?

A

Infrarenal (95%)

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74
Q

What is the incidence of AAA?

A

5% of all adults older than 60 years

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75
Q

What percentage of patients with AAA have a peripheral arterial aneurysm?

A

20%

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76
Q

What are the risk factors for AAA?

A

Atherosclerosis, HTN, smoking, male, advanced age, connective-tissue disease

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77
Q

What are the symptoms of AAA?

A

Most AAAs are asymptomatic and discovered during routine abdominal exam by PCPs.
Vague epigastric discomfort to back and abdominal pain.

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78
Q

What do testicular pain and AAA signify?

A

Retroperitoneal rupture with ureteral stretch and referred pain to the testicle

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79
Q

What are the risk factors for AAA rupture?

A

Increasing aneurysm diameter, COPD, HTN, recent rapid expansion, large diameter, symptomatic

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80
Q

What are the signs of AAA rupture?

A
  1. Abdominal pain
  2. Pulsatile abdominal mass
  3. Hypotension
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81
Q

By how much each year do AAAs grow?

A

3 mm/year on average

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82
Q

Why do larger AAAs rupture more often and grow faster than small AAAs?

A

Laplace’s Law (wall tension = pressure X diameter)

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83
Q

What is the risk of rupture per year based on AAA diameter size?

A

< 5 cm: 4%
5-7 cm: 7%
> 7 cm: 20%

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84
Q

Where does the aorta bifurcate?

A

At the level of the umbilicus (thus when palpating for an AAA, palpate above the umbilicus and below the xiphoid process)

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85
Q

What is the differential diagnosis for AAA?

A

Acute pancreatitis, aortic dissection, mesenteric ischemia, MI, perforated ulcer, diverticulosis, renal colic

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86
Q

What are the diagnostic tests for AAA?

A

U/S (follow AAA clinically); CT or A-gram (assess lumen patency and iliac/renal involvement)

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87
Q

What is the limitation of A-gram with AAA?

A

AAAs often have large mural thrombi, which result in a falsely reduced diameter because only the patent lumen is visualized

88
Q

What are the signs of AAA on AXR?

A

Calcifications in the aneurysm wall, best seen on lateral projection

89
Q

What are the indications for surgical repair of AAA?

A

AAA > 5.5 cm in diameter, if the patient does is not a terrible surgical candidate; AAA rupture; rapid growth; symptoms; embolization of plaque

90
Q

What is the treatment for AAA?

A
  1. Prosthetic graft placement with rewrapping of the native aneurysm adventitia around the prosthetic graft after the thrombus is removed (when rupture is strongly suspected, proceed to immediate laparotomy)
  2. Endovascular repair
91
Q

What is endovascular repair of a AAA?

A

Placement of a stent proximal and distal to a AAA through a distant percutaneous access (usually groin).

92
Q

Why wrap the AAA graft in the native aorta?

A

To reduce the incidence of enterograft fistula formation

93
Q

What type of repair should be performed with AAA and iliac arteries severely occluded or iliac aneurysm(s)?

A

Aortobi-iliac or aortobifemoral graft replacement (bifurcated graft)

94
Q

What is the treatment for AAA if the patient has abdominal pain, pulsatile abdominal mass, and hypotension?

A

Take the patient to the OR for emergent AAA repair

95
Q

What is the treatment if the patient has known AAA and new onset of abdominal pain or back pain?

A

CT scan:

  1. Leak: go to OR
  2. No leak: repair during next elective slot
96
Q

What is the mortality rate for elective AAA treatment?

A

< 4%

97
Q

What is the mortality rate for treatment of ruptured AAA?

A

50%

98
Q

What is the leading cause of postoperative death in a patient undergoing elective AAA treatment?

A

MI

99
Q

What are non-atherosclerotic etiologies of AAA?

A

Inflammatory (connective tissue diseases), mycotic (usually bacteria, not fungi)

100
Q

What is the mean normal abdominal aorta diameter?

A

2 cm

101
Q

What are the possible operative complications of AAA repair?

A

MI, atheroembolism, declamping hypotension, ARF, ureteral injury, hemorrhage

102
Q

Why is colonic ischemia a concern in the repair of AAA?

A

Often the IMA is sacrificed during the surgery.

If the collaterals are not adequate, the patient will have colonic ischemia

103
Q

What are the signs of colonic ischemia?

A

Heme-positive stool; BRBPR; diarrhea; abdominal pain

104
Q

What is the study of choice to diagnose colonic ischemia?

A

Colonoscopy

105
Q

When is colonic ischemia seen postoperatively?

A

Usually in the first week

106
Q

What is the treatment of necrotic sigmoid colon from colonic ischemia?

A
  1. Resection of necrotic colon
  2. Hartmann’s pouch or mucous fistula
  3. End colostomy
107
Q

What is the possible long-term complication that often presents with both upper and lower GI bleeding?

A

Aortoenteric fistula

108
Q

What are possible postoperative complications of AAA repair?

A

Colonic ischemia, aortoenteric fistula, erectile dysfunction, retrograde ejaculation, aortovenous fistula (to IVC), graft infection, anterior spinal syndrome

109
Q

What is anterior spinal syndrome?

A
  1. Paraplegia
  2. Loss of bladder/bowel control
  3. Loss of pain/temperature sensation below level of involvement
  4. Sparing of proprioception
110
Q

Which artery is involved in anterior spinal syndrome?

A

Antery of Adamkiewicz (supplies anterior spinal cord)

111
Q

What are the most common bacteria involved in aortic graft infections?

A
  1. Staph aureus

2. Staph epidermidis (late)

112
Q

How is an aortic graft infection with an aortoenteric fistula treated?

A

Perform an extra-anatomic bypass with resection of graft

113
Q

What is an extra-anatomic bypass graft?

A

Axillofemoral bypass graft (not in normal vascular path, usually goes from axillary artery to the femoral artery and then from one femoral artery to the other)

114
Q

Which vein crosses the neck of the AAA proximally?

A

Left renal vein

115
Q

What part of the small bowel crosses in front of the AAA?

A

Duodenum

116
Q

Which large vein runs to the left of the AAA?

A

IMV

117
Q

Which artery comes off the middle of the AAA and runs to the left?

A

IMA

118
Q

Which vein runs behind the right common iliac artery?

A

Left common iliac vein

119
Q

Which renal vein is longer?

A

Left

120
Q

What is chronic mesenteric ischemia?

A

Chronic intestinal ischemia from long-term occlusion of the intestinal arteries.
Most commonly results from atherosclerosis.
Usually in 2 or more arteries because of the extensive collaterals.

121
Q

What are the symptoms of chronic mesenteric ischemia?

A

Weight loss, postprandial abdominal pain, anxiety or fear of food, +/- heme occult, +/- diarrhea/vomiting

122
Q

What is intestinal angina?

A

Postprandial pain from gut ischemia

123
Q

What are the signs of chronic mesenteric ischemia?

A

Abdominal bruit is common

124
Q

How is the diagnosis of chronic mesenteric ischemia made?

A

A-gram, duplex, MRA

125
Q

What supplies blood to the gut?

A
  1. Celiac axis vessels
  2. SMA
  3. IMA
126
Q

What is the classic finding on A-gram with chronic mesenteric ischemia?

A

2 of the 3 mesenteric arteries are occluded, and there is atherosclerotic narrowing of the third patent artery

127
Q

What are the treatment options for chronic mesenteric ischemia?

A

Bypass, endarterectomy, angioplasty, stenting

128
Q

What is acute mesenteric ischemia?

A

Acute onset of intestinal ischemia

129
Q

What are the causes of acute mesenteric ischemia?

A
  1. Emboli to a mesenteric vessel from the heart

2. Acute thrombosis of long-standing atherosclerosis of mesenteric artery

130
Q

What are the causes of emboli from the heart?

A

AFib, MI, cardiomyopathy, valve disease, endocarditis, mechanical heart valve

131
Q

What drug has been associated with acute mesenteric ischemia?

A

Digitalis

132
Q

To which intestinal artery do emboli preferentially go?

A

SMA

133
Q

What are the signs and symptoms of acute mesenteric ischemia?

A

Severe pain (out of proportion to physical exam), no peritoneal signs until necrosis, vomiting, diarrhea, hyperdefecation, +/- heme stools

134
Q

What is the classic triad of acute mesenteric ischemia?

A
  1. Acute onset of pain
  2. Vomiting, diarrhea, or both
  3. History of AFib or heart disease
135
Q

What is the gold standard diagnostic test for acute mesenteric ischemia?

A

Mesenteric A-gram

136
Q

What is the treatment of a mesenteric embolus?

A

Perform Fogarty catheter embolectomy, resect obviously necrotic intestine, and leave marginal looking bowel until a second-look laparotomy is performed in 24-72 hours

137
Q

What is the treatment of acute thrombosis in acute mesenteric ischemia?

A

Papaverine vasodilator via A-gram catheter until patient is in the OR.
Most surgeons will perform a supraceliac aorta graft to the involved intestinal artery or endarterectomy.
Intestinal resection and second-look as needed.

138
Q

What is median arcuate ligament syndrome?

A

Mesenteric ischemia resulting from narrowing of the celiac axis vessels by extrinsic compression by the median arcuate ligament

139
Q

What is the median arcuate ligament comprised of?

A

Diaphragm hiatus fibers

140
Q

What are the symptoms of median arcuate ligament syndrome?

A

Postprandial pain, weight loss

141
Q

What are the signs of median arcuate ligament syndrome?

A

Abdominal bruit in almost all patients

142
Q

How is the diagnosis of median arcuate ligament syndrome made?

A

A-gram

143
Q

What is the treatment for median arcuate ligament syndrome?

A

Release arcuate ligament surgically

144
Q

What are the signs and symptoms of carotid vascular disease?

A

Amaurosis fugax, TIA, RIND, CVA

145
Q

What is amaurosis fugax?

A

Temporary monocular blindness (“curtain coming down”).

Seen with microemboli to retina.

146
Q

What is TIA?

A

Transient Ischemic Attack:

Focal neurologic deficit with resolution of all symptoms within 24 hours

147
Q

What is RIND?

A

Reversible Ischemic Neurologic Deficit:

Transient neurologic impairment (without any lasting sequelae) lasting 24-72 hours

148
Q

What is CVA?

A 
CerebroVascular Accident (stroke):
Neurologic deficit with permanent brain damage
149
Q

What is the risk of a CVA in patients with TIA?

A

10% a year

150
Q

What is the noninvasive method of evaluating carotid disease?

A

Carotid U/S or Doppler (gives general location and degree of stenosis)

151
Q

What is the gold standard invasive method of evaluating carotid disease?

A

A-gram

152
Q

What is the surgical treatment of carotid stenosis?

A

CEA: Carotid EndArterectomy:

Removal of the diseased intima and media of the carotid artery, often performed with a shunt in place

153
Q

What are the indications for CEA in the asymptomatic patient with carotid disease?

A

Carotid stenosis > 60%

154
Q

What are the indications for CEA in the symptomatic patient with carotid disease?

A

Carotid stenosis > 50%

155
Q

Before performing a CEA in the symptomatic patient, what study other than the A-gram should be performed?

A

Head CT

156
Q

In bilateral high-grade carotid stenosis, on which side should the CEA be performed in the asymptomatic, right-handed patient?

A

Left CEA first, to protect the dominant hemisphere and speech center

157
Q

What is the dreaded complication after CEA?

A

Stroke (CVA)

158
Q

What are the possible postoperative complications after a CEA?

A

CVA, MI, hematoma, wound infection, hemorrhage, hypotension/hypertension, thrombosis, vagus nerve injury (change in voice), hypoglossal nerve injury (tongue deviation toward side of injury), intracranial hemorrhage

159
Q

What is the mortality rate after CEA?

A

1%

160
Q

What is the perioperative stroke rate after CEA?

A

Asymptomatic: 1%
Symptomatic: 5%

161
Q

What is the postoperative medication after a CEA?

A

Aspirin (inhibits platelets by inhibiting cyclooxygenase)

162
Q

What is the most common cause of death during the early postoperative period after a CEA?

A

MI

163
Q

What is a Hollenhorst plaque?

A

Microemboli to retinal arteriole seen as bright defects

164
Q

What thin muscle is cut right under the skin in the neck?

A

Platysma muscle

165
Q

What are the extracranial branches of the internal carotid artery?

A

None

166
Q

Which vein crosses the carotid bifurcation?

A

Facial vein

167
Q

What is the first branch of the external carotid artery?

A

Superior thyroid artery

168
Q

Which muscle crosses the common carotid proximally?

A

Omohyoid muscle

169
Q

Which muscle crosses the carotid artery distally?

A

Digastric muscle

170
Q

Which nerve crosses approximately 1 cm distal to the carotid bifurcation?

A

Hypoglossal nerve (cut it and the tongue will deviate toward the side of the injury)

171
Q

Which nerve crosses the internal carotid near the ear?

A

Facial nerve (marginal branch)

172
Q

What is in the carotid sheath?

A
  1. Carotid artery
  2. Internal jugular vein
  3. Vagus nerve (lies posteriorly in 98%)
  4. Deep cervical lymph nodes
173
Q

What is subclavian steal syndrome?

A

Arm fatigue and vertebrobasilar insufficiency from obstruction of the left subclavian artery or innominate proximal to the vertebral artery branch point.
Ipsilateral arm movement causes increased blood flow demand, which is met by retrograde flow from the vertebral artery, thereby stealing from the vertebrobasilar arteries.

174
Q

Which artery is most commonly occluded in subclavian steal syndrome?

A

Left subclavian

175
Q

What are the symptoms of subclavian steal syndrome?

A

Upper extremity claudication, syncopal attacks, vertigo, confusion, dysarthria, blindness, ataxia

176
Q

What are the signs of subclavian steal syndrome?

A

Upper extremity blood pressure discrepancy, bruit (above the clavicle), vertebrobasilar insufficiency

177
Q

What is the treatment for subclavian steal syndrome?

A

Surgical bypass or endovascular stent

178
Q

What is renal artery stenosis?

A

Stenosis of renal artery, resulting in decreased perfusion of the juxtaglomerular apparatus and subsequent activation of the renin-angiotensin-aldosterone system

179
Q

What is the incidence of renal artery stenosis?

A

4% of patients with HTN

180
Q

What is the etiology of renal artery stenosis?

A

Atherosclerosis (66%) or fibromuscular dysplasia

181
Q

What is the classic profile of a patient with renal artery stenosis from fibromuscular dysplasia?

A

Young woman with HTN

182
Q

What are the associated risks/clues for renal artery stenosis?

A

Family history, early onset of HTN, HTN refractory to medical treatment

183
Q

What are the signs and symptoms of renal artery stenosis?

A

Most patients are asymptomatic.

HA, diastolic HTN, flank bruits, decreased renal function

184
Q

What is the role of an A-gram in renal artery stenosis?

A

Maps artery and extent of stenosis

185
Q

What is the role of IVP in renal artery stenosis?

A

80% of patients have delayed nephrogram phase

186
Q

What is the role of renal vein renin ratio (RVRR) in renal artery stenosis?

A

If sampling of renal vein renin levels shows ratio between the two kidneys > 1.5, then diagnostic for a unilateral stenosis

187
Q

What is the role of the captopril provocation test in renal artery stenosis?

A

Will show a drop in BP

188
Q

Are renin levels in serum always elevated in renal artery stenosis?

A

No: systemic renin levels may also be measured but are only increased in malignant HTN, as the increased intravascular volume dilutes the elevated renin level in most patients

189
Q

What is the invasive non-surgical treatment for renal artery stenosis?

A

Percutaneous Renal Transluminal Angioplasty (PRTA) +/- stenting

190
Q

What is the surgical treatment for renal artery stenosis?

A

Resection, bypass, vein/graft interposition, or endarterectomy

191
Q

What antihypertensive medication is contraindicated in patients with HTN from renal artery stenosis?

A

ACE inhibitors (results in renal insufficiency)

192
Q

What are the causes of splenic artery aneurysm?

A

In women, medial dysplasia

In men, atherosclerosis

193
Q

How is the diagnosis of splenic artery aneurysm made?

A

Usually by abdominal pain, leading to U/S or CT; in the OR after rupture; incidentally by eggshell calcifications seen on AXR

194
Q

What is the risk factor for splenic artery aneurysm rupture?

A

Pregnancy

195
Q

What are the indications for splenic artery aneurysm removal?

A

Pregnancy, > 2 cm in diameter, symptoms, woman of child-bearing age

196
Q

What is the treatment for splenic artery aneurysm?

A

Resection or percutaneous catheter embolization in high-risk patients

197
Q

What is a popliteal artery aneurysm?

A

Aneurysm of the popliteal artery caused by atherosclerosis and rarely bacterial infection

198
Q

How is the diagnosis of popliteal artery aneurysm made?

A

PE, A-gram, U/S

199
Q

Why examine the contralateral popliteal artery?

A

50% of patients have bilateral popliteal artery aneurysm

200
Q

What are the indications for elective surgical repair of a popliteal artery aneurysm?

A
  1. > 2 cm
  2. Intraluminal thrombus
  3. Artery deformation
201
Q

Why examine the rest of the arterial tree (especially the abdominal aorta) in popliteal artery aneurysm?

A

75% of patients have additional aneurysms elsewhere

202
Q

What size thoracic aortic aneurysm is considered an indication for surgical repair?

A

> 6.5 cm

203
Q

What size abdominal aortic aneurysm is considered an indication for surgical repair?

A

> 5.5 cm

204
Q

What size iliac artery aneurysm is considered an indication for surgical repair?

A

> 4 cm

205
Q

What size femoral artery aneurysm is considered an indication for surgical repair?

A

> 2.5 cm

206
Q

What size popliteal artery aneurysm is considered an indication for surgical repair?

A

> 2 cm

207
Q

What is milk leg?

A

AKA Phlegmasia alba dolens:

Seen in pregnant women with occlusion of the iliac vein resulting from extrinsic compression by the uterus

208
Q

What is phlegmasia cerulean dolens?

A

Cyanotic leg resulting from severe venous outflow obstruction.
The extensive venous thrombosis results in arterial inflow impairment.

209
Q

What is Reynaud’s phenomenon?

A

Vasospasm of digital arteries with color changes of the digits, usually initiated by cold or emotions.
White (spasm), then blue (cyanosis), then red (hyperemia)

210
Q

What is Takayasu’s arteritis?

A

Arteritis of the aorta and aortic branches, resulting in stenosis/occlusions/aneurysms

211
Q

What is Buerger’s disease?

A

AKA Thromboangiitis obliterans:
Occlusion of the small vessels of the hands and feet, often results in digital gangrene.
See in young men who smoke.

212
Q

What is the treatment for Buerger’s disease?

A

Smoking cessation, +/- sympathectomy

213
Q

What is blue toe syndrome?

A

Microembolization from proximal atherosclerotic disease of the aorta resulting in blue, painful, ischemic toes

214
Q

What is a paradoxical embolus?

A

Venous embolus gains access to the left heart after going through an intracardiac defect, most commonly a PFO, and then lodges in a peripheral artery

215
Q

What is Behcet’s disease?

A

Genetic disease with aneurysms from loss of vaso vasorum.

Seen with oral, ocular, and genital ulcers and inflammation.

ENTREGA (40 decks)

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