Vascular Surgery Flashcards by pardis hejazi

How long can skeletal muscles tolerate ischemia?

6 h (unless acute on chronic ischemia)

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Ischemia due to embolus vs thrombus

Embolus:
Acute onset
Prominent loss of function/sensation
No Hx of claudication
No atrophic changes
Normal contralateral limb pulses

Thrombus:
Progressive onset or acute on chronic
Less profound loss of function/sensation(due to underlying collaterals)
May have Hx of claudication
May have atrophic changes
Decreased or absent contralateral limb pulses

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Inv for acute limb ischemia

ABI
ECG, troponin
CBC
PTT/INR
Echo
CT-Angio
Angio

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Tx of acute limb ischemia

Immediate Heparinization:
5000 bolus,
Then continuous to PTT 70-90

If impaired neurovascular status:
Emergent revascularization

If intact neurovascular status:
Time for W/U (angio, CTA…)

If embolus: embolectomy

If thrombus: thrombectomy, bypass graft, endovascular therapy

If irreversible ischemia: amputation

Treat underlying

Continue heparin, ad warfarin

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Reperfusion complications

Compartment syndrome

Arrhythmia

RF, MOF due to toxic metabolites

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Major RFs for lower extremity chronic ischemia

DM
Smoking
Older age

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Minor RFs for lower extremity chronic ischemia

HTN
Hyperlipidemia
Obesity
Sedentary lifestyle
PMHx or FHx of CAD/CVD

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Vascular claudication Sx

Pain with exertion (calf…)

Relieved by 2-5 min rest

No postural changes necessary

Reproducible

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Critical limb ischemia

Rest pain

Night pain

Tissue loss

Pain most commonly over the forefoot

Wakes from sleep

Relieved by hanging the foot off bed

Ankle pressure < 40, ABI < 0.4, toe pressure < 30

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Signs if chronic poor perfusion

Hair loss

Hypertrophic nails

Atrophic muscle

Ulceration

Infections

Slow capillary refill

Prolonged pallor on elevation

Prolonged rubor on dependency

Venous troughing (collapse of superficial veins)

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Inv for chronic atrial insufficiency

Routine blood work

Fasting metabolic w/u

ABI

CTA/MRA (for planning intervention)

Arteriography (better than CTA/MRA, for tibial arteries

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ABI interpretation

> 1.2: suspect wall calcification

> 0.95 normal

0.5 -0.8 claudication

< 0.4 critical

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Tx of chronoc limb ischemia

RF modification

Exercise program (30 min x 3/w)

Foot care

Antiplatelet

Cilostazol

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Indications of surgical intervention for chronic limb ischemia

Severe lifestyle impairing

Vocational impairment

Critical ischemia

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Surgical interventions

Angioplasty +/- stenting

Endarterectomy

Bypass graft

Amputation, if:
Non suitable for above
Persistent serious infection, gangrene
Unremitted rest pain poorly controlled by analgesics

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Mx of critical limb ischemia

If limb salvageable:
Arteriography
Duplex scanning

If not salvageable:
Amputation
(Analgesia in moribund pt)

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Aortic dissection classification

Type A: involving ascending aorta

Type B: not involving ascending aorta

Acute: <2 wk

Chronic: >2 wk

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What’s the most common etiology for aortic dissection?

HTN

RFs for aortic dissection

HTN

Marfan, EDS, other CTDs

Atherosclerosis

Coarctation of aorta

Bicuspid aortic valves

PDA

Cystic medial necrosis

Syphilis

Trauma

Arteritis (Takayasu)

Epidemio of AD

M> F

African-Canadian >…> asian

Peak age: 50-65 yr

If CTD: 20-40 yr

Sx of aortic dossection

Tearing pain radiating to back +

HTN (Asymmetric BP/Pulse between limbs)

Ischemic syndromes (occlusion of branches)

Unseating of aortic valve cusps ( new diastolic murmur)

Rupture into pleura, pericardium, retroperitoneum

Syncope

Inv for AD

CTA (mainstay)

ECG, troponin

CXR:
Pleural cap (pleural effusion in lung apices)
Widened mediastinum
Left pleural effusion

TEE:
Visualizes aortic valve and thoracic aorta

Lactate
Amylase

Mx of aortic dissection

Type A:
Urgent surgery

Type B:
Medical Mx:
IV antihypertensives
Transition to oral meds
( BB, if BBs contraindicated, CCB)
\+/- ACEI

Selective interventions for complications or refractory symptoms

+/- aortic stent-grafting

Aortic aneurism definition

Diameter at least x1.5 that of expected

RFs for AA

``` Smoking HTN PVD CAD CVD Age>70 FHx Degenerative Traumatic Mycotic (salmonella, staph) CTD Vasculitis Infectious (syphilis, fungal) Ascending thoracic aneurysms are associated with bicuspid aortic valve ```

Most common Sx of aorta aneurism

Asymptomatic

Most common site of AA

Abdominal

Inv for AA

``` CBC Lytes Urea Cr PTT,INR Type and cross ``` Abdominal U/S (screening, surveillance) CT with contrast Peripheral arterial doppler/duplex (R/O aneurisms elsewhere)

Screening for AAA

Men 65-74 Women 65 yr with cardiovascular disease and FHx of AAA Men >50 with FHx of AAA

Indications for surgical Tx of AA

Ruptured Symptomatic Size > 5-5.9 cm Ascending thoracic aorta aneurism if: > 6cm > 2x normal > 4.5 cm + aortic regurgitation/marfan

RFs of carotid stenosis

``` For atherosclerosis: Smoking HTN DM Hyperlipidemia CVD CAD Older age ```

Inv for carotid stenosis

CBC PTT/INR Fundoscopy: Cholesterol emboli in retinal vessels Carotid bruit Carotid duplex CTA, MRA

Tx of carotid stenosis

RF modification: Control DM, HTN, lipids ASA +/- dipyridamole Clopidogrel Surgical

Indication fo carotid endarterectomy

Symptomatic and > 70% stenosis

Factors aggrevating Sx of varicose veins

Prolonged standing PMS

Tx of varicose veins

Coservative: Elastic compression stocking Surgery

Indications for surgery of varicose veins

Failure of conservative treatment Symptomatic varix: Pain Bleeding Recurrent thrombophlebitis Tissue changes: Hyperpigmentation Ulceration Cosmetic

Inv for chronic venous insufficiency | Venous insufficiency and skin damage

Not required Doppler U/S for pre-operative assessment

Tx of chronic venous insufficiency

Conservative: Elastic compression stocking Periodic rest/elevation Avoid prolonged standing Ulcer: multilayer compression bandage. ABx PRN Surgical

Indications of surgical Tx for chronic venous insufficiency

If conservative measures fail Recurrent large ulcers

Most common form of primary lymphedema

Lymphedema praecox Starts in adolescence

Types of primary lymphedema

Milroy’s syndrome Lymphedema praecox, starts in adolescence Lymphedema tarda: starts after 35 yr

The most common cause of secondary lymphedema worldwide

Filariasis The most common cause in north America: surgery, RT

Tx of lymphedema

Avoid limb injury Early treatment of cellulitis Skin hygiene: Daily moisturizers Early Tx of fungal/bacterial infection Compression bandage Compression garment Gentle daily exercise of affected limb Gradual increase in ROM Must wear compression bandage when doing exercise Massage (manual lymph drainage therapy)