Vascular Surgery Lecture Powerpoint Flashcards
Aortic aneurysms are present when vessel (not the lumen) exceeds ___ x normal diameter. Most common area to see development?
1.5x, abdominal infrarenal most often
Risk factors for aortic aneurysm (5)
- smoking***
- hypertension
- age most important**
- diabetes
- dyslipidemia
Prognosis of ruptured AAA
Majority never make it to hospital, 40-80% do not survive so rather variable, only 10-15% overall survive, best results is to repair before rupture
Median rate of expansion of an aneurysm approx ___cm per year but highly variable
.5cm
Screening for AAA (3)
- physical exam (feeling for pulsatile mass)
- age appropriate noninvasive screening >65 or younger if family hx of aneurysm
- ultrasound is continuing screening test of choice
AAA clinical presentation (4)
- many asymptomatic
- gnawing steady discomfort lower back or hypogastrium unaffected by movement
- severe lower abdomen or back pain with radiation to groin and legs
- evidence of other peripheral vascular disease or coronary artery disease
- embolization and thrombosis
- GI hemorrhage (duodenum and aorta fistula)
Ruptured AAA clinical presentation (6)
- abrupt onset back and abdominal pain
- abdominal tenderness
- palpable pulsatile mass
- hypotension
- shock
- often mimics GI bleed
- flank hematoma (grey turners sign) if retroperitoneal rupture
Diagnostic studies for ruptured AAA (3)
- ultrasound
- CT if hemodynamically stable
- angiography if planning on operating
Most common site of embolism in a patient with “blue toe syndrome”
the heart - 2nd most common is the aorta!
Repair of AAA options (3)
- percutaneous placement of implantable endovascular stent (has to be infrarenal)
- insertion of synthetic graft
- resection of aneurysm (not common)
Surgical mortality of repair of AAA
Increases greatly if rupture impending or has ruptured
What cutaneous level to the iliacs bifurcate from the aorta?
Just below the umbilicus
Rare complication of AAA repair that results in permanent lower extremity paralysis
Having to suture off the lumbar vessels that exit the posterior abdominal aorta due to backflow bleeding after removal of the aneurysm
Pathogenesis of stroke
- ischemic due to plaque development, most often at bifurcations, platelet aggregation and thrombus formation that potentially embolizes occluding a vessel, majority are these
- hemorrhagic often due to injury or rupture
Thrombosis vs embolism
Thrombosis is narrowing due to blood clot formation vs embolism is when piece of clot comes loose and lodges at a downstream location
Risk factors of stroke (4)
- hypertension
- smoking
- lipids
- excessive alcohol
Management of carotid artery disease - indications for carotid endarterectomy (1)
-surgery of symptomatic stenosis (post TIA or minor stroke) greatly reduces ipsilateral stroke risk after undergoing carotid endarterectomy
The workup studes for carotid artery disease (3)
- ultrasound/doppler
- angiography
- look for associated illness
Carotid endarterectomy (CEA) procedure (4)
- isolate stenosis location (ultrasound guidance frequently)
- SCM and jugular vein retracted laterally
- place a shunt proximal and distal and clamp off vessels to prevent leakage (collateral flow thru circle of willis)
- plaque removal, shunt removal, and suturing of artery closed
Periperal artery disease to the lower extremity definition
Chronic build up of atherosclerosis of femoral and popliteal arteries, results in pain (reproducible claudication), ulcers, or nonhealing wounds, requires intervention or amputation
Vasclar claudication definition, what occurs when it becomes more severe?***
Reversible muscle ischemia causing cramping or ache like pain that develops during exercise and increases until patient must stop due to intolerable pain, unilateral or bilateral and very reproducible
-when it occurs at rest then it has become ischemic - progression from claudication and far more severe vascular disease, often describe having to dangle feet off bed to restore flow***
Neurogenic claudication, unlike vascular, is often not ____
easily reproducable
Signs and symptoms of peripheral artery disease (5)
- cool/cold feet to touch
- loss of pulses in legs or feet
- dependent rubor
- nonhealing wound or ulcer
- loss of muscle or fatty tissue or gangrene
Ankle brachial index (ABI)
Measure of lower extremity systolic pressure divided by upper extremity systolic pressure, normal ratio should be between .9-1.3, but the lower it is indicates the severity of the peripheral artery disease
Imaging studies for peripharal artery disease (3)
- ultrasound
- invasive arteriography
- MRA
Acute arterial ischemia definition
Occlusion of existing graft, embolism formation, or native vessel thrombosis resulting in sudden cold leg with the 5 P’s (pulseless, pain, pallor, paresthesia, paralysis) that is much more sudden onset than peripheral artery disease
Acute arterial ischemia treatment options (3)
- heparin anticoag to prevent
- thrombolytics
- referral to vascular surgeon for angiography or bypass surgery
Peripheral artery disease treatment options (5)
- medical management first - not surgical!!!
- smoking cessation
- aspirin therapy
- clopidogrel (plavix)
- surgical revascularization with angioplasty or arterial bypass
Complications of peripheral vascular surgery (4)
- graft failure up to 50% of time
- amputation
- infection
- seroma (serum buildup under skin often at site of surgical incision
