Vascular Surgery Lecture Powerpoint

Question 1

Aortic aneurysms are present when vessel (not the lumen) exceeds ___ x normal diameter. Most common area to see development?

Answer 1

1.5x, abdominal infrarenal most often

Question 2

Risk factors for aortic aneurysm (5)

Answer 2

• smoking***
• hypertension
• age most important**
• diabetes
• dyslipidemia

Question 3

Prognosis of ruptured AAA

Answer 3

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

Question 4

Median rate of expansion of an aneurysm approx ___cm per year but highly variable

Answer 4

.5cm

Question 5

Screening for AAA (3)

Answer 5

• 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

Question 6

AAA clinical presentation (4)

Answer 6

• 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)

Question 7

Ruptured AAA clinical presentation (6)

Answer 7

• 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

Question 8

Diagnostic studies for ruptured AAA (3)

Answer 8

• ultrasound
• CT if hemodynamically stable
• angiography if planning on operating

Question 9

Most common site of embolism in a patient with “blue toe syndrome”

Answer 9

the heart - 2nd most common is the aorta!

Question 10

Repair of AAA options (3)

Answer 10

• percutaneous placement of implantable endovascular stent (has to be infrarenal)
• insertion of synthetic graft
• resection of aneurysm (not common)

Question 11

Surgical mortality of repair of AAA

Answer 11

Increases greatly if rupture impending or has ruptured

Question 12

What cutaneous level to the iliacs bifurcate from the aorta?

Answer 12

Just below the umbilicus

Question 13

Rare complication of AAA repair that results in permanent lower extremity paralysis

Answer 13

Having to suture off the lumbar vessels that exit the posterior abdominal aorta due to backflow bleeding after removal of the aneurysm

Question 14

Pathogenesis of stroke

Answer 14

• 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

Question 15

Thrombosis vs embolism

Answer 15

Thrombosis is narrowing due to blood clot formation vs embolism is when piece of clot comes loose and lodges at a downstream location

Question 16

Risk factors of stroke (4)

Answer 16

• hypertension
• smoking
• lipids
• excessive alcohol

Question 17

Management of carotid artery disease - indications for carotid endarterectomy (1)

Answer 17

-surgery of symptomatic stenosis (post TIA or minor stroke) greatly reduces ipsilateral stroke risk after undergoing carotid endarterectomy

Question 18

The workup studes for carotid artery disease (3)

Answer 18

• ultrasound/doppler
• angiography
• look for associated illness

Question 19

Carotid endarterectomy (CEA) procedure (4)

Answer 19

• 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

Question 20

Periperal artery disease to the lower extremity definition

Answer 20

Chronic build up of atherosclerosis of femoral and popliteal arteries, results in pain (reproducible claudication), ulcers, or nonhealing wounds, requires intervention or amputation

Question 21

Vasclar claudication definition, what occurs when it becomes more severe?***

Answer 21

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***

Question 22

Neurogenic claudication, unlike vascular, is often not ____

Answer 22

easily reproducable

Question 23

Signs and symptoms of peripheral artery disease (5)

Answer 23

• 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

Question 24

Ankle brachial index (ABI)

Answer 24

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

Question 25

Imaging studies for peripharal artery disease (3)

Answer 25

• ultrasound
• invasive arteriography
• MRA

Question 26

Acute arterial ischemia definition

Answer 26

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

Question 27

Acute arterial ischemia treatment options (3)

Answer 27

• heparin anticoag to prevent
• thrombolytics
• referral to vascular surgeon for angiography or bypass surgery

Question 28

Peripheral artery disease treatment options (5)

Answer 28

• medical management first - not surgical!!!
• smoking cessation
• aspirin therapy
• clopidogrel (plavix)
• surgical revascularization with angioplasty or arterial bypass

Question 29

Complications of peripheral vascular surgery (4)

Answer 29

• graft failure up to 50% of time
• amputation
• infection
• seroma (serum buildup under skin often at site of surgical incision