Vascular Surgery Review

Question 1

give the ladder of reconstruction options for a vascular injury

Answer 1

• lateral arteriorraphy
• lateral suture patch angioplasty
• resection with end-to-end anastomosis
• resection and interposition graft
• bypass grafting
• ligation

Question 2

when would you use lateral arteriorraphy to repair a vascular injury?

Answer 2

• when there is 50% circumferential damage, you can consider primary repair

Question 3

How large of a vascular injury would you consider patch angioplasty as a repair option?

Answer 3

• generally 50-75% circumferential injury to vessel

Question 4

Talking about vascular injuries…what is the upper limit of segmental loss you can safely transverse with an end-to-end anastomosis?

Answer 4

• 2cm is your upper limit

- beyond that you should consider an interposition graft vs bypass graft

Question 5

Give Rutherford Classification and management

• slow capillary refill
• intact/minimal motor deficit
• partial/no sensory loss
• inaudible arterial doppler

Answer 5

• Rutherford class IIA (salvageable)

- urgent surgical revascularization vs thrombolysis

Question 6

Give Rutherford Classification and management

• slow or absent capillary refill
• partial paralysis
• partial sensory loss with rest pain
• absent arterial doppler signal

Answer 6

• Rutherford class IIB (salvageable)

- immediate surgical re-vascularization

Question 7

Give Rutherford Classification and management

• absent capillary refill
• profound paralysis, often with rigor
• profound loss, anesthetic
• absent arterial doppler

Answer 7

• Rutherford class III

- amputation this is not salvageable

Question 8

patient presents with unilateral leg swelling, pain in said limb, cyanotic changes, faint doppler signals, and large DVT on US…what is the diagnosis

Answer 8

phlegmasia cerulea dolens

Question 9

what is the treatment for phlegmasia cerulea dolens?

Answer 9

pharmacomechanical (systemic and endovascular thronbolysis) thrombolysis and fasciotomy

Question 10

Thrombotic occlusion of SMA…what is affected?

Answer 10

proximal jejunum to distal transverse colon

Question 11

embolic occlusion of SMA…what is affected

Answer 11

• proximal jejunum to ascending colon

Question 12

if you have a thrombotic occlusion of the SMA, where is the occlusion

Answer 12

at the origin of the SMA

Question 13

if you have an embolic occlusion of the SMA where is the occlusion

Answer 13

middle to distal SMA

Question 14

most common adverse event after protamine infusion

Answer 14

hypotension

Question 15

in who should you be worried about ischemic monomelic neuropathy

Answer 15

diabetic women

Question 16

how do you diagnose ischemic monolemic neuropathy

Answer 16

diminished motor and sensation/pain out of proportion with exam, pulses must still be present…or this is then considered steal syndrome

Question 17

what PSV is associated with >70% occlusion of SMA

Answer 17

PSV > 275 cm/sec

Question 18

PSV for celiac stenosis > 70%

Answer 18

PSV > 200 cm/sec

Question 19

Vasculopath with wet gangrene at left toe angiogram showing short stenosis > 75%, signs of sepsis…next step?

Answer 19

amputate the toe…once recovered from infection perform revascularization

Question 20

ICA peak velocity of 125 cm/sec

Answer 20

50% stenosis

Question 21

ICA peak velocity of 125-230 cm/sec

Answer 21

50-69% stenosis

Question 22

ICA peak velocity > 230 cm/sec

Answer 22

70-99% stenosis

Question 23

Patient with known thigh and hip claudication comes in with acute onset paralysis of both LEs and cyanosis inferior to umbilicus…what caused his paralysis?

Answer 23

• occlusion of the artery of Adamkiewicz
• main supply to the spinal cord below T8…patient has acute on chronic aorto-occlusive disease that took this artery out too

Question 24

when do you use distal radial artery ligation in the setting of an AVF?

Answer 24

• when patient has palmer steal syndrome…there is no option for distal revascularization like in a brachia-cephalic AVF

Question 25

when should you consider a carotid endarterectomy?

Answer 25

• symptomatic ICA stenosis

- asymptomatic ICA stenosis 60-99% if stroke risk is < 3%

Question 26

one day out from EVAR patient has bloody diarrhea, what is happening and what do you do next?

Answer 26

• likely ischemic colitis
• if stable sigmoidoscopy
• if unstable immediate exploration

Question 27

Renal arteriogram shows string bean appearance

Answer 27

Fibromuscular dysplasia

Question 28

Treatment for fibromuscular dysplasia

Answer 28

• balloon angioplasty

Question 29

initial therapy for pseudoaneurysm at access site

Answer 29

• compression under US guidance

- some places will go straight to thrombin injection

Question 30

at what GFR should a patient be considered for an AVF to start HD?

Answer 30

• GFR <7 even if asx

- GFR 10-15 with sxs of CKD

Question 31

which vessel does the internal thoracic artery come from?

Answer 31

1st branch off of the subclavian artery

Question 32

function of the sural nerve

Answer 32

sensation to:

• posterolateral aspect of distal leg
• lateral foot

Question 33

function of saphenous nerve

Answer 33

sensation to:

• medial aspect of leg
• medial aspect of calf
• medial aspect of foot

Question 34

surgery along the saphenous vein carries risk of what kind of nerve injury?

Answer 34

• typically sural nerve injury (loss of sensation along lateral aspect of lower leg and foot)

Question 35

function of peroneal nerve

Answer 35

sensation to dorsum of foot

dorsiflexion of foot

Question 36

function of posterior tibial nerve

Answer 36

sensation to sole of foot

plantar flexion of foot

Question 37

treatment for a complicated pseudo aneurysm

Answer 37

surgical repair