Vascular & Thoracic Flashcards
Predicted post op FEV1 & DLCO needed for safe lung resection
> 60%
If 30-60%, need low-technology exercise testing
PPO FEV1 = preoperative FEV1× (1 – y/z)
PPO DLCO = preoperative DLCO × (1 – y/z)
y = Number of functional or unobstructed lung segments removed.
z = Total number of functional segments (~19)
Light’s criteria for pleural effusions
An effusion with any of the following characteristics is classified as an exudate:
1. pleural:serum ratio > 0.5
2. pleural:serum LDH ratio > 0.6
3.pleural LDH > 2/3 of the upper limit of normal for the serum.
Indications for CEA & initial medical management
Indications for CEA → Symptomatic >50%; Asymptomatic >70-80% or EDV > 140 cm/s
Stroke: RULE OUT A FIB FIRST, needs echo & ekg
Start aspirin, clopidogrel, statin & obtain HbA1c
TIming of CEA
Crescendo TIAs: Emergently
Small/TIA: Wait 2 days, but perform within 2 weeks
Hemorrhagic stroke: 6-8 weeks
CEA steps
- Shoulder roll, neck slightly extended
- Incision along anterior border of SCM
- Identify & ligate facial vein, open carotid sheath, retract SCM & IJ laterally
- Dissect carotid; identify & protect vagus nerve; control w vessel loops
- Heparinize, clamp ICA, CCA, ECA, make longitudinal arteriotomy, place shunt
- Carotid endarterectomy (remove intima and part of media) with patch angioplasty using bovine pericardium
- Remove clamps (ECA, CCA, ICA) & shunt, flush carotid
- Confirm good repair with U/S
EVAR steps
- Bilateral CFA access, insert sheaths
- Aortogram
- Flush main trunk w heparinized saline, deploy in proximal neck, just inferior to lowest renal artery
- Similarly deploy contralateral limb via contralateral sheath
- IVUS if any questions
- Completion angiogram, check distal pulses
- Perclose vs cut down to repair arteries
Indications for AAA repair & ideal criteria for EVAR
Repair indications
≥ 5.5 cm for average male patient
≥ 5.0 cm for women or those w/ high rupture risk (eg severe COPD, numerous relatives w/ rupture, poorly controlled HTN, eccentric shape)
Growth > 1.0 cm/yr
Symptomatic or infected (mycotic)
Ideal criteria for EVAR
Neck
-Neck length > 10 mm
-Neck diameter < 32 mm
-Neck angulation < 60 °s
CIA
-CIA length > 10 mm?
-CIA diameter > 8 mm
-Non-tortuous, noncalcified iliac arteries
-Lack of neck thrombus
Endoleaks and treatments
I: Proximal (A) or distal (B) attachment sites, means endograft isn’t sealed
Need to tx → Extension cuffs
II: Collaterals from lumbars
May be able to observe; if expanding, tx → coil embolization
III: Overlap sites when using multiple grafts or graft tears
Need to tx → Secondary endograft
IV: Graft wall porosity or suture holes
May be able to observe; tx → new endograft
Rutherfords classification for ALI
CFA thromboembolectomy
- Systemic heparin 80U/kg bolus followed by gtt to PTT 2x baseline; prep both legs
- Verticle skin incision below inguinal ligament, expose CFA, SFA, profunda & loop w vessel loops
- Heparinize to ACT>250
- Secure vessel loops, perform transverse arteriotomy over bifurcation
- Pass 4/5F fogarty proximally until clean & distally 2x, establishing inflow and outflow
- Close arteriotomy, shoot angiogram, check distal pulses
- Close groin in layers, place drain
How to perform ABI
- Apply the blood pressure cuff.
- Listen for waveforms with the Doppler pen.
- Pump up the cuff (20 mmHg above when you hear the last arterial beat).
- Slowly release the pressure and record when the first arterial beat returns.
Do this for bilateral brachial, DP, & PT arteries
Highest brachial P is the denominator, highest DP vs PT is numerator for L & R
Exposure of anterior tibial artery, posterior tibial artery, peroneal artery
Anterior tibial a.
Exposure → Lateral incision, halfway between tibia & fibula, into plane between tibialis anterior & EHL/EDL
Anterior tibial vessels will be most anterior
Deep peroneal nerve will be most posterior
Posterior tibial a. Exposure → Medial incision, 2 cm posterior to tibia; gastrocnemius m. retracted posteriorly & soleus m. is taken off tibia
Peroneal a. Exposure
Medial approach as above, deeper dissection to anterior FHL m.
Lateral approach, requires partial fibulectomy
Retroperitoneal exposure of aortic bifurcation
- Left flank incision along lateral border of rectus
- Divide EO, IO, TA muscles
- Separate & mobilize peritoneum, reflect peritoneum to the right
- Identify iliopsoas muscle & ureter; develop plane between colon anteriorly & ureter posterior, mobilize colon to the right
- Dissect infrarenal aorta & CFA
GSV ablation steps
- Access GSV at knee with micropuncture kit, insert 7F sheath over wire
- Insert ablation catheter to saphenofemoral junction
- Inject tumescence around GSV along course of vein
- Ablate starting 2 cm distal to saphenofemoral junction
- U/S to assess for clot in CFV
- If Venous stasis ulcer: Tx w unna boot (zinc compression wrap) following GSV ablation
Dialysis work up
Ask for handedness, time needed to dialyze, life expectancy
Vein should be 3 mm, artery should be 2 mm (can increase following axillary block)
Rule of 6 dialysis
6 mm diameter, < 6 mm deep, > 600 mL/min flow, cannulated two needles 8 cm apart
