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ABSITE > 27 Vascular > Flashcards

27 Vascular Flashcards

1
Q

Most common congenital hypercolaguable disorder?

A

Resistance to activated protein C (Factor V leiden)

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2
Q

Most common acquired hypercoagulable disorder?

A

Smoking

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3
Q

Stage 1 of atherosclerosis

A

Foam cells

Macrophages that have absorbed fat and lipids in the vessel wall

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4
Q

Stage 2 of atherosclerosis

A

Smooth muscle proliferation
Caused by growth factors released from macrophages (PGDF)
Results in wall injury

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5
Q

Stage 3 of atherosclerosis

A 
Intimal disruption (from smooth muscle cell proliferation)
Leads to collagen exposure --> thrombus formation --> fibrous plaques
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6
Q

Risk factors for atherosclerosis

A 
Smoking
HTN
Hypercholesterolemia
DM
Hereditary factors
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7
Q

Most important risk factor for stroke?

A

HTN

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8
Q

Most common site of carotid stenosis?

A

Carotid bifurcation

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9
Q

Carotids supply ____ of blood flow to brain?

A

85%

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10
Q

What is the normal flow of the internal carotid?

A

Continuous forward flow

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11
Q

What is the first branch of the internal carotid artery?

A

Ophthalmic artery

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12
Q

What is the normal flow of the external carotid?

A

Triphasic flow

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13
Q

Communication between the ICA and ECA occurs via?

A 
Opthalmic artery (ICA)
Internal maxillary artery (ECA)
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14
Q

Most commonly diseased intracranial artery?

A

Middle cerebral artery

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15
Q

MCC of cerebral ischemic events?

A

Arterial embolization from ICA
Others:
- Thrombosis
- Low-flow state through a severely stenotic lesion
- Emboli from heart (second most common source)

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16
Q

Arterial source of event?

Mental status changes, release, slowing

A

Anterior cerebral artery

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17
Q

Arterial source of event?
Contralateral motor and speech if dominant side)
Contralateral facial droop

A

Middle cerebral artery events

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18
Q

Arterial source of event?

Vertigo, tinnitus, drop attacks, incoordination

A

Posterior cerebral artery

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19
Q

Visual changes - shade coming down over eyes

Hollenhorst plaques on ophthalmologic exam

A

Amaurosis fugax
Occlusion of the ophthalmic branch of ICA
Transient

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20
Q

Treatment of carotid traumatic injury with major fixed deficit?

A

If occluded - do NOT repair (can exacerbate injury with bleeding)
If not occluded - repair with carotid stent or open procedure

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21
Q

Indications for carotid endarterectomy

A

Symptomatic >70% stenosis

Asymptomatic >80% stenosis

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22
Q

When do you perform a CEA after a stroke?

A

Wait 4-6 weeks and then perform CEA if it meets criteria

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23
Q

When do you perform an emergent CEA?

A

Fluctuating neurologic symptoms

Crescendo/evolving TIA

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24
Q

When do you need to use a shunt during CEA?

A

Stump pressures < 50

Contralateral side is tight

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25
Q

With bilateral carotid artery stenosis - how do you decide which side to repair first?

A

Repair tightest side first

If they are equally tight - dominant side first

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26
Q

Complication after CEA: hoarseness

A

Vagus nerve injury

Secondary to vascular clamping

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27
Q

MC cranial nerve injury after CEA

A

Vagus nerve injury

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28
Q

Complication after CEA: speech and mastication difficulty

A

Hypoglossal nerve injury

Tongue deviates to the side of injury

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29
Q

Complication after CEA: Difficulty swallowing

A

Glossopharyngeal nerve injury

Rare - occurs with high carotid dissection

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30
Q

Complication after CEA: Loss of innervation to strap muscles

A

Ansa cervicalis

No serious deficit

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31
Q

Complication after CEA: Changes in the corner of the mouth, difficulty smiling

A

Mandibular branch of facial nerve

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32
Q

Complication after CEA: Acute event immediately after CEA, what do you do?

A

Back to OR

Check for flap or thrombosis

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33
Q

Complication after CEA: Pulsatile, bleeding mass

A

Pseudoaneurysm
Tx: drape and prep before intubation
Intubate, then repair

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34
Q

Complication after CEA: Hypertension

A

Injury to carotid body

Tx: Nipride to avoid bleeding

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35
Q

MCC cause of non-stroke morbidity and mortality following CEA?

A

Myocardial infarction

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36
Q

Rate of restenosis after CEA

A

15%

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37
Q

Indications for carotid stenting (versus CEA)

A

Previous CEA with restenosis
Multiple medical comorbidities
Previous neck XRT

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38
Q

Anatomy of the vertebrobasilar artery system

A

Subclavian arteries –> vertebral arteries –> combine –> basilar artery –> splits –> posterior cerebral arteries

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39
Q

Source of arterial deficit:

Diplopia, vertigo, tinnitus, drop attacks, incoordination

A

Basilar artery or bilateral vertebral artery disease - vertebrobasilar insufficiency
Causes: atherosclerosis, spurs, bands
Tx: PTA with stent

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40
Q

Painless neck mass, near carotid bifurcation

A

Carotid body tumor
Origin - neural crest cells
Extremely vascular
Tx: resection

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41
Q

Aortic arch vessels antomy

A

Innominate artery (–> right subclavian and right common carotid artery)
Left common carotid artery
Left subclavian artery

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42
Q

Ascending aortic aneurysm

A

Often picked up on CXR

Sx are due to compression: back pain (vertebra), voice changes (RLN), dyspnea/PNA (bronchi), dysphagia (esophagus)

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43
Q

Indications for treatment of ascending aortic aneurysm?

A

Acutely symptomatic
>5.5cm (with Marfan’s >5.0cm)
Rapid increase in size (>0.5 cm/yr)

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44
Q

Indications for treatment of descending aortic aneurysm?

A

If endovascular repair possible >5.5cm

If open repair needed >6.5cm

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45
Q

How do you prevent paraplegia with open repair for a descending aortic aneurysm?

A

Reimplant intercostal arteries below T8

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46
Q

Stanford classification: any ascending aortic involvement?

A

Class A

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47
Q

Stanford classification: only descending aortic involvement?

A

Class B

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48
Q

Debakey classification: ascending and descending

A

Type I

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49
Q

Debakey classification: ascending only

A

Type II

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50
Q

Debakey classification: descending only

A

Type III

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51
Q

Where do most dissections start?

A

Ascending aorta

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52
Q

Risk factors for aortic dissection?

A

Severe HTN
Marfan’s syndrome
Previous aneurysm
atherosclerosis

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53
Q

Diagnosis of aortic dissection?

A

Chest CT with contrast

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54
Q

Where does dissection occur within the blood vessel?

A

Medial layer of the wall

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55
Q

Cause of death in ascending aortic dissection?

A

Cardiac failure secondary to aortic insufficiency, cardiac tamponade or rupture

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56
Q

Initial treatment of aortic dissection?

A

Medical - control BP (B-blockers and Nipride)

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57
Q

Surgical intervention for aortic dissection?

A 
All ascending (open repair, graft)
Descending if: visceral/extremity ischemia, contained rupture (endograft, open repair, fenestrations)
Follow with lifetime serial MRI
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58
Q

Most common complications for thoracic aortic surgery?

A

MI
Renal failure
Paraplegia (descending)

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59
Q

Cause of paraplegia after descending thoracic aorta ?

A

Spinal cord ischemia due to occlusion of intercostal arteries and artery of Adamkiewicz

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60
Q

Normal aorta diameter?

A

2-3cm

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61
Q

Cause of abdominal aortic aneurysm?

A

Degeneration of the medial layer

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62
Q

Risk factors for AAA?

A

Male, age, smoking, family history

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63
Q

Presentation of AAA?

A

Rupture
Distal embolization
Compression of adjacent organs

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64
Q

How do you diagnose AAA rupture?

A 
US
Abdominal CT (fluid in retroperitoneal space and extraluminal contrast)
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65
Q

Most likely location for AAA rupture?

A

Left posterolateral wall, 2-4cm below renals

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66
Q

Co-morbid medical conditions that can lead to AAA expansion?

A

HTN

COPD

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67
Q

Treatment of AAA?

A

Repair if:
Symptomatic
>5.5cm
Growth >0.5cm/year

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68
Q

Indications for reimplantation of inferior mesentaric artery in AAA repair?

A

If back pressure is <40mmHg (poor back bleeding)
Previous colonic surgery
Stenosis at the superior mesenteric artery
Flow to left colon appears inadequate

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69
Q

If you perform an aorto-bifemoral repair instead of a straight tube graft for AAA repair, what must you ensure?

A

Flow to at least one internal iliac artery (hypogastric artery) to avoid vasculogenic impotence

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70
Q

What major vein can get injured with cross clamping of the aorta?

A

Rero-aortic left renal vein

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71
Q

MCC of acute death after AAA repair?

A

MI

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72
Q

MCC of late death after AAA repair?

A

Renal failure

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73
Q

Risk factors for mortality after AAA repair?

A 
Creatinine >1.8
CHF
EKG ischemia
Pulmonary dysfunction
Older age
Female
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74
Q

AAA graft infection rate

A

1%

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75
Q

Incidence of pseudoaneurysm formation after AAA repair?

A

1%

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76
Q

MCC late complication after aortic graft placement?

A

Atherosclerotic occlusion

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77
Q

Bloody diarrhea after AAA repair?

A

Ischemic colitis
IMA typically sacrificed - left colon most common
Dx: endoscopy or abdomianl CT (middle and distal rectum)
OR if: peritoneal signs, mucosa is black on endoscopy, part of colon looks dead on CT

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78
Q

Ideal criteria for AAA endovascular repair?

A 
Neck length >15mm
Neck diameter 20-30mm
Neck angulation <60 degrees
Common iliac artery length >10mm
Common iliac artery diameter 8-18mm
Non-tortuous, noncalcified iliac arteries
Lack of neck thrombus
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79
Q

Endoleak - at site of proximal or distal graft attachment

A

Type I endoleak

Tx: extension cuffs

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80
Q

Endoleak - through collaterals

A

Type II endoleak

Tx: Observe - if vessels are pressurizing the aneurysm –> perutaneous coil emolization

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81
Q

Endoleak - via overlap sites when multiple grafts were used or fabric tear

A

Type III endoleak

Tx: Secondary endograft to cover overlap site or tear

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82
Q

Endoleak - via graft wall porosity or suture holes

A

Type IV endoleak

Tx: observe - can place nonporous stent if that fails

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83
Q

Endoleak - expansion of aneurysm without evidence of leak

A

Type V - endotension

Tx: repeat EVAR or open repair

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84
Q

Inflammatory aneurysm

A

NOT due to infection
Can get adhesion in 3/4th porttion of the duodenum
Can get ureteral entrapment (place stents before repair)
Wt loss, increased ESR
CT scan shows thickened rim above calcifications
Inflammatory process resolves after aortic graft placement

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85
Q

Mycotic aneurysm

A

Salmonella, Staphylococcus
Bacteria infects atherosclerotic plaque
Pain, fever, positive blood cultures
Periaortic fluid, gas, retroperitoneal soft tissue edema, LAD
Need extra-anatomic bypass and resection of infrarenal abdominal aorta to clear infection

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86
Q

Aortic graft infections

A

Staphylococcus, E. Coli
Fluid, gas, thickening around graft
Blood cultures negative
Tx: bypass through non-contaminate field and then resect infected graft

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87
Q

Most common graft to get infected?

A

Those going to the groin

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88
Q

Aortoenteric fistula

A

Occurs 6mo after abdominal aortic surgery
Herald bleed with hematemesis, then blood per rectum
Graft erodes into 3/4th portion of the duodenum near proximal suture line
Tx: bypass through non-contaminate field, resect graft, then close hole in duodenum

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89
Q

Contents of the anterior leg compartment

A

Deep peroneal nerve (dorsiflexion, sensation b/t 1/2nd toes)

Anterior tibial artery

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90
Q

Contents of the lateral leg compartment

A

Superficial peroneal nerve (eversion, lateral foot sensation)

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91
Q

Contents of the deep posterior leg compartment

A

Tibial nerve (plantar flexion)
Posterior tibial artery
Peroneal artery

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92
Q

Contents of the superficial posterior leg compartment

A

Sural nerve

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93
Q

Signs of peripheral artery disease

A

Pallor
Dependent rubor
Hair loss
Slow capillary refill

Most commonly due to atherosclerosis

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94
Q

Number one preventive agent of atherosclerosis?

A

Statin drugs

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95
Q

Medical treatment of claudication

A

ASA
Smoking cessation
Exercise until pain occurs to create collaterals

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96
Q

Source of obstruction - buttock claudication

A

Aortoiliac disease

97
Q

Source of obstruction - mid-thigh claudication

A

External iliac

98
Q

Source of obstruction - calf claudication

A

Common femoral artery

Proximal superifical femoral artery

99
Q

Source of obstruction - foot claudication

A

Distal superficial femoral artery

Popliteal disease

100
Q

Lumbar stenosis can mimic which symptom of PAD?

A

Claudication

101
Q

Diabetic neuropathy can mimic which symptom of PAD?

A

Rest pain

102
Q

No femoral pulses
Buttock or thigh claudication
Impotence

A

Leriche syndrome
Lesion at aortic bifurcation or above
Impotence is due to decreased flow in the internal iliacs
Tx: aorto-bifemoral bypass graft

103
Q

Most common atherosclerotic occlusion in lower extremities?

A

Hunter’s canal - distal superficial femoral artery exits

Sartorius muscle covers Hunter’s canal

104
Q

Borders of the adductor canal

A

Hunter’s canal
Anterior - sartorius
Lateral - vastus medialis
Posterior - adductor longus and magnus

105
Q

What collateral circulation forms in the lower extremities from abnormal pressure gradients?

A

Circumflex iliacs to subcostals
Circumflex femoral arteries to gluteal arteries
Geniculate arteries around the knee

106
Q

Ankle-brachial index - start to get claudication

A

<0.9

107
Q

Ankle-brachial index - start to get rest pain

A

<0.5 (distal arch and foot)

108
Q

Ankle-brachial index - ulcers

A

<0.4 (starts in toes)

109
Q

Ankle-brachial index - gangrene

A

<0.3

110
Q

What patients can have inaccurate ABIs? what do you do instead?

A

Diabetes and severe calcification
Incompressible vessels
Doppler waveforms

111
Q

Pulse volume recordings

A

Used to find significant occlusion and at what level

112
Q

Indications for arteriogram in PAD

A

PVRs suggesting significant disease

Can also perform intervention

113
Q

Surgical indications for PAD

A

Rest pain
Ulceration or gangrene
Lifestyle limitation
Atheromatous embolization

114
Q

PTFE (Gortex)

A

Only for bypasses above the knee

Use vein for below the knee

115
Q

Dacron

A

Good for aorta and large vessels

116
Q

Treatment of aortoiliac occlusive disease

A

Aorto-bifemoral repair
Ensure flow to atleast 1 internal iliac artery (hypogastric artery) to prevent vasculogenic impotence and pelvic ischemia

117
Q

Treatment of isolated iliac lesions

A

PTA with stent (first choice)

If that fails - femoral-to-femoral crossover

118
Q

Femoropopliteal grafts

A

75% 5-year patency
Better for claudication versus limb salvage
Popliteal artery exposure below knee - gastrocnemius (post), popliteus (ant)

119
Q

Femoral-distal grafts

A

Peroneal, anterior tibial or posterior tibial artery
50% 5-year patency (NOT influenced by level of distal anastomosis
Distal lesions are more threatening due to lack of collaterals
Bypasses to distal vessels are only for limb salvage

120
Q

What do you use below the knee? Why?

A

Saphenous vein

Synthetic grafts have decreased patency below the knee

121
Q

When do you use extra-anatomic grafts?

A

To avoid hostile conditions in the abdomen (i.e. infection, multiple previous abdominal operations, frail patient)

122
Q

Complication of femoral-to-femoral crossover graft?

A

Vascular steal in donor leg due to doubling of the blood flow to the donor artery

123
Q

Early swelling following lower extremity bypass?

A

Reperfusion injury and compartment syndrome

Tx: Fasciotomy

124
Q

Late swelling following lower extremity bypass?

A

DVT
Dx: US
Tx: Heparin, Coumadin

125
Q

Complications of reperfusion of ischemic tissues?

A

Compartment syndrome
Lactic acidosis
Hyperkalemia
Myogloinuria

126
Q

MCC of early failure of reversed saphenous vein grafts

A

Technical problem

127
Q

MCC of late failure of reversed saphenous vein grafts

A

Atherosclerosis

128
Q

Treatment of patients with heel ulceration to bone

A

Amputation

129
Q

Dry gangrene

A

Noninfectious
If small or just toes - autoamputation
Large lesions - amputate
First see if there is a correctable vascular lesion

130
Q

Wet gangrene

A

Infectious
Tx: remove infected necrotic material and antibiotics
Surgical emergency: extensive infection or systemic complications (guillotine amputation)

131
Q

Mal perforans ulcer

A

At metatarsal head - 2nd MTP joint most common
Diabetics - risk for osteomyolitis
Tx:
- Non-weight bearing
- Debridement of metatarsal head (remove cartilage)
- Antibiotics
- May need revascularization

132
Q

Percutaneous transluminal angioplasty

A

Excellent for common iliac artery stenosis
Best for short stenosis
Intima ruptures and media stretched - pushes plaque out

133
Q

Compartment syndrome

A

Reperfusion injury
Cessation of blood flow to extremity and reperfusion >4-6hrs later
Causes swelling of muscle compartments - increases pressures, overwhelming blood flow - ischemia
Dx: clinical, compartment pressures >20-30mmHg
Tx: fasciotomy (5-10 days before closure)

134
Q

What cells are responsible for reperfusion injury?

A

PMNs

135
Q

Compartment most likely to get compartment syndrome?

A

Anterior compartment

You get foot drop

136
Q

Popliteal entrapment syndrome

A

Mild, intermittent claudication
Men, 40s - loss of pulses with plantar flexion
Medial deviation of popliteal artery around medial heat of gastrocnemius muscle
Tx: resection of medial head of gastrocnemius

137
Q

Advential cystic disease

A

Men, 40s, popliteal fossa most common
BILATERAL
Ganglia originate from adjacent joint capsule or tendon sheath
Sx: intermittent claudication, change with knee flexion/extension
Dx: Angiogram
Tx: resection of cyst, vein graft if vessel is occluded

138
Q

Sources of arterial autografts?

A

Radial artery grafts for CABG

IMA for CABG

139
Q

Indications for amputation?

A

Gangrene
Large, non-healing ulcers
Unrelenting rest pain, not amenable to surgery

140
Q

Indications for emergency amputation?

A

Systemic complications

Extensive infection

141
Q

Outcomes of BKA

A

80% heal
70% walk again
5% mortality

142
Q

Outcomes of AKA

A

90% heal
30% walk again
10% mortality

143
Q

Characteristics of acute arterial embolism

A

Arrhythima
No prior claudication or rest pain
Normal contralateral pulses
No physical findings of chronic limb ischemia

Do not have collaterals
Sx: pain, paresthesia, poikilothermia, paralysis

144
Q

Characteristics of acute arterial thrombosis

A

No arrhythmia
History of claudication or rest pain
Contralateral pulses absent
Physical findings of chronic limb ischemia

145
Q

Progression of extremity ischemia?

A

Pallor (white) > cyanosis (blue) > marbling

146
Q

MCC acute arterial embolism

A

Afib*
Recent MI with left ventricular thrombus
Myxoma
Aorto-iliac disease

147
Q

Most common site for peripheral obstruction from emboli?

A

Common femoral artery

148
Q

Treatment of acute arterial embolism

A

Embolectomy; after pulse return do a post-op angiogram

Consider fasciotomy if ischemia >4-6hrs

149
Q

Patient presents with acute loss of both femoral pulses?

A

Aortoiliac emboli

Tx: bilateral femoral artery cutdowns and bilateral embolectomys

150
Q

Most common site of atheroma embolization?

A

Renal arteries

151
Q

Atheroma embolism

A

Cholesterol clefts that can lodge in small arteries
Dx: chest/abdomen/pelvis CT scan (for aneruysmal source), ECHO (clot/myxoma in heart)
Tx: anerusyms repair or arterial exclusion with bypass

152
Q

Blue toe syndrome

A

Flaking atherosclerotic emboli off abdominal aorta or branches
Typically have good distal pulses
Aortoiliac disease most common source

153
Q

Acute arterial thrombosis

A

Tx:

  • Threatened limb (loss of sensation or motor function): heparin and thrombectomy
  • Non-threatened limb: angiography for thrombolytics
154
Q

Thrombosis of PTFE graft

A

Threatened limb - OR for thrombectomy

Non-threatened limb - thrombolytics adn anticoagulation

155
Q

Course of the right renal artery in relation to the IVC?

A

Posterior

156
Q

Causes of renovascular HTN?

A

Renal atherosclerosis

Fibromuscular dysplasia

157
Q

Renovascular HTN?

A 
Bruits, diastolic BP >115, HTN
Children or premenopausal women
HTN resistant to drug therapy
Dx: Angiogram
Tx: PTA, place stent if due to atherosclerotic disease
158
Q

Renal atherosclerosis

A

Left side
Proximal 1/3
Men

159
Q

Renal fibromuscular dysplasia

A

Right side
Distal 1/3
Women

160
Q

Indications for nephrectomy with renal HTN?

A

Atrophic kidney <6cm with persistently high renin levels

161
Q

UE occlusive disease

A

Proximal lesions asymptomatic due to collaterals
MC site - subclavian
Tx: PTA with stent, common carotid to subclavian artery bypass if that fails

162
Q

Subclavian steal syndrome

A

Proximal subclavian artery stenosis resulting in reversal of flow through ipsilateral vertebral artery into the subclavian artery
Operative if limb or vertebrobasial symptoms
Tx: PTA with stent to subclavian artery, common carotid to subclavian artery bypass if that fails

163
Q

Thoracic outlet syndrome

A

Sx: back/neck/arm pain/weakness/tingling; worse with palpation/manipulation
Dx: MRI (cervical spine and chest), duplex US (vascular etiology)
Neurologic involvement more common than vascular

164
Q

Normal anatomy of subclavian vein

A

Passes over the 1st rib, anterior to the anterior scalene muscle, then behind clavicle

165
Q

Normal anatomy of brachial plexus and subclavian artery

A

Pass over the 1st rib posterior to the anterior scalene muscle and anterior to the middle scalene muscle

166
Q

MC anatomic abnormality in thoracic outlet syndrome

A

Cervical rib

167
Q

MC cause of pain in thoracic outlet syndrome

A

Brachial plexus irritation

168
Q

Brachial plexus irritation with TOS

A

Normal neurological exam; positive Tinsel’s test
Ulnar nerve distribution most common
Tx: cervical rib and 1st rib resection; divide anterior scalene muscle

169
Q

Symptoms of ulnar nerve deficits

A

C8-T1
Inferior portion of brachial plexus
Tricep muscle, intrinsic muscles of hand, weak wrist flexion

170
Q

Effort induced thrombosis of subclavian vein

A

Page-von shrotter disease
Acutely painful, swollen blue limb
Dx: venography (gold standard), duplex US
Tx: thrombolytics, then same admission repair (cervical rib and 1st rib resection, divide anterior scalene muscle)

171
Q

Compression of subclavian artery secondary to anterior scalene hypertrophy

A

Weight lifters
Least common cause of TOS
Sx: hand pain from ischemia, absent radial pulse with head turned to ipsilateral side (Adson’s test)
Dx: duplex US or angiogram (gold standard)
Tx: surgery (cervical rib and 1st rib resection, divide anterior scalene muscle, possible bypass graft if artery is too damaged or aneurysmal

172
Q

Why does motor function of the hand remain in digits after prolonged hand ischemia?

A

Motor groups are located in the proximal forearm

173
Q

Most common artery in mesenteric ischemia?

A

Superior mesenteric artery

174
Q

Abdominal CT findings that suggest intestinal ischemia?

A

Vascular occlusion
Bowel wall thickening
Intramural gas
Portal venous gas

175
Q

Most common causes of visceral ischemia?

A

Embolic occlusion - 50%
Thrombotic occlusion - 25%
Nonocclusive - 15%
Venous thrombosis - 5%

176
Q

SMA embolism

A

Occurs near origin of SMA (heart - Afib)
Sx: pain out of proportion, sudden onset; hematochezia and peritoneal signs are late findings
Ass. hx: afib, endocarditis, recent MI, recent angiography
Dx: angiogram or abdominal CT with IV contrast
Tx: embolectomy, resect infarcted bowel

177
Q

Exposing the SMA

A

Divide ligament of Treitz

SMA is to teh right of the near the base of the transverse colon mesentary

178
Q

SMA thrombosis

A

History of chronic problems (food fear, weight loss)
Ass. hx: vasculitis or hypercoagulable state
Sx: history of chronic food problems
Dx: angiogram or abdominal CT with IV contrast
Tx: Thrombectomy; may need PTA with stent or open bypass if residual stenosis; resect infarcted bowel

179
Q

Mesenteric vein thrombosis

A

Involves short segments of intestine - bloody diarrhea, crampy abdominal pain
Ass. hx: vasculitis, hypercoagulable state, portal HTN
Dx: abdominal CT or angiogram with venous phase
Tx: heparin, resect infarcted bowel

180
Q

Non-occlusive mesenteric ischemia

A

Spasm, low-flow states, hypovolemia, hemoconcentratio, digoxin - low cardiac output to visceral vessels
Risk: prolong shock, CHF, prolong cardiopulmonary bypass
Sx: bloody diarrhea, pain
Tx: volume resuscitation, catheter-directed nitroglycerin (increase visceral blood flow), increase cardiac output (dobutamine); resect infarcted bowel

181
Q

Griffith’s watershed area

A

Splenic flexure

182
Q

Sudak’s watershed area

A

Upper rectum

183
Q

Median arcuate ligament syndrome

A

Causes celiac artery compression
Bruit near epigastrium, chronic pain, weight loss, diarrhea
Tx: transect median arcuate ligament, may need arterial reconstruction

184
Q

Chronic mesenteric angina

A

Food angina
Dx: lateral visceral vessel aortography to see origins of celiac and SMA
Tx: PTA and stent - bypass if that fails

185
Q

Arc of Riolan

A

Collateral that forms between the SMA and celiac

186
Q

MCC of aneurysm above inguinal ligament

A

Rupture

187
Q

MCC of aneurysm below inguinal ligament

A

Thrombosis and emboli

188
Q

Risk factors for visceral artery aneurysm

A

Medial fibrodysplasia
Portal HTN
Arterial disruption secondary to inflammatory disease (i.e. pancreatitis)

189
Q

Indications for repair of visceral artery aneurysms

A

> 2cm (except splenic)

Tx: covered stent; exclusion with bypass if that fails

190
Q

Splenic artery aneurysm

A

Repair if: symptomatic, pregnant, woman of childbearing age, >3-4cm
Usually ruptures in the third trimester
Splenic artery can be ligated if open procedure - good collaterals

191
Q

Renal artery aneurysm

A

Treat if >1.5cm

Tx: Covered stent

192
Q

Iliac artery aneurysm

A

Treat if >3.0cm

Tx: covered stent

193
Q

Femoral artery aneurysm

A

Treat if >2.5cm

Tx: covered stent

194
Q

Popliteal artery aneurysm

A

Prominent popliteal pulses
50% bilateral, 50% associated with other aneurysms
Complications: thrombosis or emboli with limb ischemia; pain from compression of adjacent structures
Dx: US
Surgical indications: symptomatic, >2cm mycotic
Tx: exclusion and bypass (NOT covered stent)

195
Q

MC visceral artery aneurysm

A

Splenic artery aneurysm

196
Q

MC peripheral artery aneurysm

A

Popliteal artery aneurysm

197
Q

Pseudoaneurysm

A

Collection of blood in continuity with the arterial system, but NOT enclosed by all three layers of the arterial wall
Risk: percutaneous intervention; disruption of a suture line between graft and artery
Tx: after PTI - US guided compression with thrombin injection, surgical repair if it fails; suture line - surgical repair

198
Q

MC location for pseudoaneurysm

A

Femoral artery

199
Q

Pseudoaneurysm that occurs at suture lines late after surgery (month to years)

A

Suggests graft infection

200
Q

Course of the greater saphenous veins

A

Joins femoral vein near groin

Runs medially

201
Q

Can you clamp the IVC?

A

NO - will tear

202
Q

Ligating the renal veins - which and where?

A

Left can be ligated near the IVC - has multiple collaterals (left gonadal vein, left adrenal vein)
Right side does NOT have these collaterals

203
Q

Most common failure of AV grafts for dialysis?

A

Venous obstruction secondary to intimal hyperplasia

204
Q

Cimino AVF

A

Radial artery to cephalic vein

Wait 6 weeks to use - allows vein to mature

205
Q

Interposition graft

A

Brachiocephalic loop graft

Wait 6 weeks to use - allows for fibrous scar formation

206
Q

Acquired AV fistulas

A

Trauma -> peripheral arterial insufficiency, CHF, aneurysm, limb-length discrepancy
Repair - lateral venous suture; arterial side may need patch or bypass graft; place interposing tissue so it does not recur

207
Q

Varicose veins

A

Smoking, obesity, low activity

Tx: sclerotherapy

208
Q

Venous ulcers

A

Secondary to venous valve incompetence
Above and posterior to malleoli
<3cm will heal without surgery
Tx: unna boot; if fails, ligate perforates or have vein stripping of greater saphenous vein

209
Q

Fibromuscular dysplasia

A

Young women, HTN (renal), headaches, stroke (carotid)
String of bead apperance
Medial fibrodysplasia
Tx: PTA, bypass if that fails

210
Q

Buerger’s disease

A

Young men, smokers
Severe rest pain with bilateral ulceration; gangrene of digits
Corkscrew collaterals on aginogram; normal arterial tree proximal to popliteal and brachial vessels
Tx:
stop smoking

211
Q

Marfan’s disease

A

Fibrillin defect (connective tissue elastic fibers)
Marfanoid habitus
Retinal detachment
Aortic root dilation

212
Q

Ehlers-Danlos syndrome

A 
Collagen defect
Sx: easy bruising, hypermobile joints, tendency for arterial rupture
Aneurysms and dissections
NO angiogram - increased risk of rupture
Too difficult to repair - ligate vessels
213
Q

Temporal arteritis

A

Larger artery, inflammation
Women, >55yo, headache, fever, blurred vision
Dx: Temporal artery biopsy (giant cell arteritis, granulomas)
Long segment of smooth stenosis alternating with segments of larger diameter
Tx: Steroids, bypass of large vessels if needed; NO endarterectomy

214
Q

Polyarteritis nodosa

A 
Medium artery
Weight loss, rash, arthralgias, HTN, kidney dysfunction
Aneurysms that thrombose or rupture
Most common renal arteries
Tx: Steroids
215
Q

Kawasaki’s disease

A

Medium artery
Children, febril illness with erythematous mucosa and epidermis
Aneurysms of coronary arteries and brachiocephalic vessels
Die from arrhythmias
Tx: steroids, (ASA at initial illness), eventual CABG

216
Q

Hypersensitivity angiitis

A

Small artery
Secondary to drug or tumor antigen
Sx: palpable purpura, fever, symptoms of end-organ dysfunction
Tx: CCB, pentoxifylline, stop offending agent

217
Q

Early radiation arteritis

A

Sloughing and thrombosis

Obliterative endarteritis

218
Q

Late radiation arteritis

A

1-10 years

FIbrosis, scar, stenosis

219
Q

Late late radiation arteritis

A

3-30 years

Advanced atherosclerosis

220
Q

Raynaud’s disease

A

Young women
Pallor > cyanosis > rubor
Tx: CCB, warmth

221
Q

Venous insufficiency

A

Aching, swelling, night cramps, brawny edema, venous ulcers
Incompetent perforators and/or valves
Tx: leg wraps, ambulation with avoidance of long standing
Sx: grater saphenous veins stripping, removal of perforators (severe symptoms or recurrent ulcers)

222
Q

Superficial thrombophlebitis

A

Nonbacterial inflammation

Tx: NSAIDs, warm packs, ambulation

223
Q

Suppurative thrombophlebitis

A

Pus filled vein
Fever, increased WBC, erythema, fluctuance
Following infected peripheral IV
Tx: resect entire vein

224
Q

Migrating thrombophlebitis

A

Trousseau syndrome

Pancreatic CA

225
Q

Normal findings on doppler US

A

Augmentaton of flow with distal compression or release of proximal compression

226
Q

Benefit of sequential compression devices

A

Prevent blood clots
Decreases venous stasis
Increased tPA release

227
Q

Why are DVTs more common in the left leg?

A

Longer iliac vein gets compressed by right iliac artery

228
Q

Virchow’s triad

A

Venous stasis
Hypercoagulability
Venous wall injury

229
Q

Phlegmasia alba dolens

A

Tenderness, pallor (whiteness), edema

Tx: heparin

230
Q

Phlegmasia cerulea dolens

A

Tenderness, cyanosis (blueness), massive dedma

Tx: heparin, rarely surgical intervention

231
Q

DVT treatment

A

Heparin, coumadin

232
Q

Indications for IVCF

A

Contraindications to anticoagulation
PE while on coumadin
Free-floating ileofemoral thrombi
After pulmonary embolectomy

233
Q

Venous thrombosis with central line

A

Pull of line if not needed, then heparin

If access site is important - systemic heparin or tPA down the line

234
Q

Where do you NOT find lymphatics?

A

Bone, muscle, tendon, cartilage, brain, cornea

235
Q

Lymphedema

A

Obstructed lymphatics, too few numbers or nonfunctional
Leads to woody edema secondary to fibrosis in subQ tissue
Cellulitis, lymphangitis –> leads to complications
MC infection - strep
Congenital lymphedema L>R
Tx: leg elevation, compression, antibiotics for infection

236
Q

Lymphagiosarcoma

A

Raised blue/red coloring

Early metastases to lung

237
Q

Lymphangiosarcoma associated with breast axillary dissection and chronic lymphedema

A

Stewart-Treves syndrome

238
Q

Lymphocele following surgery

A

Dissection of groin
Leakage of clear fluid
Tx: Percutaneous drainage; resection if that fails

ABSITE (41 decks)

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