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Flashcards in Vascular Surgery Deck (44)
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1
Q

How long can skeletal muscles tolerate ischemia?

A

6 h (unless acute on chronic ischemia)

2
Q

Ischemia due to embolus vs thrombus

A
Embolus:
Acute onset
Prominent loss of function/sensation
No Hx of claudication
No atrophic changes
Normal contralateral limb pulses

Thrombus:
Progressive onset or acute on chronic
Less profound loss of function/sensation(due to underlying collaterals)
May have Hx of claudication
May have atrophic changes
Decreased or absent contralateral limb pulses

3
Q

Inv for acute limb ischemia

A
ABI
ECG, troponin
CBC
PTT/INR
Echo
CT-Angio
Angio
4
Q

Tx of acute limb ischemia

A

Immediate Heparinization:
5000 bolus,
Then continuous to PTT 70-90

If impaired neurovascular status:
Emergent revascularization

If intact neurovascular status:
Time for W/U (angio, CTA…)

If embolus: embolectomy

If thrombus: thrombectomy, bypass graft, endovascular therapy

If irreversible ischemia: amputation

Treat underlying

Continue heparin, ad warfarin

5
Q

Reperfusion complications

A

Compartment syndrome

Arrhythmia

RF, MOF due to toxic metabolites

6
Q

Major RFs for lower extremity chronic ischemia

A

DM
Smoking
Older age

7
Q

Minor RFs for lower extremity chronic ischemia

A
HTN
Hyperlipidemia
Obesity
Sedentary lifestyle
PMHx or FHx of CAD/CVD
8
Q

Vascular claudication Sx

A

Pain with exertion (calf…)

Relieved by 2-5 min rest

No postural changes necessary

Reproducible

9
Q

Critical limb ischemia

A

Rest pain

Night pain

Tissue loss

Pain most commonly over the forefoot

Wakes from sleep

Relieved by hanging the foot off bed

Ankle pressure < 40, ABI < 0.4, toe pressure < 30

10
Q

Signs if chronic poor perfusion

A

Hair loss

Hypertrophic nails

Atrophic muscle

Ulceration

Infections

Slow capillary refill

Prolonged pallor on elevation

Prolonged rubor on dependency

Venous troughing (collapse of superficial veins)

11
Q

Inv for chronic atrial insufficiency

A

Routine blood work

Fasting metabolic w/u

ABI

CTA/MRA (for planning intervention)

Arteriography (better than CTA/MRA, for tibial arteries

12
Q

ABI interpretation

A

> 1.2: suspect wall calcification

> 0.95 normal

0.5 -0.8 claudication

< 0.4 critical

13
Q

Tx of chronoc limb ischemia

A

RF modification

Exercise program (30 min x 3/w)

Foot care

Antiplatelet

Cilostazol

14
Q

Indications of surgical intervention for chronic limb ischemia

A

Severe lifestyle impairing

Vocational impairment

Critical ischemia

15
Q

Surgical interventions

A

Angioplasty +/- stenting

Endarterectomy

Bypass graft

Amputation, if:
Non suitable for above
Persistent serious infection, gangrene
Unremitted rest pain poorly controlled by analgesics

16
Q

Mx of critical limb ischemia

A

If limb salvageable:
Arteriography
Duplex scanning

If not salvageable:
Amputation
(Analgesia in moribund pt)

17
Q

Aortic dissection classification

A

Type A: involving ascending aorta

Type B: not involving ascending aorta

Acute: <2 wk

Chronic: >2 wk

18
Q

What’s the most common etiology for aortic dissection?

A

HTN

19
Q

RFs for aortic dissection

A

HTN

Marfan, EDS, other CTDs

Atherosclerosis

Coarctation of aorta

Bicuspid aortic valves

PDA

Cystic medial necrosis

Syphilis

Trauma

Arteritis (Takayasu)

20
Q

Epidemio of AD

A

M> F

African-Canadian >…> asian

Peak age: 50-65 yr

If CTD: 20-40 yr

21
Q

Sx of aortic dossection

A

Tearing pain radiating to back +

HTN (Asymmetric BP/Pulse between limbs)

Ischemic syndromes (occlusion of branches)

Unseating of aortic valve cusps ( new diastolic murmur)

Rupture into pleura, pericardium, retroperitoneum

Syncope

22
Q

Inv for AD

A

CTA (mainstay)

ECG, troponin

CXR:
Pleural cap (pleural effusion in lung apices)
Widened mediastinum
Left pleural effusion

TEE:
Visualizes aortic valve and thoracic aorta

Lactate
Amylase

23
Q

Mx of aortic dissection

A

Type A:
Urgent surgery

Type B:
Medical Mx:
IV antihypertensives
Transition to oral meds
( BB, if BBs contraindicated, CCB)
\+/- ACEI

Selective interventions for complications or refractory symptoms

+/- aortic stent-grafting

24
Q

Aortic aneurism definition

A

Diameter at least x1.5 that of expected

25
Q

RFs for AA

A
Smoking
HTN
PVD
CAD
CVD
Age>70
FHx
Degenerative
Traumatic
Mycotic (salmonella, staph)
CTD
Vasculitis
Infectious (syphilis, fungal)
Ascending thoracic aneurysms are associated with bicuspid aortic valve
26
Q

Most common Sx of aorta aneurism

A

Asymptomatic

27
Q

Most common site of AA

A

Abdominal

28
Q

Inv for AA

A
CBC
Lytes
Urea
Cr
PTT,INR
Type and cross

Abdominal U/S (screening, surveillance)

CT with contrast

Peripheral arterial doppler/duplex (R/O aneurisms elsewhere)

29
Q

Screening for AAA

A

Men 65-74

Women 65 yr with cardiovascular disease and FHx of AAA

Men >50 with FHx of AAA

30
Q

Indications for surgical Tx of AA

A

Ruptured

Symptomatic

Size > 5-5.9 cm

Ascending thoracic aorta aneurism if:
> 6cm
> 2x normal
> 4.5 cm + aortic regurgitation/marfan

31
Q

RFs of carotid stenosis

A
For atherosclerosis:
Smoking
HTN
DM
Hyperlipidemia
CVD
CAD
Older age
32
Q

Inv for carotid stenosis

A

CBC

PTT/INR

Fundoscopy:
Cholesterol emboli in retinal vessels

Carotid bruit

Carotid duplex

CTA, MRA

33
Q

Tx of carotid stenosis

A

RF modification:
Control DM, HTN, lipids

ASA +/- dipyridamole
Clopidogrel

Surgical

34
Q

Indication fo carotid endarterectomy

A

Symptomatic and > 70% stenosis

35
Q

Factors aggrevating Sx of varicose veins

A

Prolonged standing

PMS

36
Q

Tx of varicose veins

A

Coservative:
Elastic compression stocking

Surgery

37
Q

Indications for surgery of varicose veins

A

Failure of conservative treatment

Symptomatic varix:
Pain
Bleeding
Recurrent thrombophlebitis

Tissue changes:
Hyperpigmentation
Ulceration

Cosmetic

38
Q

Inv for chronic venous insufficiency

Venous insufficiency and skin damage

A

Not required

Doppler U/S for pre-operative assessment

39
Q

Tx of chronic venous insufficiency

A

Conservative:

Elastic compression stocking
Periodic rest/elevation
Avoid prolonged standing

Ulcer: multilayer compression bandage. ABx PRN

Surgical

40
Q

Indications of surgical Tx for chronic venous insufficiency

A

If conservative measures fail

Recurrent large ulcers

41
Q

Most common form of primary lymphedema

A

Lymphedema praecox

Starts in adolescence

42
Q

Types of primary lymphedema

A

Milroy’s syndrome

Lymphedema praecox, starts in adolescence

Lymphedema tarda: starts after 35 yr

43
Q

The most common cause of secondary lymphedema worldwide

A

Filariasis

The most common cause in north America: surgery, RT

44
Q

Tx of lymphedema

A

Avoid limb injury

Early treatment of cellulitis

Skin hygiene:
Daily moisturizers
Early Tx of fungal/bacterial infection

Compression bandage
Compression garment

Gentle daily exercise of affected limb
Gradual increase in ROM
Must wear compression bandage when doing exercise

Massage (manual lymph drainage therapy)