Nms Surgery Vascular Disorders

Front 1

If TIA untreated what are chances of recurrence?

Back 1

40% chance of another TIA or stroke in 2 years

Front 2

Tests to eval TIA?

Back 2

Carotid bruits, neuro exam, murmurs, echocardiogram, duplex of carotids

Front 3

What percent stenosis of carotids does better with surgery?

Back 3

70% stenosis 3x more effective than aspirin in prev strokes

Front 4

Additional preop for CEA?

Back 4

BP control, cardiac eval

Front 5

Perioperative risk of major stroke for CEA?

Back 5

1-3%

Front 6

Nerves to avoid during CEA?

Back 6

Hypoglossal, Vagus, Marginal branch of facial

Front 7

What imaging do you do to make sure CEA is perfect?

Back 7

On table angiogram or duplex

Front 8

What is the risk percent for carotid narrowing on operated side?

Back 8

13% over 5 years

Front 9

What drug to take postop?

Back 9

ASA

Front 10

What are CEA pts most likely to die form?

Back 10

MI because TIA is a sign of atherosclerosis. Should take up exercise regimen, lifestyle changes, lipid control

Front 11

Name of ophthalmic finding with amaurosis fugax?

Back 11

Hollenhorst Plaque

Front 12

What eval do you do if a person strokes, and it's not a TIA?

Back 12

Carotid duplex, observation for improvement, operate after patient stable. Usually 2-4 weeks post stroke or when neuro status stabilizes

Front 13

At what percent carotid stenosis should asymptomatics get surgery?

Back 13

65%. In a 2 year period, 2.5% of pts had stroke compared to 11% of ASA pts.

Front 14

6 Ps for acute arterial occlusion of extremity?

Back 14

Pain, Pallor, Paresthesia, Paralysis, Pulselessness, Poikilothermia

Front 15

When do you operate on acute occlusion of leg? What do you give them immediately?

Back 15

ASAP. Within 6 hours. Give heparin.

Front 16

What's the surgical procedure for acute occlusion?

Back 16

Fogarty catheter embolectomy. (balloon catheter)

Front 17

Complications of acute reperfusion?

Back 17

Compartment syndrome

Front 18

At what pressure can compartment syndrome get dangerous?

Back 18

20-40mmHg: ischemic injury of muscles and nerves

Front 19

3 most common sites for lower limb embolus?

Back 19

Femoral, then Iliac, then aortic saddle, then popliteal

Front 20

Long term care for post fasciotomy?

Back 20

Coumadin, ECHO, CT to search for embolic source

Front 21

2 common causes for acute arterial ischemia?

Back 21

1. Femoral arterial puncture: raise intimal flaps, dislodge emboli, cause local thrombosis
2. Aortic dissection where false lumen extends to femoral artery

Front 22

Workup for claudication?

Back 22

Pulses, bruits, thrills, skin exam for ulcerations, sensory and motor function exam, depended rubor, history of DM, CV dz

Front 23

Where in the superficial femoral A is there most likely to be an occlusion?

Back 23

at adductor hiatus

Front 24

If you don't get pulses in some places, what test do you do?

Back 24

ABI with doppler tracing

Front 25

What are worrisome signs with claudication?

Back 25

Rest pain, ischemic ulceration

Front 26

What are the ranges of normal and abnormal ABI values?

Back 26

Normal= 1.1 to .9
Mild claudication= .8 to .6
Severe claudication= <.5
Rest pain or tissue loss= <.3

Front 27

In what type of patients can ABIs be artificially high?

Back 27

Diabetics, cause they have calcified vessels

Front 28

What happens to doppler waveforms with claudication?

Back 28

Triphasic to biphasic to monophasic

Front 29

Why wouldn't you operate on claudication?

Back 29

risk benefit. Dangers of arteriogram, possibility of thrombosis, infection, amputation, unfavorable medical condition such as CAD. Exercise seems to help.

Front 30

How many claudicators get better?

Back 30

1/3 get better. 1/3 same, 1/3 deteriorate.

Front 31

Why would you operate quicker on an aortoiliac dz than just a plain old claudication?

Back 31

Progresses faster

Front 32

How can you tell if a diabetic foot ulcer is likely to heal or not?

Back 32

Ankle systolic BPs in torr.
Nondiabetics probable healing 55-65
Diabetics probable healing 80-90

Front 33

Why would we do non-preop arteriogram for diabetics with claudication?

Back 33

because it changes our strategy for operation or not.

Front 34

Which arteries are given preference when doing femorodistal bypass?

Back 34

Poplital, anterior and posterior tibial, then peroneal

Front 35

What f/u procedures after a bypass?

Back 35

Frequent duplex of graft for patency, ASA, lipid control, foot care

Front 36

What is Leriche syndrome?

Back 36

aortoiliac dz
Claudication+atrophy+impotence (occlusion of internal iliac that gives rise to pudendal)

Front 37

Treatment for short segment iliac stenosis?

Back 37

Percutaneous transluminal angioplasty

Front 38

Surgery for b/l aortoiliac dz?

Back 38

Aortobifem bypass. If at risk for complications or poor general health, ax-fem-fem may be better

Front 39

Surgery for unilateral aortoiliac dz?

Back 39

fem-fem

Front 40

What part of aortobifem bypass graft surgery has greatest risk?

Back 40

Anesthesia induction and during hemorrhage/stress.
During clamping: high afterload, must manage BP.
During unclamping sudden decrease in afterload possible hypotension and decreased CO. Unclamping flushes blood from lower body that could have become acidotic and hyperkalemia, causing arrhythmia

Front 41

What is trash foot?

Back 41

Microvessel occlusion following revascularization from fibrin, platelts, atherosclerotic debris that travels down to toes. With good pulses, it should heal

Front 42

Post op for aortoiliac dz?

Back 42

heparin bridge to coumadin, assess toes for necrosis, watch for evidence of infection, ASA

Front 43

Cardiac morbidity perioperatively in major vessel reconstruction?

Back 43

up to 10%

Front 44

Cardiac mortality perioperatively in major vessel reconstruction?

Back 44

2-3%

Front 45

Substance used for stress echo?

Back 45

Regadenosone or Dobutamine

Front 46

How to use Eagle's criteria?

Back 46

For Prediction of Perioperative cardiac morbidity
Age >70, Angina, Diabetes, DTS redistribution, Ventricular arrhythmia, Q waves on ECG.
0 risk factors: 3% risk of MI. operate.
1-2 risk factors: 15% risk of MI. do DTS testing.
3 risk factors: 50% risk of MI. do coronary angiography and revascularize heart if necessary

Front 47

AAA imaging modalities?

Back 47

US or CT

Front 48

AAA more common in who?

Back 48

4:1 males, 11x in first degree relatives, 50% of pts with popliteal aneurysm

Front 49

When should AAAs be repaired?

Back 49

>.5cm growth per year or >5cm in size

Front 50

Post op complications of AAA?

Back 50

1. third spacing of fluids. increase fluid requirements
2. third day mobilization of fluids, need diuresis and fluid restriction or else pulmonary edema

Front 51

Why might a AAA pt get impotence after surgery?

Back 51

Damage to hypogastric circulation or to autonomic nerves on anterior surface of aorta near IMA

Front 52

What percent of ruptured AAA die?

Back 52

more than half

Front 53

What are 5 year rupture rates for AAA?

Back 53

<5cm= 20%
5-7cm= 33%
>7cm= 95%

Front 54

Should the ER resuscitate fluids in ruptured AAA?

Back 54

No, do it after you've clamped the aorta in OR

Front 55

Complications of aortic replacement?

Back 55

Ischemic colitis in rectosigmoid due to interruption of IMA flow: do sigmoidoscopy,bowel rest, NPO, GI decompression, abx, frequent reexamination, fill thickness involvement requires resection and colostomy
Vascular graft infection due to S.epidermidis or aureus. Remove, debride, do extra anatomic bypass, long term abx
Upper GI bleed from aortoenteric fistula into third or fourth part of duodenum. remove, repair GI tract, extraanatomic bypass

Front 56

How to manage mesenteric ischemia?

Back 56

Mesenteric angiogram, bypass graft from aorta to distal to obstruction. could be obstruction of celic axis or SMA usually.

Front 57

Sxs of aortic dissection?

Back 57

Tearing chest pain, back pain, severe hypertension, tachycardia, diaphoresis

Front 58

Imaging for aortic dissection?

Back 58

TEE, MRI, CT, arteriography

Front 59

Types of dissections and treatments?

Back 59

Type A: Ascending involvement. Operate.
Type B: Descending only. BP control with Beta blockers.

Front 60

Sxs of lower extremity DVT?

Back 60

Pain with movement esp dorsiflexion (Homan's sign), leg swelling, palpable cord (thrombosed superficial vein)

Front 61

How to diagnose DVT?

Back 61

Duplex

Front 62

How to treat DVT?

Back 62

Heparin 70-100U/kg bolus then maintenance of 15-25U/kg/hr for 5-7 days. Bridge to warfarin within first few days, continue 3-6 mo

Front 63

Heparin mechanism?

Back 63

activates antithrombin which inactivates II, VII, IX, X

Front 64

Goals of heparin tx for DVT?

Back 64

PTT 1.5 to 2x normal and INR of 2-3, follow platelet counts for HIT

Front 65

Why do we bridge?

Back 65

Becuase warfarin inhibits protein C synthesis, a relatively hypercoagulable state. Gotta wait till the effects kick in.

Front 66

What is postthrombotic syndrome and how to we treat?

Back 66

After DVT treatment: 10% get edema, skin ulceration, venous claudication for chronic venous HTN. Treat with support hose.

Front 67

Virchow triad?

Back 67

Venous stasis, hypercoag, endothelial injury

Front 68

Some DVT risk factors?

Back 68

Over 40, recent surgery, obesity, smoking, previous history, Cancer, PV, MM, MI, CHF, COPD, pregnancy, DIC, HIT, SLE

Front 69

What is preventative heparin?

Back 69

5000 U subQ preop and every 8-12 hrs postop until ambulatory. Don't forget to raise legs and give pneumatic compression devices

Front 70

workup for suspected PE?

Back 70

ABG, ECG, CXR, pulse ox, V/Q scan, CT if necessary, DVT history

Front 71

How to treat PE?

Back 71

Same as treating DVT. Heparin bolus and drip and bridge to coumadin

Front 72

How to treat recurrent PE?

Back 72

IVC filter with heparin failure or complications such as HIT

Front 73

What to do if someone has GI bleeding with heparin?

Back 73

discontinue, put in IVC (greefield) filter, antiulcer tx

Front 74

Suspected diagnosis with severe DVT and advanced pelvic carcinoma? Tx?

Back 74

Phlegmasia Cerulea Dolens.
Acute interruption of venous outflow due to malignancy. Anticoagulate and elevate leg. duplex and CT afterward.