Vascular

Front 1

60 yo F with single episode of woekaness and numbness lasting for 15 minutes.
1. Diagnosis?
2. Workup?
3. Risk of recurrence?
4. Treatment options?

Back 1

1. TIA
2. Neuro exam, carotid exam/duplex, murmurs --> (if yes, echo)
3. up to 40%
4. medical: aspirin; surgical: carotid endarterectomy

Front 2

1. What two groups is carotid endarterectomy indicated?
2. What study supports one of these indications?

Back 2

1. symptomatic AND >70% stenosis, asympomatic bruit and >70% stenosis
2. NASCET trial showed best stroke prevention (as compared to aspirin and no treatment) - NNT of 6 to prevent stroke in two years in symptomatic patients with carotid stenosis 70-99%

Front 3

1. 2-year risk of stroke with symptomatic carotid artery stenosis - no treatment, aspirin and carotid endarterectomy?
2. What about 5-year risk of stroke asympomatic CAS > 60% - CEA versus aspirin?
2. where do these results come from respectively

Back 3

1. no treatment: 40%, aspirin: ~26%, CEA: ~9%
2. CEA: 5% verus aspirin: 11%
2. NASCET AND ACAS trial respectively

Front 4

perioperative risk of stroke of carotid endarterectomy?what other risk of surgery is important to discuss with patient?

Back 4

1-3%
nerve injuries (hypoglossal, vagus, branch of facial nerve)

Front 5

what are two important elements of carotid endarterectomy surgery?

Back 5

1. assessment of neurologic status: (talking to patient if awake, EEG - general anesthesia)
2. good BP control

Hint 5

think about perioperative risks

Front 6

What is amaurosis fugax? Hollenhorst plaque?

Back 6

transient blindness form an emboli traveling from ICA to opthalmic artery; Hollenhorst plaque- cholesterol embolus seen as bright shiny spot in retinal artery after episode

Hint 6

eyes

Front 7

aphasia with TIA in carotid dz, which side carotid affected?

Back 7

left carotid

Front 8

Is carotid endarterectomy indicated with prior stroke?

Back 8

depends, if duplex show stenosis, a and neuro fnxn is good, then yes

Front 9

65 yo m hx of acute pain onset in leg with difficulty moving it; PE: absence of pulses in legs, cool and cyanotic, dereased sensation, weakness - Diagnosis? Management?

Back 9

1. Diagnosis: acute arterial embolus
2. first, heparin ---> then to OR for revascularization via balloon catheter embolectomy

Front 10

Time for revascularization after an arterial embolus directly impacts recovery. After how long is after ischemia starts is there a high likelihood of impaired limb or even amputation?

Back 10

6 hours

Front 11

6 p's of arterial occlusion?

Back 11

pain (ischemic rest pain), pulselessness, pallor, poikolothermia (cold below site of occlusion), parasthesias, paralysis

Front 12

procedure of choice for revascularization after acute arterial embolic event (e.g. femoral artery)? Typically done intraoperatively to assess revascularization?

Back 12

balloon catheter (Fogarty) embolectomy; intraoperative arteriogram (intra-arterial thrombolyitc therapy used if residual thrombus)

Front 13

what can occur after revascularization procedure in extremity? Why?

Back 13

compartment syndrome (due to edema causes by reperfusion edema --> increased pressure --> irreversible muscle/nerve injury)

Front 14

1. most common sources/causes of arterial emboli (3)?
2. most common sites?

Back 14

1.a. fib, MI, atherosclerotic plaque
2. femoral>iliac>popliteal>carotid&aortic saddle

Front 15

diagnosis and treatment for compartment syndrome?

Back 15

1. needle with pressure-measuring device
2. fasciotomy

Front 16

long term management post-embolectomy?

Back 16

1. warfarin chronically
2. echo (aortography/CT) to look for embolic source

Front 17

exercise-induced calf pain relieved with rest? diagnosis? etiology?

Back 17

intermittent claudication; atherosclerotic occlusion

Front 18

1. what are signs/symptoms that may be present in claudication syndrome (5-7)? 2. Coexisting conditions? (name 2)

Back 18

1. bruits, reduced pulses, thrills, skin ulcerations, motor/sensory loss, shiny skin, dependent rubor
2. DM, CAD

Front 19

most common site for occlusive dz in LE? what pulses reduced/absent?

Back 19

superficial femoral artery; popliteal and pedal

Front 20

two best noninvasive ways to assess peripheral vascular disease?

Back 20

1. ABI (ankle/brachial) pressures with doppler
2. doppler tracings (to detect stenotic areas)

Front 21

1. normal ABI
2. mild claudication?

Back 21

1. >1.0
2. 0.6-0.8

Front 22

4 signs of PVD/insufficiency? give 4 biggies

Back 22

.1 reproducible exercise-induced ischemia/pain
2. toe and foot nonhealing ulcerations
3. gangrene
4. rest pain (forefoot)

Front 23

normal doppler waveform form? what happens in less compliant vessel due to atherosclerosis?

Back 23

triphasic; biphasic (moderate stenosis), monophasic (severe stenosis)
*loses reverse flow

Front 24

give percentages of patients that: a)require vascularization, b)require subsequent amputation, or c)remain stable or improve

Back 24

stable or improve (70%), vasc (20%), amp (10-15%)

Front 25

;Nonoprative therapy for claudication syndrome (3-4)? 1st one most important

Back 25

exercise, lifestyle modifications (smoking cessation, weight loss, dietary changes), lipid-lowering agents

Front 26

Does workup for claudication syndrome include an arteriogram?

Back 26

No, it has inherent risk - only done preoperatively

Front 27

60 yo woman with claudication syndrome with absent femoral pulse? diagnosis? treatment options (3)?

Back 27

aortoiliac occlusive disease; balloon dilation, stent placement, surgical revascularization

Front 28

clinical measure that would suggest need for revascularization with nonhealing ulcer in diabetic?

Back 28

ABI<0.3
Or systolic BP in ankle <80

Front 29

procedure used for occlusion of SFA?

Back 29

Fem-pop (saphenous vein graft)

Front 30

high grade stenosis of iliac artery?

Back 30

large diameter aorto-fem graft, OR stent/balloon dilation

Front 31

high grade stenosis of iliac artery and occlusion of SFA? procedure?

Back 31

aortoiliac reconstruction, fem-pop and distal revscularization

Front 32

occlusion of SFA and popliteal arteries?

Back 32

Fem-pop bypass (with distal connection to distal anterior/posterior tibial arteries)

Front 33

multiple obstructionsin upper and distal leg, with run off vessels below ankle?

Back 33

amputation indicated

Front 34

post-reconstruction/revascularization imagine, plus long term management (2-3)?
most common condition causing death?

Back 34

1. duplex exams of graft,
2. aspirin,
3. lipid control,
4. foot care education
CAD (peripheral is marker)

Front 35

factors going into whether to reconstruct aortoiliac occlusive disease (3)? procedure?

Back 35

1. presence of rest pain
2. level of discomfort
3. operative risk
Procedure: graft from aorta @ renal vein to aortoiliac branch / common iliacs

Front 36

risks of aortobifemoral bypass due to clamping/unclamping aorta?

Back 36

clamping: inc cardiac work (MI)
unclamping aorta: bleeding, hypotension

Front 37

post-op complication of revascularization procedure in which painful, cyanotic big toe?

Back 37

atheroembolization - blocking small pedal/digital arteries
Called Trash Foot

Front 38

discharge instructions/meds post-aortobifemoral / aortoiliac graft revascularization?

Back 38

1. call if signs of infection (risk of graft infection)
2. start aspirin
3. antibiotics

Front 39

what is chance of cardiac event (e.g. MI, arrhythmia, heart failure) in major revascularization procedure?

Back 39

10% (mortality of approx 2-3%)

Front 40

indications for coronary angiography prior to major vascular surgery (3)?

Back 40

mod-severe angina, HF with exertion, LVEF<20%

Front 41

indications for thallium (D-T) scan prior to major vascular surgery?

Back 41

MI hx, moderate angina, mild angina with sedentary lifestyle

Front 42

problem with D-T thallium scan?

Back 42

Low positive predictive value, resulting high rate of coronary angiography

Front 43

physical exam of pulsatile mass in abdomen - next steps?

Back 43

abdominal U/S or CT to determine level of aorta and size

Front 44

what are two big risk factors for AAA?

Back 44

1. male
2. + family hx of AAA (11x risk)

Front 45

AAA associated with what other aneurysms?

Back 45

iliofemoral and popliteal aneurysms

Front 46

elective repair of AAAs > __ cm assuming what two conditions?

Back 46

>5cm; will tolerate surgery and life expectancy > 2 years

Front 47

in AAA repair, what is done?

Back 47

prosthetic graft inserted is sewn to prozimal and distal ends of aneurysm;
note: aneurysm not resected

Front 48

concern with AAA postoperatively? management?

Back 48

third space losses; aggressive resuscitation for 1-2 days until mobilization of fluid, then possibly fluid restriction / diuretics

Front 49

possible postoperative complication in men of AAA repair?

Back 49

impotence from disturbance of hypogastric circ (from over aortic bifurcation)

Front 50

68 yo male, pale, BP 102/60, passed out in AM, abdominal pain, weakness, tenderness in epigastrium and back pain. what do you feel for on clinical exam? diagnosis and management?

Back 50

feel for pulsatile abdominal mass; ruptured AAA; management: straight to OR

Front 51

what active resuscitation for AAA is performed in OR?

Back 51

None - volume expansion can worsen contained rupture into free intraperitoneal resuscitation

Front 52

major perioperative risk and %mortality in rupture AAA repair?

Back 52

exsanguination (bleeding out); up to 80% mortality

Front 53

small amt of bloody diarrhea 3 days post-op AAA repair - what ssuspected? What about upper GI bleed one year post-AAA repair?

Back 53

1. ischemic colitis (usually involving rectosigmoid segment)
2. aortoenteric fistula

Front 54

1. initial steps in management of ischemic bowel dz? name 4-5
2. surgical treatment?

Back 54

1. bowel rest / NPO, antibiotics, IV fluids, maintenence of hematocrit, NGT (or other decompression)
2. surgical (resection of nonviable bowel)

Front 55

3 year post-op AAA tepair,patient found to have graft infection by CT scan - what therapy indicated?

Back 55

removal of graft, debridement of infeted tissue, revascularization by extra-anatomic bypass,and long term abc

Front 56

three major complications of AAA repair (with graft), occuring days to years after?

Back 56

1. ischemic colitis
2. graft infection
3. aortoentric fistula

Front 57

49 yo woman with 6 mo hx of post-prandial pain, 20 lb weight loss, intermittent diarrhea, and multiple abdominal bruits - what suspected? cause? treatment?

Back 57

1. chronic mesenteric ischemia
2. atherosclerotic occlusion to celiac and SMA
3. revascularization via prosthetic/saphenous vn from aorta to affected vessel

Front 58

58 yo male comes to ED with sudden onset of chest pain and back pain - BP is 200/140. with HR of 120. diagnosis? '

Back 58

aortic dissection

Front 59

management of aortic dissection? exception?

Back 59

control HTN with Beta-blockers; dissection of ascending aorta needs to be repaired surgucally

Front 60

67 yo woman post-op day 2 with suspected DVT - what is most reliable clinical sign. Also, name couple others that aren't so specific

Back 60

1. New onset, unilateral leg swelling
2. Homan's sign, calf pain

Front 61

confirmation of diagnosis of DVT via what?

Back 61

venous duplex ultrasound

Front 62

49 yo F present with 6 month hx of postprandial abdominal pain with postprandial pain with a 20lb weight loss, and intermittent diarrhea. multiple abdominal bruits
1. suspected diagnosis?
2. evaluation and potential treatment?

Back 62

1. chronic mesenteric ischemia
2. mesenteric arteriogram, and potential revascularization (bypass)

Front 63

67 yo F post-op for colecotomy develops mild LE swelling. Duplex US of LE reveals a DVT with extension into proximal thigh.
1. Treatment?
2. Monitoring of patient's treatment for efficacy? what is therapeutic?
3. What else should be monitored?
4. Bridging to coumadin why?

Back 63

1. IV heparin (standard of LMWH)
2. PTT 1.5-2x normal
3. platelet count for risk of thrombocytopenia
4. prothrombotic state initially with warfarin b/c of deficiency of protein C (hypercoagulable state), coumadin allows long term anticoagulation

Front 64

Long term therapy post-DVT post-op?

Back 64

Warfarin can be started before discharge with target INR of 2-3.

Front 65

10% of patient with DVT develop what complication marked by chronic, marked edema with skin ulceration around ankle areas? best treatment?

Back 65

postthrombotic state (chronic venous insufficiency)
Best treatment: compression stockings / support hose

Front 66

DVT follows 20% of general surgeries and up to 70% of orthopedic LE procedures - what are prophylocatic measure that can be taken post-op (6 answers)? Which two have solid demonstrated efficacy?

Back 66

1. leg elevation
2. compression stocking
3. venodynes / SCDs
4. early post-op ambulating
5. low dose heparin (LDH)
-SCDs and LDH

Front 67

how (meaning how much and how often) do you administer pre and post-op heparin for DVT prophylaxis?

Back 67

5000 units x 1 preoperatively, q8-12 post-op

Front 68

50 year old post-op day 4 for SBO reports brief episode of acute SOB overnight? No hx of cardiopulmonary disease (asthma, COPD, MI, etc.)
1. Highest on differential?
2. What is broad workup for significant SOB in post-op patient (not necessarily in this patient) (3-4 things)?
3. what about in this case, what test for suspected diagnosis (2)?

Back 68

1. PE
2. pulse ox, CXR, EKG, ABG
3. CTPA (CT-pulmonary angiogram), V-Q scan