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58 Cards in this Set

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What are the risk factors for AAA?
Atherosclerosis, HTN, smoking, male, age

Inheritance- Marfan's, Ehler's Danlos

Common underlying defect is vessel wall weakness 2ry to elastin/collagen degradation
what is the role of ultrasound in AAA?
best screening tool.
can assess x-sectional screening tool and diameter to 95% accuracy
used to follow diameter over time
What is the role of PEX in AAA?
first step in feeling an abdominal mass
What is the definition of a AAA?
>1.5-2.0 cm with all three layers involved
What is the role of CT/MRI in AAA?
helps get better precision on a AAA.
what is the role of angiography in AAA?
- largely replaced by MRI
- limitation- size may not be accurate due to thrombus
- best way to evaluate lumen patency, iliac and renal involvement
what is the role of plain film in AAA?
shows calcifications. not used for work-up
what is the law of laplace?
tension is directly proportional to intra-luminal pressure. inversely related to wall thickness.
what is the difference between big aneurysms and small aneurysms in relation to diameter and risk of rupture?
4% annual risk for < 5 cm
7% risk for 5-7 cm
20% risk for > 7 cm
what are independent risk factors for AAA rupture?
recent expansion
HTN
COPD
abdom/back pain near site
when should one operate on a AAA?
when rupture risk is greater than surgery risk:
- diameter 5-5.5 cm or greater
- the triad: severe ab/back pain, pulsatile ab mass, hypotension
- symptomatic aneurysm
Describe the technique of an open surgery for AAA.
dissection
proximal and diststal arteries are isolated
- heparin
- clamp, aneurysm incised. Prosthetic graft is sewn in place and covered w/ the residual aneurysm sac.
Infrarenal risk?
less than 5%.
Involvement of the iliac arteries or more proximal portions of the abdominal or thoracic aorta are technically more challenging.
what are some serious complications of AAA treatment?
renal impairment
MI
extremity amputation
CVA
colonic ischemia, distal emboli, and hemorrhage
what are the long-term complications of AAA treatment?
graft infection, graft thrombosis, pseudoaneurysm.
what are the advantages to an open procedure
lower morbidity/mortality
durable
better option in those that can tolerate it.
what are the disadvantages to a open procedure?
not tolerated in frail pts
- CAD contraindicates
what is the procedure for endovascular repair of a AAA?
Placement of stents via the femoral artery. catheters
what are the advantages of endovascular AAA repair?
no CVRR or GI distress from lack of clamping.
shorter hospital stay
what are the disadvantages of endovascular AAA repair?
higher post-op failure rate
requires wide open vessels for access.
what are common locations of peripheral aneurysms?
palpiteal artery- presents bilaterally, presents with distal emboli, thrombosis "blue toe syndrome"; total occlusion is a 50% amputation risk.

Iliac- resection if >3cm; common iliac-> aortofem bypass; hypogastric-> pulsatile mass on DRE.

Femoral- uncommon, local pain, venous obstruction, embolism/thrombosis; resect if >2.5cm
Where is an aneurysm found in syphilis?
ascending aorta
where is an aneurysm typically found in marfan's?
descending thoracic aorta
where is mycotic aneurysms found?
anywhere
where are pseudoaneurysms found?
trauma or surgical anastomosis site
what are the five Ps of acute ischemia?
pallor
pulselessness
pain
paresthesia
paralysis
Poikilothermia

emergency- paralysis, paresthesia
what are the major sources of emboli in acute ischemia?
1. left side of heart- afib, acute mi
2. aneurysm- stasis for clot
Other-
- ventricular aneurysm
- mitral stenosis
- popiteal or other arterial emboli
- bacterial endocarditis
- paradoxical embolis- rare, venous, needs shunt
what are the sources of thrombus in acute ischemia?
- atherosclerotic plaque rupture
- aneurysm
- trauma
- posterior knee dislocation
- supracondylar humerus fracture- may entrap the brachial. Volkman's- compartment syndrome
- hypercoaguable state
what is rest pain in chronic ischemia?
pain in the toes and metatarsals, relieved with walking.
Arterial foot ulcers:
what are common causes?
What are the symptoms?
Where are they seen?
What do they look like?
What are associated findings?
cuases- atherosclerosis, diabetes
symps- painful (not in DM), heavy, weak, fatigued legs
where- bony prominences, toes, heals, top of foot.
appearance- punched out, gray necrotic bases.
Venous foot ulcers:
what is the etiology?
What are the symptoms?
Where are they seen?
What do they look like?
What are associated findings?
Venous Hypertension-> capilarry leaks-> edema (protein to skin)-> inhibbed oxygen, nutrients-> skin breakdown
symps- edema, achiness, stasis, (red-brown pigmentation), dermatitis, atrophie blanche (white spots)
Location- above the ankle, below the knee
appearance- irregular borders, granulating base.
findings- vericose veins, venous thrombosis, phlebitis, post-thrombotic syndrome
neuropathic foot ulcers:
what is the etiology?
What are the symptoms?
Where are they seen?
What do they look like?
What are associated findings?
areas of pressure have decreased flow, go unnoticed.
symps- painless, may have burning, shooting pains, hyperesthesia, parasthesia
location- areas of pressure, lateral and plantar parts of foot, heel, toes, metatarsal
appearance- formed boarders, deep; pale, gray, black base, surrounded by callous
associated findings- dry, hyperkeratotic skin; deformed foot; infections, neuropathic edema, stunted deep tendon reflexes, and joint position senses; arterial ischemia
What are the indications for surgical bypass?
claudication
Rest Pain
Gangrene (wet- with purulent discharge; dry- dead, black)
non-healing ulcers, sores in lower extremity
What is a normal ABI?
When is there claudication?
When is there rest pain?
when is there gangrene?
when are they incompressible?
normal .9-1.2
rest pain .5-.8
gangrene <.2
incompressable >1.2
What PEX findings can be found in a patient experiencing claudication?
hair loss
muscle atrophy
color changes
ulcers
gangrene
Buerger's sign- (dependant rubor)
What are the Rx options for claudication?
1. Exercise program- walk for 30-45 min 6 days a week. Conditions muscles and develops collaterals
2. Stop smoking
3. angioplasty/stenting
4. Endarterectomy
- used in bifurcation
5. bipass
6. amputation
What are the variables in angioplasty results?
a. location- lower leg only has 40-50% patency after 1 year
b. length
c. degree of occlusion
d. amount of calcification
e. tortuosity
what are the reasons for amputation in PVD?
severe rest pain, gangrene
site chosen for best wound healing. Knees are attempted to be spared.
what is Virchow's triad? risks for clotting.
i. venous endothelial injury
ii. stasis
iii. hypercoag state

other risks- birth control, pregs, history of DVT, surgery, sepsis, obesity
what is triphasic, biphasic, and monophasic wave forms?
triphasic- normal
biphasic- mild ischemia
monophasic- progressive occulsion
What does high velocity on a duplex mean?
means stenosis
what are signs of corotid occulsive disease?
Amarousis Fugax- transient monocular blindness
TIA- neurodeficit for < 24 hrs
CVA- neuro lasting > 24 hrs

dizziness, headache, syncopeare not symps
what are the indications for an endarterectomy?
stenosis > 50%, symps, 70-90% stenosis w/ symps showed benefit for endarderectomy Nascat.
what are the risks of carotid endarterectomy?
stroke- 3-5% risk
MI
death (caused by above)
nerve injury
what nerves are at risk in carotid surgery?
Hypoglossal
Vagus- posterior
posterior auricular
Glossopharyngeal
Marginal Mandibular
what is the role of Pentoxifylline in claudication?
improves abnl erythrocyte deformability, reduces blood viscosity, decreases platelet activity
what is the role of Cilostazol in claudication?
type III posphodiesterase inhibitor, possesses an anti-platelet and vasodilating properties
What are the signs of a PE?
pleuritic chest pain
dyspnea, tachycardia, cough, hemoptisis
what tests are used to diagnose a PE?
spiral ct
chest xray
d-dimer
pulm angiogram
V/Q scan
how is heparin used in PE treatment?
IV infusion
till PTT is double normal.
what are the indications for placement of a vena cava filter? (Greenfield filter)
pt with LE venous thrombis, but contraindicated to anti-coag. or with symps while anti-coagulated.
What is post phlebetic syndrome?
weeks after a DVT, pain, redness, thickness, glossy skin.
What is an UNNA boot?
gauze bandage covered with ointments
What are the risks for developing vericose veins?
family Hx
obesity
pregnancy
the pill
work that requires standing for a long time.
what is the role of sclerotherapy in vericose veins?
dilute sclerosing agent is injected into the skin. vein irritation-> occlusion
What is the gold standard for treating spider veins?
sclerotherapy
what is a common comorbidity of vericose veins?
DVTs in 25%
What is the trendelenberg test?
pt. lies flat, leg is elevated, Tie tourniquet at thigh, w/out competent valve, sudden filling when tourniquet removed