Vascular Surgery - Specific Diseases

Front 1

what is acute arterial occlusion?

Back 1

acute occlusion of an artery, usually by emboliztion; other causes include acute thrombosis of an atheromatous lesion, vascular trauma

Front 2

what are the classic signs/sx of acute arterial occlusion?

Back 2

the 6 Ps: pain, paralysis, pallor, paresthesia, polar (poikilothermia), pulselessness (KNOW THESE!)

Front 3

what is the classic timing of pain w/acute arterial occlusion from an embolus?

Back 3

acute onset, the patient can classically tell you when and where it happened

Front 4

what is the immediate preoperative management of acute arterial occlusion?

Back 4

1. anticoagulate w/IV heparin (bolus followed by constant infusion). 2. a-gram

Front 5

what are the sources of emboli in acute arterial occlusion? what is the most common cause of embolus from the heart?

Back 5

1. heart (85%, e.g., clot from AFib, clot forming on dead muscle post-MI, endocarditis, myxoma). 2. aneurysms. 3. atheromatous plaque (atheroembolism). most common cause of embolus from the heart is AFib.

Front 6

what is the most common site of arterial occlusion by an embolus?

Back 6

common femoral artery (SFA is the most common site of arterial occlusion from atherosclerosis)

Front 7

what diagnostic studies should you order w/acute arterial occlusion?

Back 7

1. a-gram 2. ECG (look for MI, AFib) 3. echocardiogram (+/-) looking for clot, MI, valve vegetation

Front 8

what is the treatment for acute arterial occlusion?

Back 8

surgical embolectomy via cutdown and fogarty balloon (bypass is reserved for embolectomy failure)

Front 9

what is a fogarty? how is a fogarty used?

Back 9

fogarty balloon catheter - catheter w/a balloon tip that can be inflated w/saline, used for embolectomy. to use, insinuate the catheter w/the balloon deflated past the embolus and then inflate the balloon and pull the catheter out; the balloon brings the embolus w/it.

Front 10

how many mm in diameter is a 12 french fogarty catheter?

Back 10

simple: to get mm from french measurements, divide the french # by pi --> a 12 french is 4 mm in diameter

Front 11

what must be looked for postoperatively after reperfusion of a limb?

Back 11

COMPARTMENT SYNDROME, hyperkalemia, renal failure from myoglobinuria, MI

Front 12

what is compartment syndrome?

Back 12

leg (calf) is separated into compartments by very unyielding fascia; tissue swelling from reperfusion can increase the intracompartmental pressure, resulting in decreased capillary flow, ischemia, and myonecrosis; myonecrosis may occur after the intracompartment pressure reaches only 30 mmHg

Front 13

what are the signs/sx of compartment syndrome?

Back 13

classic signs include pain, especially after passive flexing/extension of the foot, paralysis, paresthesias, and pallor; pulses are present in most cases b/c the systolic pressure is much higher than the minimal 30 mmHg needed for compartment syndrome

Front 14

can a a patient have a pulse and compartment syndrome?

Back 14

yes!

Front 15

how is the dx of compartment syndrome made?

Back 15

history/suspicion, compartment pressure measurement

Front 16

what is the treatment of compartment syndrome?

Back 16

tx includes opening compartments via bilateral calf-incision fasciotomies of all 4 compartments in the calf

Front 17

what is chronic mesenteric ischemia?

Back 17

chronic intestinal ischemia from long-term occlusion of the intestinal arteries; most commonly resutls from atherosclerosis; usually in 2 or more arteries b/c of the extensive collaterals

Front 18

what are the symptoms of chronic mesenteric ischemia? what are the signs?

Back 18

weight loss, postprandial abdominal pain, anxiety/fear of food b/c of postprandial pain, +/- heme occult, +/- diarrhea/vomiting. abdominal bruit is commonly heard.

Front 19

how is the dx of chronic mesenteric ischemia made? what is the classic finding on A-gram?

Back 19

a-gram, duplex, MRA. on a-gram, 2 of the 3 mesenteric arteries are occluded and there is atherosclerotic narrowing of the 3rd patent artery is classic.

Front 20

what is intestinal angina?

Back 20

postprandial pain from gut ischemia

Front 21

what supplies blood to the gut?

Back 21

celiac axis vessels, SMA, IMA

Front 22

what are the treatment options for chronic mesenteric ischemia?

Back 22

bypass, endarterectomy, angioplasty, stenting

Front 23

what is acute mesenteric ischemia? what are the causes?

Back 23

acute onset of intestinal ischemia. caused by (1) emboli to a mesenteric vessel from the heart or (2) acute thrombosis of long-standing atherosclerosis of mesenteric artery.

Front 24

what are the causes of emboli from the heart?

Back 24

A FIB, MI, cardiomyopathy, valve disease/endocarditis, mechanical heart valve

Front 25

what drug has been associated w/acute intestinal ischemia?

Back 25

digitalis

Front 26

to which intestinal artery do emboli preferentially go?

Back 26

superior mesenteric artery

Front 27

what are the signs/sx of acute mesenteric ischemia?

Back 27

severe pain - classically pain out of proportion to physical exam, no peritoneal signs until necrosis, vomiting/diarrhea/hyperdefecation +/- heme stools

Front 28

what is the classic triad of acute mesenteric ischemia?

Back 28

acute onset of pain + vomiting, diarrhea, or both + history of AFib or heart disease

Front 29

what is the gold standard diagnostic test of acute mesenteric ischemia?

Back 29

mesenteric a-gram

Front 30

what is the treatment of a mesenteric embolus?

Back 30

perform fogarty catheter embolectomy, resect obviously necrotic intestine, and leave marginal looking bowel until a 2nd look laparotomy is performed 24-72 hr.s postoperatively

Front 31

what is the treatment of acute thrombosis?

Back 31

papaverine vasodilator via a-gram catheter until patient is in the OR; then, most surgeons would perform a supraceliac aorta graft to the involved intestinal artery or endarterectomy; intestinal resection/second look as needed

Front 32

what is median arcuate ligament syndrome?

Back 32

mesenteric ischemia resulting from narrowing of the celiac axis vessels by extrinsic compression by the median arcuate ligament

Front 33

what is the median arcuate ligament comprised of?

Back 33

diaphragm hiatus fibers

Front 34

what are the symptoms of median arcuate ligament syndrome? signs? how do you diagnose?

Back 34

postprandial pain, weight loss; signs are abdominal bruit in almost all patients. dx made on a-gram

Front 35

what is the tx of median arcuate ligament syndrome?

Back 35

release arcuate ligament surgically

Front 36

what are the signs/sx of carotid vascular disease?

Back 36

amarous fugax, TIA, RIND, CVA

Front 37

define amaurousis fugax

Back 37

temporary monocular blindness ("curtain coming down"): seen w/microemboli to retina; example of TIA

Front 38

define TIA, RIND, CVA

Back 38

TIA: transient ischemic attack - focal neurologic deficit w/resolution of all sx w/in 24 hr.s. RIND: reversible ischemic neurologic deficit: transient neurologic impairment (w/o lasting sequelae) lasting 24-72 hr.s. CVA: cerebrovascular accident (stroke): neurologic deficit w/permanent brain damage.

Front 39

what is the risk of a CVA in patients w/TIA?

Back 39

~10% a year

Front 40

what is the noninvasive method of evaluating carotid disease? what is the gold standard invasive method of evaluating carotid disease?

Back 40

noninvasive: carotid ultrasound/doppler - gives general location and degree of stenosis. invasive: A-gram

Front 41

what is the surgical treatment of carotid stenosis?

Back 41

carotid endarterectomy (CEA): the removal of the diseased intima and media of the carotid artery often performed w/a shunt in place

Front 42

what are the indications for CEA in the asymptomatic patient? in the symptomatic (CVA, TIA, RIND) patient?

Back 42

asymptomatic: carotid artery stenosis >60% (greatest benefit probably in patients w/>80% stenosis). symptomatic: carotid stenosis >50%.

Front 43

before performing a CEA in the symptomatic patient, what study other than the A-gram should be performed?

Back 43

head CT

Front 44

in bilateral high-grade carotid stenosis, on which side should the CEA be performed in the asymptomatic, Rt-handed patient?

Back 44

left CEA first, to protect the dominant hemisphere and speech center

Front 45

what is the dreaded complication after a CEA? what are other possible postop complications?

Back 45

stroke. other postop complications: MI, hematoma, wound infection, hemorrhage, hypotension/hypertension, thrombosis, vagus nerve injury (change in voice), hypoglossal nerve injury (tongue deviation toward side of injury), intracranial hemorrhage

Front 46

what is the mortality rate after CEA? what is the perioperative stroke rate after CEA? what is the most common cause of death during the early postoperative period after a CEA?

Back 46

mortality rate ~1%. stroke rate is b/w 1% (asymptomatic) and 5% (symptomatic patient). most common cause of death in early postop period is MI.

Front 47

what is the postop medication for CEA?

Back 47

aspirin (inhibits platelets by inhibiting cyclo-oxygenase)

Front 48

define hollenhorst plaque

Back 48

microemboli to retinal arterioles seen as bright defects

Front 49

what is subclavian steal syndrome?

Back 49

arm fatigue and vertebrobasilar insufficiency from obstruction of the L subclavian artery or innominate proximal to the vertebral artery branch point; ipsilateral arm movement causes increased blood flow demand, which is met by retrograde flow from the vertebral artery, thereby stealing from the vertebrobasilar arteries

Front 50

what is in the carotid sheath?

Back 50

carotid artery, internal jugular vein, vagus nerve (lies posteriorly in 98% of patients), deep cervical liymph nodes

Front 51

which artery is most commonly occluded in subclavian steal syndrome?

Back 51

L subclavian

Front 52

what are the symptoms of subclavian steal syndrome? what are the signs?

Back 52

symptoms: upper extremity claudication, syncopal attacks, vertigo, confusion, dysarthria, blindness, ataxia. signs: upper extremity blood pressure discrepancy, bruit (above the clavicle), vertebrobasilar insufficiency.

Front 53

what is renal artery stenosis?

Back 53

stenosis of renal artery, resulting in decreased perfusion of the JG apparatus and subsequent activation of the RAAS system (i.e., HTN from renal artery stenosis)

Front 54

what is the treatment for subclavian steal syndrome?

Back 54

surgical bypass or endovascular stent

Front 55

what is the incidence of renal artery stenosis?

Back 55

~10-15% of the US population have HTN; of these, ~4% have potentially correctable renovascular HTN. also note that 30% of malignant HTN have a renovascular etiology

Front 56

what is the etiology of renal artery stenosis?

Back 56

~66% result from atherosclerosis (men > women), ~33% result from fibromuscular dysplasia (women > men, avg age 40 yrs, 50% w/bilateral disease). note: another rare cause is hypoplasia of the renal artery

Front 57

what is the classic profile of a patient w/renal artery stenosis from fibromuscular dysplasia?

Back 57

young woman w/hypertension

Front 58

what are the associated risks/clues with renal artery stenosis?

Back 58

family hx, early onset of HTN, HTN refractory to medical treatment

Front 59

what are the signs/symptoms of renal artery stenosis?

Back 59

most patients are asymptomatic but may have h/a, diastolic HTN, flank bruits (present in 50%), and decreased renal function

Front 60

what are the diagnostic tests for renal artery stenosis?

Back 60

A-gram (maps artery and extent of stenosis, gold standard), IVP (80% of patients have delayed nephrogram phase, i.e., delayed filling of contrast), renal vein renin ratio (if sampling of renal vein renin levels show ratio b/w 2 kidneys >=1.5, then diagnostic for unilateral stenosis), captopril provocation test (will show drop in BP)

Front 61

are renin levels in serum always elevated in renal artery stenosis?

Back 61

no: systemic renin levels may also be measured but are only increased in malignant HTN, as the increased intravascular volume dilutes the elevated renin level in most patients

Front 62

what is the invasive nonsurgical treatment for renal artery stenosis? what is the surgical treatment?

Back 62

nonsurgical: percutaneous renal transluminal angioplasty (PRTA)/stenting: w/FM dysplasia use PRTA, w/atherosclerosis use PRTA/stent. surgical treatment: resection, bypass, vein/graft interposition, or endarterectomy

Front 63

which antihypertensive medication is contraindicated in patients w/HTN from renovascular stenosis

Back 63

ACE-inhibitors (result in renal insufficiency)

Front 64

what are the causes of splenic artery aneurysm?

Back 64

women: medial dysplasia. men: atherosclerosis

Front 65

how is the diagnosis of splenic artery aneurysm made?

Back 65

usually by abdominal pain --> U/S or CT scan, in the OR after rupture, or incidentally by eggshell calcifications seen on AXR

Front 66

what is the risk factor for splenic artery aneurysm rupture? what are the indications for splenic artery aneurysm removal?

Back 66

rupture risk factors: pregnancy. indications for removal: pregnancy, >2cm in diameter, symptoms, in women of childbearing age.

Front 67

what is the treatment for spenic aneurysm?

Back 67

resection or percutaneous catheter embolization in high risk (e.g., portal HTN) patients

Front 68

what is popliteal artery aneurysm?

Back 68

aneurysm of the popliteal artery caused by atherosclerosis and, rarely, bacterial infection

Front 69

how is the diagnosis of popliteal artery aneurysm made? why examine the contralateral popliteal artery?

Back 69

usually by physical exam --> A-gram, U/S. 50% of all patients w/a popliteal artery aneurysm have a popliteal artery aneurysm in the contralateral popliteal artery

Front 70

what are the indications for elective surgical repair of a popliteal aneurysm?

Back 70

1. >=2cm in diameter 2. intraluminal thrombus 3. artery deformation

Front 71

w/popliteal artery aneurysm, why examine the rest of the arterial tree (especially the abdominal aorta)?

Back 71

75% of all patients w/popliteal aneurysms have additional aneurysms elsewhere, >50% of these are located in the abdominal aorta/iliacs

Front 72

what size of the following aneurysms are usually considered indications for surgical repair? thoracic aorta, abdominal aorta, iliac artery, femoral artery, popliteal artery

Back 72

thoracic aorta >6.5 cm, abdominal aorta >5.5 cm, iliac artery >4 cm, femoral artery >2.5 cm, popliteal artery >2 cm

Front 73

define milk leg

Back 73

AKA phlegmasia alba dolens, often seen in pregnant women w/occlusion of iliac vein resulting from extrinsic compression by the uterus (thus the leg is white b/c of subcutaneous edema)

Front 74

define phlegmasia cerulea dolens

Back 74

in comparison to phlegmasia alba dolens, phlegmasia cerulea dolens is secondary to severe venous outflow obstruction and results in a cyanotic leg; the extensive venous thrombosis results in arterial inflow impairment

Front 75

define raynaud's phenomenon

Back 75

vasospasm of digital arteries w/color changes of the digits, usually initiated by cold/emotion. white (spasm), then blue (cyanosis), then red (hyperemia).

Front 76

define takayasu's arteritis

Back 76

arteritis of the aorta and aortic branches, resulting in stenosis/occlusion/aneurysms. seen mostly in women.

Front 77

define buerger's disease

Back 77

aka thromboangiitis obliterans: occlusion of the small vessels of the hands and feet, seen in young men who smoke, often results in digital gangrene --> amputations

Front 78

what is thte treatment for buerger's disease?

Back 78

smoking cessation +/- sympathectomy

Front 79

what is blue toe syndrome?

Back 79

microembolization from proximal atherosclerotic disease of the aorta resulting in blue, painful, ischemic toes

Front 80

what is a paradoxical embolus?

Back 80

venous embolus gains access to the L heart after going through an intracardiac defect, most commonly a patent foramen ovale, and then lodges in a peripheral artery

Front 81

what size iliac aneurysm should be repaired?

Back 81

>4 cm in diameter

Front 82

what is behcet's disease?

Back 82

genetic disease w/aneurysms from loss of vaso vasorum; seen w/oral, ocular, and genital ulcers/inflammation (increased incidence in japan, mediterranean)