Vascular Surgical Recall

Front 1

What is atherosclerosis?

Back 1

A diffuse disease process in arteries; artheromas containing cholesterol and lipid form within the intima and inner media, often accompanied by ulcerations and smooth muscle hyperplasia

Front 2

What is the common theory of how atherosclerosis is initiated?

Back 2

Endothelial injury --> platelets adhere --> growth factors released --> smooth muscle hyperplasia/plaque deposition

Front 3

What are the risk factors for atherosclerosis?

Back 3

HTN, smoking, diabetes mellitus, family history, hypercholesterolemia, high LDL, obesity, and sedentary lifestyle

Front 4

What are the common sites of plaque formation in arteries?

Back 4

Branch points (carotid bifurcation), tethered sites (superficial femoral artery [SFA] in Hunter's canal in the leg)

Front 5

What must be present for a successful arterial bypass operation?

Back 5

1. Inflow (e.g. patent aorta)
2. Outflow (e.g. open distal popliteal artery)
3. Run off (e.g. patent trifurcation vessels down to the foot)

Front 6

What is the major principle of safe vascular surgery?

Back 6

Get proximal and distal control of the vessel to be worked on

Front 7

What does it mean to "POTTS" a vessel?

Back 7

Place a vessel loop twice around a vessel so that if you put tension on the vessel loop, it will occlude the vessel

Front 8

What is the suture needle orientation through graft versus diseased artery in a graft to artery anastomosis?

Back 8

Needle "in to out" of the lumen in diseased artery to help tack down the plaque and the needle "out-to-in" on the graft

Front 9

What are the layers of an artery?

Back 9

1. Intima
2. Media
3. Adventitia

Front 10

Which arteries supply the blood vessel itself?

Back 10

Vasovasorum

Front 11

What is a true aneurysm?

Back 11

Dilation (> 2X nL diameter) of all three layers of a vessel

Front 12

What is a false (pseudo) aneurysm?

Back 12

Dilation of artery not involving all three layers (e.g. hematoma with fibrous covering)
Often connects with vessel lumen and blood swirls inside to the false aneurysm

Front 13

What is "ENDOVASCULAR" repair?

Back 13

Placement of a catheter in artery and then deployment of a graft intraluminally

Front 14

How can you remember the orientation of the lower exterior arteries below the knee on A-gram?

Back 14

"L.A.M.P"
Lateral Anterior tibial
Medial Posterior tibial

Front 15

What is peripheral vascular disease (PVD)?

Back 15

Occlusive atherosclerotic disease in the lower extremities

Front 16

What is the most common site of arterial atherosclerotic occlusion in the lower extremities?

Back 16

Occlusion of the SFA in Hunter's canal

Front 17

What are the symptoms of PVD?

Back 17

Intermittent claudication, rest pain, erectile dysfunction, sensorimotor impairment, tissue loss

Front 18

What is Intermittent claudication?

Back 18

Pain, cramping, or both of the lower extremity, usually the calf muscle, after walking a specific distance, then the pain/cramping resolves after stopping for a specific amount of time while standing; this pattern is reproducible

Front 19

What is rest pain?

Back 19

Pain the foot, usually over the distal metatarsals; this pain arises at rest (classically at night, awakening the patient)

Front 20

What classically resolves rest pain?

Back 20

Hanging the foot over the side of the bed or standing; gravity affords some extra-flow to the ischemic area

Front 21

How can vascular causes of claudication be differentiated from nonvascular causes, such as neurogenic claudication or arthritis?

Back 21

History (in the vast majority of pts) and noninvasive tests; remember vascular claudication appears after a specific distance and resolves after a specific time of rest while standing (not so with most other forms of claudication)

Front 22

What is the DDx of lower extremity claudication?

Back 22

Neurogenic (e.g. nerve entrapment/discs)
Arthritis
Coarctation of the aorta
Popliteal artery syndrome
Chronic compartment syndrome
Neuromas
Anemia
Diabetic neuropathy pain

Front 23

What are the signs of PVD?

Back 23

Absent pulse, bruits, muscular atrophy, decreased hair growth, thick toenails, tissue necrosis/ulcers/infection

Front 24

What is the site of a PVD ulcer vs. a venous stasis ulcer?

Back 24

PVD arterial insufficiency uler - usually on the toes/foot
Venous stasis ulcer - medial malleolus (ankle)

Front 25

What is the ABI?

Back 25

The Ankle to Brachial Index (ABI): simply the ratio of the systolic blood pressure at the ankle to the systolic blood pressure at the arm (brachial artery) A:B; ankle pressure taken with Doppler; the ABI is noninvasive

Front 26

What ABIs are associated with normals, claudicators, and rest pain?

Back 26

Normal ABI = >1.0
Claudicator ABI = <0.6
Rest pain ABI = <0.4

Front 27

Who gets false ABI readings?

Back 27

Pts with calcified arteries, especially those with diabetes

Front 28

What are PVRs?

Back 28

Pulse Volume Recodings; pulse wave forms are recorded from lower extremities representing volume of blood per heart beat at sequential sites down leg
A large wave form means good collateral blood flow
(noninvasive using pressure cuffs)

Front 29

Prior to surgery for chronic PVD, what diagnostic test will every patient receive?

Back 29

A-gram (arteriogram: dye in vessel and x-rays) maps disease and allows for best treatment option (i.e. angioplasty vs. surgical bypass vs. endarterectomy)
Gold standard for diagnosing PVD

Front 30

What is the bedside management of a patient with PVD?

Back 30

1. Sheep skin (easy on heels)
2. Foot cradle (keeps sheets/blankets off the feet)
3. Skin lotion to avoid further cracks in the skin that can go on to form a fissure and then an ulcer

Front 31

What are the indications for surgical treatment in PVD?

Back 31

"S.T.I.R"
- Severe claudication refractory to conservative treatment that affects quality of life/livelihood (e.g. can't work b/c of the claudication)
- Tissue necrosis
- Infection
- Rest pain

Front 32

What is the treatment of claudication?

Back 32

For the vast majority, conservative treatment, including exercise, smoking cessation, treatment of HTN, diet, aspirin, with or without Trental (pentoxifylline)

Front 33

How can you remember the medical conservative treatment for claudication?

Back 33

P.A.C.E
- Pentoxifylline
- Aspirin
- Cessation of smoking
- Exercise

Front 34

How does aspirin work?

Back 34

Inhibits platelets (inhibits cyclooxygenase and platelet aggregation)

Front 35

How does Trental (pentoxifylline) work?

Back 35

Results in increased RBC deformity and flexibility

think: pentoXifylline = RBC fleXibility

Front 36

What is the risk of limb loss with claudication?

Back 36

Five percent limb loss at 5 years (think: 5 in 5), 10% at 10 years (think: 10 in 10)

Front 37

What is the risk of limb loss with rest pain?

Back 37

More than 50% of pts will have amputation of the limb at some point

Front 38

In the pt with PVD, what is the main postoperative concern?

Back 38

Cardiac status, b/c most pts with PVD have coronary artery disease; about 20% have an AAA
MI is the most common cause of postoperative death after a PVD operation

Front 39

What is Leriche's syndrome?

Back 39

Impotence, buttock claudication, and leg muscle atrophy from occlusive disease of the iliacs/distal aorta
Think: "C.I.A."
- Claudication
- Impotence
- Atrophy
(think: CIA spy Leriche)

Front 40

What are the treatment options for severe PVD?

Back 40

1. Surgical graft bypass
2. Angioplasty - balloon dilation
3. Endarterectomy - remove diseased intima and media
4. Surgical patch angioplasty (place patch over stenosis)

Front 41

What is a FEM-POP bypass?

Back 41

Bypass SFA occlusion with a graft from the femoral artery to the popliteal artery

Front 42

What is a FEM-DISTAL bypass?

Back 42

Bypass from the femoral artery to a distal artery (peroneal artery, anterior tibilal artery, or posterior tibilal artery)

Front 43

What graft material has the longest patency rate?

Back 43

Autologous vein graft

Front 44

What is an "in situ" vein graft?

Back 44

Saphrenous vein is more less left in place, all branches are ligated, and the vein valves are broken with a small hook or cut out. A vein can also be used if reversed so that the valves do not cause a problem

Front 45

What type of graft is used for above-the-knee FEM-POP bypass?

Back 45

Either vein or Gortex graft; vein still has better patency

Front 46

What type of graft is used for below-the-knee FEM-POP or FEM-DISTAL bypass?

Back 46

Must use vein graft; prostethic grafts have a prohibitive thrombosis rate

Front 47

What is DRY gangrene?

Back 47

Dry necrosis of tissue without signs of infection ("mummified tissue")

Front 48

What is WET gangrene?

Back 48

Moist necrotic tissue with signs of infection

Front 49

What is blue toe syndrome?

Back 49

Intermittent painful blue toes (or fingers) due to microemboli from a proximal arterial plaque

Front 50

What are the indications for lower extremity amputations?

Back 50

Irreversible tissue ischemia (no hope for revascularization bypass) and necrotic tissue, severe infection, severe pain with no bypassable vessels, or if pt is not interested in a bypass procedure

Front 51

What is a Ray amputation?

Back 51

Removal of toe and head of metatarsal

Front 52

What is acute arterial occlusion?

Back 52

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

Front 53

What are the classic signs/symptoms of acute arterial occlusion?

Back 53

The "six P's"
- Pain
- Paralysis
- Pallor
- Parasthesia
- Polor (Poikilothermia)
- Pulselessness

Front 54

What is the classic timing of pain with acute arterial occlusion from an embolus?

Back 54

Acute onset; the patient can classically tell you when and where it happened

Front 55

What is the immediate preoperative management of acute arterial occlusion?

Back 55

1. Anticoagulate with IV heparin (bolus followed by constant infusion)
2. A-gram

Front 56

What are the sources of emboli in acute arterial occlusion?

Back 56

1. Heart - 85% (e.g. clot from AFib, clot forming on dead muscle after MI, endocarditis, myxoma)
2. Aneurysms
3. Atheromatous plaque (atheroembolism)

Front 57

What is the most common cause of embolus from the heart in acute arterial occlusion?

Back 57

AFib

Front 58

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

Back 58

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

Front 59

What diagnostic studies are in order for acute arterial occlusion?

Back 59

1. A-gram
2. ECG (looking for MI, AFib)
3. Echocardiogram (+/-) looking for clot, MI, valve vegetation

Front 60

What is the treatment of acute arterial occlusion?

Back 60

Surgical embolectomy via cutdown and Fogarty balloon (bypass is reserved for embolectomy failure)

Front 61

What is a Fogarty?

Back 61

Fogarty balloon catheter - catheter with a balloon tip that can be inflated with saline; used for embolectomy

Front 62

How do you use a Fogarty catheter?

Back 62

Insinuate the catheter with the balloon deflated past the embolus and then inflate the balloon and pull the catheter out; the balloon brings the embolus with it

Front 63

How many mm in diameter is a 12 French Fogarty catheter?

Back 63

Simple; to get mm from French measurements, divide the French number by pi, or 3.14; thus, a 12 French catheter is 12/3 = 4 mm in diameter

Front 64

What must you look for postoperatively after reperfusion of a limb?

Back 64

Compartment syndrome, hyperkalemia, renal failure from myoglobinuria, MI

Front 65

What is compartment syndrome?

Back 65

The 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