Vascular Surgery

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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

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