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Section II General Surgery P203Surgical Recall Sixth > Vascular Surgery, C66 P489-516 > Flashcards

Vascular Surgery, C66 P489-516 Flashcards

1
Q

What is atherosclerosis?

P489

A 
Diffuse disease process in arteries;
atheromas containing cholesterol and
lipid form within the intima and inner
media, often accompanied by ulcerations
and smooth muscle hyperplasia
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2
Q

What is the common theory
of how atherosclerosis is
initiated?
P490

A

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

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3
Q

What are the risk factors for
atherosclerosis?
P490

A

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

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4
Q

What are the common sites
of plaque formation in
arteries?
P490

A 
Branch points (carotid bifurcation),
tethered sites (superficial femoral artery
[SFA] in Hunter’s canal in the leg)
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5
Q

What must be present for a
successful arterial bypass
operation?
P490

A
  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)
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6
Q

What is the major principle
of safe vascular surgery?
P90

A

Get proximal and distal control of the

vessel to be worked on!

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7
Q

What does it mean to
“POTTS” a vessel?
P490

A

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

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8
Q 
What is the suture needle
orientation through graft
versus diseased artery in a
graft to artery anastomosis?
P490
A

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

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9
Q

What are the three layers of
an artery?
P490

A
  1. Intima
  2. Media
  3. Adventitia
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10
Q

Which arteries supply the
blood vessel itself?
P490

A

Vaso vasorum

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11
Q

What is a true aneurysm?

P490

A

Dilation ( >2x nL diameter) of all three

layers of a vessel

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12
Q

What is a false aneurysm
(a.k.a pseudoaneurysm)?
P490

A

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

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13
Q

What is “ENDOVASCULAR”
repair?
P491 (picture)

A

Placement of a catheter in artery and

then deployment of a graft intraluminally

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14
Q

PERIPHERAL VASCULAR DISEASE
Define the arterial anatomy:

P491 (picture)

A
  1. Aorta
  2. Internal iliac (hypogastric)
  3. External iliac
  4. Common femoral artery
  5. Profundi femoral artery
  6. Superficial femoral artery (SFA)
  7. Popliteal artery
  8. Trifurcation
  9. Anterior tibial artery
  10. Peroneal artery
  11. Posterior tibial artery
  12. Dorsalis pedis artery
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15
Q 
PERIPHERAL VASCULAR DISEASE
How can you remember the
orientation of the lower
exterior arteries below the
knee on A-gram?
P492
A

Use the acronym “LAMP”:
Lateral Anterior tibial
Medial Posterior tibial

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16
Q

PERIPHERAL VASCULAR DISEASE
What is peripheral vascular
disease (PVD)?
P492

A

Occlusive atherosclerotic disease in the

lower extremities

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17
Q 
PERIPHERAL VASCULAR DISEASE
What is the most
common site of arterial
atherosclerotic occlusion in
the lower extremities?
P492
A

Occlusion of the SFA in Hunter’s canal

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18
Q

PERIPHERAL VASCULAR DISEASE
What are the symptoms of
PVD?
P492

A

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

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19
Q

PERIPHERAL VASCULAR DISEASE
What is intermittent
claudication?
P492

A

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

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20
Q

PERIPHERAL VASCULAR DISEASE
What is rest pain?
P492

A

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

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21
Q

PERIPHERAL VASCULAR DISEASE
What classically resolves rest
pain?
P492

A

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

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22
Q 
PERIPHERAL VASCULAR DISEASE
How can vascular causes of
claudication be differentiated
from nonvascular causes,
such as neurogenic
claudication or arthritis?
P492
A

History (in the vast majority of patients)
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)

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23
Q 
PERIPHERAL VASCULAR DISEASE
What is the differential
diagnosis of lower extremity
claudication?
P492
A 
Neurogenic (e.g., nerve entrapment/
discs), arthritis, coarctation of the aorta,
popliteal artery syndrome, chronic
compartment syndrome, neuromas,
anemia, diabetic neuropathy pain
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24
Q

PERIPHERAL VASCULAR DISEASE
What are the signs of PVD?
P493

A

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

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25
Q 
PERIPHERAL VASCULAR DISEASE
What is the site of a PVD
ulcer vs. a venous stasis
ulcer?
P493
A

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

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26
Q

PERIPHERAL VASCULAR DISEASE
What is the ABI?
P493

A

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

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27
Q 
PERIPHERAL VASCULAR DISEASE
What ABIs are associated
with normals, claudicators,
and rest pain?
P493
A

Normal ABI— ≥1.0

Claudicator ABI— <0.4

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28
Q

PERIPHERAL VASCULAR DISEASE
Who gets false ABI
readings?
P493

A

Patients with calcified arteries, especially

those with diabetes

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29
Q

PERIPHERAL VASCULAR DISEASE
What are PVRs?
P493

A 
Pulse Volume Recordings; pulse wave
    forms are recorded from lower
    extremities representing volume of
    blood per heart beat at sequential
    sites down leg
Large wave form means good collateral
    blood flow
(Noninvasive using pressure cuffs)
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30
Q 
PERIPHERAL VASCULAR DISEASE
Prior to surgery for chronic
PVD, what diagnostic test
will every patient receive?
P493
A

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

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31
Q 
PERIPHERAL VASCULAR DISEASE
What is the bedside
management of a patient
with PVD?
P493
A
  1. Sheep skin (easy on the 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
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32
Q

PERIPHERAL VASCULAR DISEASE
What are the indications for
surgical treatment in PVD?
P494

A 
Use the acronym “STIR”:
Severe claudication refractory to
    conservative treatment that affects
    quality of life/livelihood (e.g., can’t
    work because of the claudication)
Tissue necrosis
Infection
Rest pain
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33
Q

PERIPHERAL VASCULAR DISEASE
What is the treatment of
claudication?
P494

A 
For the vast majority, conservative
treatment, including exercise, smoking
cessation, treatment of HTN, diet,
aspirin, with or without Trental
(pentoxifylline)
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34
Q 
PERIPHERAL VASCULAR DISEASE
How can the medical
conservative treatment for
claudication be remembered?
P494
A 
Use the acronym “PACE”:
    Pentoxifylline
    Aspirin
    Cessation of smoking
    Exercise
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35
Q

PERIPHERAL VASCULAR DISEASE
How does aspirin work?
P494

A 
Inhibits platelets (inhibits cyclooxygenase
and platelet aggregation)
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36
Q

PERIPHERAL VASCULAR DISEASE
How does Trental®
(pentoxifylline) work?
P494

A

Results in increased RBC deformity and
flexibility (Think: pentoXifylline = RBC
fleXibility)

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37
Q

PERIPHERAL VASCULAR DISEASE
What is the risk of limb loss
with claudication?
P494

A

5% limb loss at 5 years (Think: 5 in 5),

10% at 10 years (Think: 10 in 10)

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38
Q

PERIPHERAL VASCULAR DISEASE
What is the risk of limb loss
with rest pain?
P494

A

>50% of patients will have amputation of

the limb at some point

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39
Q 
PERIPHERAL VASCULAR DISEASE
In the patient with PVD, what
is the main postoperative
concern?
P494
A 
Cardiac status, because most patients
    with PVD have coronary artery
    disease; ≈20% have an AAA
MI is the most common cause of
    postoperative death after a PVD
    operation
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40
Q

PERIPHERAL VASCULAR DISEASE
What is Leriche’s syndrome?
P495

A 
Buttock Claudication, Impotence (erectile
dysfunction), and leg muscle Atrophy
from occlusive disease of the iliacs/distal
aorta
Think: “CIA”:
    Claudication
    Impotence
    Atrophy
    (Think: CIA spy Leriche)
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41
Q

PERIPHERAL VASCULAR DISEASE
What are the treatment
options for severe PVD?
P495

A
  1. Surgical graft bypass
  2. Angioplasty—balloon dilation
  3. Endarterectomy—remove diseased
    intima and media
  4. Surgical patch angioplasty (place patch
    over stenosis)
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42
Q

PERIPHERAL VASCULAR DISEASE
What is a FEM-POP bypass?
P495 (picture)

A

Bypass SFA occlusion with a graft from the

FEMoral artery to the POPliteal artery

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43
Q

PERIPHERAL VASCULAR DISEASE
What is a FEM-DISTAL
bypass?
P496 (picture)

A 
Bypass from the FEMoral artery to a
DISTAL artery (peroneal artery, anterior
tibial artery, or posterior tibial artery)
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44
Q

PERIPHERAL VASCULAR DISEASE
What graft material has the
longest patency rate?
P496

A

Autologous vein graft

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45
Q

PERIPHERAL VASCULAR DISEASE
What is an “in situ” vein
graft?
P496

A 
Saphenous vein is more or 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
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46
Q 
PERIPHERAL VASCULAR DISEASE
What type of graft is used
for above-the-knee FEM-POP
bypass?
P496
A

Either vein or Gortex® graft; vein still has

better patency

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47
Q 
PERIPHERAL VASCULAR DISEASE
What type of graft is used
for below-the-knee FEM-POP
or FEM-DISTAL bypass?
P496
A

Must use vein graft; prosthetic grafts

have a prohibitive thrombosis rate

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48
Q

PERIPHERAL VASCULAR DISEASE
What is DRY gangrene?
P496

A

Dry necrosis of tissue without signs of

infection (“mummified tissue”)

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49
Q

PERIPHERAL VASCULAR DISEASE
What is WET gangrene?
P497

A

Moist necrotic tissue with signs of

infection

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50
Q

PERIPHERAL VASCULAR DISEASE
What is blue toe syndrome?
P497

A

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

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51
Q

LOWER EXTREMITY AMPUTATIONS
What are the indications?
P497

A

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

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52
Q

LOWER EXTREMITY AMPUTATIONS
Identify the level of the
following amputations:
P497 (picture)

A
  1. Above-the-Knee Amputation (AKA)
  2. Below-the-Knee Amputation (BKA)
  3. Symes amputation
  4. Transmetatarsal amputation
  5. Toe amputation
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53
Q

LOWER EXTREMITY AMPUTATIONS
What is a Ray amputation?
P497

A

Removal of toe and head of metatarsal

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54
Q

ACUTE ARTERIAL OCCLUSION
What is it?
P498

A

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

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55
Q 
ACUTE ARTERIAL OCCLUSION
What are the classic
signs/symptoms of acute
arterial occlusion?
P498
A 
The “six P’s”:
    Pain
    Paralysis
    Pallor
    Paresthesia
    Polar (some say Poikilothermia—you
          pick)
    Pulselessness
    (You must know these!)
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56
Q 
ACUTE ARTERIAL OCCLUSION
What is the classic timing of
pain with acute arterial
occlusion from an embolus?
P498
A

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

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57
Q

ACUTE ARTERIAL OCCLUSION
What is the immediate
preoperative management?
P498

A
  1. Anticoagulate with IV heparin (bolus
    followed by constant infusion)
  2. A-gram
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58
Q

ACUTE ARTERIAL OCCLUSION
What are the sources of
emboli?
P498

A 
1. Heart—85% (e.g., clot from AFib, clot
    forming on dead muscle after MI,
    endocarditis, myxoma)
2. Aneurysms
3. Atheromatous plaque (atheroembolism)
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59
Q 
ACUTE ARTERIAL OCCLUSION
What is the most common
cause of embolus from the
heart?
P498
A

AFib

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60
Q 
ACUTE ARTERIAL OCCLUSION
What is the most common
site of arterial occlusion by
an embolus?
P498
A

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

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61
Q

ACUTE ARTERIAL OCCLUSION
What diagnostic studies are
in order?
P498

A
  1. A-gram
  2. ECG (looking for MI, AFib)
  3. Echocardiogram ( ± ) looking for clot,
    MI, valve vegetation
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62
Q

ACUTE ARTERIAL OCCLUSION
What is the treatment?
P499

A 
Surgical embolectomy via cutdown and
Fogarty balloon (bypass is reserved for
embolectomy failure)
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63
Q

ACUTE ARTERIAL OCCLUSION
What is a Fogarty?
P499

A

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

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64
Q

ACUTE ARTERIAL OCCLUSION
How is a Fogarty catheter
used?
P499

A

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

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65
Q 
ACUTE ARTERIAL OCCLUSION
How many mm in diameter
is a 12 French Fogarty
catheter?
P499
A

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

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66
Q 
ACUTE ARTERIAL OCCLUSION
What must be looked for
postoperatively after
reperfusion of a limb?
P499
A

Compartment syndrome,
hyperkalemia, renal failure from
myoglobinuria, MI

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67
Q

ACUTE ARTERIAL OCCLUSION
What is compartment
syndrome?
P499

A

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 mm Hg

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68
Q 
ACUTE ARTERIAL OCCLUSION
What are the signs/
symptoms of compartment
syndrome?
P499
A

Classic signs include pain, especially after
passive flexing/extension of the foot,
paralysis, paresthesias, and pallor; pulses
are present in most cases because
systolic pressure is much higher than
the minimal 30 mm Hg needed for the
syndrome!

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69
Q

ACUTE ARTERIAL OCCLUSION
Can a patient have a pulse
and compartment syndrome?
P499

A

YES!

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70
Q

ACUTE ARTERIAL OCCLUSION
How is the diagnosis made?
P499

A

History/suspicion, compartment pressure

measurement

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71
Q

ACUTE ARTERIAL OCCLUSION
P500What is the treatment of
compartment syndrome?
P500

A

Treatment includes opening compartments
via bilateral calf-incision fasciotomies of
all four compartments in the calf

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72
Q

ABDOMINAL AORTIC ANEURYSMS
What is it also known as?
P500

A

AAA, or “triple A”

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73
Q

ABDOMINAL AORTIC ANEURYSMS
What is it?
P500 (picture)

A

Abnormal dilation of the abdominal aorta
( >1.5–2x normal), forming a true
aneurysm

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74
Q

ABDOMINAL AORTIC ANEURYSMS
What is the male to female
ratio?
P500

A

≈6:1

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75
Q

ABDOMINAL AORTIC ANEURYSMS
By far, who is at the highest
risk?
P500

A

White males

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76
Q

ABDOMINAL AORTIC ANEURYSMS
What is the common
etiology?
P500

A

Believed to be atherosclerotic in 95%

of cases; 5% inflammatory

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77
Q

ABDOMINAL AORTIC ANEURYSMS
What is the most common
site?
P500

A

Infrarenal (95%)

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78
Q

ABDOMINAL AORTIC ANEURYSMS
What is the incidence?
P500

A

5% of all adults older than 60 years

of age

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79
Q 
ABDOMINAL AORTIC ANEURYSMS
What percentage of patients
with AAA have a peripheral
arterial aneurysm?
P500
A

20%

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80
Q

ABDOMINAL AORTIC ANEURYSMS
What are the risk factors?
P501

A

Atherosclerosis, hypertension, smoking,
male gender, advanced age, connective
tissue disease

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81
Q

ABDOMINAL AORTIC ANEURYSMS
What are the symptoms?
P501

A 
Most AAAs are asymptomatic and
discovered during routine abdominal
exam by primary care physicians; in
the remainder, symptoms range from
vague epigastric discomfort to back and
abdominal pain
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82
Q

ABDOMINAL AORTIC ANEURYSMS
Classically, what do testicular
pain and an AAA signify?
P501

A

Retroperitoneal rupture with ureteral

stretch and referred pain to the testicle

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83
Q

ABDOMINAL AORTIC ANEURYSMS
What are the risk factors for
rupture?
P501

A

Aneurysm diameter (value + progression), HTN, symptomatic, COPD

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84
Q

ABDOMINAL AORTIC ANEURYSMS
What are the signs of
rupture?
P501

A

Classic triad of ruptured AAA:

1. Abdominal pain
2. Pulsatile abdominal mass
3. Hypotension
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85
Q

ABDOMINAL AORTIC ANEURYSMS
By how much each year do
AAAs grow?
P501

A

≈3 mm/year on average (larger AAAs

grow faster than smaller AAAs)

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86
Q 
ABDOMINAL AORTIC ANEURYSMS
Why do larger AAAs rupture
more often and grow faster
than smaller AAAs?
P501
A

Probably because of Laplace’s law

wall tension = pressure x diameter

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87
Q 
ABDOMINAL AORTIC ANEURYSMS
What is the risk of rupture
per year based on AAA
diameter size?
P501
A

<5cm = 4%
5-7cm = 7%
7 cm = 20%

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88
Q

ABDOMINAL AORTIC ANEURYSMS
What are other risks for
rupture?
P501

A

Hypertension, smoking, COPD

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89
Q

ABDOMINAL AORTIC ANEURYSMS
Where does the aorta
bifurcate?
P501

A

At the level of the umbilicus; therefore,
when palpating for an AAA, palpate
above the umbilicus and below the
xiphoid process

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90
Q

ABDOMINAL AORTIC ANEURYSMS
What is the differential
diagnosis?
P501

A

Acute pancreatitis, aortic dissection,
mesenteric ischemia, MI, perforated
ulcer, diverticulosis, renal colic, etc.

91
Q

ABDOMINAL AORTIC ANEURYSMS
What are the diagnostic
tests?
P502

A

Use U/S to follow AAA clinically; other
tests involve contrast CT scan and A-gram;
A-gram will assess lumen patency and
iliac/renal involvement

92
Q

ABDOMINAL AORTIC ANEURYSMS
What is the limitation of
A-gram?
P502

A

AAAs often have large mural thrombi,
which result in a falsely reduced diameter
because only the patent lumen is visualized

93
Q

ABDOMINAL AORTIC ANEURYSMS
What are the signs of AAA
on AXR?
P502

A

Calcification in the aneurysm wall, best
seen on lateral projection (a.k.a.
“eggshell” calcifications)

94
Q

ABDOMINAL AORTIC ANEURYSMS
What are the indications for
surgical repair of AAA?
P502

A 
AAA >5.5 cm in diameter, if the patient
is not an overwhelming high risk for
surgery; also, rupture of the AAA, any
size AAA with rapid growth, symptoms/
embolization of plaque
95
Q

ABDOMINAL AORTIC ANEURYSMS
What is the treatment?
P502 (picture)

A
  1. Prosthetic graft placement, with
    rewrapping of the native aneurysm
    adventitia around the prosthetic graft
    after the thrombus is removed; when
    rupture is strongly suspected, proceed
    to immediate laparotomy; there is
    no time for diagnostic tests!
  2. Endovascular repair
96
Q

ABDOMINAL AORTIC ANEURYSMS
What is endovascular
repair?
P502

A

Repair of the AAA by femoral catheter

placed stents

97
Q

ABDOMINAL AORTIC ANEURYSMS
Why wrap the graft in the
native aorta?
P503

A

To reduce the incidence of enterograft

fistula formation

98
Q 
ABDOMINAL AORTIC ANEURYSMS
What type of repair should
be performed with AAA and
iliacs severely occluded or
iliac aneurysm(s)?
P503
A

Aortobi-iliac or aortobifemoral graft

replacement (bifurcated graft)

99
Q 
ABDOMINAL AORTIC ANEURYSMS
What is the treatment if the
patient has abdominal pain,
pulsatile abdominal mass,
and hypotension?
P503
A

Take the patient to the O.R. for emergent

AAA repair

100
Q 
ABDOMINAL AORTIC ANEURYSMS
What is the treatment if the
patient has known AAA and
new onset of abdominal pain
or back pain?
P503
A

CT scan:
1. Leak → straight to OR
2. No leak → repair during next elective
slot

101
Q 
ABDOMINAL AORTIC ANEURYSMS
What is the mortality rate associated with the following
types of AAA treatment:
Elective?
P503
A

Good; <4% operative mortality

102
Q 
ABDOMINAL AORTIC ANEURYSMS
What is the mortality rate associated with the following
types of AAA treatment:
Ruptured?
P503
A

≈50% operative mortality

103
Q 
ABDOMINAL AORTIC ANEURYSMS
What is the leading cause
of postoperative death in a
patient undergoing elective
AAA treatment?
P503
A

Myocardial infarction (MI)

104
Q

ABDOMINAL AORTIC ANEURYSMS
What are the other
etiologies of AAA?
P503

A

Inflammatory (connective tissue
diseases), mycotic (a misnomer because
most result from bacteria, not fungi)

105
Q

ABDOMINAL AORTIC ANEURYSMS
What is the mean normal
abdominal aortic diameter?
P503

A

2 cm

106
Q

ABDOMINAL AORTIC ANEURYSMS
What are the possible
operative complications?
P503

A

MI, atheroembolism, declamping
hypotension, acute renal failure
(especially if aneurysm involves the renal
arteries), ureteral injury, hemorrhage

107
Q 
ABDOMINAL AORTIC ANEURYSMS
Why is colonic ischemia a
concern in the repair of
AAAs?
P503
A

Often the IMA is sacrificed during
surgery; if the collaterals are not adequate,
the patient will have colonic ischemia

108
Q

ABDOMINAL AORTIC ANEURYSMS
What are the signs of
colonic ischemia?
P504

A 
Heme-positive stool, or bright red blood
per rectum (BRBPR), diarrhea,
abdominal pain
109
Q 
ABDOMINAL AORTIC ANEURYSMS
What is the study of
choice to diagnose colonic
ischemia?
P504
A

Colonoscopy

110
Q

ABDOMINAL AORTIC ANEURYSMS
When is colonic ischemia
seen postoperatively?
P504

A

Usually in the first week

111
Q 
ABDOMINAL AORTIC ANEURYSMS
What is the treatment of
necrotic sigmoid colon from
colonic ischemia?
P504
A
  1. Resection of necrotic colon
  2. Hartmann’s pouch or mucous fistula
  3. End colostomy
112
Q 
ABDOMINAL AORTIC ANEURYSMS
What is the possible longterm
complication that often
presents with both upper
and lower GI bleeding?
P504
A 
Aortoenteric fistula (fistula between aorta
and duodenum)
113
Q

ABDOMINAL AORTIC ANEURYSMS
What are the other possible
postoperative complications?
P504

A

Erectile dysfunction (sympathetic plexus
injury), retrograde ejaculation, aortovenous
fistula (to IVC), graft infection, anterior
spinal syndrome

114
Q

ABDOMINAL AORTIC ANEURYSMS
What is anterior spinal
syndrome?
P504

A 
Classically:
    1. Paraplegia
    2. Loss of bladder/bowel control
    3. Loss of pain/temperature sensation
       below level of involvement
    4. Sparing of proprioception
115
Q 
ABDOMINAL AORTIC ANEURYSMS
Which artery is involved
in anterior spinal cord
syndrome?
P504
A

Artery of Adamkiewicz—supplies the

anterior spinal cord

116
Q 
ABDOMINAL AORTIC ANEURYSMS
What are the most common
bacteria involved in aortic
graft infections?
P504
A
  1. Staphylococcus aureus
  2. Staphylococcus epidermidis
    (usually late)
117
Q 
ABDOMINAL AORTIC ANEURYSMS
How is a graft infection with
an aortoenteric fistula
treated?
P504
A

Perform an extra-anatomic bypass with

resection of the graft

118
Q

ABDOMINAL AORTIC ANEURYSMS
What is an extra-anatomic
bypass graft?
P505 (picture)

A 
Axillofemoral bypass graft—graft not
in a normal vascular path; usually,
the graft goes from the axillary artery to
the femoral artery and then from one
femoral artery to the other (fem-fem
bypass)
119
Q

ABDOMINAL AORTIC ANEURYSMS
What is an endovascular
repair?
P505

A

Placement of a stent proximal and distal
to an AAA through a distant percutaneous
access (usually through the groin); less
invasive; long-term results pending

120
Q 
CLASSIC INTRAOP QUESTIONS DURING
AAA REPAIR
Which vein crosses the neck
of the AAA proximally?
P505
A

Renal vein (left)

121
Q 
CLASSIC INTRAOP QUESTIONS DURING
AAA REPAIR
What part of the small
bowel crosses in front of
the AAA?
P505
A

Duodenum

122
Q 
CLASSIC INTRAOP QUESTIONS DURING
AAA REPAIR
Which large vein runs to the
left of the AAA?
P505
A

IMV

123
Q 
CLASSIC INTRAOP QUESTIONS DURING
AAA REPAIR
Which artery comes off the
middle of the AAA and runs
to the left?
P505
A

IMA

124
Q 
CLASSIC INTRAOP QUESTIONS DURING
AAA REPAIR
Which vein runs behind the
RIGHT common iliac artery?
P506
A

LEFT common iliac vein

125
Q

CLASSIC INTRAOP QUESTIONS DURING
AAA REPAIR
Which renal vein is longer?
P506

A

Left

126
Q

MESENTERIC ISCHEMIA
CHRONIC MESENTERIC ISCHEMIA
What is it?
P506

A 
Chronic intestinal ischemia from
long-term occlusion of the intestinal
arteries; most commonly results from
atherosclerosis; usually in two or more
arteries because of the extensive
collaterals
127
Q

MESENTERIC ISCHEMIA
CHRONIC MESENTERIC ISCHEMIA
What are the symptoms?
P506

A

Weight loss, postprandial abdominal
pain, anxiety/fear of food because of
postprandial pain, ± heme occult,
± diarrhea/vomiting

128
Q

MESENTERIC ISCHEMIA
CHRONIC MESENTERIC ISCHEMIA
What is “intestinal angina”?
P506

A

Postprandial pain from gut ischemia

129
Q

MESENTERIC ISCHEMIA
CHRONIC MESENTERIC ISCHEMIA
What are the signs?
P506

A

Abdominal bruit is commonly heard

130
Q

MESENTERIC ISCHEMIA
CHRONIC MESENTERIC ISCHEMIA
How is the diagnosis made?
P506

A

A-gram, duplex, MRA

131
Q 
MESENTERIC ISCHEMIA
CHRONIC MESENTERIC ISCHEMIA
What supplies blood to the
gut?
P506
A
  1. Celiac axis vessels
  2. SMA
  3. IMA
132
Q 
MESENTERIC ISCHEMIA
CHRONIC MESENTERIC ISCHEMIA
What is the classic finding
on A-gram?
P506
A

Two of the three mesenteric arteries are
occluded, and there is atherosclerotic
narrowing of the third patent artery

133
Q 
MESENTERIC ISCHEMIA
CHRONIC MESENTERIC ISCHEMIA
What are the treatment
options?
P506
A

Bypass, endarterectomy, angioplasty,

stenting

134
Q

MESENTERIC ISCHEMIA
ACUTE MESENTERIC ISCHEMIA
What is it?
P506

A

Acute onset of intestinal ischemia

135
Q

MESENTERIC ISCHEMIA
ACUTE MESENTERIC ISCHEMIA
What are the causes?
P506

A
  1. Emboli to a mesenteric vessel from
    the heart
  2. Acute thrombosis of long-standing
    atherosclerosis of mesenteric artery
136
Q 
MESENTERIC ISCHEMIA
ACUTE MESENTERIC ISCHEMIA
What are the causes of
emboli from the heart?
P507
A

AFib, MI, cardiomyopathy, valve disease/

endocarditis, mechanical heart valve

137
Q 
MESENTERIC ISCHEMIA
ACUTE MESENTERIC ISCHEMIA
What drug has been
associated with acute
intestinal ischemia?
P507
A

Digitalis

138
Q 
MESENTERIC ISCHEMIA
ACUTE MESENTERIC ISCHEMIA
To which intestinal artery do
emboli preferentially go?
P507
A

Superior Mesenteric Artery (SMA)

139
Q 
MESENTERIC ISCHEMIA
ACUTE MESENTERIC ISCHEMIA
What are the signs/
symptoms of acute
mesenteric ischemia?
P507
A

Severe pain—classically “pain out of
proportion to physical exam,” no
peritoneal signs until necrosis, vomiting/
diarrhea/hyperdefecation, ± heme stools

140
Q 
MESENTERIC ISCHEMIA
ACUTE MESENTERIC ISCHEMIA
What is the classic triad of
acute mesenteric ischemia?
P507
A
  1. Acute onset of pain
  2. Vomiting, diarrhea, or both
  3. History of AFib or heart disease
141
Q 
MESENTERIC ISCHEMIA
ACUTE MESENTERIC ISCHEMIA
What is the gold standard
diagnostic test?
P507
A

Mesenteric A-gram

142
Q 
MESENTERIC ISCHEMIA
ACUTE MESENTERIC ISCHEMIA
What is the treatment of a
mesenteric embolus?
P507
A 
Perform Fogarty catheter embolectomy,
resect obviously necrotic intestine, and
leave marginal looking bowel until a
“second look” laparotomy is performed
24 to 72 hours postoperatively
143
Q 
MESENTERIC ISCHEMIA
ACUTE MESENTERIC ISCHEMIA
What is the treatment of
acute thrombosis?
P507
A 
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
144
Q

MEDIAN ARCUATE LIGAMENT SYNDROME
What is it?
P507

A

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

145
Q

MEDIAN ARCUATE LIGAMENT SYNDROME
What is the median arcuate
ligament comprised of?
P507

A

Diaphragm hiatus fibers

146
Q

MEDIAN ARCUATE LIGAMENT SYNDROME
What are the symptoms?
P508

A

Postprandial pain, weight loss

147
Q

MEDIAN ARCUATE LIGAMENT SYNDROME
What are the signs?
P508

A

Abdominal bruit in almost all patients

148
Q

MEDIAN ARCUATE LIGAMENT SYNDROME
How is the diagnosis made?
P508

A

A-gram

149
Q

MEDIAN ARCUATE LIGAMENT SYNDROME
What is the treatment?
P508

A

Release arcuate ligament surgically

150
Q 
CAROTID VASCULAR DISEASE 
ANATOMY
Identify the following
structures:
P508 (picture)
A
  1. Internal carotid artery
  2. External carotid artery
  3. Carotid “bulb”
  4. Superior thyroid artery
  5. Common carotid artery
    (Shaded area: common site of plaque
    formation)
151
Q 
CAROTID VASCULAR DISEASE 
ANATOMY
What are the signs/
symptoms?
P508
A

Amaurosis fugax, TIA, RIND, CVA

152
Q 
CAROTID VASCULAR DISEASE 
ANATOMY
Define the following terms:
Amaurosis fugax
P508
A

Temporary monocular blindness (“curtain
coming down”): seen with microemboli
to retina; example of TIA

153
Q 
CAROTID VASCULAR DISEASE 
ANATOMY
Define the following terms:
TIA
P508
A

Transient Ischemic Attack: focal
neurologic deficit with resolution of all
symptoms within 24 hours

154
Q 
CAROTID VASCULAR DISEASE 
ANATOMY
Define the following terms:
RIND
P509
A

Reversible Ischemic Neurologic Deficit:
transient neurologic impairment (without
any lasting sequelae) lasting 24 to 72 hours

155
Q 
CAROTID VASCULAR DISEASE 
ANATOMY
Define the following terms:
CVA
P509
A 
CerebroVascular Accident (stroke):
neurologic deficit with permanent brain
damage
156
Q 
CAROTID VASCULAR DISEASE 
ANATOMY
What is the risk of a CVA in
patients with TIA?
P509
A

≈10% a year

157
Q 
CAROTID VASCULAR DISEASE 
ANATOMY
What is the noninvasive
method of evaluating carotid
disease?
P509
A

Carotid ultrasound/Doppler: gives

general location and degree of stenosis

158
Q 
CAROTID VASCULAR DISEASE 
ANATOMY
What is the gold standard
invasive method of
evaluating carotid disease?
P509
A

A-gram

159
Q 
CAROTID VASCULAR DISEASE 
ANATOMY
What is the surgical
treatment of carotid
stenosis?
P509
A

Carotid EndArterectomy (CEA): the
removal of the diseased intima and media
of the carotid artery, often performed
with a shunt in place

160
Q 
CAROTID VASCULAR DISEASE 
ANATOMY
What are the indications for
CEA in the ASYMPTOMATIC
patient?
P509
A

Carotid artery stenosis 60% (greatest
benefit is probably in patients with >80%
stenosis)

161
Q 
CAROTID VASCULAR DISEASE 
ANATOMY
What are the indications for
CEA in the SYMPTOMATIC
(CVA, TIA, RIND) patient?
P509
A

Carotid stenosis >50%

162
Q 
CAROTID VASCULAR DISEASE 
ANATOMY
Before performing a CEA in
the symptomatic patient, what
study other than the A-gram
should be performed?
P509
A

Head CT

163
Q 
CAROTID VASCULAR DISEASE 
ANATOMY
In bilateral high-grade carotid
stenosis, on which side should
the CEA be performed in the
asymptomatic, right-handed
patient?
P509
A

Left CEA first, to protect the dominant

hemisphere and speech center

164
Q 
CAROTID VASCULAR DISEASE 
ANATOMY
What is the dreaded
complication after a CEA?
P509
A

Stroke (CVA)

165
Q 
CAROTID VASCULAR DISEASE 
ANATOMY
What are the possible
postoperative complications
after a CEA?
P510
A

CVA, MI, hematoma, wound infection,
hemorrhage, hypotension/hypertension,
thrombosis, vagus nerve injury (change in
voice), hypoglossal nerve injury (tongue
deviation toward side of injury—“wheelbarrow”
effect), intracranial hemorrhage

166
Q 
CAROTID VASCULAR DISEASE 
ANATOMY
What is the mortality rate
after CEA?
P510
A

≈1%

167
Q 
CAROTID VASCULAR DISEASE 
ANATOMY
What is the perioperative
stroke rate after CEA?
P510
A

Between 1% (asymptomatic patient) and

5% (symptomatic patient)

168
Q 
CAROTID VASCULAR DISEASE 
ANATOMY
What is the postoperative
medication?
P510
A

Aspirin (inhibits platelets by inhibiting

cyclo-oxygenase)

169
Q 
CAROTID VASCULAR DISEASE 
ANATOMY
What is the most common
cause of death during the
early postoperative period
after a CEA?
P510
A

MI

170
Q 
CAROTID VASCULAR DISEASE 
ANATOMY
Define “Hollenhorst
plaque”?
P510
A

Microemboli to retinal arterioles seen as

bright defects

171
Q

CLASSIC CEA INTRAOP QUESTIONS
What thin muscle is cut right
under the skin in the neck?
P510

A

Platysma muscle

172
Q 
CLASSIC CEA INTRAOP QUESTIONS
What are the extracranial
branches of the internal
carotid artery?
P510
A

None

173
Q

CLASSIC CEA INTRAOP QUESTIONS
Which vein crosses the
carotid bifurcation?
P510

A

Facial vein

174
Q

CLASSIC CEA INTRAOP QUESTIONS
What is the first branch of
the external carotid?
P510

A

Superior thyroidal artery

175
Q

CLASSIC CEA INTRAOP QUESTIONS
Which muscle crosses the
common carotid proximally?
P510

A

Omohyoid muscle

176
Q

CLASSIC CEA INTRAOP QUESTIONS
Which muscle crosses the
carotid artery distally?
P510

A

Digastric muscle

Think: Digastric = Distal

177
Q 
CLASSIC CEA INTRAOP QUESTIONS
Which nerve crosses
approximately 1 cm distal to
the carotid bifurcation?
P511
A

Hypoglossal nerve; cut it and the tongue
will deviate toward the side of the injury
(the “wheelbarrow effect”)

178
Q

CLASSIC CEA INTRAOP QUESTIONS
Which nerve crosses the
internal carotid near the ear?
P511

A

Facial nerve (marginal branch)

179
Q

CLASSIC CEA INTRAOP QUESTIONS
What is in the carotid sheath?
P511

A
  1. Carotid artery
  2. Internal jugular vein
  3. Vagus nerve (lies posteriorly in 98%
    of patients and anteriorly in 2%)
  4. Deep cervical lymph nodes
180
Q

SUBCLAVIAN STEAL SYNDROME
What is it?
P511 (picture)

A

Arm fatigue and vertebrobasilar
insufficiency from obstruction of the left
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

181
Q

SUBCLAVIAN STEAL SYNDROME
Which artery is most
commonly occluded?
P512

A

Left subclavian

182
Q

SUBCLAVIAN STEAL SYNDROME
What are the symptoms?
P512

A

Upper extremity claudication, syncopal
attacks, vertigo, confusion, dysarthria,
blindness, ataxia

183
Q

SUBCLAVIAN STEAL SYNDROME
What are the signs?
P512

A

Upper extremity blood pressure
discrepancy, bruit (above the clavicle),
vertebrobasilar insufficiency

184
Q

SUBCLAVIAN STEAL SYNDROME
What is the treatment?
P512

A

Surgical bypass or endovascular stent

185
Q

RENAL ARTERY STENOSIS
What is it?
P512

A

Stenosis of renal artery, resulting in
decreased perfusion of the juxtaglomerular
apparatus and subsequent activation of the
renin-angiotensin-aldosterone system (i.e.,
hypertension from renal artery stenosis)

186
Q

RENAL ARTERY STENOSIS
What is the incidence?
P512

A 
≈10% to 15% of the U.S. population have
    HTN; of these, ≈4% have potentially
    correctable renovascular HTN
Also note that 30% of malignant HTN
    have a renovascular etiology
187
Q

RENAL ARTERY STENOSIS
What is the etiology of the
stenosis?
P512

A 
≈66% result from atherosclerosis
(men > women), ≈33% result from
fibromuscular dysplasia (women >
men, average age 40 years, and 50%
with bilateral disease)
Note: Another rare cause is hypoplasia of
the renal artery
188
Q 
RENAL ARTERY STENOSIS
What is the classic profile of
a patient with renal artery
stenosis from fibromuscular
dysplasia?
P512
A

Young woman with hypertension

189
Q

RENAL ARTERY STENOSIS
What are the associated
risks/clues?
P512

A

Family history, early onset of HTN, HTN

refractory to medical treatment

190
Q

RENAL ARTERY STENOSIS
What are the signs/
symptoms?
P513

A

Most patients are asymptomatic but may
have headache, diastolic HTN, flank
bruits (present in 50%), and decreased
renal function

191
Q

RENAL ARTERY STENOSIS
What are the diagnostic tests?
A-gram
P513

A

Maps artery and extent of stenosis (gold

standard)

192
Q

RENAL ARTERY STENOSIS
What are the diagnostic tests?
IVP
P513

A

80% of patients have delayed nephrogram

phase (i.e., delayed filling of contrast)

193
Q 
RENAL ARTERY STENOSIS
What are the diagnostic tests?
Renal vein renin ratio
(RVRR)
P513
A

If sampling of renal vein renin levels
shows ratio between the two kidneys
≥1.5, then diagnostic for a unilateral
stenosis

194
Q

RENAL ARTERY STENOSIS
What are the diagnostic tests?
Captopril provocation test
P513

A

Will show a drop in BP

195
Q

RENAL ARTERY STENOSIS
Are renin levels in serum
ALWAYS elevated?
P513

A 
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
196
Q

RENAL ARTERY STENOSIS
What is the invasive
nonsurgical treatment?
P513

A

Percutaneous Renal Transluminal
Angioplasty (PRTA)/stenting:
With FM dysplasia: use PRTA
With atherosclerosis: use PRTA/stent

197
Q

RENAL ARTERY STENOSIS
What is the surgical
treatment?
P513

A

Resection, bypass, vein/graft

interposition, or endarterectomy

198
Q 
RENAL ARTERY STENOSIS
What antihypertensive
medication is
CONTRAINDICATED in
patients with hypertension
from renovascular stenosis?
P513
A 
ACE inhibitors (result in renal
insufficiency)
199
Q

SPLENIC ARTERY ANEURYSM
What are the causes?
P513

A

Women—medial dysplasia

Men—atherosclerosis

200
Q

RENAL ARTERY STENOSIS
How is the diagnosis made?
P514

A

Usually by abdominal pain → U/S or CT
scan, in the O.R. after rupture, or
incidentally by eggshell calcifications
seen on AXR

201
Q

RENAL ARTERY STENOSIS
What is the risk factor for
rupture?
P514

A

Pregnancy

202
Q 
RENAL ARTERY STENOSIS
What are the indications for
splenic artery aneurysm
removal?
P514
A

Pregnancy, >2 cm in diameter, symptoms,

and in women of childbearing age

203
Q

RENAL ARTERY STENOSIS
What is the treatment for
splenic aneurysm?
P514

A

Resection or percutaneous catheter
embolization in high-risk (e.g., portal
hypertension) patients

204
Q

POPLITEAL ARTERY ANEURYSM
What is it?
P514

A

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

205
Q

POPLITEAL ARTERY ANEURYSM
How is the diagnosis made?
P514

A

Usually by physical exam → A-gram, U/S

206
Q 
POPLITEAL ARTERY ANEURYSM
Why examine the
contralateral popliteal
artery?
P514
A

50% of all patients with a popliteal artery
aneurysm have a popliteal artery aneurysm
in the contralateral popliteal artery

207
Q 
POPLITEAL ARTERY ANEURYSM
What are the indications for
elective surgical repair of a
popliteal aneurysm?
P514
A
  1. ≥2 cm in diameter
  2. Intraluminal thrombus
  3. Artery deformation
208
Q 
POPLITEAL ARTERY ANEURYSM
Why examine the rest of the
arterial tree (especially the
abdominal aorta)?
P514
A 
75% of all patients with popliteal
aneurysms have additional
aneurysms elsewhere; >50% of
these are located in the abdominal
aorta/iliacs
209
Q

POPLITEAL ARTERY ANEURYSM
What size of the following aneurysms are usually
considered indications for surgical repair:
Thoracic aorta?
P514

A

> 6.5 cm

210
Q

POPLITEAL ARTERY ANEURYSM
What size of the following aneurysms are usually
considered indications for surgical repair:
Abdominal aorta?
P514

A

>5.5 cm

211
Q

POPLITEAL ARTERY ANEURYSM
What size of the following aneurysms are usually
considered indications for surgical repair:
Iliac artery?
P515

A

> 4 cm

212
Q

POPLITEAL ARTERY ANEURYSM
What size of the following aneurysms are usually
considered indications for surgical repair:
Femoral artery?
P515

A

>2.5 cm

213
Q

POPLITEAL ARTERY ANEURYSM
What size of the following aneurysms are usually
considered indications for surgical repair:
Popliteal artery?
P515

A

>2 cm

214
Q

MISCELLANEOUS
Define the following terms:
“Milk leg”
P515

A 
A.k.a. phlegmasia alba dolens (alba 
white): often seen in pregnant women
with occlusion of iliac vein resulting
from extrinsic compression by the uterus
(thus, the leg is “white” because of
subcutaneous edema)
215
Q 
MISCELLANEOUS
Define the following terms:
Phlegmasia cerulea
dolens
P515
A 
In comparison, 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
216
Q

MISCELLANEOUS
Define the following terms:
Raynaud’s phenomenon
P515

A

Vasospasm of digital arteries with color
changes of the digits; usually initiated
by cold/emotion
White (spasm), then blue (cyanosis), then
red (hyperemia)

217
Q

MISCELLANEOUS
Define the following terms:
Takayasu’s arteritis
P515

A

Arteritis of the aorta and aortic branches,
resulting in stenosis/occlusion/
aneurysms
Seen mostly in women

218
Q

MISCELLANEOUS
Define the following terms:
Buerger’s disease
P515

A 
A.k.a. thromboangiitis obliterans:
occlusion of the small vessels of the
hands and feet; seen in young men
who smoke; often results in digital
gangrene → amputations
219
Q

MISCELLANEOUS
What is the treatment for
Buerger’s disease?
P515

A

Smoking cessation, +/– sympathectomy

220
Q

MISCELLANEOUS
What is blue toe syndrome?
P515

A

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

221
Q

MISCELLANEOUS
What is a “paradoxical
embolus”?
P516

A 
Venous embolus gains access to the left
heart after going through an intracardiac
defect, most commonly a patent foramen
ovale, and then lodges in a peripheral
artery
222
Q

MISCELLANEOUS
What size iliac aneurysm
should be repaired?
P516

A

> 4 cm diameter

223
Q

MISCELLANEOUS
What is Behçet’s disease?
P516

A

Genetic disease with aneurysms from loss
of vaso vasorum; seen with oral, ocular, and
genital ulcers/inflammation (↑ incidence in
Japan, Mediterranean)

Section II General Surgery P203Surgical Recall Sixth (33 decks)

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