1
Q
What structure commonly overlies the carotid artery bifurcation?
A
the facial vein
2
Q
What is the first branch off the external carotid artery? First branch of the internal carotid?
A
- external: the superior thyroid artery
- internal: ophthalmic
3
Q
A patient has hoarseness after carotid endarterectomy. What structure was likely injured and how?
A
the vagus from a clamp on the carotid that accidentally included it
4
Q
A patient has tongue deviation toward the side of a carotid endarterectomy. Was structure was injured?
A
the hypoglossal nerve which lies just cephalic to the carotid bifurcation
5
Q
A patient has ipsilateral mouth droop after a carotid endarterectomy, what structure was likely injured?
A
the marginal mandibular from retraction on the mandible
6
Q
Which nerve lies deep to the posterior belly of the digastric and can be injured during carotid endarterectomy? What is the deficit?
A
- the glossopharyngeal
- leads to disabling dysphagia
7
Q
What are the four nerves at risk during carotid endarterectomy, how are they injured, what is the deficit?
A
- vagus; included in the carotid clamp; hoarseness
- marginal mandibular; due to mandibular retraction; ipsilateral mouth droop
- glossophargyneal; dissection; dysphagia
- hypoglossal; dissection; ipsilateral tongue deviation
8
Q
Which layers are removed during endarterectomy?
A
the intima and part of the media
9
Q
What are the indications for carotid endarterectomy?
A
- symptomatic stenosis > 50%
- asymptomatic stenosis > 70% (EDV > 100cm/s)
10
Q
What is included in medical management for peripheral vascular disease?
A
- aspirin
- high dose statin (40mg lipitor daily)
- smoking cessation
- blood pressure control
- glycemic control
11
Q
A patient presents with 100% carotid occlusion and stroke, what is the appropriate management?
A
medical therapy given the risk of hemorrhagic conversion with recannulation
12
Q
In what situation is emergent carotid endarterectomy indicated?
A
crescendo TIAs that are more frequent, more severe, or longer lasting
13
Q
What is the most common non-stroke cause of morbidity and mortality following carotid endarterectomy?
A
myocardial infarction, highlighting the importance of cardiac workup prior to CEA
14
Q
When should you operate on a patient who recently had a stoke from carotid stenosis?
A
- between 2 days and 2 weeks if it was a small stroke or TIA, once they’ve returned to normal
- 6-8 weeks if it was a hemorrhagic stroke
15
Q
How should you assess cerebral perfusion during carotid endarterectomy? What are the options and what should you do if there is concern for diminished perfusion?
A
- options for monitoring: awake surgery, check ICA stump pressure (okay if >40-50mmHg), EEG monitoring, cerebral oximetry
- in all cases, check your monitoring after clamping, if okay then you can proceed
- if there are deficits then you need to shunt the carotid during surgery to maintain perfusion
16
Q
What is cerebral hyper-perfusion syndrome? How is it worked up and how is it treated?
A
- a syndrome seen after carotid endarterectomy in those with severe stenosis who have impaired cerebral vascular autoregulation
- presents with headaches and hypertension but normal neurological exam
- get a CT head to rule out acute infarct
- then admit to the ICU for monitoring, blood pressure control, and seizure prophylaxis
17
Q
A patient is in PACU after carotid endarterectomy. They have stroke symptoms. What is the next step?
A
- duplex in PACU
- if ICA is patent, go to CT and look for distal emboli or watershed infarct
- if ICA is thromboses, go to OR for thrombectomy and replace patch with saphenous vein
18
Q
When should you consider carotid stenting/TCAR rather than endarterectomy?
A
in general: patients with multiple co-morbidities, prior neck radiation or surgery, recurrent disease, inability to sew in a patch
- age > 75
- 2 vessel coronary disease with angina
- unstable angina
- CHF class III or IV
- LVEF < 30%
- MI < 6 weeks prior to procedure
- contralateral recurrent laryngeal nerve injury
- ESRD
- need for major operation within 30 days
19
Q
A young patient presents with TIA and CTA neck shows a beads on a string appearance of the internal carotid. What is the diagnosis?
A
fibromuscular dysplasia, should also work-up disease of the renal vasculature and treat with anti-platelet medications
20
Q
Name the structures of the thoracic outlet from anterior to posterior.
A
- subclavian vein
- phrenic nerve
- anterior scalene
- subclavian artery
- brachial plexus
- middle scalene
- first rib
21
Q
Describe the presentation and management of neurogenic thoracic outlet syndrome.
A
- present with pain, weakness, numbness, and tingling in the hand, particularly in the ulnar distribution
- symptoms are exacerbated by elevation of the arm
- treated with physical therapy as first line
- second line is diagnostic/therapeutic scalene block
- if they respond, perform first rib resection, scalenectomy with neurolysis
22
Q
How will venous thoracic outlet syndrome present? How is it managed?
A
- presents with a blue, swollen arm in a young, athletic individual
- treat with catheter directed thrombolysis followed by first rib resection during that hospitalization
23
Q
How does arterial thoracic outlet syndrome present? What is the pathophysiology? How is it managed?
A
- presents with ischemia of the hand in a young person with no risk factors
- due to anomalous cervical rib compressing the subclavian, which produces an aneurysm, which produces emboli
- treat with anticoagulation and first rib resection with interposition graft for the artery
24
Q
Describe the pathophysiology and management of subclavian steal syndrome.
A
- a stenosis or occlusion of the proximal subclavian artery results in reversal of blood flow in the vertebral when the extremity is exerted, stealing cerebral perfusion
- treat with endovascular recanalization versus carotid-subclavian bypass
25
What should you consider when placing a temporary line for dialysis access?
put it on the side that you're not planning a fistula given that temporary access catheters carry a risk of central venous stenosis and failure of permanent access
26
What are you looking for on pre-operative vein mapping? What are the principles for selecting your location for vascular access?
- need a vein that is 3mm
- need an artery that is 2mm with triphasic flow
- start in the upper extremity before lower
- start distal before proximal
- start in the non-dominant hand before the dominant
27
What is the most common reason for AV fistula failure? How does this present, how is it diagnosed, and how is it managed?
- venous outflow problems are most common
- present with high venous return pressures and increased bleeding after dialysis
- diagnose with duplex ultrasound
- treat with fistulagram and venoplasty
28
What criteria do fistulas need to meet to be usable?
- vein > 6mm
- vein < 6mm from surface
- flow > 600mL/min
29
How does steal syndrome present after fistula creation? How is it diagnosed and treated?
- it is diversion of arterial flow into the fistula causing distal ischemia
- confirm diagnosis with waveform flow analysis of the digits with and without compression of the fistula; 50% improvement with compression confirms steal syndrome
- if mild symptoms (occasional pain or coolness) can observe
- if severe symptoms (tissue loss, constant pain) require surgical intervention (fistula ligation, banding, distal revascularization and interval ligation, proximalization of inflow)
30
How should you manage a bleeding fistula?
- pinpoint bleeding can be managed with a stitch and urgent fistulagram
- bleeding from an ulcer is a surgical emergency and requires excision/ligation
31
What is distal revascularization and interval ligation for steal syndrome?
- placement of arterial bypass beginning proximal to AVF to the distal artery
- ligation of the arterial segment between the AVF and the distal bypass implantation
32
When should you consider fasciotomies?
after four hours of limb ischemia
33
During a lateral incision for fasciotomy, what nerve is at risk and what would the deficit be?
- superficial peroneal nerve
- see difficulties with foot eversion
34
How do you release the deep posterior compartment during a lower leg fasciotomy?
take the soles off the tibia
35
What are the size criteria for treating descending thoracic aortic aneurysms?
> 5.5cm for endovascular repair
> 6.5cm for open repair
36
What is the feared complication of thoracic aortic aneurysm repair? How is it treated?
- paraplegia
- treated with lumbar drain and targeted spinal perfusion pressure goals
37
What differentiates a type A from a type B thoracic aortic aneurysm?
- type A are proximal to the left subclavian
- type B are distal to the left subclavian
38
Which types of thoracic aortic aneurysm is a surgical emergency?
- type A given the risk of cardiac tamponade
- type B if ruptured or with signs of malperfusion/ischemia
39
How do you get open access to the SMA?
- lift the transverse colon cephalad
- the SMA is just to the right of the ligament of Treitz
- mobilize the LOT to access the ostium of the SMA
40
What is the typical and rescue treatment for venous mesenteric ischemia?
- typical is systemic anti-coagulation
- rescue is TIPS and then instillation of a lytic catheter via the IJ
41
How do you get supra celiac aortic control quickly?
- incise the gastrohepatic ligament
- identify the aorta beneath the diaphragmatic crus
- compress it against the spine
42
What is the treatment of choice for carotid and renal fibromuscular dysplasia?
- anti-platelet agent for carotid
- angioplasty for renal
43
Which splenic artery aneurysms should be treated?
- over 3cm
- women of child bearing age
- ruptured
44
Which hepatic artery aneurysms should be treated and how?
- treat those > 2cm
- treat with resection and reconstruction
45
Which SMA aneurysms should be treated and how?
- treat all of these
- treat with resection and reconstruction
46
What are the size criteria for treating the following aneurysms:
- popliteal
- femoral
- iliac
- aortic
- popliteal > 2cm
- femoral > 2.5cm
- iliac > 3.5cm
- aortic > 5.5cm for men or > 5cm for women
47
Which popliteal artery aneurysms should be treated? What else should the workup include?
- treat if > 2cm, have significant mural thrombus, or are symptomatic
- must also screen for AAA
48
What are the indications for AAA repair?
- male > 5cm
- female > 5.5cm
- growth > 0.5cm in 6 months
- growth > 1cm in a year
- symptoamtic/infected
49
Which patients should be considered for open AAA repair?
- young patients with good cardiopulmonary reserve
- those with small iliacs that would make endovascular access difficult
- those with complex anatomy (e.g. pararenal disease)
50
When should you re-implant the IMA during open AAA repair?
- marginal back bleeding
- dusky appearing colon
- prior colon surgery
51
What vein is at risk when clamping the proximal aorta during AAA repair?
the retro-aortic left renal vein
52
How is a chyle leak treated?
a low fat, high protein diet with MCFA supplementation
53
What is the recommended surveillance interval for those with an AAA?
- yearly for 4-4.9cm
- every 6 months if >5cm
54
What is the treatment of choice for an infra-renal aortic graft infection?
ax to bi-fem bypass with aortic graft excision
55
What is the diagnosis for someone who is year out from open AAA repair and now has hypotension and hematemesis?
- aorta-enteric fistula
- can temporize with endovascular coverage
- will need aortic resection, extra-anatomic bypass, and repair of duodenum
56
How do you decide between an end-to-end or an end-to-side AAA repair?
- must maintain perfusion to at least one internal iliac
- so if external iliacs are patent, can perform end-to-end
- if external iliacs are not, need to perform end-to-side
57
How do you tunnel an aorta-bifem bypass relative to the ureters?
- tunnel under the ureters to prevent hydronephrosis
- tunnel directly over the native artery
58
What criteria are needed to perform an EVAR?
- neck diameter less than 32mm
- neck length at least 10mm
- neck angle less than 60 degrees
- iliac diameter of at least 7mm
- iliac length at least 10mm
59
What are the types of endoleaks and how are they managed?
- type Ia: proximal seal leak, requires cuff placement
- type Ib: distal seal leak, requires cuff placement
- type II: lumbar arteries or IMA, embolism if growing
- type III: junction leak, must reinforce
- type IV: porous material or tear, reline
60
How do you calculate an ABI? How is this interpreted?
- divide the highest pedal pressure by the highest brachial pressure
- > 0.9 is normal
- < 0.9 may have claudication
- < 0.5 may have rest pain
- < 0.3 may have tissue loss
61
How do you council patients on exercise therapy for claudication?
- tell patients wo walk until they experience pain
- continue walking through the pain for a moderate distance
62
What are the indications for vascular intervention for lower extremity PAD?
- lifestyle limiting claudication
- tissue loss
- rest pain
63
Why is the CFA rarely repaired endovascularly?
- it is prone to kinking
- it is easily accessed in open fashion
64
Which peripheral arterial lesions are well suited to endovascular intervention?
short lesions with minimal calcifications
65
A patient presents with classic symptoms of claudication but normal ABIs, what should your next step in workup be?
check exercise ABIs, iliac disease often has normal ABIs at rest due to collateralization but will drop significantly during exertion
66
Describe lower extremity angiogram anatomy.
- anterior tibial branches first
- then TP trunk
- the peroneal then courses posterior to the fibula
- the PT travels behind the tibia
67
What does the deep posterior compartment of the leg contain? What about the anterior?
- the posterior tibial neuromuscular bundle and peroneal artery
- the anterior tibial artery
68
Which should come first, debridement or revascularization for chronic tissue loss? With acute infection?
- for chronic get an angiogram and maximize perfusion before definitive debridement
- for acute infection, control this first and then perform revascularization
69
How do you operatively approach the right CIV?
with division of the overlying right iliac artery
70
When ligating a major vein, consider what adjunct?
fasciotomies
71
Which renal vein can be divided?
the left if it is central to a patent gonadal vein
72
How do you treat deep venous reflux?
compression and elevation, cannot ablate these
73
What defines saphenous vein reflux?
greater than 500ms
74
Where can you perform saphenous heat ablation?
- only above the knee
- below the knee risks saphenous nerve injury
- below the knee you should use a glue or sclerosant
75
How far from the saphenofemoral junction should you begin your ablation?
2-3cm
76
What is the management of exothermal heat induced thrombosis of the saphenofemoral junction?
- if there is thrombus in the CFV, 3 months AC
- if thrombus is flush with the CFV, short course AC until resolved
- if thrombus is within 2cm of CFV, serial US every 1-2 weeks
77
A swollen, blue leg with intact motor and sensation is suggestive of what diagnosis? What is the treatment?
- suggests iliofemoral DVT causing phlegmasia
- treat with catheter directed thrombolsis
78
Where in the IVC is a filter placed?
caudal to the renal veins
79
What pre-operative imaging should be obtained for a carotid endarterectomy?
would get a duplex US to make the diagnosis and CTA neck to evaluate extent of lesion and cerebral perfusion anatomy
80
What defines 50% to 70% internal carotid artery stenosis on duplex US?
- PSV: 125-230
- EDV: 40-100
- ICA/CCA PSV Ratio: 2.0-4.0
81
What can be done to get better exposure to the distal ICA during endarterectomy?
- nasotracheal intubation with mandibular subluxation
- division of the digastric, hypoglossal nerve medialization, styloglossus and stylopharyngeus division, styloid process excision
82
Describe carotid endarterectomy.
- positioning with arterial blood pressure monitoring and cerebral perfusion monitoring
- incision over the carotid bifurcation, retract the SCM laterally, enter the carotid sheath, divide the facial nerve
- minimize carotid manipulation during dissection
- heparinize the patient, test clamp the ICA and decide if shunting is needed
- clamp the ICA, CCA, and ECA and make a longitudinal arteriotomy
- start the endarterectomy and remove any debris
- place any tacking sutures needed
- perform a patch angioplasty
- back bleed the ECA and ICA and flush the CCA in series before completing the patch
- unclamp the ECA, CCA, and then ICA
- check an intra-operative duplex
- close +/- drain placement
83
What is the dosing and ACT goal for heparinization of a patient?
100U/kg with an ACT goal > 250
84
What is the blood pressure goal for a patient that is s/p carotid endarterectomy?
SBP 100-140
85
When should surveillance duplex US be performed for someone following carotid endarterectomy?
at 3 and 12 months
86
What is the screening recommendation for AAA?
one time US screening for anyone 65-75 with a history of smoking or a family history of AAA
87
Describe the technique for an EVAR.
- percutaneous or open femoral access
- heparinization of the patient
- bilateral iliofemoral sheaths and aortagram
- deployment of main body of the graft just below the renal arteries
- cannulation of the contralateral gate
- deployment of contralateral iliac limb
- balloon angioplasty to seal all connections
- completion angiography
- protamine administration
- femoral access closure
- confirmation of pedal pulses
88
What is the recommended surveillance after a AAA repair?
CT angiography 1 and 12 months later and then annually
89
Describe the technique for an open AAA repair.
- midline laparotomy
- dissection of the duodenum off the aorta and proximal aortic exposure below the renals
- distal exposure of the common iliacs
- heparinization of the patient
- clamp the iliacs and then proximal aorta
- open the aneurysm sac longitudinally and evacuate thrombus and plaque
- oversew the lumbars
- sew in the proximal graft with 3-0 prolene
- make a decision about the IMA
- sew in the distal graft with 4-0 prolene
- release clamps, give protamine, and ensure hemostasis
- close the aneurysm sac and peritoneum over the graft
- close the abdomen and check distal pulses
90
How should you handle a case where a patient needs AAA repair and is found to have an intra-abdominal malignancy?
- if discovered pre-op, this is an indication for EVAR followed by malignancy resection
- if discovered intra-op, perform the AAA repair first and then resect malignancy in 6-12 weeks
- exception would be a nearly obstructing colon cancer, which should be diverted first and then come back for AAA repair
91
What medications are given prior to clamping the infra-renal aorta during AAA repair?
- heparin (unless ruptured)
- lasix and mannitol for renal protection
92
What's a good general principle for deciding on endovascular versus open revascularization?
consider open if patients have a life expectancy more than 2 years, amenable arterial anatomy, and a good quality greater saphenous for conduit material
93
Pre-operative testing for elective open lower extremity bypass should include what two tests?
- CTA to identify a proximal and distal target
- vein mapping to evaluate the saphenous as a conduit
94
A saphenous vein should be what diameter to be suitable as a conduit material for lower extremity bypass?
3mm to below knee, 3.5mm to above knee
95
Most endovascular treatment of iliac disease is via what approach?
retrograde approach via the ipsilateral femoral
96
Describe an open fem-above knee pop bypass.
- explore the inflow artery and find a suitable site for anastomosis
- explore the outflow artery and find a suitable site for anastomosis
- evaluate and harvest the saphenous for conduit material
- heparinize the patient
- perform the proximal anastomosis
- tunnel a non-reversed saphenous, confirm arterial flow
- perform the distal anastomosis
- confirm flow with conduit, outflow, and pedal pulses
97
What size suture is used to sew in a bypass in the leg?
- femoral: 5-0
- popliteal 6-0
- tibial 7-0
98
If after an open bypass, you don't have good flow, what should be your next step?
perform a completion angiogram via direct cannulation of the proximal graft
99
What would be an alternative to saphenous vein for conduit material?
- contralateral greater saphenous
- lesser saphenous
- upper extremity veins (don't use in ESRD)
- synthetic material
- can also splice together materials
100
What is the surveillance regimen for a lower extremity bypass?
duplex US at 1, 6, and 12 months, then annually
101
What is the most accurate method to evaluate lower leg arterial circulation?
DSA rather than CTA
102
Look up BKA, AKA, TMA, and guillotine amputations
103
What is an important part of the post-op care for patients who undergo open lower extremity bypass?
neurovascular checks
104
What medication can be given to help with claudication?
cilastazol, black box warning for those with heart failure
105
Patients with lower extremity PAD should be screened for what?
coronary and cerebral vascular disease
106
Describe the TASC II criteria.
- TASC A (favor endovascular): single 5cm occlusion or 10cm stenosis
- TASC B (favor endovascular): multiple stenosis or occlusions each less than 5cm, single lesion up to 15cm of the SFA, heavily calcified occlusion less than 5cm, or single infrageniculate stenosis or occlusion
- TASC C (favor open): multiple lesions > 15cm in total, recurrent lesions that have undergone 2 or more interventions
- TASC D (favor open): total occlusion of the SFA with extension into the poop, total occlusion of the pop with extension into the tibials
107
How is the above knee popliteal exposed?
- longitudinal lateral incision between the iliotibial tract and biceps femoris
- deepen the incision in the lateral inter muscular septum to enter the popliteal space
108
How is the below knee popliteal exposed?
- longitudinal incision 1cm posterior to the posterior border of the tibia taking care to avoid the greater saphenous
- open the fascia of the superficial posterior compartment
- retract the gastrocnemius posteriorly
- dissect the coleus off the tibia to reach the popliteal
109
How should you plug in a bypass graft to a calcified common femoral?
do an endarterectomy with patch angioplasty and plug the graft into the patch
110
What are the 6Ps of acute limb ischemia?
- poikilothermia
- pallor
- pain
- pulselessness
- paresthesia
- paralysis
111
Patients with acute limb ischemia should have what additional workup?
workup of etiology, remember to get a hyper coagulable workup (ATIII, protein C/S, FVL) and an echo to look for embolic source
112
What are the Rutherford classes of ALI?
- I: viable
- IIa: salvageable with prompt treatment (minimal sensory loss, no paralysis)
- IIb: salvageable with emergent treatment (increased sensory loss, rest pain, and motor deficits)
- III: unsalvageable (profound anesthesia and paralysis without venous doppler signal)
113
How should you manage a Rutherford class III limb ischemia?
amputation given the significant systemic morbidity associated with reperfusion at this stage
114
Catheter-directed thrombolysis is an option for which stage of ALI?
Rutherford IIa since they have more time to await therapeutic results
115
Describe the medications and management of lytic catheters.
- an infusion of heparin (300-500U/h) and tPA (0.5-1.0mg/hr)
- monitor fibrinogen levels q6
- if fibrinogen < 150, cut the tPA rate in half
- if fibrinogen < 100, stop tPA
116
Describe the technique for embolectomy including sizing.
- generally make a transverse incision unless you suspect you'll also need to perform an endarterectomy
- control the vessel with elastic loops
- pass it proximally first, distally next
- pull back with gentle inflation of the balloon in a continuous motion
- make passes until two in a row don't return clot
- 2-3 Fogarty below the knee, 4-5 Fogarty above the knee
117
How do you get open brachial access for embolectomy?
make a transverse incision just above the antecubital fossa
118
If concerned about vasospasm on completion angiogram for acute limb ischemia, what can you do?
inject intra-arterial papaverine or nitroglycerin
119
What is the preferred intervention for occluded bypass grafts?
- less than 14 days, catheter direct thrombolysis
- more than 14 days of occlusion, open surgical management
120
How should you manage the AC/AP agents for a patient that was treated for acute limb ischemia?
- continue an anti-platelet agent
- add an anti-coagulant for at least 6 months
121
Describe lower leg fasciotomies.
- make a lateral incision between the tibia and fibula
- identify the anterior intra-muscular septum and make a longitudinal incision on either side to release the anterior and lateral compartments
- make a second longitudinal incision 2cm proximal to the medial malleolus and extending cranially, just medial to the tibia
- identify the saphenous vein and nerve and retract them anteriorly
- incision the superficial compartment by incision the gastrocnemius fascia ia
- take the soleus off the tibia until you identify the PT neuromuscular bundle
122
Describe thigh fasciotomies.
- lateral incision from intertrochanteric line and extending to the lateral epicondyle of the femur
- incise the IT band and fascia of the vastus lateralis to decompress the anterior
- reflect the vastus lateralis medially to expose the inter muscular septum which is incised to release the lateral
- rarely need to decompress the medial, which is done through an incision over the adductor muscle group
123
Describe forearm fasciotomies.
- gentle S shaped incision beginning 1cm proximal to the medial condyle to release the volar compartment
- longitudinal incision beginning 3cm distal to the lateral epicondyle and toward the Lister tubercle releases the dorsal compartment
- third incision laterally directly over the mobile wad
124
Describe hand fasciotomies.
- on the volar side, make longitudinal incisions over the radial and ulnar metacarpals
- on the dorsal side, make longitudinal incisions over the 2nd and 4th metacarpals and dissect on either side
- include a carpal tunnel release
125
How is an open SMA embolectomy performed.
- laparotomy
- retract the transverse mesocolon superiorly and the bowel to the right
- incision the peritoneum at the root of the transverse mesocolon to isolate the SMA
- make a transverse arrteriotomy
- pass a 2-3 Fogarty catheter antegrade and a 3-4 Fogarty retrograde
126
What are your options for SMA revascularization in acute mesenteric ischemia?
- open embolectomy
- bypass
- ROMS
127
What constitutes a flow-limiting lesion in the mesenteric vessels? What US findings correlate with this degree of stenosis?
> 70% stenosis
- SMA PSV > 275
- celiac PSV > 200
128
How do you diagnose chronic mesenteric ischemia?
- finding of hemodynamically significant stenosis
- appropriate clinical symptoms (e.g. intestinal angina)
129
How should you manage patients with asymptomatic mesenteric vascular stenosis?
expectantly
130
What role does TPN have for those with chronic mesenteric ischemia?
- recommendations against this
- prolongs time to revascularization
131
What is the recommended approach for chronic mesenteric ischemia?
an endovascular approach with balloon angioplasty and stenting
132
Describe SMA endovascular revascularization for chronic mesenteric ischemia.
- prefer a brachial approach (perc or open) to give a downward angle of approach to the mesenteric takeoff
- insert sheaths and catheters
- perform AP and lateral abdominal aortograms
- heparinize patient
- wire access the mesenteric vessel
- place a properly sized stent
- treat additional vessels as indicated
- remove access and close access site as indicated
133
Mesenteric stents should be managed post-operatively with what kind of AC/AP?
DAPT for at least 3-6 months
134
How do you perform an SMA endarterectomy?
- midline laparotomy
- left medial visceral rotation
- proximal and distal control
- heparinize
- trap door incision on the aorta (above celiac, below SMA, connected on the left side)
- removal of atherosclerotic plaque
- closure of arteriorotomy and abdomen
135
How do you perform an SMA bypass?
- midline laparotomy
- decide on antegrade (supraceliac aorta) versus retrograde (CIA/EIA) bypass
- expose the inflow vessel (lesser sac for antegrade or infrarenal aorta for retrograde)
- expose the target vessel (SMA)
- harvest or choose a conduit
- heparinize
- complete inflow anastmosis
- complete outflow anastomosis
- check pulses and bowel viability
- close
136
Is antegrade or retrograde SMA bypass preferred?
- antegrade given that it allows for easier mutli-vessel revascularization and avoids kinking
- may not have a target and may be more hemodynamically stressful, though)
137
Describe an acute DVT on US.
non-compressible vessel with hypo echoic clot
138
Describe phlegmasia.
- edema
- violaceous discoloration
- pain
- severe venous outflow obstruction
139
What are your options for treating phelgmasia?
consider catheter directed thrombus versus open thrombectomy with fogarty
140
How do we define venous insufficiency?
- retrograde flow > 1 second in deep veins
- retrograde flow > 500 ms in superficial veins
141
Abdominal, suprapubic, or groin varicosities are suggestive of what?
iliofemoral venous insufficiency
142
What is the primary treatment for symptomatic varicose veins?
- compression
- leg elevation
- weight loss
- exercise
143
What is a contraindication to treatment of superficial venous insufficiency?
DVT given that the superficial vessels may be a critical source of outflow for these patients
144
Describe high-ligation and stripping of the GSV.
- oblique incision 1cm above the groin crease over the femoral canal
- visualize the SFJ
- ligate the saphenous at its junction
- transverse venotomy and pass stripper distally
- transverse incision over the GSV at the knee
- afix stripper head to the cephalic portion of the GSV and strip it out inferiorly
- ligate the ciudad portion at the knee
- hold pressure and dress the leg
145
What are contraindications to RFA ablation of the GSV?
- vein < 2mm
- vein > 15mm
- history of superficial thrombophlebitis
- superficial venous thormbosis
- extensive GSV tortuosity
- coagulopathy
- pregnancy
146
Describe RFA ablation of the GSV.
- percutaneous GSV access at the knee
- passage of a catheter to the level of the SFJ
- positioning of the tip 2cm from the SFJ and distal to the insertion of the superficial inferior epigastric vein
- tumescent anesthesia (50mL 1% lido, 5mL bicarbonate, 450mL NS) to increase compartment pressure for wall aposition and to serve as a heat sink
- T-berg position to promote venous collapse
- sequential heat ablation
- completion US to ensure no thrombus in the femoral vein
147
Describe the Allen test.
- occlude both the radial and ulnar arteries
- have the patient open and close hand several times to induce ischemia
- release the ulnar artery
- if re-perfusion is seen the palmar arch and ulnar artery are intact, safe to use the radial for dialysis access
148
Which patients are better served with long-term tunneled dialysis catheters?
those with less than 6-12 months life expectancy
149
Patients undergoing dialysis access procedures should have what testing done in pre-an?
get a glucose and a potassium
150
What pre-operative antibiotics are given to dialysis access patients? Why?
vancomycin given the exposure to dialysis centers and frequent prior hospitalizations
151
What incision is made for the following AVF creations?
- radiocephalic at the wrist
- radiocephalic upper forearm
- brachial cephalic
- longitudinal
- transverse below the AC fossa
- transverse above the AC fossa
152
What is the benefit of a two-stage brachiobasilic fistula?
at the second stage, it is arterialized and therefore more resistant to torque, making it easier to mobilize
153
ABSCE
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