Vascular surgery

Question 1

vascular disease:

1. what is the earliest lesions of atherosclerosis? (FS)
2. what is the hallmark of atherosclerosis? (P)
3. what are the 3 component of plaque? (L, SMC, CTM)
4. is the goal for plaque for it to be stable?
5. is stable or unstable plaque vulnerable to cause acute thrombosis?

Answer 1

1. fatty streak
2. plaque
3. lipid, smooth muscle cells, CT matrix
4. yes
5. unstable

Question 2

what are the 12 risk factors for developing an therosclerotic lesion? (ET, H, G, CS, H, DM, O, SL, M, IGR, H, CRP)

Answer 2

1. elevated triglycerides
2. hypercholesterolemia
3. genetics
4. cigarette smoking
5. HTN
6. diabetes mellitus
7. obesity
8. sedentary lifestyle
9. male
10. impair glucose regulation
11. homocysteine
12. c-reactive protein

Question 3

vascular disease:

1. expect atherosclerosis in what 3 artery groups? (C,C,R)
2. more than half the mortality associated with PVD results from adverse what events? (C)
3. what % of pts presenting with AAA repair have significant CAD?

Answer 3

1. coronary, cerebral, renal
2. cardiac
3. 42%

Question 4

Revised cardiac risk index:

1. what type of surgery? (HR)
2. history of what 3 things? (IHD, HF, CVD)
3. DM requiring what? (I)
4. preop creatinine greater than what mg/dL?

Answer 4

1. high risk
2. ischemic heart disease, heart failure, cerebrovascular disease
3. insulin
4. > 2 mg/dL

Question 5

% of major C/V event:

1. no risk factors
2. 1 risk factor
3. 2 risk factors
4. 3 or more risk factors

Answer 5

1. 0.4%
2. 1%
3. 6.6%
4. 11%

Question 6

what are the 3 major periop CV risks? (UCS, DCHF, SA)

Answer 6

unstable coronary syndrome, decompensated CHF, significant arrythmias

Question 7

define unstable coronary syndrome:

1. MI less than how many days with evidence of ischemic risk by clinical symptoms?
2. unable or severe what? (A)

Answer 7

1. < 30 days

2. angina

Question 8

what are the 3 types of significant arrythmias? (HGAVB, PVCs, SAwUVR)

Answer 8

1. high grade AV block
2. PVCs
3. supraventricular arrhythmias with uncontrolled ventricular rate

Question 9

what are the 4 intermediate periop CV risks? (MA, PMI, CCHF, DM)

Answer 9

1. mild angina
2. prior MI (Q wave on EKG)
3. compensated CHF
4. diabetes mellitus

Question 10

what are the 6 minor periop CV risks? (AA, AE, ROTNS, LFC, HOCVA, HOUH)

Answer 10

1. advanced age
2. abnormal ECG
3. rhythm other than normal sinus
4. low functional capacity
5. history of CVA
6. history of uncontrolled HTN

Question 11

HIGH risk noncardiac procedures:

1. cardiac risk > what %?
2. what type of major operations, particularly in the elderly? (E)
3. anticipated prolong surgical procedures associated with large fluid waht and/or what else? (S, BL)
4. what 2 types of vascular procedures? (PV, MV/A)

Answer 11

1. > 5%
2. emergent
3. shift, blood loss
4. peripheral vascular, major vascular/aorta

Question 12

Intermediate cardiac risk, non-cardiac procedures:

1. cardiac risk less than what %?
2. what 7 procedures? (CHIP, ION)

Answer 12

1. < 5%

2. carotid endarterectomy, head, intrathoracic, prostate, intraperitoneal, orthopedic, neck

Question 13

Low cardiac risk, non-cardiac procedures:

1. < what %?
2. what 4 procedures? (B,E,C,S)

Answer 13

1. < 1%

2. breast, endoscopic, cataract, superficial

Question 14

EKG is indicated if what:

1. for what system symptoms? (C/V)
2. surgery risk of what? with > how many risk factors?
3. any pt undergoing what risk of surgery?

Answer 14

1. cardiovascular
2. intermediate risk, >1
3. high risk

Question 15

chest x ray:

1. indicated for pts with new or unstable what S/S? (CP)
2. is it indicated for an asymptomatic health pt?
3. should pts with an increased risk have one done if the results would alter surgery?

Answer 15

1. cardiopulmonary
2. no
3. yes

Question 16

TTE:

1. pts should get one if ischemic heart disease with reduced what? (FC)
2. pts should get one if there is a murmur in the presence of what 2 systems’ symptoms? (C,R)
3. pts should get one if one of these 3 symptoms are present? (USOB, AE, ACXR)
4. Is a repeat TTE needed if the previous TTE was within 12 months and there is no change in clinical status?

Answer 16

1. functional capacity,
2. cardiac, respiratory
3. unexplained SOB, abnormal EKG, abnormal chest x ray
4. no

Question 17

dobutamine stress echo predicts what in vascular surgery but is expensive? (M)

Answer 17

morbidity

Question 18

higher or lower risk for vascular surgery if coronary revascularization precedes the vascular procedure?

Answer 18

lower

Question 19

Patients with systemic manifestations of atherosclerotic heart disease & are at risk for ischemia in what 4 places? (C, C, R, SC)

Answer 19

1. cardiac
2. cerebral
3. renal
4. spinal cord

Question 20

Vascular procedures physiologic changes:

1. hypercalcemia or hypocalcemia?
2. hyperthermia or hypothermia?
3. acidosis or alkalosis?
4. what are 3 other changes? (FS, TS, BL)

Answer 20

1. hypocalcemia
2. hypothermia
3. acidosis
4. fluid shift, third spacing, blood loss

Question 21

Carotid Endarterectomy (CEA):

1. the carotid artery is incised and what is removed from the lumen to improve cerebral blood flow? (P)
2. severity of ischemia is related to degree of blood flow what? (C)
3. Asymptomatic patients are potential candidates for CEA if > what % occlusion of common internal carotid?
4. CEA performed in an asymptomatic 70% stenosis reduces stroke by what % over 2 years?
5. with TIAs or stroke, untreated lesions have annual stroke incidence of what %?
6. is it a recommended procedure in pts with < 50% stenosis?
7. is it a recommended procedure in pts with chronic total occlusion of targeted carotid artery?
8. is it a recommended procedure in pts with severe disability caused be cerebral infarction that precludes preservation of useful function?

Answer 21

1. plaque
2. collateralization
3. 70%
4. 17%
5. 5%
6. no
7. no
8. no

Question 22

Carotid Endarterectomy (CEA):

1. what is the most common risk during and after? (S)
2. what is associated with up to 50% of all mortalities after CEA?
3. HTN in about what % of pts?
4. HTN in pts undergoing a CEA have an increased risk of what? (S)
5. what 4 things can impact whether or not a pt strokes during the CEA?

Answer 22

1. stroke
2. myocardial infarction
3. 70%
4. stroke
5. collateral blood flow, concurrent atherosclerosis, plaque size, presenting symptoms

Question 23

CEA cerebral monitoring:

1. what is the gold standard for monitoring?
2. carotid stump pressure assesses collateral flow to distal portion of what after cross clamping? (OCA)
3. stump pressure < what mmHg range reflects hypoperfusion and need for shunt placement?
4. what monitor assess BF velocity in the MCA? (TD)
5. what monitor assess cerebral regional oxygen saturation using near-infrared spectrometry? (CO)
6. decrease of O2 saturation by what range of % for > 4 minutes indicates potential for deficits?

Answer 23

1. EEG
2. operative carotid artery
3. <40-50 mmHg
4. transcranial doppler
5. cerebral oximetry
6. 20-25%

Question 24

Carotid Endarterectomy (CEA):

1. do all pts need an art line?
2. how many IVs?

Answer 24

1. yes

2. 2 (IVF and blood; another for drips)

Question 25

Anesthetic Technique for CEA: 1. block superficial and deep cervical plexus from what spinal range? 2. awake pts are able to monitor what function best? (N) 3. what are 5 disadvantages of regional anesthesia? (P, LOC, C, P, S) 4. for general, avoid what extremes? (H) 5. for general, goal is a smooth what? (E) 6. is a moderate narcotic dose used? 7. pts should be able to follow commands immediately postop for a rapid what exam? (N)

Answer 25

1. C1-C4 2. neuro 3. pain, loss of cooperation, confusion, panic, seizure 4. hemodynamic 5. emergence 6. yes 7. neuro

Question 26

CEA: 1. procedures is minimally stimulating, but hemodynamic changes occur secondary to what reflexes? (N) 2. manipulation of the carotid sinus causes an abrupt decrease in what 2 things? 3. these hemodynamic changes can be prevent with infiltration of the carotid sinus with what by the surgeon? 4. common practice is to maintain BP > or equal to what % of highest recorded BP during carotid occlusion? 5. cerebral perfusion pressure is what minus what? 6. maintain MAP between what mmHg range? 7. what is the one word inhalation with naroic technique? (L) 8. have what 4 uppers and downers available? (E, P, N, N)

Answer 26

1. neural 2. HR, BP 3. LA 4. 20% 5. MAP minus ICP 6. . 60-160 mmHg 7. light 8. ephedrine, phenyl, nitro, nicardipine

Question 27

CEA emergence: 1. document what postop? (NA) 2. coughing on emergence can result in severe what? (H)

Answer 27

1. neuro assessment | 2. HTN

Question 28

CEA postop: 1. what are the 2 most common causes of postop neuro deficits? (T, E) 2. HTN associated with increased incidence of what 2 system complications? 3. hypotension can result in ischemia in what 2 places? (C, M) 4. superior laryngeal nerve injury results in impaired what? (P) 5. recurrent laryngeal nerve injury results in what? (H) 6. what are 6 postop complications? (RI, CBD, TP, H, HI, CHS)

Answer 28

1. thrombosis, emboli 2. neuro, cardiac 3. cerebral, myocardial 4. phonation 5. hoarseness 6. resp insufficiency, carotid body dysfunction, tension pneumo, hematoma, hemodynamic instability, cerebral hyperperfusion syndrome

Question 29

problem with what CN? (7,9,10,11,12) 1. ipsilateral neck/shoulder weakness 2. VC paralysis, hoarseness, inadequate gag reflex 3. difficulty swallowing with ipsilateral horner syndrome 4. asymmetric smile 5. ipsilateral tongue droop

Answer 29

1. 11 2. 9 3. 10 4. 7 5. 12

Question 30

Carotid artery stent placement: 1. anesthesia technique is most often LA at the insertion site and what one word sedation and what type of therapy? (M, A) 2. observe for what 2 hemodynamic changes? (H, B) 3. anticoagulation is initiated with a heparin bolus of what range of units/kg to maintain an activated clotting time of greater than how many seconds? 4. Balloon inflation in the internal carotid artery can stimulate the baroreceptor response, resulting in prolonged what 2 symptoms? 5. what 2 meds do you need on hands to combat these symptoms? (G, A) 6. will fluoro be used throughout the procedure?

Answer 30

1. minimal sedation, antithrombotic therapy 2. hypotension, bradycardia 3. 50-100 units/kg; greater than 250 seconds 4. hypotension, bradycardia 5. glyco, atropine 6. yes

Question 31

pts are candidates of lower extremity surgery if what 4 things are present? (ALC, IRP, IU, G)

Answer 31

1. activity-limiting claudication 2. ischemic rest pain 3. ischemic ulcer 4. gangrene

Question 32

Lower extremity procedures: 1. inflow procedures alleviate obstruction in what segment? (A) 2. inflow procedure replaces diseased segment with what? (YSPG) 3. outflow procedures bypass what 3 obstructions? (F, P, D) 4. outflow procedures can be done with what 3 things? (RSV, ISSV, PG) 5. is an acute embolic occlusion an emergency vascular surgery? 6. emboli originates in the heart in pts with what 3 things? (A, RMI, VA) 7. what % of lower extremity emboli? 8. correct ischemia in a few hour or the limb is what? (L)

Answer 32

1. aortoiliac 2. Y-shaped prosthetic graft 3. femoral, popiteal, distal 4. reversed saphenous vein, in situ saphenous vein, prosthetic graft 5. yes 6. arrhythmias, recent MI, vascular aneurysms 7. 90% 8. lost

Question 33

anesthesia and lower extremity surgeries: 1. regional anesthesia block what response and may have best what? (S, O) 2. consider what before placing a regional block? (A) 3. what are the 5 benefits of doing a regional block for a lower extremity surgery? (MSH, RH, BWH, RP, RSR) 4. general anesthesia can be performed safely but be vigilant regarding what and of signs of what? (H, CI) 5. is an LMA acceptable for shorter procedures?

Answer 33

1. stress, outcomes 2. anticoagulation 3. more stable hemodynamics, reduced hypercoagulability, better wound healing, reduced pain, reduced sympathetic response 4. hemodynamics, coronary ischemia 5. yes

Question 34

Aneurysm: 1. an arterial expansion that occurs as the vascular wall what? (W) 2. where is the most common site? (IAA) 3. what are 5 arteries? (T,E,R,P,S) 4. what risk factor is most highly associated with AAA? 5. what are the 9 other risk factors of an aneurysm? (O,M,FH,C,HC,C,H,P,C)

Answer 34

1. weakens 2. infrarenal abdominal aorta 3. thoracoabdominal aorta, extracranial carotid, renal, popliteal, splenic artery, 4. smoking 5. old, male, family history, CAD, high cholesterol, COPD, HTN, PVD, caucasian

Question 35

Aneurysm: 1. law of what is related to aneurysms? (L) 2. what does that laws equation? 3. aneurysm > what range cm in diameter requires surgery? 4. what is the average operative mortality %? 5. waht is the mortality % with a ruptured AAA? 6. what 5 risk factors increase risk factors of mortality? (RMI, CHF, SPI, RF, age > what?) 7. what is the name of the aneurysm classification system? (C)

Answer 35

1. LaPlace 2. tension = pressure x radius 3. 4-5 cm 4. 3.5% 5. 75% 6. recent MI, CHF, severe pulmonary insufficiency, renal failure, >80 7. crawford

Question 36

Aortic dissections: 1. does type A or B involve the ascending aorta? 2. does type A or B involve the descending aorta?

Answer 36

1. A | 2. B

Question 37

aortic aneurysm monitoring: 1. a femoral art line is used for an aneurysm surgery where because knowing the BP distal to the cross clamp helps with managing hemodynamics? (T, TA) 2. never put bair hugger on the extremity that will be what? (CC) 3. placing the bair hugger on that extremity can result in what 2 things? (B, TD)

Answer 37

1. thoracic, thoracoabdominal 2. cross-clamped 3. burns, tissue damage

Question 38

Cross-clamping: 1. hypertension or hypotension above the clamp? 2. hypertension or hypotension below the clamp? 3. absence of BF distal to clamp to what 2 parts of the body? (LE, P) 4. cross clamping increases what 2 physiologic measurements and tension where? (MWT) 5. can pts with adequate cardiac reserve compensate for cross clamping? 6. if pts with ischemic heart disease are unable to compensate, decrease function where and ischemia where can occur? (GVF, M) 7. increases preload and blood volume to organs proximal or distal to the clamp? 8. increase in BP from cross clamping is related to proximity of clamp to what?

Answer 38

1. hypertension 2. hypotension 3. lower extremities, pelvis 4. SVR, MAP; myocardial wall tension 5. yes 6. global ventricular function, myocardial ischemia 7. proximal 8. heart

Question 39

cross clamping: 1. does blood volume go from distal to proximal or proximal to distal? 2. does an aorta clamp above or below splanchnic region increase preload?

Answer 39

1. distal to proximal | 2. above

Question 40

cross clamping: 1. if aorta clamped above the splanchnic region, blood goes to where? 2. if aorta clamped below the splanchnic region, blood goes to where? 3. what vasodilator can be used to control HTN? 4. for thoracic cross-clamps, what can be used to reduce afterload? (S) 5. what drug can be used to decrease preload? (N) 6. preload reduction is underlying principle used to control cross-clamp HTN when using partial CPB during aneurysm repair where? (T)

Answer 40

1. heart 2. splanchnic system 3. SNP 4. shunts 5. nitroglycerin 6. thoracic

Question 41

bypassing and shunting techniques that divert flow from what 3 areas to distal of the lowest clamp have been used to blunt the effects of cross clamping? (LA, LV, PA)

Answer 41

1. left atrium 2. left ventricle 3. proximal aorta

Question 42

cross clamping: 1. what type of metabolism occurs distal to the clamp? (A) 2. what acid increases distal to the clamp? 3. release of arachidonic acid derivatives contributes to what organs instability? 4. synthesis of what accelerates during cross clamping and may be responsible for decreases in myocardial contractility and CO (T)

Answer 42

1. anaerobic 2. lactic 3. cardiac 4. thromboxane A2

Question 43

mesenteric traction syndrome: 1. flushing where? 2. what 2 measurements decrease? 3. heart rate increase or decrease? 4. CO increased or decreased?

Answer 43

1. facial 2. BP, SVR 3. increase 4. increased

Question 44

Renal protection: 1. cross clamping above or below the renal arteries will cause temporary renal ischemia 2. common to give how many grams of mannitol per 70 kg 10-15 minutes before cross clamping? 3. renal dose of what can help preserve the kidneys? 4. anticipate increased what requirements? (F) 5. will potassium increase or decrease? 6. will a cross clamp of less than 30 minutes result in a less likely postop renal failure?

Answer 44

1. above 2. 12.5 g 3. dopamine 4. fluids 5. decreased 6. yes

Question 45

SC protection: 1. what is the name of the large radicular vessel that supplies the SC (ARM) 2. aka for this artery? (AoA) 3. originates from what spinal range? 4. this artery provides the majority of BF to what spinal artery? (ASA) 5. the anterior spinal artery supplies what aspect of the SC? 6. this aspect of the SC is responsible for what? (MC) 7. cross clamping of this artery may lead to what? (P) 8. up to what % of thoracic and thoracoabdominal repairs have SC hypoperfusion? 9. neurologic deficits are the result of hypoperfusion of the SC during what reconstruction? (TA)

Answer 45

1. artery radicularis magna 2. artery of adamkiewicz 3. T8-L2 4. anterior spinal artery 5. ventral 6. motor control 7. paraplegia 8. 40% 9. thoracic artery

Question 46

these are strategies for SC protection: 1. identification/reimplantation of what? (SV) 2. increase proximal or distal aortic perfusion? 3. CSF drainage via what? (LD) 4. intrathecal what? (P) 5. what type of arrest? (C) 6. what 2 evoked potentials can be used to monitor for ischemia but not treatment?

Answer 46

1. segmental vessels 2. distal 3. lumbar drain 4. papaverine 5. circulatory 6. somatosensory and motor evoked

Question 47

cross clamp release: 1. hemodynamic changes vary according to what 4 things? (EoRT, OT, ATA, SU) 2. most acute observation is a decrease in what? 3. metabolites of anaerobic metabolism are liberated and cause what 2 things? (V, VP) 4. SVR decreases and blood is sequestered into previously dilated veins resulting in a decrease of what? (P) 5. cross clamp release where can cause profound hypotension? (S) 6. what can be vigorously done before release to combat profound hypotension? (H) 7. does CO2 increase or decrease during cross clamp release and reperfusion?

Answer 47

1. extent of reperfused tissue, occlusion time, administered therapeutic agents, shunt use 2. BP 3. vasodilation, vasomotor paralysis 4. preload 5. supraceliac 6. hydration 7. increase

Question 48

GA and cross clamping: 1. keep MAC less than what? 2. supplement VAs with what? (N) 3. what type of ETT is necessary for thoracic aorta surgery? 4. is extubation the goal at the end of the procedure that depends on the stability of the pt and the particular preference of the surgeon? 5. may brisk fluid therapy be needed?

Answer 48

1. < 1 2. narcotic 3. double lumen tube 4. yes 5. yes

Question 49

combined anesthesia and cross clamping: 1. should intraop and postop management issues be clearly separated? 2. what type of neuraxial drugs can be used intraop to decreased MAC requirements? 3. can these neuraxial drugs also be used postop? 4. epidural blocks block what type of stimuli at level of somatic afferents? (N) 5. with this technique, only low dose VAs are required to produce what 3 things? (U, A, ToETT) 6. what can be severe with this technique? (H)

Answer 49

1. yes 2. narcotics 3. yes 4. noxious 5. unconsciousness, amnesia, tolerance of ETT 6. hypotension

Question 50

ischemia where is common postoperatively and it may be silent? (M)

Answer 50

myocardium

Question 51

deep hypothermic circulatory arrest: 1. provides brain protection by relying on the what effects of hypothermia on cerebral metabolic rate of O2 consumption? (P) 2. use for repair of what 2 aneurysms? (T, A) 3. cool pt to what degrees celsius? 4. use what drugs to decrease CMRO2? (B) 5. what is the safe duration minute range of CPB stop to decrease risk of cerebral tissue injury?

Answer 51

1. protection 2. thoracoabdominal, arch 3. 20 degrees celsius 4. barbiturates 5. 30-40 minutes

Question 52

endovascular aortic aneurysm repair (EVAR) 1. what is the mortality rate % range? 2. what is the open approach mortality %? 3. estimated that what % of AAA repairs will be accomplished by EVAR technique in the next 10 years? 4. also used to treat pts with what other type of aneurysm? (TA) 5. was it initially developed to help pts with severe coexisting disease who ere not surgical candidates?

Answer 52

1. 3.5-12.5% 2. 10% 3. 90% 4. thoracic aortic 5. yes

Question 53

endovascular aortic aneurysm repair (EVAR): 1. what is deployed within the aortic lumen that restricts BF to the portion of the aorta where the aneurysm exists? (SG) 2. is cannulation of both femoral arteries performed? 3. are radial forces or fixation mechanisms such as hooks or barbs on the stent used so it becomes embedded into the aortic wall and prevention migration? 4. where does this procedure take place?

Answer 53

1. stent graft 2. yes 3. yes 4. interventional radiology

Question 54

EVAR advantages: 1. what 5 things are decreased? (E, BL, SR, RD, PD) 2. is the aorta cross clamped? 3. are hemodynamics more stable?

Answer 54

1. embolisms, blood loss, stress response, renal disease, postop discomfort 2. no 3. yes

Question 55

anesthesia and EVAR: 1. general, neuraxial and LA with sedation can be used, is there data supporting one over the others? 2. what is the heparin units/kg dose needed to be given prior to catheter manipulation? 3. is abx coverage recommended at the beginning of the surgery? 4. local anesthesia with sedation compared to general has decreased complications with what 3 organs and and overall decrease in what? (C, R, R; M)

Answer 55

1. no 2. 50-100 units/kg 3. yes 4. cardiac, respiratory, renal

Question 56

EVAR complications: 1. what are 4 graft complications? (T, M, R, I) 2. what are 4 other complications? (E, IAR, LEI, CE)

Answer 56

1. thrombosis, migration, rupture, infection | 2. endoleak, iliac artery rupture, lower extremity ischemia, cerebral embolism

Question 57

Summary: 1. do pts needing vascular disease usually have multisystem disease processes? 2. what are 6 risks for atherosclerosis? (H, TU, D, H, FH, M) 3. is the preop risk assessment most helpful if it leads to risk modification or influences surgical/anesthetic care decisions? 4. CAD is responsible for what % of mortality in peripheral vascular surgery pts? 5. most MIs occur when and how? (P, S) 6. can aggressive periop management of CAD improve outcomes? 7. should hemodynamic extremes be avoided in CEAs? 8. maintain BP at or up to what % greater baseline for CEAs?

Answer 57

1. yes 2. HLD, tobacco use, diabetes, HTN, family history, male 3. yes 4. 50% 5. postop, silent 6. yes 7. yes 8. 20%

Question 58

Summary: 1. what is LaPlace law equation? 2. a 5 cm AAA has a rupture rate of what %? 3. a 7 cm AAA has a rupture rate of what %? 4. what are the 3 treatment options for increased LV afterload? (S, AD, V) 5. is VO2 increased or decreased during cross clamping? 6. is anaerobic metabolism proximal or distal to clamping?

Answer 58

1. tension = pressure x radius 2. 4% 3. 19% 4. shunting, arteriolar dilation, venodilation 5. decreased 6. distal

Question 59

summary: 1. unclamping aortic cross clamp leads to an acute fall in BP secondary to a decrease in what? 2. what are 5 ways to attenuate this decrease in BP? (FBU, AFR, VD, LA, V) 3. if BP does not respond within several minutes, what should be done? (RCC) 4. what response should be controlled postop? (SR)

Answer 59

1. SVR 2. fluids before unclamping, aggressive fluid resuscitation, vasodilators discontinuation, lightened anesthesia, vasopressors 3. reapply cross clamp 4. stress response

Question 60

Is an EKG indicated for someone undergoing a low risk surgery and RCRI is < 1?

Answer 60

no