Most common congenital hypercoagulaboe disorder
Leiden factor (resistance to protein C)
Most common aquired hypercoagulability disorder
Smoking
Macrophages that have absorbed fat and lipids in the blood vessel wall
Foam cells
Exposure of collagen in vessel wall and eventual throbus formation
Intimal disruption
Atherosclerosis: layer that it effects
Intima
Hypertension: layer that it effects
Media
3rd most common cause of death in US
stroke
amount of blood supply provided to brain by carotids
85%
flow pattern of a normal internal carotid artery
continuous forward flow
normal flow pattern of the external carotid artery
triphasic flow
1st branch of external carotid artery
superior thyroid
vessels that provide communication between internal carotid and external carotid (2)
ophthalmic artery, internal maxillary artery
most commonly diseased intracranial artery
middle cerebral artery
most common source of cerebral ischemic events
arterial embolization from ICA
symptoms associated with anterior cerebral artery events
mental status changes, release, slowing
symptoms associated with middle cerebral artery events
contralateral motor and speech, face droop
occlusion of ophthalmic branch of ICA causing transient visual effects
amaurosis fugax
candidates for CEA
>= 70% stenosis and symptoms
stump pressures requiring shunt during CEA
>50
most commonly injured cranial nerve during CEA
vagus
complications of CEA
stroke, pseudoaneurysm, hypertension, MI
signs of vertebrobasilar insufficiency (7)
diplopia, dysarthria, vertigo, tinnitus, drop attack, incoordination, binocular vision loss
tumor presenting as painless neck mass near bifurcation of carotid
carotid body tumor
symptoms of ascending aortic aneurysm
aortic insufficiency, back pain, voice changes, dyspnea, dysphagia
indications for repair of ascending aortic aneurysm (4)
>=7cm, >=6cm with Marfan?s, diameter 2X normal, rapid increase in size
aneurysm classification for those with any ascending aortic involvement
Class A
Aneurysm classification for those with descending involvement only
Class B
DeBakey classification for aneurysms with ascending an descending involvement
Type I
DeBakey classification for aneurysms with ascending involvement only
Type II
DeBakey classification for aneurysms with descending involvement only
Type III
Layer of blood vessel where dissection occurs
Media
Ascending aortic dissections that need operative repair
ALL of them
Descending aortic dissections that need operative repair
Visceral, renal or leg ischemia, persistent pain, large size
Artery perfusing spinal cord, whose injury causes paraplegia if occluded during repair
Artery of Adamkiewicz
Symptoms of AAA
Rupture, distal embolixation, compression of adjacent organs
Rupture risk of AAA 5cm
15-20% 5-year
rupture risk of AAA >8cm
100% 5-year
indications for AAA repair (3)
symptomatic, >5cm, growth >0.5cm/yr
situations when IMA should be reimplanted during AAA repair
backpressure <40mmHg, previous colon surgery, SMA stenosis, inadequate flow to colon
bloody diarrhea after AAA: dx?
Ischemic colitis
Organisms common in mycotic aneurysms (2)
Salmonella, staph
Treatment of mycotic aneurysm
Extraanatomic bypass, resection of infected portion of aorta
Organisms common in aortic graft infections (2)
Staph, E.coli
Treatment of aortic graft infection
Resect graft, bypass through noncontaminated field
Herald bleed with hematemesis, then blood per rectum ~6mos after AAA
Aortoenteric fistula
Treatment of aortoenteric fistula
Axillary bifem, graft resection
Endoleak that is proximal, distal, or through the stent
Type I endoleak
Endoleak that is persistent blood flow through lumbars or IMA
Type II endoleak
Nerve and vessel in anterior compartment of leg
Deep peroneal nerve, anterior tibial artery
Nerve in lateral compartment of the leg
Superficial peroneal nerve
Nerve and 2 vessels in the deep posterior compartment of the leg
Tibial nerve, posterior tibial and peroneal arteries
Nerve in superficial posterior compartment of the leg
Sural nerve
Treatment of homocysteinuria
Folate, B6, B12
Yearly risk of gangrene and amputation with claudication
2%/year and 1%/year
symptoms of aortoiliac occlusion
buttock pain
symptoms of external iliac occlusion
midthigh claudication
symptoms of common femoral or proximal superficial femoral artery occlusion
calf claudication
symptoms of distal SFA or popliteal disease
foot claudication
syndrome with a lesion at or above aortic bifurcation, causing lack of femoral pulse, buttock/thigh claudication, impotence
Leriche syndroma
Most common atherosclerotic occlusion in lower extremities
Hunter?s canal (exit of SFA)
ABI where claudication starts
<0.9
ABI where rest pain starts
<0.6
ABI where ulcers start (usually on toes)
<0.5
ABI where gangrene starts
<0.3
studies to find significant occlusion and at what level
PVRs (peripheral vascular resistance studies
Gold standard for vascular imaging to detect occlusion
Angiogram
Surgical indications for PVD (4)
Rest pain, ulceration or gangrene, lifestyle limitation, atheromatous embolixation
Graft material good for aorta and large vessels
Dacron
Typeical repair for aortoiliac disease
Aortobifemoral repair
5-year patency of femoropopliteal grafts
75%
5-year patency of femoral-distal grafts
50%
complications of reperfusion of ischemic tissue (4)
lactic acidosis, hyperkalemia, myoglobinuria, compartment syndrome
tx for patients with heel ulceration to bone
amputation
tx for patients with dry gangrene
allow to autoamputate
tx for wet gangrene
amputation to remove infected necrotic tissue + antibiotics (surgical emergency)
good lesions for PCTA
common iliac lesions, short segments
tx for pseudoaneurysm after arteriography
thrombin injection (u/s guided)
most common compartment of leg to get compartment syndrome
anterior
pressures requiring fasciotomies
>20-30
mild intermittent claudication in med in their 40?s; primary symptom is loss of pulses with plantarflexion
popliteal entrapment syndrome
treatment for popliteal entrapment syndrome
resection of medial head of gastroc
intermittent claudication with changes in symptoms with knee flexion and extension
adventitial cystic disease
tx of adventitial cystic disease
vein graft if occluded, resection of cyst
3-year mortality after BKA or AKA
50%
% of patients who walk again after BKA
70
% of people who walk again after AKA
30%
most common cause of acute arterial emboli
atrial fibrillation
most common site of peripheral obstruction from emboli
common femoral artery
flaking of atherosclerotic emboli off abdominal aorta or branches; good distal pulses
blue toe syndrome
treatment of acute arterial thrombosis
heparin, OR for thrombectomy (if limb threatened), angio for thrombolytics (if limb not threatened)
treatment of thrombosed PTFE graft
thrombolytics, anticoagulation
source of most renal emboli
heart
most common location for renal atherosclerosis
Left proximal 1/3, more in men
Most common location for renal fibromuscular dysplasia
Right distal 1/3, more in women
Diagnostic study for renal artery stenosis
Renal angiogram
Tx of renal artery stenosis
PTA with stent
Indications for nephrectomy with renal HTN
Atrophic kidney <6cm with persistently elevated rennin level
Most common site of upper extremity stenosis
Subclavian
Proximal subclavian artery stenosis resulting in reversal of flow through ipsilateral vertebral artery into subclavian
Subclavian steal syndrome
Treatment of subclavian steal syndrome
Carotid to subclavian bypass or PTA
Normal position of subclavian vein in relation to ribs, scalene and clavicle
Vein passes over 1st rib anterior to anterior scalene, then behind clavicle
Normal position of subclavian artery and brachial plexus in relation to ribs, scalene and clavicle
Artery passes over 1st rib posterior to anterior scalene and anterior to middle scalene
Test looking at radial pulse with head turned to the ipsilateral side
Adson?s test
Location of ulnar nerve on brachial plexus (superior, middle, or inferior)
Inferior portion
Location of radial nerve on brachial plexus (superior, middle or inferior)
Superior portion
Treatment of thoracic outlet syndrome
Cervical rib resection, division of anterior scalenes and middle scalenes. Possible 1st rib resection
Effort induced thrombosis of subclavian vein
Paget von Schrotter disease
CT findings that suggest intestinal ischemia
Bowel wall thickening, intramural gas, portal venous air, vascular occlusion
Most common cause of visceral ischemia
Acute embolic occlusion (50%)
Causes of visceral ischemia (4)
Embolus, thrombotic occlusion, low flow state, venous thrombosis
Most common source of SMA embolus
Heart
Treatment of SMA embolus
Resuscitation, antibiotics, embolectomy, resection, heparin
Treatment of SMA thrombus
Thrombectomy, SMA bypass, resection, heparin
Treatment of mesenteric vein thrombosis
Heparin, thrombolytics, thrombectomy if diagnosed early
Nonocclusive mesenteric ischemia: definition
low cardiac output state to visceral vessels caused by spasm, low-flow states, or hypovolemia
most vulnerable areas for nonocclusive mesenteric ischemia (2)
Griffiths and Sudak?s points
Celiac compression causing chronic abdominal pain, weight loss, diarrhea
Median arcuate ligament syndrome
Visceral angina 30 min after meals, weight loss due to food fear
Chronic mesenteric ischemia
Most common complication of aneurysms above inguinal ligament
Rupture
Most common complication of aneurysms below inguinal ligament
Thrombus/emboli
Most common visceral aneurysm in women
Splenic
Indications for splenic artery aneurysm repair
Symptomatic, pregnancy, women of childbearing age
Treatment of visceral, iliac and femoral aneurysm
Exclusion and bypass graft
Indications for surgery for iliac aneurysm
Symptomatic, >3cm, mycotic
Indications for surgery for femoral aneurysm
Symptomatic, >2.5cm, mycotic
Most common peripheral aneurysm
Popliteal
% of people with popliteal aneurysm who have another aneurysm
50%
surgical indications for popliteal aneurysm
symptomatic, >2cm, mycotic
collection of blood in continuity with arterial system but unenclosed by all 3 layers of arterial wall
femoral pseudoaneurysm
disease with string of beads appearance on angiogram
fibromuscular dysplasia
gangrene of fingers>toes, severe rest pain with bilateral ulceration
Buerger?s disease
Type I collagen defect causing retinal detachment, aortic root dilatiation
Marfan?s syndrome
Collagen defect resulting in easy bruising, hypermobile joints, arterial rupture
Ehlers-Danlos syndrome
Large artery arteritis causing fever, arthralgia, visual changes, myalgia, anorexia (common in women >55)
Temporal arteritis
Large artery arteritis causing fever, arthralgia, myalgia, and anorexia (common in women <35)
Takayasu?s arteritis
Treatment of large vessel arteritis
Steroids, bypass
Medium vessel arteritis (2)
Polyarteritis nodosa, kawasaki?s disease
Small vessel arteritis, often secondary to drug/tumor antigens
Hypersensitivity angitis
Vasculitis of young women with subsequent vasoconstriction and cyanotic extremities
Raynaud?s disease
Most common failure of AV grafts for dialysis
Venous obstruction secondary to intimal hyperplasia
Indications for surgical treatment of varicose veins
Symptomatic, recurrent ulcers, severe varicosities
Disease secondary to venous incompetence
Venous ulcers
Treatment of venous ulcers
Unna boot, ligate perforators, vein stripping
Trendelenburg test
Test of venous insufficiency: elevate leg, occlude greater saphenous, then lower leg to see how rapid the refilling of the vein is
Disease with achy, swollen legs and night cramps, as well as brawny edema
Venous insufficiency
Nonbacterial inflammation of superficial veins
Superficial thrombophlebitis
Bacterial infection of superficial veins
Suppurative thrombophletibis
Self-limiting thrombophlebitis of the breast
Mondor?s disease
Methods by which SCD?s prevent clots (3)
Decreased venous stasis, increased ATIII and tPA, increased fibrinolysis
Leg more commonly affected by DVT
Left (longer iliac vein compressed by iliac artery)
Virchows triad
Venous stasis, hypercoaguability, venous wall injury
Tenderness, pallor and edema of lower extremity
Phlegmasia alba dolens
Tenderness, cyanosis and massive edema of lower extremity
Phlegmasia cerulea dolens
Source of PE when a DVT filter is in place (3)
Ovarian veins, IVC superior to filter, upper extremities
Treatment of 1st DVT
Coumadin 6 months
Treatment of 2nd DVT
Coumadin 12 months
Treatment of 3rd DVT or PE
Lifetime Coumadin
ABG changes of PE
Dec pO2, dec pCO2, respiratory alkalosis
Tissue types with no lymphatics (6)
Bone, muscle, tendon, cartilage, brain, cornea
Lymphangiosarcoma associated with breast axillary dissection
Stewart-Treves syndrome
Dilation of preexisting lymphatic channels
Lymphangiectasia