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260 terms

Vascular I

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First sign on arterial waveform of occlusive disease
Loss of dicrotic notch
Dilatation of artery <50% of normal diameter
Ectasia
Dilatation of artery >50% of normal diameter
Aneurysm
Diffuse arterial enlargement >50% with no discrete aneurysms
Arteriomegaly
Multiple discrete aneurysms
Aneurysmosis
False or pseudoaneurysms
Do not contain all three layers of arterial wall
Most common site of false or pseudoaneurysms
Femoral (usually iatrogenic following use of percutaneous femoral and upper extremity access to perform diagnostic and interventional procedures)
Treatment of false or pseudoaneurysms
1. Small (<1.0 cm) FAs may spontaneously thrombose
2. Ultrasound-guided thrombin injection (UGTI) (success rates greater than 95% in most reported series) [for ones >2cm]
3. Ultrasound-guided compression
4. Open repair [in patients that have active bleeding, overlying skin necrosis, distal limb ischemia, nerve deficits from compression, and large aneurysm > 5cm with wide necks]
Pathophysiology of aneurysms
1. ↓quantities of elastin and collagen
2. Imbalance between wall proteases and anti-proteases
3. Congenital collagen structural deficiencies
Congenital collagen structural deficiencies
1. Marfan's syndrome
2. Ehlers-Danlos syndrome
3. Loeys Dietz syndrome
Most common location of AAA
Infrarenal aorta
Most common etiology of AAA
Atherosclerosis (with degeneration of the medial layer)
Crawford's classification of AAA
I. Infrarenal
2. Juxtarenal
3. Pararenal
4. Suprarenal (extend above the renal arteries and correspond with the type IV thoracoabdominal aneurysm)
Positive risk factors for developing AAA
Age, gender (male>female), race (white>black), tobacco use, and a family history (1st degree relatives) of aneurysmal disease; PAD and high cholesterol; COPD
Negative risk factors for developing AAA
1. Race (black)
2. Gender (female)
3. Diabetes mellitus (1:2)
Natural history of AAA
Continuous expansion
Most frequent and lethal complication of AAAs
Rupture is the most frequent and lethal complication of AAAs
Average rate of growth of AAA
0.4 cm/year
Size and risk for rupture. Annual vs. 5 years
Annual risk for rupture
4.0~5.4 cm - 0.5% to 1%
5.5~6.0 cm - 5% and 10%
6.0~7.0 cm - 10% to 20%

5-year risk for rupture
5 cm - 25%
6 cm - 40%
7 cm - 60%
8 cm - 80%
Growth rate that is high risk for AAA rupture
>0.6 cm/yr
Clinical presentation of AAA
1. Incidental palpation of a pulsatile abdominal mass on physical exam
2. Symptoms may be caused by contained or free rupture of the aneurysm, by thrombosis, or by distal embolism
3. Classic triad of sudden-onset midabdominal or flank pain, shock, and the presence of a pulsatile abdominal mass (1/3 of patients)
Diagnostic studies of AAA
1. Physical exam
2. Abdominal U/S
3. Spiral CT scanners with multiplanar views and three-dimensional CT angiography (CTA) *
4. MRI (modality of choice for patients with AAA who have renal insufficiency)/MRA
5. Contrast arteriography
Preferred method of screening for AAA
U/S: reduction in AAA-related mortality ranging from 21% to 68% as well as a 45% to 49% reduction in the incidence of ruptured AAA.
_____ and _____ are predictors of AAA expansion and rupture, especially for large aneurysms
Diastolic HTN; severe COPD
Indications for repair of AAA
1. >5 cm (female) or >5.5 cm (male)
2. Rapidly expanding (>0.5 cm/yr)
3. Symptomatic/ruptured
4. Atypical aneurysms (dissecting, pseudoaneurysms, mycotic, saccular, and penetrating ulcers) regardless of size
+ presence of cerebrovascular or COPD
Techniques of open repair for AAA
1. Transperitoneal approach, through a long midline incision or through a mini-laparotomy
2. Retroperitoneal approach through a left flank incision.
Complications following elective open aortic aneurysm repair
1. Nonfatal myocardial infarction, 3.1% to 16% (average 6.9%), usually within the first 48 hours after surgery.
2. Renal failure is the second most frequent complication (markedly increases mortality)
3. Post-operative bleeding
4. Most serious gastrointestinal complication is ischemia of the left colon and rectum
5. Lower extremity ischemia may result from embolization of mural thrombus or atherosclerotic plaque from the aneurysm, or thrombosis distal to the vascular clamp
6. Postoperative sexual dysfunction in males is more frequent and is due to injury to the autonomic nerves during para-aortic dissection and dissection of the iliac arteries (retrograde ejaculation & loss of potency)
7. DVT
Most significant predictors of mortality of AAA are the presence of _____ and _____
Pre-op hypotension
Low hematocrit

Other factors:
age
intraperitoneal rupture
transfusion requirements
gender (F>M)
#1 cause of acute death after AAA surgery
MI
#1 cause of late death after AAA surgery
Renal failure
Graft infection rate following AAA repair
1%
Most common late complication after aortic graft placement
Atherosclerotic occlusion
Bloody diarrhea after AAA, you must worry about ...
Ischemic colitis
Major vein injury with proximal cross-clamp during AAA repair
Retroaortic renal vein
Mortality with elective AAA repair
3-5%
Indications for re-implantation of IMA following aortic bypass (AAA repair)
Mandatory
- Previous colon resection

Relative
- Backpressure < 40 mmHg (poor backbleeding)
- SMA stenosis
- Large meandering artery with retrograde flow
- Loss of Doppler signal in mesentery
- Clinical ischemia (flow to left colon appears inadequate)
How do you avoid vasculogenic impotence during repair of AAA
Maintain flow to at least one internal iliac atery
Most important factor in survival following ruptured aneurysm
Time to clamping/occluding the aorta
Overall mortality following ruptured aneurysms
>90%
Ideal criteria for EVAR
1. Neck length >15mm (proximal) >10mm (distal)
2. Neck diameter <30mm
3. Neck angulation <60°
4. Common iliac artery length >35mm
5. Common iliac artery diameter <22mm
6. Nontortuous, noncalcified iliac arteres
7. Lack of neck thrombus
Endoleak Type I
Leakage around the proximal neck (IA) or the distal iliac end (IB). This leak is usually identified at the completion angiogram during the procedure and requires immediate repair.

Tx: Balloon the endograft again - if this is unsuccessful, an extension aortic cuff is placed proximally (IA) or an iliac limb extension is placed distally (IB)
Endoleak Type II
Blood flow into the aneurysm sac due to opposing blood flow from collateral vessels (patent lumbar arteries, inferior mesenteric artery, or hypogastric arteries)
Endoleak Type III
Leakage from overlap sites (IIIa) or through a defect in the endograft material (IIIb) [endograft components].

*This leak is becoming uncommon because of the continuous improvement in device design and because we now know that at least 2 to 3 cm of overlap are required

Tx: Secondary graft (immediately)
Endoleak Type IV
Endotension: sac continues to expand without any of the previously described endoleaks on thin-cut CT scan and angiogram → endograft acts as a filter, allowing serum to leak through and filtering most of the cells.

Tx: Secondary stenting (nonporous) or observe
AAA (elective) + intraabdominal malignancy
Patients with AAAs >5 cm and concomitant CRC, a synchronous operation may be the best approach (bowel resection with loop colostomy)

Patients with AAAs <5 cm and concomitant CRC might best be treated with colonic resection first , followed by staged AAA repair.
AAA (elective) + cholelithiasis
Avoid prophylactic cholecystectomy at the time of open repair and believe that the patient ought to be managed expectantly with a low-fat diet and possibly medication such as ursodiol in the postoperative period
What is inflammatory aneurysm?
Occurs in 5-10% of AAA, typically have a dense fibrous, inflammatory rind that is usually adherent to the 3rd and 4th portions of the duodenum and often involves the inferior vena cava and left renal vein; ureteral entrapment in 25%

*Diagnosis is best made by CT and CTA, with four separate layers typically identified: aortic lumen, mural thrombus, thickened aortic wall, periaortic inflammatory tissue.

**Male preponderance; process is believed to be autoimmune
Clinical presentation(s) of inflammatory aneurysms
- Abdominal or flank pain
- Associated weight loss
- ESR significantly elevated (75%)
Operative strategy for inflammatory AAA
Proximal aortic control above the left renal vein; use ureteral catheters if the inflammatory process extends to the iliac vessels → aneurysmorrhaphy with graft placement WITHOUT dissecting off adherent structures (i.e. duodenum) and AVOID ureterolysis is possible

[inflammatory process gradually resolves with ESR returning to normal]
Most common venous anomalies encountered during open AAA repair in order
- Left-sided vena cava (0.5%)
- Retroaortic left renal vein
- Circumaortic venous collar (two renal veins encircling the aorta-6%)
- Double inferior vena cava (lying on each side of the aorta-3%)
AAA + horseshoe kidney
Its association with AAA is rare, but it complicates graft replacement because the kidney mass is usually fused anterior to the aorta. The collecting system and ureters are displaced inferiorly, and there are often multiple or anomalous renal arteries arising from the aorta

Tx: left retroperitoneal approach is advocated because it allows easier management of the multiple accessory renal arteries.

Endovascular repair is difficult or not possible because of multiple renal arteries.
Indications for retroperitoneal approach to the infrarenal aorta
1. "Hostile abdomen" (from multiple transabdominal procedures
2. Presence of enteric or urinary stomas
3. Presence of ascites
4. Presence of peritoneal dialysis catheters
5. Morbid obesity
6. Inflammatory aneurysms
7. Horseshoe kidney
Most common organisms causing mycotic aneurysms include:
Salmonella species (#1; 40%), Staphylococcus aureus (#2), and Escherichia coli

*Infections with gram-negative organisms are less common but are associated with a higher incidence of aneurysm rupture
Infected (mycotic) aneurysms account for ____ % of all AAA cases
0.1 to 1.5%
Most common symptoms in patients with infected (mycotic) aneurysms
Fever
Abdominal or back pain
Common locations of mycotic aneurysms
Femoral artery
Aorta
Diagnostic approach to mycotic aneurysms
Blood cultures, local wound culture, and indium-labeled white blood cell scan, may be needed.
Treatment of mycotic aneurysms
Surgical treatment usually includes resection and replacement with a prosthetic interposition graft via extra-anatomic bypass.

An attempt is always made to revascularize the profunda femoris artery as well (fem-fem). In an infected field, reconstruction with femoral or saphenous vein graft or rifampin-soaked prosthetic graft is an option.

Revascularization of the limb with an obturator bypass or an extra-anatomic axillofemoral or axillopopliteal bypass can also be considered.
Etiology of aortoenteric fistula
Primary aortoduodenal fistulas are rare lesions developing in up to 1% of aortic graft cases (usually occurs >6 months after surgery
Presentation of aortoenteric fistula
Aortoenteric fistula is considered in all patients with GI hemorrhage with a known abdominal aortic aneurysm or a previous prosthetic aneurysm repair. Hemorrhage in this situation is often massive and fatal unless immediate surgical intervention is undertaken.

Typically, patients with bleeding from an aortoenteric fistula will present first with a "sentinel bleed." This is a self-limited episode (with hematemesis) that heralds the subsequent massive, and often fatal, hemorrhage.
Therapy of aortoenteric fistula
Ligation of the aorta proximal to the graft, removal of the infected prosthesis, and extra-anatomic bypass
Most common organisms causing prosthetic aortic graft infections
1. Staphylococcus (#1) -- epidermidis or aureus
2. E. coli (#2)
Most common complications of aneurysm below inguinal ligament
Thrombosis and emboli
Most common peripheral aneurysm
Popliteal aneurysm
Almost all patients (97%) with PAAs are (male or female), and the disease is bilateral in ____ %
Male; 50-70%
Patients with PAAs are at high risk for ...
Thromboembolism (embolization > thrombosis) with limb ischemia
Indication for PAA repair
1. >2 cm
2. Symptomatic [tibial nerve compression or popliteal v. thrombosis]
3. Mycotic
Approach to PAAs when no runoff vessels are seen on CTA/angiogram
Thrombolytics
When patient is diagnosed with PAAs, what the next step in diagnosis?
Rule out aneurysm elsewhere - AAA, femoral, etc.
Treatment of PAAs
Exclusion (proximal and distal ligation) and bypass of all poplitealaneurysms
What accounts for 90% of peripheral aneurysms?
Popliteal and femoral aneurysms
____% of patients have a concomitant aortoiliac aneurysm
>90%
How does FAAs (common and SFA aneurysms) behave
All true FAAs larger than 2 cm need to be considered for repair because of either risk for thromboembolic complications or an increased risk for rupture
FAA involving _________ artery has high risk of rupture
Profunda femoris (50%)
Treatment of FAAs
Bypass with exclusion
Idiopathic non-atherosclerotic lesions of arterial wall with alternating stenoses and small aneurysms
Fibromuscular dysplasia

"String of beads" finding on CT-A/angio and duplex US
Most common variant of fibromuscular dysplasia
Medial fibrodysplasia
Most commonly involved vessels
Renal (right) > carotid > iliac

[Subclavian and mesenteric vessels are not involved]
Incidence of intracranial aneurysms in patients with FMD
23%
Classic appearance on angiography of fibromuscular dysplasia
String of beads
Typical patient with FMD
Young female (multiparous) +/- HTN (if renal artery involved)
Treatment of FMD
PTA (1st choice) vs. bypass vs. open arteriotomy and serial dilation
Typical macroscopic morphology of renal artery aneurysms
Most are saccular, and 75% occur at the bifurcation of the primary or secondary branches
Most common etiology of renal artery aneurysms
Medial fibroplasia/degeneration is the most frequent cause of true renal aneurysms, followed by degenerative atherosclerosis and polyarteritis nodosa
Most frequent cause of false renal aneurysms
Spontaneous or traumatic dissection
Clinical presentation of patients with RAAs
Patients are usually asymptomatic or have associated renal artery occlusive disease and renovascular hypertension or ischemic nephropathy. Rupture occurs in less than 3% of cases
Indications for surgical repair of RAAs
Any aneurysm >2 cm in a woman of childbearing age (when the aneurysm ruptures in a pregnant woman, the fetal mortality rate is 75%, and the maternal mortality rate is 50%) should be repaired; symptomatic, expansion, >1.5 cm
Treatment of RAAs
Reconstruction with vein patch; nephrectomy if rupture occurs
Disease of intima
Atherosclerosis
Disease of media
HTN
Large vesel vasculitis
1. Temporal arteritis (giant cell arteritis)
2. Takayasu's arteritis
Typical patient population of temporal arteritis
Patients older than 50 years of age, with a slight (2 : 1) female preponderance.
Clinical presentation(s) of temporal arteritis
There are often signs of systemic inflammation (fever, myalgias). Ischemic symptoms are common, including claudication of facial or extremity muscles and retinal ischemia. Headache is a common symptom. Blindness, usually irreversible, is a dreaded complication if left untreated.
Treatment of temporal arteritis
When the clinical diagnosis is suspected, treatment must be prompt and consists of high-dose corticosteroid therapy.
Takayasu's arteritis is also known as ...
Pulseless disease
Typical patient population of Takayasu's arteritis
Younger female patients (85%) and has a higher prevalence in those of Eastern European or Asian descent.
4 types of Takayasu's arteritis
1. Aortic arch and arch vessels (brachiocephalic vessels of the arch)
2. Descending thoracic and abdominal aorta
3. Arch vessels and abdominal aorta & branches (65%)
4. Primarily pulmonary involvement (15%)
The arterial pathology of Takayasu's arteritis is focused on which vessel(s)?
Aorta (arch) and its major branches; pulmonary artery
Treatment of large vessel vasculitis
Steroids; bypass of large vessels if needed ( indicated for ischemic manifestations and is only undertaken when active inflammation is under control; normalized ESR)

NO endarterectomy
Phases of radiation arteritis
1. Early - sloughing and thrombosis (obliterative endarteritis)
2. Late (1~10 years) → fibrosis, scar, stenosis
3. Late-late (3~30 years) → advanced atherosclerosis
Pathophysiology of radiation-induced arteritis
Intimal proliferation and thickening; medial hyalinization; cellular infiltration of adventitia
Treatment of radiation-induced arterial damage
Standard surgical techniques - avoid prosthetic grafts; use vein graft
Types of medium arteritis
1. Polyarteritis nodosa
2. Kawasaki's disease (pediatric)
3. Drug abuse arteritis
Treatment for polyarteritis nodosa
Steroid +/- cyclophosphamide therapy
What type of lesions does polyarteritis nodosa cause and location?
Focal necrotizing lesions; medium muscular arteries
Polyarteritis nodosa commonly involved which organs
1. Kidney
2. Liver
3. GI tract
4. Heart
Complications secondary to polyarteritis nodosa
Formation of aneurysms in multiple areas that rupture or thrombose
Febrile exanthematous illness that affect children
Kawasaki's disease
Patients with Kawasaki's disease commonly die from ____
Cardiac conditions (arrhythmias or MI)
Kawasaki's disease is associated with what types of vascular lesions
Dilated coronaries and brachiocephalic vessels (>20%)
Treatment for Kawasaki's disease
Steroids +/- CABG
Iritis associated with oral and genital ulcers
Behçet's
Most common vascular disorder associated with Behçet's disease
Venous thrombosis (12-27%)
Once DVT develops in Behçet's, the patient must go on what ____
Life-long anticoagulation
Surgical repair of Behçet's is associated with ___
↑Thrombosis, pseudoaneurysm
Treatment of Behçet's
Steroids & immunosuppressive agents
Behçet's is commonly found in what regions of the world
Middle East and Asia (Turkey)
Types of small vessel arteritis
1. Hypersensitivity vasculitis
2. Buerger's disease (thromboangiitis obliterans)
Conditions associated with hypersensitivity vasculitis
Henoch-Schonlein purpura
Cryoglobulinemia
Clinical presentation of Buerger's disease
Young male smoker who presents with severe distal medium to small arterial disease → severe rest pain with bilateral ulceration OR ischemia or gangrene of digits

*Rare in African-Americans
Feature on angiogram that is suggestive of Buerger's disease
Corkscrew vessels/collaterals
Associated condition of Buerger's disease elicited from history
Superficial migratory thrombophlebitis
Raynaud's syndrome
Treatment of Buerger's disease
Cessation of smoking
+/- Pletal
+/- Limb amputation
Leg compartments
Anterior
Lateral
Deep Posterior
Superficial Posterior
Nerve of the anterior compartment and what does it innervate
Deep fibular (peroneal) nerve → dorsiflexion of anterior compartment muscles and sensation between 1st and 2nd toes
What artery does deep peroneal nerve run along with
Anterior tibial artery
Nerve of the lateral compartment and what does it innervate
Superficial peroneal nerve → eversion, lateral foot sensation
Arteries that travels in the lateral compartment
Anterior and posterior tibial branches of the popliteal artery
Nerve of the deep posterior compartment and what does it innervate
Tibial nerve → plantarflexion
Arterial supply of deep posterior compartment
Posterior tibial artery
Peroneal artery
Most common cause of PVD
Atherosclerosis
Signs of PVD
Pallor
Dependent rubor (redness of the feet) caused by
reactive hyperemia
Hair loss
Abnormal nail growth/nail brittleness
Slow capillary refill
Muscle wasting/atrophy
Thinning of skin
#1 preventative agent for atherosclerosis
Statin drugs
What inherited disorder that affects the metabolism of the amino acid methionine ↑risk of atherosclerosis
Homocystinuria

Treatment: Folate, B₆, B₁₂
2 broad categories of PVD patients based on symptomatology
Claudication vs.
Critical limb ischemia
Define claudication
Reproducible ischemic muscle pain 2° inadequate O₂ delivery during exercise with relief soon after cessation of activity
% of patients with claudication that progress to CLI over their lifetime
5 to 10%
Annual rate of mortality in patients with claudication
2 to 5%
Annual rate of limb loss in patients with claudication; 5-year risk for loss of limb
1%; 5 %
Annual rate of gangrene in patients with claudication
2%
Most common atherosclerotic disease pattern encountered distal to the inguinal ligment
Short-segment total occlusion of the SFA (distal > proximal)
Symptoms and relation to the level of occlusion
Occur one level below the occlusion
- Aortoiliac disease → buttock claudication
- External iliac disease → midthigh claudication
- CFA/pSFA disease → calf claudication
- dSFA/popliteal disease → foot claudication
Define critical limb ischemia
Presence of rest pain or tissue loss in the lower limb
When does rest pain occur?
When blood flow is inadequate to meet resting metabolic requirements → in the LE, ischemic rest pain is localized to the foot (frequently in the instep; usually centered over the metatarsal heads, not the toes)

The severe discomfort in the forefoot usually wakes patient from sleep (at night) → temporary symptomatic relief from hanging affected extremity over the edge of the bed [walking, standing, or sleeping in a chair may relief the pain]
% of patients with CLI who will die at 1 year
25%
% of patients with CLI who will undergo major amputation
30%
% of patients with CLI who will be alive with 2 limbs
45%
Treatment for CLI
Revascularization for limb salvage
What condition can mimic claudication?
Lumbar stenosis or nerve root compression (usually develops when patients maintain a stationary standing posture)
What condition can mimic rest pain?
Diabetic neuropathy
ABI
Ankle-brachial index +/- toe pressures
0.5-0.9 claudication
<0.5 rest pain
<0.4 distal ulcers
<0.3 gangrene
ABI can be inaccurate in which patient population
Diabetics (or CRI) 2° incompressibility of vessels (vascular calcifications)
Adjunct to ABI if not accurate
Pulse volume recordings (PVRs) to find significant occlusion (and at what level)
Gold standard technique for imaging of the vascular tree prior to intervention
Angiography (digital subtraction angiography)
CTA
Therapeutic goals of occlusive arterial disease of the lower extremities
1. Relieve pain
2. Prevent limb loss
3. Maintain bipedal gait
Medical management of LE occlusive disease
Risk factor modification
- smoking cessation
- weight and BP reduction
- lipid control
- BG control
- antiplatelet therapy (ASA, clopidogrel)
- structure walking program to ↑walking distance
- cilostazol (Pletal 50-100 mg PO BID) or pentoxifylline (400 mg PO TID)

"Stop smoking and keep walking"
Claudication progresses to gangrene in ____ % of patients
2 to 3%
Indications for revascularization
Lifestyle-limiting claudication
Limb-threatening critical ischemia (rest pain,
ulceration or gangrene)
Less common indications for infrainguinal arterial reconstruction
Trauma-related vessel disruption
Popliteal artery entrapment syndrome
Femoropopliteal arterial aneurysm with thromboembolism
Common inflow bypass grafting procedures
Aortobifemoral
Femorofemoral
Axilofemoral
Femoropopliteal
Femoral-distal (peroneal, AT, or PT)
Non-operative options for revascularization
Aortoiliac angioplasty
Stenting
Preferred conduit for infrainguinal bypass surgery
Autogenous vein graft (ipsilateral GSV) > prosthetic conduits (Dacron or PTFE)
Patency rates for above-knee saphenous vein grafts are approximately _____ % @ 1 year and _____ % @ 5 years
80-90%; 75%
PTFE patency ↓ significantly when compared to vein graft when ____ at 5 years
Performing fem-distal pop bypass (65% vs. 40%)
Patency of arterial bypass grafting is adversely affected by:
1. Grafts performed below-the-knee
2. Continued tobacco use
3. Poor distal run-off
4. Small vein size (<4mm)/size mismatch
Blue toe syndrome
Microemboli from iliac occlusive disease (or from aorta or femoral vessels)

*Palpable pedal pulses
Leriche syndrome
Aorto-iliac disease with intermittent claudication of thighs and buttocks

+impotence (2° to hypogastric [internal iliac] arterial occlusion with ↓flow through the internal pudendal artery and the corpora cavernosa)
↓ or absent femoral pulses
Comparison of in situ bypass grafts vs. reversed vein grafts
No difference in patency rates to popliteal
_____ grafts should be the first choice for all infrainguinal revascularization both above- and below-knee bypasses
Autologous vein (saphenous)
Advantages of in situ grafting
1. Minimize trauma to the vein (preservation of vasa vasorum and endothelium)
2. Increase vein utilization
3. Create more technically precise anastomoses (proximal and distal vein diameters are more closely matched to those of the inflow/outflow targets)
4. Minimize ischemic time
5. Decrease wound healing complications
Ideal lesion for percutaneous ballon angioplasty and stenting
Large artery with focal lesion (not at bifurcation; no calcification)
Best results of percutaneous balloon angioplasty are seen in ____ arteries
Iliac (common > external)
85% 4-year patency
Absolute indication for placement of stent
Recoil following PTA
Residual intimal flap (local dissection)
6 P's of actue ischemia/arterial occlusion
Pain
Pallor
Pulselessness
Paresthesia (webspace S1)
Paralysis
Poikilothermia
Most common location for embolus to lodge that results in acute arterial occlusion
Femoral bifurcation
How to differentiate acute ischemia 2° to thrombosis vs. embolus
History of claudication (thrombosis) vs. no history of claudication (embolus)
Management of acute LE ischemia
Heparin (immediately) -- to prevent formation and
propagation of thrombosis distal to the embolus
Lytic agents (acute thrombosis superimposed on
chronic ischemia) or surgery

*Always consider fasciotomies
Management of isolated iliac lesions
PTA with stent → aortobifem or fem-fem if PTA fails
Management of aortoiliac occlusive disease
Aortobifem repair (or ax-fem +/- fem-fem)
Causes of swelling following LE bypass
DVT → get LE duplex US
Edema from reperfusion injury
Complications of reperfusion of ischemic tissue
Lactic acidosis
Hyperkalemia
Myoglobinuria
Compartment syndrome
Treatment of rhabdomyolysis and 2° myoglobinuria due to reperfusion of ischemia limb ± muscular necrosis
1. Treat hyperkalemia
2. IV sodium bicarbonate to alkalinize the urine and treat systemic metabolic acidosis
3. Osmotic diuresis with mannitol (to prevent renal tubular obstruction)
#1 cause of late failure of reversed SVG
Atherosclerosis
#1 cause of early failure of reversed SVG
Technical problem
Management of dry gangrene
Noninfectious → allow to autoamputate (if just toe)

*consider amputation for larger lesions
*see if patient has correctable vascular lesion
Management of wet gangrene
Infectious → amputate to remove infected necrotic tissue + antibiotics
Common location of malperforans ulcer
Metatarsal head (2nd MTP most common)
Most likely compartment to develop compartment syndrome
Anterior → footdrop
Compartmental pressure suggestive of compartment syndrome
>20-30 mmHg
Define popliteal entrapment syndrome
Intermittent claudication or acute occlusion or embolization of popliteal artery given its relation to the medial head of the gastrocnemius muscle; commonly affects MEN before the age of 40
PE that is suggestive of popliteal artery entrapment syndrome
Loss of tibial pulses with active planta flexion or passive dorsiflexion to tighten the gastrocnemius muscle
Most common type of popliteal entrapment syndrome
Type I: medial deviation of the artery to normally placed muscle (50%)
Treatment for popliteal entrapment disease
Resection of medial head of gastrocnemius muscle; repair or bypass artery if needed
Indications for LE amputation
Complications of DM (60-80%)
Non-diabetic infection with ischemia (15-25%)
Ischemia without infection (5-10%)
Chronic osteomyelitis (3-5%)
Trauma (2-5%)
Neuroma, frostbite, tumor, pain, non-healing wound (5-10%)
Therapeutic approach to trophic ulcer infection in a diabetic patient
1. Aggressive initial debridement of all necrotic tissue
2. Systemic antibiotics
3. Arterial revascularization if associated occlusive disease is present
Emergent amputation is indicated in what condition
Uncontrolled or ascending infection
Diabetic foot abscess
Types of amputation above the knee
Hip disarticulation
High thigh
Mid thigh
Supracondylar
Knee disarticulation
Types of amputation below the knee
Below knee
Syme's (ankle)
Trans-metatarsal
Digital/Ray amputation
% mortality within 3 years following either AKA or BKA
50%
Complications of amputations
DVT, PE, CHF, arrhythmia, MI, stroke, renal failure, stump complications (non-healing, infection, hematoma, contractures, ulceration, phantom pain, and trauma), PNA
Independent risk factor for developing coronary and peripheral atherosclerosis
Cigarette smoking
Hypercholesterolemia
Diabetes mellitus
HTN
What non-surgical therapy can reduce rest pain until the arterial circulation can be improved with a bypass operation or angioplasty? Mechanism?
IV heparin → vasodilation by promoting NO release → improvement of extremity arterial circulation
Therapeutic approach to aortoenteric fistulas (following aorto-iliac bypass grafting)
Prompt diagnosis (MRI/CT)
Administration of antibiotics
Removal of the entire prosthesis
Re-establishment of vascular continuity through non-
contaminated fields
Abnormal findings on CT that are suggestive of aortoenteric fistulas/infections of bypass grafting
Perigraft fluid
Gas
Tissue inflammation
Extra-anatomic routes for revascularization following infection of aorto-iliac bypass graft
Axillofemoral and/or femorofemoral grafts (better than bilateral axillofemoral grafts given better outflow)
If revascularization through a contaminated area is required, what conduit material should be used?
Autologous tissue (superficial femoral vein)
Diminished or absent pulses is a(n) (early or late) finding of compartment syndrome
Late (may have irreversible neurologic damage)
Toe pressures lower than _____ mm Hg are consistent with severe ischemia in non-diabetic patients and _____ mm Hg in diabetic patients
30; 50
Features of external carotid artery on duplex examination
Triphasic flow (not continuous flow) with flow reversal -- supplies flow to face and its musculature, all high-resistance systems
Features of internal carotid artery on duplex examination
Biphasic flow (continuous flow) -- supplies flow to the brain, a low-resistance system
What occurs within the atherosclerotic vessel during percutaneous transluminal balloon angioplasty?
Balloon dilation → rupture and compression of atherosclerotic intima → allowing media to become overstretched
PTA works best for _____ or _____ in large arteries
Short stenoses; occlusions
Success rates for PTA of the common iliac artery and of the external iliac artery are ____ % at 1 year and _____ % at 2 years, respectively
~80%; 55%
_____ affects all blood vessels that have undergone intervention (most notably on small arteries with diameters < 5mm)
Myointimal hyperplasia
Myointimal hyperplasia can lead to failure rates of up to ____ % at 6 months for small arteries that have undergone PTA
40%

- With recurrent stenosis or thrombosis
Success rate for PTA of the long superficial femoral artery at 1 year.
22%
Complications of any attempted percutaneous intervention
Atheroembolization
Dissection
Thrombosis
Possible loss of limb
Transverse aortic arch aneurysms are almost always the result of _____
Atherosclerosis
What imaging modalities are required to differentiate transverse aortic arch aneurysms from mediastinal tumors and to define the vascular anatomy prior to repair?
Aortography and CT
The introduction of _____ and _____ has significantly reduced the operative mortality rate for transverse aortic arch aneurysm repair
Cardiopulmonary bypass; hypothermic circulatory arrest

[Concomitant association with coronary and cerebrovascular disease along with temporary disruption of blood flow to the brain → higher operative mortality than other repairs]
Treatments of occlusive aortoiliac disease
Goal: to re-establish adequate blood flow to the tissue being supplied

1. Thromboendarterectomy (for patients with disease confined to the distal aorta and common iliac arteries)
2. Aortofemoral bypass grafts
3. Axillofemoral and thoracofemoral bypas grafts
4. Femorofemoral and ileofemoral bypass grafts (when only one iliac artery is diseased)
5. Percutaneous balloon angioplasty (isolated short-segment lesions of the iliac arteries with good distal run-off)
Thromboendarterectomy is contraindicated in patients with occlusive aortoiliac disease when which conditions are involved?
Patients with aneurysmal disease and disease that extends to the external iliac arteries
Most common graft-related late complications of aortic bypass grafts
Graft occlusion (progressive atherosclerosis at or just beyond the distal anastomosis)
Other late complications of aortic bypass grafts
Anastomotic pseudoaneurysm (1 to 5%)
Graft infection (1%)
Aortoenteric fistula (rare) [GI bleeding]
Most common cause of death after recovery from a successful aortic bypass graft operation
Coronary artery disease
Risk factors predictive of post-op cardiac events
Age >70
Previous MI
History of ventricular arrhythmias
Diabetes mellitus
Angina pectoris
CT features suggestive of graft infection
Fluid or gas around the graft
Obliteration of the normal RP tissue planes
Pseudoaneurysm formation
Soft tissue swelling; increased soft tissue between
graft and wrap
Focal bowel thickening
Graft infections diagnosed within _____ months are more virulent than those diagnosed later.
4
High mortality rates (10-50%) of AAA graft infection are due to:
Aortic stump blowout
Persistent sepsis
Complications following endovascular repair (EVAR) of AAA
Endoleaks (most common)
Microembolization
Improper or incomplete placement of stent
Graft migration
Graft thrombosis
Delayed aneurysm rupture
Following successful endograft deployment, patients are monitored with various imaging modalities (commonly spiral CT) @ ____ intervals for the possible development of a new endoleak
6 months
If endoleak is associated with growth of AAA -- recommendation?
Repair
Treatment of infected (mycotic) AAA (once diagnosed)
Broad-spectrum antibiotics
Excision of the aneurysm with debridement of all
involved tissues, secure aortic stump closure, and
extra-anatomic reconstruction
Parenteral antibiotics (post-op) x 4-6 weeks
Incidence of prosthetic aortic bypass grafts infection following aortoiliac bypass and aortofemoral bypass
1%; 1.5-2%
Treatment of infected prosthetic aortic graft following AAA repair
Graft excision
Wide debridement of infected tissues
Secure aortic stump closure
Extra-anatomic reconstruction
Long-term antibiotic regimen
Alternative option(s) for patients with late graft infections of low virulence (S. epidermidis) and no gross contamination
Segmental graft excision and in situ graft replacement
Long-term antibiotic regimen
Close follow-up
Most common graft-related complication following aortofemoral bypass
Graft limb occlusion (single)
10 to 20% of patients
Most common cause of late graft limb occlusion
Progressive atherosclerotic disease at or just beyond the distal anastomosis

Other causes:
- Worsening disease of the outflow vessels (commonly the proximal profunda femoris artery)
- Thrombosis of an anastomotic aneurysm
- Arterial embolism from a cardiac source
- Low-output states
- Hypercoagulable states
- Iatrogenic injury to the graft or native vessels following cardiac catheterization or diagnostic angiography
_____ therapy is limited to patients with acute graft occlusion and non-limb-threatening ischemia
Thrombolytic
Therapeutic options for unilateral graft limb occlusion
1. Graft limb thrombectomy
2. Femorofemoral bypass
3. Aortofemoral bypass graft reoperation
a. Proximal aortic disease
b. Anastomotic complications
c. Significant degeneration or dilation of the original
prosthesis
± Profundaplasty, graft limb extension, or bypass to the popliteal or tibial level
Therapeutic options for multiple occluded grafts or "hostile" abdomens
Extra-anatomic reconstructions
Axillofemoral or
Descending thoracic aortofemoral bypass
Ulcers resulting from arterial insufficiency usually involve _____ or _____ and are painful.
Toes; plantar surface of the foot
Stenoses (atherosclerotic occlusive disease) _____ cm are considered ideal lesions for percutaneous treatment via endovascular approaches; those _____ cm have poor patency with endovascular repair
Less than 2 cm; longer than 10 cm
True or False: both iliac stenoses and occlusions may be treated with percutaneous endovascular technique
True (similar long-term patency rates)
Better vs. Worse vs. Similar? 3 to 5 year graft patency rates (for infrainguinal revascularization) in patients with ESRD vs. population with normal renal function
Similar
Long-term patency of bypass grafts to the tibioperoneal vessels are better when _____
Pedal arch is angiographically intact

[Diabetes/previous revascularization operations/level of distal anastomosis do not significantly adversely affect patency on bypasses to the popliteal or tibial levels]
Gold standard for assessing the completeness of thromboembolectomy
Restoration of distal pulses or Doppler signals and IOP arteriography (when necessary)
Aortoiliac emboli should be removed via _____ approach
Bilateral femoral arteriotomies
Most common symptom(s) of thoracic outlet syndrome
Pain or paresthesia 2° to brachial plexus compression (most commonly C8-T1 area, or ulnar nerve distribution)
Symptoms of arterial compression (subclavian-axillary vessels) 2° to thoracic outlet syndrome
Ischemic pain
Fatigue
↓Temp
Embolic events → digital gangrene

*Less common than brachial plexus compression symptoms
Raynaud's disease or phenomenon most frequently affect young ____ (90% younger than ____ years of age)
Women; 40
Classic pattern of Raynaud's disease or phenomenon
Pallor (vasospasm with ↓dermal circulation), cyanosis (sluggish flow of blood), and rubor after exposure to cold or stress
Initial drug of choice (if needed) for the treatment of Raynaud's
CCB
Therapeutic approach to cold-injured extremity
1. Rapid rewarming @ 40-42°C in warm water
2. Elevate and expose extremity
3. Abx (if open wound present) ± tetanus
_____ disease is the most common source of LE microemboli
Aortoiliac atherosclerotic
Livedo reticularis
Microemboli lodged in capillaries of the skin
_____ is characteristically the first and dominant symptom of anterior tibial compartment syndrome
Pain located over the anterior compartment
Patients with acute embolic events causing ischemia require _____
Immediate intervention

Example: embolectomy with a transverse arteriotomy (to prevent stenosis with closure)
Division of the _____ muscle allows cephalad exposure of the distal ICA; division of the _____ muscle allows better exposure of the CCA
Digastric; omohyoid
_____ is the main cause of swelling after bypass
Lymphedema

*Minimal dissection and ligation of lymphatics decreases the incidence